OBSTETRICS
Williamsport Family Medicine Residency
Goals:
1. On completion of the residency, the resident will be able to demonstrate competency in the care of obstetrical patients to the level expected of a new family physician. This will include specific skills, attitudes, and knowledge as outlined below, within the framework of the ACGME Competencies.
2. Residents are expected to achieve competency deemed by the FMRC faculty via direct observation during the first year to assure sufficient experience to assume a supervisory role as a second year resident.
4. During their residency training, the resident will provide longitudinal obstetrical care for a minimum of 5 patients, consisting of antenatal, natal, and postnatal care according to Hospital and Residency standards. (See Longitudinal Family Medicine Obstetrics)
6. Upon completion of the residency, the resident may be able to obtain hospital privileges in Obstetrics at outside institutions on an individualized basis.
Faculty Contacts
1. The majority of the supervision during the obstetrical rotation is provided by our Family Medicine Residency faculty. This includes the prenatal care provided to our patients in our family physician run Prenatal Center and the actual delivery of these patients.
2. Residents also have the opportunity to deliver patients with OB/Gyns, certified nurse midwives, and other local community FM physicians.
3. During c-sections, residents are responsible for being first assistant and are under the direct supervision of the obstetrical attending.
Obstetrical Preceptors: Susquehanna Health OB/Gyn physicians and midwives
Williamsport OB/Gyn physicians and midwives
FMRC Faculty
Faculty Coordinator: Janice Schifferli, DO
Resident Expectations
1. First Year Resident
a. The 1st year resident will provide patient care under the supervision of the 2nd year resident and Family Medicine faculty on the OB Service.
b. The 1st year resident’s primary responsibility is the patients in Labor and Delivery (L&D). Deliveries will take precedence over everything except Family Medicine Office hours.
c. The 1st year resident on OB will meet at 6:30 am on weekdays for signout from the Night Float residents.
d. Prenatal Center (PNC)
1. In the PNC, the first year resident will evaluate the patients and decide on appropriate treatment and management plans. Every patient will be precepted in the moment with the FMRC faculty member. That faculty member may choose to re-examine the patient at their discretion.
2. They are expected to evaluate, precept, and educate the average prenatal center patient in about 30 minutes. They should be seeing about 4-5 patients per half day in the first half of the academic year. In the second half of the academic year they should be able to see 6-7 patients per half day.
3. PNC notes are expected to be completed 24 hours after the encounter has taken place. Prompt completion of notes is imperative to safe patient care in OB.
4. The 1st year resident will, under the supervision of the 2nd year resident and/or FMRC faculty, handle the majority of phone calls on Prenatal Center patients.
5. The Prenatal Protocols should be reference frequently during patient care.
6. Residents should share the responsibility of any paperwork / forms that need to be filled out for the PNC patients.
e. Labor & Delivery (L&D)
1. Prior to morning report, the resident is expected to round on any PNC post-partum patients or SHOB deliveries that they were involved with. If the volume of patients is excessive, the second year resident is expected to assist.
2. If there is a patient on L & D that needs to be evaluated, the second year resident can help prioritize which patients to see first and, or split the patient load accordingly.
3. NSTs should be reviewed daily with supervision of the second year resident / FMRC faculty until the first year becomes confident in their ability to read NSTs.
4. During the first week of their first OB rotation, the 1st year resident and 2nd year resident will discuss how to interpret fetal monitoring with the attending physician.
5. The resident is responsible for logging each encounter, delivery, C-section assist, ER evaluation of patients in New Innovations on an ongoing and timely basis.
6. Admission to L&D: Upon arrival of all patients to L&D, the nursing staff will call the 1st year resident.
a. Resident FMRC private patients: If the patient is a private OB patient from the FMRC, the resident will speak with the resident is assigned to that patient in the FMRC office and see how involved they can be in that patient’s care based on their rotation responsibilities that day. The OB team can assist this resident in caring for the patient periodically throughout the day. If that resident cannot attend to their private patient because of work hour restrictions, then it is the responsibility of the OB team to assume care.
b. PNC patients: The resident will evaluate the patient under the supervision of the 2nd year resident on the OB rotation. The OB team will discuss the case and formulate a differential diagnosis and management plan. The 1st year resident will discuss the case with the FMRC faculty attending and finalize the plan of care. The 1st year resident will manage the labor under the close supervision of the 2nd year resident and FMRC faculty. Included in the management of labor are such things as emotional support, evaluation of fetal monitoring, assessment of pain tolerance, coaching, and assessing the progression of labor with appropriately timed vaginal exams. If there are patients in the early stages of a normal labor, the resident will be expected to attend Prenatal Center, Conferences, etc. It is appropriate for the resident to be on L&D if there is a high risk case or an imminent delivery. The 2nd year resident will handle other duties (i.e. Prenatal Center, phone calls) if the 1st year is needed in L&D. The attending will supervise the 1st year in this incidence. The 1st year resident will keep the faculty and 2nd year resident informed of any deviations from a normal labor pattern and also when delivery is imminent. The 1st year resident will deliver the patient under the supervision of the faculty (and 2nd year resident should assist, if available).
d. “Ward” patients (patient who presents to L&D without a provider that has Obstetrical Privileges in SH or has had no prenatal care): The resident will be called by the nurse to evaluate the patient under supervision of the 2nd year in L&D. The resident will call the Ward OB attending to discuss the management of this patient, not the FMRC faculty. The 1st year resident will deliver the patient under supervision of the 2nd year resident and the Ward OB attending. If the residents are in the PNC or not available because of direct imminent patient responsibilities, it is appropriate to call and ask the midwife of the assigned “ward attending” that day for their assistance in managing this patient.
f. Resident Involvement with C-sections
1. The 1st year resident will dictate admission H&Ps on all patients having emergent C-sections. On weekends, this becomes the duty of the resident on call for OB. For elective, scheduled C-sections it is the 1st year resident’s responsibility to dictate an H&P one week prior to the C-section date. It is expected either the 1st or 2nd year resident will assist during a C-section for a Prenatal Center patient (either scheduled or emergent).
2. It is expected that all Prenatal Center patients who have C-sections will be rounded on daily during their post-partum stay.
3. An OB resident should be available to attend an emergency C-section (even if it is a SHOB pt) if there is no first assistant present. Residents are not able to attend scheduled C-sections for patients other than Prenatal Center or a resident’s “private” if it should occur Monday am, Tuesday am, Wednesday pm, and during noonday conference. Residents may not be available if other duties interfere (i.e. codes, critically ill patients needing attention, etc., or in the case of illness etc.).
g. Rounds
1. The 1st year resident will make daily weekday rounds with the 2nd year resident and attending.
2. The 2nd year resident will coordinate the time and place for starting rounds with the attending and 1st year resident.
3. Weekend Rounds: There will be a resident that is on call for the weekend that will be assigned by the chief resident to perform OB rounds and subsequently present to the corresponding attending.
h. Sign Out and Off Service
1. The 1st year resident will sign out patients all patients to the 1st and second year residents on OB call/Night Float. This sign out is expected to occur at approximately 5:00PM. If there is an emergency situation or imminent delivery in which the resident is involved, he/she is expected to continue management of the situation until it is stabilized or resolved.
2. On the last day of a rotation the 1st year resident will discuss cases with the 1st year resident scheduled to start the rotation next.
i. Longitudinal OB Responsibilities: (Please refer to the Longitudinal Family Medicine Obstetrics)
2. Second Year Resident
a. The 2nd year resident will supervise patient care provided by the 1st year resident on the OB service. Additionally, the patients will also be supervised by the FMRC attending. (please read the 1t year duties above, as it is not uncommon that the second year resident has to assume these duties of the first year resident is not available / in the FMRC office)
b. The 2nd year resident on OB will meet at 6:30 am on weekdays for sign out from the Night Float residents.
c. Clinical Duties
1. The resident will attend Prenatal Center promptly at 8:00 am Monday and Tuesday, and 1:30 on Wednesday. The resident will examine and evaluate patients. He/she will discuss all high risk cases with the OB attending, or any other cases that they may have questions on.
2. Any Family Medicine Office patient who requires admission for a GYN problem will be admitted to the Family Medicine OB/GYN Service. The 2nd year resident on OB/GYN Service will have primary responsibility for the care of GYN patients on this service in conjunction with the Family Medicine attending.
d. Labor & Delivery (L&D): The 2nd year resident will attend and supervise the management of all Prenatal Center patients (except when scheduled in the Family Medicine Office). If there is a Prenatal Center delivery during Prenatal Center hours or STD Clinic hours, the 2nd year resident will remain seeing patients while the 1st year resident manages the patient in labor under the supervision of the attending. The 2nd year resident will attend and supervise the delivery of “Ward OB” patients (patients who present to L&D without prenatal care) unless in Prenatal Center, Family Medicine Office, or STD Clinic. The attending for these patients is the “Ward” OB attending on call, and should be present at the delivery.
e. Resident Involvement with C-sections
1. The 1st year resident will dictate Admission H&Ps on prenatal patients having emergent C-sections. On weekends, this becomes the duty of the resident on call for OB. For elective, scheduled C-sections it is the 1st year resident’s responsibility to dictate an H&P one week prior to the C-section date.
2. It is expected either the 1st or 2nd year resident will assist during a C-section for a Prenatal Center patient (either scheduled or emergent).
3. It is expected that Prenatal Center patients who have C-sections (either elective or emergent) will be seen daily by the resident while that patient is post-partum.
4. An OB resident will be available to attend an emergency C-section if there is no first assistant present.
f. Non-Stress Test (NST)
1. The 2nd year resident on OB will review and interpret all NST’s performed on Prenatal Center patients.
2. The nursing staff will page the 2nd year resident when an NST is completed. The 1st year resident under supervision of the 2nd year resident is expected to read the NST at that time. If he/she is unable to do so because of an emergency, delivery, or Family Medicine Office hours, the resident will read the NST as soon as the other duty is completed. All NST’s must be read by the end of the day.
3. Private Patient NST: Typically the nursing staff will call the resident on OB to handle this, however if the strip is non-reactive and further management is needed the resident on OB should then call the resident that is assigned to that patient to guide the management of that case based on availability.
g. On Wednesday mornings when the 1st year resident is in the Family Medicine Office, the 2nd year resident will assume all duties and responsibilities of the 1st year resident.
h. OB Morning Report Wednesday mornings: The 2nd year resident will present a case and lead the discussion on Wednesday mornings.
i. Rounds
1. The 2nd year resident will make daily weekday rounds with the 1st year resident and attending.
2. The 2nd year resident will coordinate the time and place for starting rounds with the attending and 1st year resident.
3. Weekend Rounds: There will be a resident that is on call for the weekend that will be assigned by the chief resident to perform OB rounds and subsequently present to the corresponding attending.
j. Sign Out and Off Service
1. The 1st year resident will sign out patients (under the supervision of the second year) to the 1st and 2nd year residents on OB call/Night Float. This sign out is expected to occur at approximately 5:00PM. If there is an emergency situation or imminent delivery in which the resident is involved, he/she is expected to continue management of the situation until it is stabilized or resolved.