Family Medicine Residency Program

Curriculum for

FAMILY MEDICINE OBSTRETICS ROTATION

Introduction

Family practice obstretrics rotation is an in-patient service rotation for the first year and second year residents. It consists of two blocks in the first year and one block in the second year. For continuity experience, each resident also provides prenatal care and must deliver at least 10 pregnant women in the Family Practice Center during the three years of residency. Through these combined experiences, residents are expected to complete at least 40 deliveries, and become competent with full spectrum of perinatal care. The resident will work with different Board certified Obstetric-Gynecology and Family-Medicine Attendings, on the labor and delivery floor and the Clinics at San Joaquin General hospital during their obstetrics rotation. The obstretrics rotation includes an OB call every third or fourth day combined with outpatient prenatal clinics. Please see the attached generic Obstretrics rotation template for further details.

Goals

1. To obtain a working knowledge of prenatal care milestones and to deliver prenatal care effectively.
2. To become Competent with vaginal delivery and repair of vaginal lacerations
3. To become competent as a first assistant in routine and emergency C-sections.
4. To teach and supervise the first year resident and/or a medical student if present.

Learning Objectives:

1. Surgical / Psychomotor
    
   1. Demonstrate the ability to perform a complete ante partum history and physical examination
   2. Demonstrate the ability to conduct a normal vaginal delivery.
   3. Demonstrate the ability to appropriately perform and interpret various ante partum fetal assessment
   4. Demonstrate an understanding of obstetric Analgesia by listing their indications, side effects and complications.
   5. Demonstrates the ability to appropriately and safely position patients for operative procedures.
   6. Demonstrates appropriate knot tying techniques and ability to identify the name and function of different common obstetric surgical instruments.
   7. Demonstrate the ability to repair first and second-degree lacerations of the perineum.
   8. Demonstrate the ability to identify third and fourth degree lacerations
   9. Be familiar with the repair of third and fourth degree perineal lacerations
   10. Demonstrate the ability to apply internal fetal and uterine monitors and an understanding of the indications, limitations and complications of the use of these devices.
   11. Demonstrate the ability to perform vacuum assisted deliveries.
   12. Be Familiar with manual extraction of placenta
   13. Demonstrate the ability to first assist a cesarean delivery.
   14. Demonstrate the ability to assess and manage a respiratory distressed and unstable neonate.
        
2. Medical/Cognitive
    
   1. Provide routine prenatal care including routine screening, early pregnancy assessment, indications for ultrasound, antenatal testing, and assessment for patients at risk of preterm labor and fetal anomalies
   2. Demonstrate the ability to appropriately manage normal labor at term with recognition of the onset of active labor, normal labor progress and abnormalities in labor progress.
   3. Manage routine postpartum care.
   4. Perform routine postoperative care for patients after cesarean section.
   5. Manage labor induction with cervical ripening under supervision.
   6. Manage postpartum hemorrhage with supervision including surgical interventions appropriate with the level of training of the resident.
   7. Demonstrate a basic understanding of intrapartum fetal assessment; both normal and abnormal fetal heart rate tracings.
   8. Understand and discuss the indications for operative vaginal and abdominal delivery.
   9. Perform appropriate preoperative work-up and counseling that lead to C-sections, and understand informed consent process for surgical procedures performed on the services.
   10. Demonstrate a basic understanding of systems based issues such as obstetric insurance coverage, public assistance and prenatal care for the uninsured.
   11. Maintain appropriate documentation of delivery notes, operative notes, postoperative and discharge orders, appropriate follow-up instructions with patients and referral services in the community.
   12. Demonstrate the appropriate evaluation and management of common postoperative complications including but not limited to bleeding, infection, wound problems, exacerbation of chronic conditions (cardiac events, chronic hypertension, diabetes, asthma, and deep venous thrombosis).
   13. Demonstrate appropriate professionalism with peers, supervising Faculty, and consultants such as obstetrician, anesthesiologist, neonatologist and other members of health care team.
   14. Demonstrate appropriate HIPPA compliance.

Implementation:

Duties/Responsibilities of the resident on the obstetrical service: 

1. Perform an initial evaluation of patients presenting to Labor and Delivery and present these patients to the attending physician or the mid-wife (CNMW), including completing the history and physical sheet.
2. A second experienced person (RN, CNMW or attending) should confirm the pelvic exam findings of the resident until the CNMW and/or attending agree that the resident’s findings are reliable.
3. All labor and delivery patients and their electronic fetal monitoring strips must be formally presented to the CNMW or to the attending on call.
4. All patients presenting prior to 36 weeks to labor and delivery floor should be presented to the attending on call. No pelvic exam to be done unless the attending authorizes it.
5. Write progress notes approximately every two hours when the patient is having active labor. The resident should discuss the patient’s progress with the CNMW or attending and document appropriately in the medical record.
6. Attend patient in active labor and perform delivery with supervision. The resident should document the presence of the CNMW or attending by requesting their signature on the delivery note. Residents may sign the delivery note, birth certificate, and other applicable forms.
7. Participate in obstetric consultation as assigned by the Attending.
8. Make rounds on postpartum patients and present patients to the attending at morning rounds.
9. The resident will keep a log of all obstetric procedures that he/she has been involved in and log it into the computer within two weeks.
10. The log will reflect the degree of involvement of the resident (Observe, assist, or perform under supervision). In addition, it will contain the evaluation of the competency of the resident in the specific procedure by the Attending.
11. The resident will keep a log of all obstetric patients (medical record number, age, and diagnosis. The log will be kept in the resident’s permanent folder in the residency office (Portfolio). The log will be reviewed timely in the scheduled quarterly resident review.
12. Assist with chart review and patient visits in the High-Risk OB Clinic as assigned.
13. Attend Monday perinatal educational conferences.
14. Attend other OB conferences as listed.
15. Take call as assigned.
16. Present the admissions and attend the morning report conference before signing off.

OB Call 

Ob call is overnight and is usually very busy. Residents are expected to be present for all activities throughout the 24 hours call. The resident should arrive by 07:00 AM the day of call and check in with the off-going Attending, Midwife, or Resident. Incoming residents are expected to assist with post-partum rounds. Post partum patients may be located on FMC, in Towers, in Pediatrics, or elsewhere. Board sign-out is at 08:00AM in the conference room by the nursing station. It usually lasts 10-15 minutes. Residents need to attend sign-out at the beginning and the end of their call. Please be on time. As the rotation progresses, residents may be asked to present some patients. Call ends at 07:00AM the following day. Residents are expected to finish post-partum rounds and attend board sign-out before leaving. 

The outgoing resident cannot admit or see any new patients between 07:00 AM and 08:00 AM.  The outgoing attending or midwife or the incoming team has to take care of any new patients that arrive between 07:00 AM and 08:00 AM.  
Implementation of Continuity Obstetric Patients 

1. Residents are required and must follow at least 10 continuity prenatal patients through delivery as required by the RRC. (Due to various rotation/call/vacation/conference/scheduling constraints or to occasional precipitous deliveries, residents may not always be available for their continuity deliveries. This means that residents may actually need to follow more than 10 patients in order to fulfill the 10 delivery requirement, as delivery is required for the patient to be counted towards the ten required.) 
    
2. Residents may begin to follow prenatal patients after they have completed two months as interns on the Obstetrics rotation. 
    
3. All Prenatal patients seen in FM clinic should be presented to the preceptor. (No patient should leave the clinic until the preceptor signs off on the clinic visit note). 
    
4. In order to provide continuity of prenatal care, residents are expected to be available by pager for their prenatal patients who are at or beyond 36 weeks gestation. 

Evaluation

The teaching Attending will provide ongoing and regular feedback throughout the rotation to advise the resident of the status of his/her performance and initiate options for improvement where and when necessary. There will be a scheduled, specific focused meeting with the Attending and the resident at the end of the rotation to discuss the overall performance of the resident and his/her strengths and weaknesses. At the end of the rotation, the teaching attending will complete a formal evaluation form, which is an outcome-based measurement of the following:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
    
2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
    
3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
    
4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals.
    
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
    
6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Methods of evaluation

The On-call Obstetric Attending as well as FM/ OB Faculty will evaluate the resident

1. Formative evaluation:
    
   1. The obstetric attending will provide ongoing and regular feedback throughout rotation to advise the resident of the status of his/her supervisory performance and provide suggestion for improvement, where and when necessary (Oral exam, Specific patient)
       
   2. FM/OB faculty will review all residents’ clinic charts for OB Continuity patients bimonthly. (Chart review)
       
2. Summative evaluation:
    
   1. The Obstetric Attending will complete a formal evaluation form at the end of the Rotation. (Global rating)
       
   2. The resident’s Faculty advisor will evaluate the results of the resident annual in-training exam in Obstetric category. The advisor will then discuss different options for improvement with the resident if necessary.
       
   3. The resident’s patient log and procedure log will be discussed among the Family medicine Faculty at the quarterly resident review.
       
3. Each resident will evaluate the teaching/supervising Attending at the end of the rotation. He/she will also evaluate the curriculum of the rotation itself. The Attending evaluations are done anonymously. (Global rating)

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