Curriculum

Rotation Goals/Objectives

R-1 Year

R-2 Year

Continuity OB

Reading List

Faculty: Joe Breuner, M.D.

Resident Chairperson (2004-05): Chris Yee, M.D. & Julie Taraday, M.D.

The goal of the OB training curriculum is to provide residents excellent training in normal/uncomplicated prenatal care, normal delivery and normal post partum care. An additional goal is to provide training in the recognition and initial management of more complex OB problems and continued prenatal care with more complicated labor and deliveries. Residents should also be able to initiate adequate care during an obstetric emergency.

Some patient problems can be handled by family physicians, some require specialist consultation and joint management; and some must be cared for in a tertiary care setting. This training will help the residents decide the appropriate level of care for their obstetric patients.

The residents will also be taught vacuum assisted deliveries, become familiar with forceps deliveries and assist C-sections. The goals will be obtained by the resident responsibilities as outlined below.

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R-1 Year

OB Rotation

	R1s will spend a total of 12 weeks at Swedish Medical Center caring for patients on the antepartum, L & D, and the post partum floors. Night call during this time is at Swedish Medical Center. The OB schedule corresponds with the Block schedule and follows this general design:

		Nights of night call in a single block, number depends on number on team – 8pm to 8am (no day responsibilities after seeing own patients and attending morning rounds) Day call – 8am to 8pm On average, 4 weekend days off per month 8 clinic half-days per month, plus didactics on Tuesday afternoons

Labor & Delivery Responsibilities

	Goals: To provide residents with an opportunity to learn normal intrapartum care, labor complications, normal and instrument deliveries, c-section assists, and antepartum/postpartum care. The resident name will be posted daily in antepartum, L&D, and postpartum units.

Duties

	Day call is from 8am to 8pm, and night call is from 8pm to 8am. The call resident is responsible for panel patients on the Labor and Delivery floor as well as panel antepartum admissions and postpartum care. Specific responsibilities to panel and non-panel attending physicians are outlined below. When a "no-doc" patient is admitted to L&D deck, the OB fellow will be called to assess and admit the patient, and will involve the R1 at their discretion. If appropriate, the R-1 will manage the patient under the supervision of the fellow, with secondary back-up by perinatology.

Antepartum Admissions

	The attending will call the on-call resident with admissions. The resident will evaluate the antepartum patient in a timely fashion, write up the history and physical, and present the patient to the OB fellow/senior resident and the attending. The R1 will be responsible for writing all orders for the patient. This is a crucial part of the service so that the resident will be included in "the information loop." If emergent orders need to be written, the fellow or attending may write them and then inform the resident. If an antepartum patient needs to be admitted urgently or the R1 is busy in a delivery, the patient may be admitted by the OB fellow/senior resident or the UW OB R3, in which case the R1 will be expected to pick up and start following the patient after admit.

Ongoing Care

	Each resident will round on his or her own antepartum patients daily. The night call resident will make every effort to see his or her own patients, but if unable to because of other call duties (ie deliveries), the team will help see those patients prior to rounds. The night call resident is relieved of duties shortly after rounds. Following rounds, those residents not on day call will sign off to the on-call resident. The on-call resident will be available during the day to answer pages from the attendings and the antepartum nurses. The attending will involve the resident in any change in management, emergent or non-emergent, (ie: medication changes, need for amniocentesis or ultrasound). This communication will help the residents’ understanding of antepartum problems.

Triage

	The on-call resident will evaluate patients in triage for possible admission and will present all patients to the OB fellow and attending for a final decision. The OB fellow will review and/or see every panel patient with the R1 so they may bill for the visit.

C-sections

	The resident will be available and are encouraged to do C-sections with panel attendings when there is no advanced OB resident or scrub in as a second-assist with the senior resident, particularly for patients they have been following in labor. They will be expected to make post-partum rounds on their C-section patients.

Other Responsibilities

	During down times, residents will have time to read about their antepartum patient's problems by reading textbooks and literature searches for current management trends. Each R-1 will do one lecture in a given OB month. Lectures should be 15 minutes in length and cover a basic topic. Additional teaching will be provided by Dr. Breuner, the OB fellows, the perinatologists, the UW OB R3, or the Family Practice R2 during morning conferences. It is expected that scheduled readings for lectures are done prior to lectures.

Teaching Assessments-Patient Care

Faculty

	The FP faculty committee member is Dr. Joe Breuner, who coordinates the OB training with the perinatalogy group. Dr. Breuner coordinates OB education, along with the FP R2, the OB fellows and the UW OB R3. The perinatology group runs morning rounds on antepartum patients, participates in teaching of the residents, and supervises the residents’ care of perinatal patients on antepartum and L&D. This group includes Dave Luthy, Dale Reisner, Jim Harding, Brigit Brock, Tanya Sorenson, Dave Gorenberg and Sameer Gopalani. In addition, there is a UW OB R3 rotating with the perinatal group at any given time and is available for questions regarding perinatal patients. R-1s on the OB Service work with specific attending physicians (THE PANEL) who have committed themselves to working with and teaching residents. This group includes private obstetricians, private Family Practitioners and the Perinatology Group at Swedish. The residents work extensively with the Health Care for Women obstetricians, a group that provides OB back-up to all of the community FPs, including the residents for their pregnancy patients.

Conferences

	1. Board Rounds 8:00 – 8:30 a.m., MTWF in the 5SW conference room. 2. OB lectures, 8:30 – 9:00 a.m. Schedule is posted on the erase board in the 5SW conference room so residents can read ahead on topics. 3. Thursdays 7:30-8:30: 1^st Thursday of month- Fetal Heart Rate Tracing Strip Review 2^nd Thursday- R2 teaching time 3^rd Thursday- R2 teaching time 4^th Thursday- OB M&M 4. Tuesday p.m. 12:30 – 5:00 p.m., Family Medicine didactics.

The Panel System

	The R-1s are to work with a specific group of physicians who have stated they will work in a supportive and educational manner with the residents.

Responsibilities of residents to private attendings on the panel

	To assume responsibility of the care of panel patients >16 weeks EGA from the time the patient arrives on L&D to her discharge. This includes making an initial evaluation on arrival on the floor and writing hourly notes on patients in active labor. Patients <16 weeks who require admission will be followed by the Family Medicine Service rather than the OB team. To notify the nurse if unable to evaluate a new patient within 30 minutes, so that the nurse can notify the fellow or attending. Also, to communicate with nurse if tied up in a c-section, delivery or emergency situation which they are unable to leave to respond to a call. To write all orders and to complete the face sheet. To complete all daily notes in a timely manner, by 8:00 at the latest, 7:30 on Thursdays. To communicate with the attending in a timely and appropriate manner on all important issues. To assist in all c-sections of patients on the attending panel, including those not being directly followed by the resident, when an upper level c-section resident is not available to assist. On patients the resident is following, the resident will be expected to round on the patient post-partum and write daily notes. To respond to all calls from nurses regarding patients the resident is following. To document clearly on the board and on the front of the chart when the patient is admitted that the patient is followed by a resident so that nurses know whom to call (red dot next to patient’s name). To respond to emergencies on any patient when requested by nurses, until attending is available. To provide non-emergent services such as gels and fever evaluations on patients of panel attendings even if that patient is not being followed by a resident, but only when the attending requests the resident directly.

Responsibilities of residents to non-panel attendings

	To provide assistance on emergent c-sections when no upper level resident or other practitioner is available. The FP R-1 will not follow such a patient during post-operative period, or dictate the op report. To respond to emergent calls from L&D or the floors, until the attending is available.

Responsibilities of panel attendings to residents

	To involve the resident in a supportive manner in all aspects of the care of the obstetrical patient. To allow and encourage the resident to perform through completion procedures including, but not limited to, vaginal delivery, instrument vaginal delivery, episiotomy and lacerations repair, when appropriate. To teach the R-1 assistant roles in C-sections, with the resident's participation increasing with increasing experience. To allow the resident to write all non-emergent orders on the patient through her hospital stay and discuss management issues with the resident directly. If the attending has determined that a particular patient should not be followed by a resident, to make this clear in advance on the patient's record so that the resident will not be involved (red dot with a line through it next to patient’s name). To communicate with the resident in advance when requesting that they perform services on the attending's patients who the resident is not following. To encourage the nurses to work directly with resident during the patient's hospital stay. To be an active and involved teacher of all aspects of perinatal care. To evaluate and report on the resident's performance and make suggestions for their further development.

Time Conflicts

	Conflicts in the prescribed duties while on the service should be resolved according to the following ACTIVITY PRIORITY: 1. Labor and delivery 2. Triage evaluations 3. Antepartum and post-partum cross-cover (if urgent, becomes first priority) 4. Anterpartum admissions

Resuscitations

	The resident may participate in, and develop experience with newborn resuscitations, when the mother's medical condition is stable. More formal teaching in neonatal resuscitations occurs during the combined neonatal curriculum month.

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R-2 Year

Welcome to Your Advanced OB Rotation!



   Each resident will do a 4-week advanced OB rotation at Swedish medical center during their second year. The goals of this rotation are for the residents to further solidify their knowledge of normal labor and delivery and normal post-partum, as well as to have an increased focus on managing abnormal labor and more complicated deliveries (including instrumented deliveries and C-sections), and admitting anterpartum patients with a variety of high-risk issues and complications of pregnancy. The R2 will also be instrumental in coordinating the teaching curriculum for the R1s, including giving two of the morning lectures to the team during the block. The R2 will act as the "senior resident/fellow" two days a week (Wednesday and Sunday, see schedule below) when there is not coverage by an OB fellow. On these days, the R2 will function as an OB fellow and oversee the management of laboring patients, triage evaluations, and antepartum and post-partum cross cover issues by the R1s, admit perinatology and panel anterpartum patients, and be the primary person called to assist with scheduled and non-scheduled C-section assists. If a "no-doc" presents in labor, the R2 will evaluate, admit and manage the patient under the supervision of the on-call perinatologist. Another goal of the rotation is to gain increasing competency with obstetrical ultrasound, including first trimester vaginal U/S for dating, third trimester U/S for biometry and dating, U/S for fetal presentation, AFI, and if desires, BPP and placental position.



Schedule

The R2 will take call 5pm TO 8AM Wednesdays and 8am to 8am Sundays (except for the third Sunday of the bock when the antepartum OB Fellow will cover for the residents’ "golden weekend’). Wednesdays 8am to 5pm will be covered by the Gyn surgery OB fellow, and R2s have the option to pursue other learning opportunities during this time such as following the lactation consultants, going to genetics clinic, etc (see list of options below). The exception to this is the first Wednesday of the block when the Gyn surgery fellow will be post-call, so the R2 will take call that day 8am to 8am. Tuesday mornings they will have the opportunity to do U/S clinic at SFM performing obstetrical U/S. Friday they will have their own continuity clinic all day and will be excused from morning rounds on those days to prepare for clinic. Mondays and Thursdays they will be off once their rounding responsibilities are finished. Chart review with the OB R3 should be done once a week and this can be arranged with them directly.

Representative weekly schedule

R2 OB

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

AM

L+D

Off

Ultrasound

L+D

(option: genetics/

Lactation)

Off

Clinic

PM

L+D

Off

Didactics

L+D

Clinic

Night

Call

Call





Teaching

The R2 will be in charge of coordinating morning teaching rounds from 8:30-9:00 MTWF. They will assign lecture topics to the UW OB R3, the OB Fellows and Dr. Joe Breuner from the three-part R1 curriculum. On Thursdays they will do teaching with the R1s at 7:30-8:30 (except 4^th Thursday when all residents go to OB M&M). They will also choose 2 topics during the block to give lectures on during morning rounds, and assist the R1s in choosing a topic to teach on during the block.



Labor and Delivery

While on call, the R2 will admit laboring Kendall and no-doc patients and assist the R1 in admitting laboring perinatal patients. They will also peripherally follow all laboring panel patients that the R1 is following and be available to assist with the delivery, particularly if it becomes a vacuum delivery or goes to C/S.

Triage

The R2 will evaluate Kendall and no-doc patients in triage and present them to the attending with their completed assessment and plan. They will also be available to assist the R1 with triage evaluations of perinatology and panel patients.

Antepartum



The R2 will admit Kendall and no-doc to antepartum under the supervision of the appropriate attending and will be primarily responsible for rounding on these patients daily and writing progress notes, writing all orders with approval of the attending, and communicating important patient information to the attending. They will also supervise the R1s in the care of their antepartum patients, including being available to answer questions that arise, and signing off on the R1 progress notes for patients the R2 admitted on call.

C-Sections

The R2 will be available to assist with any scheduled or non-scheduled (L&D) C-sections during their call shifts. Panel attendings routinely request the assistance of the senior resident/fellow for their scheduled C-sections (M-F, 7:40, 9:00, 12:30, 2:00, 4:00), as well as for laboring patients that go to C-section. The R2 may also be asked to assist with emergency C-sections with non-panel attendings and will do so as they are able, but will not be expected to round on those patients post-partum. R2’s are expected to assist with at least 10 C-sections during their advanced OB rotation, more if they desire more experience. If they are lacking numbers, they have the option of doing scheduled C-sections on Wednesdays between 8am and 5pm if they do not have other activities scheduled.

Other Responsibilities

Read NSTs and review charts with the OB R3 weekly, time will need to be arranged with the OB R3. This absolutely CANNOT be missed. It is our only chart review for the First Hill clinic and it is a GREAT learning opportunity for you. Please confirm time each week with OB R3 to assure it is not forgotten.

See patients with Bob Resta, Genetics Counselor on Wednesdays: residents will need to let the office know when they want to be there.

Orient the new R1s on labor and delivery on the first day of the new rotation, including distribution of the R1 checklist for the OB rotation.

Ultrasound will now be available to all clinics (First Hill, 45th Street, DFM) for all trimester OB scans. Tuesday am (9:00 – 12:00) is a required time slot for the R2 on Advanced OB, where you will perform ultrasounds under the supervision of Jorge Garcia, M.D. View the U/S CD-Rom in the Learning Center prior to your first U/S clinic.

Each R2 will be scheduled for 2 clinics each week, all day on Friday. Morning clinic will begin at 9am since the R2 will not be asked to attend OB round in the hospital on those days.

Round on and follow the patients they do the C-sections on (unless told not to by the attending) and sign these patients out to the OB R1 on call or fellow in the evenings.

If more experience in high risk obstetrics is desires, the R2 may consider taking day call for the fellow on Wednesday’s. Your attending will be the perinatologist on that day.

Other Recommended Activities

1. A postpartum home visit is highly recommended. You may go with the Swedish nurses/lactation specialists.

2. Attend a breast-feeding class - offered at 10:00 a.m. each weekday near L&D.

3. Spend time with nutritionist, WIC, MSS...arrange through Maternal Support Services (386-6464).

4. Lactation consults on post-partum. Contact person:

5. Follow social work while they do CPS and other evaluations. Call Shari Simmons (386-6285), she is the social worker who covers the postpartum units.

Important Phone Numbers

Ultrasound Department: 386-2379 Joe Breuner: 560-2562

Maternal Support Services: 386-6484 Paul Cunningham: 405-7937

Women/Infant Outpatient Svcs: 386-3606 Anthony Barnett: 405-7934

Bob Resta: 386-2101

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Continuity OB



Assignment of Prenatal Patients

First Hill-

At First Hill, the OB chief will review each OB chart after the initial visit and will assign each patient to a resident who will be their primary physician. Patient preferences such as male or female provider will be taken into account, as well as how many additional OB patients each resident needs.

DFM

Assignment of patient is made by MSS Screening R.N. in consultation with faculty.

45^th Street Clinic

Assignment of patients are made by Debra Cannon

Clinic Precepting and Consults

As complications are recognized during prenatal care, residents should discuss cases with FP faculty and the OB fellows, and discuss the possible need for a formal obstetrical consult from the Health Care for Women (HCM) group. The perinatal group is also available by phone or pager for acute management questions in preterm or high-risk patients. When discussing a case with HCM or the perinatologists, residents should make it clear to the consultants that they are asking about a specific case. The consultant, in turn, will make it clear to the residents whether a formal prenatal consult is required. For patients with identified problems, residents should have a clear management plan documented in the chart. Complicated OB patients should have a particular FP faculty acting as a primary consultant, rather than a different faculty member precepting each time.

Chart Review

Residents are expected to keep charts up to date. The FP Team Leader, UW OB R-3, and Advanced OB resident will review the charts of all the Swedish OB patients during the 1st and 3rd trimester, using the chart review form (see example at end of chapter). Following chart review, the chart along with management recommendations will be placed in the residents' mailboxes or on the residents' desks. Depending on the importance of the recommendations, residents may also be paged. Residents should respond to recommendations in a timely manner by either following them or by discussing the case with FP faculty and/or a consultant for an alternate plan.

First Hill

   Charts will be reviewed as above. The prenatal record will be sent to L & D no later than 37 weeks. Significant subsequent data should be added by faxing a copy of the clinic record to L & D.
OB charts are kept in specified file cabinets in each pod. If the charts are taken away (i.e. for chart review with OB R3) a sheet should be left in the file cabinet designating the chart location.

DFM

DFM OB charts will be reviewed after each visit by faculty. They are faxed to L&D at 32+ weeks. In addition, all prenatal patients are reviewed at twice a month DFM Ob case review and residents are encouraged to discuss each visit with attending.

45^th Street Clinic

45th St. Clinic OB patients are reviewed by residents and faculty at OB meetings from 12:00-1:00 each 2^nd and 4^th Wednesday. When residents begin caring for continuity OB patients, they are expected to attend these meetings, schedule permitting. Additionally, OB visits are reviewed by a clinic attending at each visit. Formal telephone consults with specialists are documented on bright lime green paper and added to official OB records. Charts are faxed to L&D at 36 weeks.

Prenatal Care responsibilities

As with all aspects of medicine, a resident should freely precept any obstetrical patient about whom he/she has questions. A resident, with faculty input, should develop a treatment care plan for OB's with resident's team leader or faculty member on the team. The resident is to keep the faculty person informed of complications in their prenatal course. The resident may also use the OB fellows as consultants.

Continuity OB: Labor and Delivery

Second and third- year FP residents are responsible for the care of their continuity OB patients on weekdays and weekday-nights when their patients are in active labor. This responsibility supersedes all other patient responsibilities. Residents have the option of signing off to the senior family medicine on-call resident on weekends. During vacations, the resident’s pod partner assumes primary responsibility for continuity OB coverage.
Patients of R-2s or R-3s who are admitted to the hospital with a complication of pregnancy, but not in active labor, are admitted to the Family Medicine Service with the primary resident working with the residents on the service in the provision of care for the patient. When the patient goes into active labor or needs to be delivered, the responsibility of that patient's care reverts to the primary resident.



Back-up for R-2's and R-3's when their patient is in labor

When a patient arrives in triage and the patient's primary continuity obstetric provider is a resident, the senior family medicine resident will be paged. He/she will evaluate the patient under the telephone supervision of the attending on call for OB. He/she may also obtain an in-person consultation by the OB fellow on-call. If the patient is in labor, the primary continuity resident will be paged in addition to the attending on call for OB. The faculty member is to come to the hospital in the following situations: active labor in a patient on pitocin or when an epidural is placed. In patients without an epidural and not receiving pitocin, the faculty member should be on campus for the second stage or sooner if indicated. The faculty member is to be present at the delivery. If the faculty person believes obstetrical consultation is warranted, Health Care for Women should be consulted and involved. Faculty may choose to have the OB fellow cover for them during clinic hours only (8 am to 5 pm) so the faculty may remain in clinic and see patients until delivery is imminent. The faculty will still attend the delivery, unless they are unable to get there in time, in which case the OB fellow may act as supervising faculty and bill accordingly. At night or on weekends, the faculty will be expected to be in-house for patients on pitocin and with epidurals as above, as well as to attend the delivery.

R-2/R-3 Sign out

7:30 am Monday - 5:00 pm Friday:

The R-2 has primary responsibility for their patient during this time as described above. If the R-2/R-3 will be unable to be present because they are on vacation or any other reason then that resident should contract with their partner in advance so that there will be no uncertainty as to who is responsible at the time of the patient's arrival.

5:00 pm Friday to 7:30 am Monday:

The R-2/R-3 may "sign-out" their patients to the senior family medicine resident on-call during these times. Even when not officially signed out, a patient in inactive labor will often by managed by the senior resident on-call until morning. This only occurs if the continuity resident has previously expressed an interest in having inactive labor be managed by his/her colleagues AND the on-call resident is capable of managing the inactive labor in addition to his/her normal responsibilities.

Admitting Routine

A resident’s continuity OB patient is either admitted by the continuity resident or by the resident on call for Family Medicine Inpatient Service. It is a resident’s responsibility to contact the FP faculty to discuss the prenatal record, anticipated complications, and outline a management plan.

Routine Delivery

In an uncomplicated labor, the FP faculty should be notified upon admission and late in the first stage. Routine decisions may be made and procedures done by the resident, if qualified, including AROM, FSE, analgesia, monitoring, local anesthesia, antibiotics, pitocin, eipdural, amnioinfusion, post-partum oxytocics and medications. The attending should be notified of any concerns (bad strip, fever, labor dystocia, etc), as well as when the patient is on pitocin or gets an epidural so they can be in house for the rest of the labor. The baby will be examined as soon as possible (within four hours) by the delivering resident as well as the attending.

Emergency

If a problem develops so quickly that the faculty may not have time to get in, the resident may consult the OB fellow for assistance. If OB back-up is needed, HCM may be consulted to provide immediate assistance (ex. Vacuum delivery or crash C/S for fetal compromise). For precipitous deliveries, the OB fellow may act as the attending.

Post-Partum Complications

Swedish 1^st Hill and DFM patients requiring readmission to the hospital are to be admitted to the Family Practice Service with the faculty on service as the attending. 45th St. patients will be admitted to, Family Medicine Service with 45th Street faculty as attending.

Liability

The Swedish Family Medicine residents will be covered under their malpractice insurance provided by the residency program through Physicians Insurance (arranged through University of Washington Family Medicine Network).

Prenatal Chart Review

PRENATAL CHART REVIEW

1. Initial Evaluation: Week gestation __________ Date______

a. Chart complete to date? (ie: done and recorded on record)

Yes! Good job _____ No _____ What it needs:

_____ Identifying data?

_____ History complete? (What isn't filled in)

_____ Physical exam, including uterine size:

_____ Initial labs: blood type and antibodies, rubella, UA and Culture, serology, HepB, Hct, PAP, cultures, HIV (offered).

_____ Additional lab work if indicated:

_____ Prenatal Risk Profile (note why if not done) if 15-20 weeks

_____ Sickle screen (if at risk of carrying thalassemia or sickle disease)

_____ PPD

_____ Herpes

_____ Other special tests:

_____ All identifying data recorded on Review of Dates, including U/S if done:

_____ Problem list complete

_____ EDC correctly identified.

_____ Visits to date: approximate intervals, all info recorded

b. Problems identified? with plan, dictated if indicated?

List any unidentified problems:

Suggestions for management of each problem if indicated: (list)

c. Need for early reevaluation? when __________ (mark on computer sheet)

Reviewer __________ Resident __________ (initial when read) date?

d. Routing:

Place in chart

Resident’s box

Resident paged

Resident notified

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Reading List