Ob/Gyn Intern Orientation and Survival Guide

Ob/Gyn Intern Orientation and Survival Guide
There is a hierarchy within the residency. It is used to promote progressive decision-making capabilities while maturing in the training process. It is to be respected and utilized. Although the attending is ultimately responsible for whatever happens, he/she recognizes the importance of allowing residents the opportunity to make decisions. Among residents, however, questions and management decisions should flow from intern to second/third year and then chief. The chief resident may then confer with the generalist attending, the MFM or ONC attending. This fosters a learning environment and a sense of security. This flow of information is also bi-directional, and it is often necessary for the more senior resident to "check behind" the intern. The junior resident will notify the chief of any changes in patient status and will inform the chief if his/her presence is needed. In the event of an emergency, the junior resident is expected to directly notify the attending if the chief resident is unable to be reached.
Acronyms and abbreviations
A&P- anterior and posterior repair
BTL- bilateral tubal ligation
BSS- bedside sono
BSO- bilateral salpingoophorectomy
ctx- contractions
EGA-estimated gestational age
EDC- est date of confiment (due date)
FM-fetal movement
EBL- estimated blood loss
EFW- est fetal weight
FHT- fetal heart tracing
GBS-group B strep
GDM- gestational diabetes mellitus
IUFD- intrauterine fetal demise
LMP- last menstrual period
LOF- leakage of fluid
LTCS- low transverse c-section
PID- pelvic inflammatory disease
POC- products of conception
PPROM- premature preterm rupture of membranes
SVD- spontaneous vaginal delivery
VAVD- vacuum assisted vaginal delivery
MVP-maximal vertical pocket
SVE- sterile vaginal exam
SSE- sterile speculum exam
SROM- sponteous rupture of membranes
TAH- total abdominal hysterectomy
TOA- tuboovarian abscess
TVH- total vaginal hysterectomy
Clinic (OB)
Clinic begins at 1pm and runs until all patients are seen.
Prenatal care
§ We have a high-volume of Ob patients, both routine and high risk. High-risk days are Tuesdays and Thursdays mornings (MFM resident is in charge of this clinic).
§ Schedule for visits for routine care:
§ Q 4 weeks up to 28 weeks
§ Q 2 weeks from 28-35 weeks
§ Q 1 week for 36-41 weeks
§ Biweekly for 41+ weeks- needs NST biweekly and weekly MVP (max vertical pocket)
§ Patients need one nurse interview during their pregnancy- make sure this has been done
§ The first Ob visit: should include a complete H&P, ultrasound to date the pregnancy and determine viability, Rx for PNV, schedule labs (more on this later), schedule sono if indicated, arrange MFM referral for high-risk.
§ Dating for a pregnancy should be based on first day of LMP. A first trimester US is the best way to confirm the EDC or to change her EDC. We can do this in clinic. If she is mid-second trimester or 3 rd trimester, then she should be sent ASAP to the hospital for a sono.
§ When to change a patient's due date:
<12 weeks- +/- 5 days difference in the LMP and sono
12-24 weeks- 10 days difference in LMP and sono
24-36 weeks- 15 days difference in LMP and sono
>36 weeks- 21 days difference in LMP and sono
TELL THE PATIENT HER DUE DATE AT THE FIRST VISIT- THIS IS HER OFFICIAL EDC UNLESS TOLD OTHERWISE!!!!!
Routine labs, screens and ultrasounds
· Prenatal panel- type and screen, RPR, rubella titer, Hep B surface Ag, HIV, H/H, hbg electrophoresis (if indicated), urine culture. Done at either the first dr visit or nurse interview
· Pap, GC/Chl- done at the first dr. visit
· All patients should try to have an official sono ASAP to document IUP and EGA
· Quad screen (15-23 wk), first trimester Down's screening (11-13wk), cystic fibrosis (any time)- all optional screens . Needs to be offered. Document if patient declines
· Early glucola (16-18wk) for risk factors (>200lb, prior hx of GDM in preg, 1 st degree relative with DM)
· Fetal movement first felt 16-24 weeks
· Try to find fetal heart with doptone after 10 weeks
· Start measuring fundal heights at 20 weeks. A normal fundal height is +/- 3 cm of EGA; if doesn't correlate or lags or gains on EGA, needs sono to measure growth/MVP
· Between 12-20 wks, record fundal height in weeks
· 12 weeks at pubic symphisis
· 16 weeks halfway to umbilicus
· 20 weeks at umbilicus
· 28 week panel- antibody screen, hct, RPR and glucola; begin counseling on "kick counts" (at least 10 fetal movements in 2 hours is reassuring)
· Rhogam at 28 weeks for all Rh neg without positive antibody screen for Rh
· One ultrasound for normal pregnancies after 16 weeks (target before 20 weeks)
· Sign sterilization papers at 28 weeks- make a copy for patient and tell her to keep handy in case the hospital copy gets lost. Pt must be over 21 years old to sign and must have signed 30 days in advance for term delivery and 72hrs in advance for preterm delivery. Morbidly obese women may want to consider another form of contraception since this is very difficult in them.
· Check position at each visit 36+ weeks by Leopolds and then sono to confirm; if breech, offer external cephalic version or schedule c-section
· Counsel on signs/symptoms of labor each visit starting at 36 weeks
Prenatal Assessment Center
Referral center for high risk pregnancies and for genetic counseling. Also does the first trimester Down's screening.
High Risk Ob
¨ Advanced Maternal Age (AMA)- older than 35 at the EDC. Needs to be offered genetic counseling and amniocentesis for chromosomes (optional)
¨ Chronic HTN (CHTN)- elevated BP prior to 20 weeks. Also needs baseline PIH labs, 24hr urine for protein clearance, EKG (if long standing). Biweekly testing at 32weeks
¨ Diabetics- preexisting or gestational. Also needs hbg AIC, 24hr urine for protein and creatinine clearance, baseline PIH panel; ophthamology, nutrition and diabetic teaching referral; early PAC sono to r/o anencephaly or other lethal anomalies; monthly US for growth after 24 weeks; fetal echocardiogram at 20-22 weeks; biweekly testing 28-32 weeks; amnio at 37 weeks for poorly controlled diabetics and delivery
¨ Previous preterm delivery- try to determine cause; if labor, determine need for cerclage, progesterone shots or BV screening. Evaluate need for 17 OH-Progesterone
Biweekly testing
One day a week will be NST and amniotic fluid check and another day will be a BPP.
Admitting from clinic
Discuss all admissions with upper level resident/attending prior to sending patient to L&D. The upper level resident on L&D and the charge nurse need to be notified prior to pt going.
Scheduled C-sections
ü Determine how dating established- if adequate, then may post at 39weeks. If poor dating (3 rd trimester sono, LMP and 2 nd tri sono do not agree, etc), then pt may need amniocentesis for FLM prior to surgery.
ü Pt should be scheduled through charge nurse on L&D
ü H&P and orders should be done by resident who sees the pt for pre-op
ü NPO after midnight
ü Discuss BTL prior to surgery. Optimally, pt will have signed tubal papers at least 30 days in advance but this is not absolutely necessary for c-sections (depends on their insurance)
Hospital Care (OB)
Rounds
§ 730 am in the L&D conference room (8 am on Sat and Sun).
§ Be prepared to give a brief overview of the patients you saw in the am (although we usually just ask if there were any problematic patients): --yo G-P- ppd/pod # s/p SVD/LTCS, doing well (or having whatever complication). Inform i f a patient is going home that day.
§ -baby's weight, delivering attending and any complications
§ All pts that the interns see must be staffed with an upper level and may need to be co-signed- at least in the beginning
§ All pts, except routine SVDs, should be seen in the evening as well (may start rounding after 12 noon for pm rounds)
§ Interns usually start with routine SVDs and see progressively more difficult patients, such as c-sections and gyn patients.
L&D Responsibilities
· Management of the low-risk laboring patient and triage are the intern's main responsibilities. This is done under the direct supervision of the upper level OB resident. They should know everything that is going on.
· A vaginal exam should NEVER be done without a nurse present, and the 2 nd year resident should preferably be present also in the beginning.
· Upper level residents are responsible for preterm (24-37wk) pts. Interns are welcome to see them, but management should come from the upper level.
· The upper level resident will be the primary surgeon for primary cesareans, BTLs and D&Cs.
· Junior residents are responsible for the ER calls and should be followed by their more senior resident prior to staffing with the attending.
· Interns should update the upper level on things that need management. Interns should not manage gyn onc or antepartum patients without the assistance of an upper level resident- calls can be redirected to the upper level.
Pound Calls (pager says #3843 for example)
Pt's are instructed to call the Ob Dr. On Call to discuss any questions or concerns they have outside of regular clinic hours.
§ Obtain the pt's EDC, phone number and where they are seen for their prenatal care
§ Complaints and above info should be recorded in Cerner for legal purposes and reviewed by the upper level.
§ If the caller is someone other than the pt, ask to speak to the pt directly to obtain the most accurate information.
§ This is not a 24-hr ob/gyn chat line; pts with routine gyn questions are urged to call clinic during hours, but if they feel they need to be seen immediately, direct them to the ER
§ Ob pts with concerns should be come to the ER (OB TRIAGE) for decreased fetal movement greater than 28 weeks, bleeding, cramping, contractions, or leaking fluid. When in doubt, they should be seen sooner than later.
§ Narcotics are not to be phoned in. If a pt requires this level of pain control, they should be seen through the ER. Of note, Vicodin and tylenol #3 can be phoned but you should evaluate why the patient is in pain.
§ Calls should be answered expeditiously, but if you are in the middle of a delivery or surgery, have the nurse call the operator and hold the calls until later. Remember to call back ASAP. These calls should not be ignored, and if the operator feels you are not calling back fast enough, your upper level will be called.
Common Pound-call Questions
Leaking fluid - anyone with possible ruptured membranes should come in. If it leaks only when she coughs/sneezes, then likely urine. She can wear a pad for a few hours and if it's soaked, then needs to come in for eval.
Decreased fetal movement - less than 10 movements in 2 hours after 28 weeks. Lie down, eat a snack, drink some fluid and if above criteria not met, then needs to be evaluated
Bleeding- spotting at term is ok. Bleeding like a period needs to be evaluated immediately. If first trimester and not accompanied by cramping, may be normal, but monitor for worsening. Explain to pt that some miscarriages are inevitable, and there is usually nothing that can be done to prevent them, but should go to the ER if bleeding greater than 1 pad/hr.
Contractions- if preterm and more than 6/hr, then needs immediate evaluation. If less frequent, she should drink a large glass of water, lie down and monitor ctx. If term, then she should wait until they are every 3-5 minutes, increasing in intensity and have been occurring for at least an hour. If a pt is unable to complete sentences while you are talking to her, then it may warrant coming in.
OB Triage
Prior to 20 weeks, they are evaluated in the main ER, but you may be called to evaluate a pregnant patient down there.
After eval, call the upper level to check out to them.
· Always verify the pt's EDC by her records; many pts will tell you the wrong due date and this may change their medical care
· Labor evaluation includes a digital exam to assess dilation. If she is in latent labor, she may walk (if reactive NST) or be sent home on therapeutic rest
· SROM evaluation involves a SSE for pooling, nitrazine (we dont use this anymore- poor quality control- but some midwives carry it with them ie. Pfaff) and/or ferning. This is performed prior to a digital exam
· Bleeding exam involves an ultrasound to verify the position of the placenta prior to SSE and an SSE if previa is ruled out. The ultrasound also reassures the pt that the baby is ok
· Decreased fetal movement exam involves an NST
· Nausea/Vomiting involves a UA to check for dehydration and IVF and antiemetics as indicated. Once a pt is tolerating po, she may be discharged
Admission Indications
¨ Cervical change (ie labor)
¨ Nonreassuring fetal surveillance
¨ Spontaneous rupture of membranes
¨ Pts who are >40wks- case by case basis
¨ Other preterm patients with problems (high BP, pyelonephritis, bleeding, etc)
Admission H&P
We have preprinted admission forms. The following is the pertinent information to gather:
For laboring patients, the first line is the most important:
--yo (race) G-P- with an LMP of - giving an EDC of --- confirmed by (or changed by) a --- week ultrasound, for an EGA of ---. Pt presents with --- (ctx, VB, LOF, decr FM, etc). SROM at - am/pm. PNC began at -wks. Pregnancy complicated by ---.
PMH: should include ob/gyn history (paps, STDs, past preg and delivery info)
PSH, Meds, Allergies, Social and family hx
Labs- GBS status
PE: vitals, general
Heart, lungs, abd ( should include fetal lie by Leopold's and EFW!!) , extremities
SVE- dilation/effacement/station/position of fetal head
SSE- pooling, ferning, nitrazine (if available)
BSS- confirm fetal position and fetal weight
Assessment- active labor, ruptured membranes, NRFHTs, etc
Plan: Admit and plan per resident
Review the "routine labor orders" to become familiar with them.
Labor Patients
§ Check patients every 2 hours when in labor; if not in labor yet, needs a note q 2 hours to document fetal heart tracing, contraction pattern and vitals
§ Check patients if change in FHT- decelerations, variables
§ Check patients if she is feeling rectal pressure or large amounts of bloody show (or if the nurse asks you to)
§ Effacement refers to the length of the cervical canal; 100% effaced means the lower uterine segment is the same thickness as the cervix
§ Station is where the presenting part is in the vagina/pelvis. "0" station is when the bony presenting part is at the level of the ischial spines and + or - refers to distal or proximal to the ischial spines
§ Position is which direction the occiput is pointing. LOA- left occiput anterior is most common, but may be occiput posterior, or occiput transverse. Difficult to determine at less than 4 cm dilation.
§ Check your exam with the plastic dilation board at the nurse's station.
§ Epidurals, IV pain meds, pudendal blocks are all acceptable pain control options for patients
§ Epidurals usually after labor well-established but may be sooner if needed
§ IV meds q 1-2 hr until close to time to delivery (have narcan available for baby if too close to delivery and narcotics given)
§ Pudendals usually just for pushing (rarely done here)
Labor Note
S: comfortable, unconfortable, etc. Preeclampsia symptoms
O: vitals
FHTs- baseline, presence of accelerations/decelerations, variability
Toco (dynomometer)- frequency and strength of contractions
SVE- dilation /effacement/station/ position
Time of AROM/SROM and color of amniotic fluid; placement of FSE or IUPC should be noted
A: progressing, not progressing, etc
P: expect SVD, proceed to C-section, start pitocin, etc
Delivery
q Attended by student, intern, upper level, attending and nursery (NICU and chief PRN).
q A resident should push with the patient and give encouragement
q The intern is responsible for delivery, assisted by the upper level, unless it is premature and then the intern will assist the upper level. The student usually gets to deliver the placenta, until the intern has adequate deliveries, then the intern is responsible for teaching the student how to do a delivery.
q Try to be as neat as possible and observe sterile technique
q Nurses appreciate efforts to help them clean up afterwards
Delivery Note - you will often find that an attending has written a comprehensive note on a patient but it's always a good idea for the delivering resident (or student) to also write a note to show continuity of care
WE have preprinted delivery notes. If you are to use a blank progress note, you may write the following:
SVD/VAVD/FAVD of a LFI/LMI at --- weeks from --- position (OA, OT, OP) (If an operative vaginal delivery was done- VAVD/FAVD- then a reason must be given)
AGPAR/weight/EBL
Resident, attending
Anesthesia/analgesia- epidural, spinal, local (perineal block, pudendal block), IV, none
Perineum- perineal laceraton, MLE, labial laceration and what was used to repair
Placenta- spontaneous vs manual extraction, intact, 3/2 vessels
Complications- shoulder dystocia, 4 th degree laceration, etc
Disposition- mom and baby doing well in room, baby to NICU, etc
NICU/neonatology
Called for the following deliveries: