Obstetrics

Obstetrics is a particularly strong rotation in our program, and our residents typically deliver 100 babies in the first year and a total of 200-300 babies over the three-year residency. Residents work closely with Park Nicollet obstetricians in the Family Birth Center at Methodist Hospital, where over 3,000 babies are delivered each year.  The primary duties during each 24 hour shift are:

• Evaluation and management of patients in the perinatal triage unit for preterm labor, early labor, or other medical issues in pregnancy
• Close labor management with attending obstetrician including pain control, amniotomy, and internal monitor placement.
• Primary management of delivery with attending obstetrician, including proficiency in vacuum-assisted delivery. Residents assist on C-sections, but can pursue more extensive training if C-sections will be part of future practice.
• During each month, residents take call every third day (24 hours) and have the following day off.  On the third day, residents have their continuity clinic and also spend 1/2 day in a variety of other maternity care sites, such as ultrasound, perinatology, and visits with the lactation specialists in the postpartum unit and the outpatient clinic.

Obstetrics Rotation Teaching Module

Rotational Goal
Residents will gain an understanding of maternity care, labor and delivery, and postpartum care, and of the roles of the family physician and obstetrician as partners in the care of pregnant women.

Rotational Objectives
By the end of the obstetrics rotations, residents will be able to demonstrate mastery in the provision of maternity care as follows: 

(A) Patient Care
Through patient care experience gained as part of the obstetrics rotations, when further presented with the pregnant patient in the family practice clinic or inpatient setting, residents will be able to:

• Accurately take an appropriate prenatal history to include menstrual and pregnancy history, assessment of exposures and risk factors, and presence of symptoms of active labor and any complications of pregnancy.
• Formulate and carry out appropriate management plans for patients in labor, including accurate cervical exams, evaluation of fetal monitoring and provision of analgesia.
• Perform vaginal deliveries, spontaneous, induced, and vacuum-assisted, and perform perineal repairs.
• Provide appropriate post-partum care, including culturally-appropriate patient education.
• Provide neonatal resuscitation and infant stabilization at deliveries.

(B) Medical Knowledge
At the completion of the obstetrics rotations, residents will be able to demonstrate medical knowledge of maternity care and “best practice treatment plans” suitable for the general practitioner, to include being able to:

• Describe the physiology of pregnancy, prenatal assessment and screening, and the course of normal labor
• Describe options for the management of complications of pregnancy, including:
• Prolonged labor and arrest of labor disorders
• Fetal distress: diagnosis and management
• Premature labor and premature rupture of the membranes
• Postdate pregnancy
• Intrauterine growth retardation
• Vaginal bleeding, threatened miscarriage and ectopic pregnancy
• Placenta previa and abruptio placenta
• Hypertensive disorders of pregnancy, preeclampsia, toxemia, eclampsia, HELLP syndrome, and pregnancy-induced hypertension (PIH)
• Intrauterine fetal demise
• Rh disease of the newborn, detection and management
• Anemia of pregnancy
• Diabetes in pregnancy
• Multiple gestations
• Malpresentations, shoulder dystocia and fetal macrosomia
• Chemical abuse in pregnancy
• Infections in pregnancy: viral, sexually transmitted diseases , AIDS
• Postpartum hemorrhage
• Common congenital anomalies
• List options for analgesia and sedation in labor, along with benefits and risks
• Describe indications for the use of ultrasound in pregnancy
• List methods of pregnancy dating, including ultrasound
• Describe theoretical and evidence basis for antepartum fetal assessment: NST, CST, Biophysical profile
• Describe indications and methods for induction of labor:
• List indications, risks and benefits of genetic screening and amniocentesis

(C) Practice-based Learning and Improvement
At the completion of the obstetrics rotations, and subsequently in the family practice clinic and inpatient setting, when presented with the pregnant patient, residents will be able to:

• Critically evaluate evidence basis for pregnancy-related care, and understand the differences between community standards of care, expert opinions, and evidence-based recommendations.
• Interpret and apply treatment guidelines for pregnancy management, utilizing the Cochrane data base when applicable.
• Modify patient treatment plans on an ongoing basis based on patient response to therapy.

(D) Interpersonal and Communication Skills
At the completion of the obstetrics rotations, and subsequently in the family medicine clinic and inpatient setting, when presented with the pregnant patient, residents will be able to:

• Obtain a full prenatal history using effective communication skills with pregnant patients.
• Provide appropriate patient education and anticipatory guidance to pregnant women, taking into account their personal wishes and cultural expectations
• Coordinate care with patient and other team members for prenatal, labor and delivery, and post-partum care as necessary

(E) Professionalism
During the obstetrics rotations, residents will exhibit characteristics of a professional health care provider by:

• Coordinating care of the labor and delivery patients with the attending physician, providing patient care to the best of their ability in exchange for the opportunity to learn from patients and attendings.
• Demonstrating sensitivity and responsiveness to patients’ experience of labor and childbirth and accommodating patients’ wishes for the labor experience as much as is feasible
• Substantively contributing to the learning community in the hospital associated with the obstetrics rotation, by attending and actively participating in educational and research presentations associated with the rotation. Residents will make one case presentation at the Monday OB Conference during each OB rotation.

(F) Systems-based Practice
At the completion of the obstetrics rotations residents will be able to:

• When presented with a pregnant patient, describe several ways in which the family physician and obstetrician can work together to provide optimal maternity care.
• Appropriately coordinate care with perinatology, genetic counselors, neonatologists, and obstetricians when needed for complicated pregnancies.

Schedule
Rotations are one month in duration starting on the first day of the month. Three residents rotate call every third day, each covering labor and delivery for 24-1/2 hours, on their “call” day, from 7:00 a.m. to 7:30 a.m. the following day.  (Residents not on Labor and Delivery call the first day or two of the rotation will be scheduled to see patients at Creekside Family Physicians).

Residents rotating through Methodist Hospital obstetrical services are required to have neonatal resuscitation certification. All residents receive NRP during the first two months of residency.  The morning session also includes a general orientation, a review of umbilical line placement, and a discussion with the medical director for obstetrical services

Residents on Labor and Delivery are given the opportunity to participate in neonatal resuscitation and infant stabilization at each delivery. Since residents are certified in neonatal resuscitation and some staff members are not, residents are expected to excuse themselves from delivery if the neonate needs stabilization or resuscitation. The attending physician will care for the obstetrical patient during the third stage of labor while you work to stabilize the newborn infant, including intubation and line placement if needed. The Department of Obstetrics and Gynecology and the residency program have coordinated this plan via the family practice liaison committee.

Day 1
On your arrival at 7:00 a.m. for your call day, introduce yourself to the head nurse, accept transfer from the outgoing resident, and familiarize yourself with patients’ currently on labor and delivery and with those arriving for scheduled inductions. Staff physicians transfer call at 7:30 a.m., so be familiar with patients and able to review them with the oncoming staff. Discuss your exact responsibilities with the staff physician of the day so your role and expectations are clear. In General, you are expected to perform a history & physical on all patients admitted to Labor and Delivery (L&D) and to evaluate all patients admitted for observation on L&D or on the Prenatal Evaluation and Treatment Unit (PETU). Patients are presented to the responsible physician, a management and evaluation plan established, and a time framework for ongoing unless other arrangements have been made. Interventions, changes in management, changes in clinical status, drug orders, and orders for analgesia or anesthesia should be reviewed with the attending physician prior to implementation unless an alternated arrangement with regards to patient care has been negotiated. A pre-printed H & P form is available for the straightforward admissions. Complex cases may require more written documentation than on the preprinted forms.

 All patients who present themselves on your shift (with the exception of elective inductions admitted after 6:00 a.m. of the following day) are our responsibility. See patients as soon as possible after your arrival, even though you may not be the delivering physician in some cases. We stress to patients that a benefit of Methodist Hospital is the availability of a physician on-call in house 24 hours a day.

On occasion, you may be asked to perform other duties usually by direct request from staff physicians or nurses, which may include circumcisions, evaluating patients on ward, accompanying the staff physician to the ER, or assisting at cesarean sections.

Day 2
Following transfer of active patients to the oncoming resident, round on the patients you have delivered during the preceding 24 hours. Write progress notes on each patient. In general, staff physicians give discharge instructions to the patient, so no orders need be written (unless specifically requested.) If you are on call Saturday nigh, make rounds with the “back-up” physician on Sunday morning (usually the Saturday day call person.) When rounds are done, you may leave.