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, Sameer Gopalani, Lan Tran, Katherine Eastwood, and Josie Amory. 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.

Morning Schedule

1. Arrive 7 a.m. or earlier to see patients.
2. Board Rounds 7:45-8 a.m., at the 5E L + D board. 
3. OB lectures, 8:00-8:30 a.m. Schedule is posted next to the door in the 5SW conference room so residents can read ahead on topics.
4. Perinatal rounds 8:30-9 5SW Conf Room. Use Thursdays as teaching time with this same schedule: at the discretion of the OB fellow supervising teaching may choose to attend Thurs am conferences instead. 
5. 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. Antepartum 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.