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Maternity Care

Dr. Millard with twins
she delivered.

Overview

Our goal is not to graduate "mini-obstetricians", but to produce family physicians skilled at appropriate labor management and knowing WHEN to intervene.  All residents receive a basic training in obstetrics.  Interested residents take an additional elective in maternity care.

Our residents staff the Pregnancy Care Center (Healthy Beginnings).  With back up from community obstetricians and faculty family physicians, they provide prenatal and postpartum care, follow the patient's  labor and deliver them.  The residents assist at C-sections and tubal ligations.  Last year the Pregnancy Care Center had over 300 deliveries.

Residents also care for "private" patients in the AFP office.  Supervised by family practice faculty, the resident cares for the same patient and does the delivery.  

As an important part of our maternity care curriculum, the residents take the ALSO course (Advanced Life Support Obstetrics) offered by our faculty.

Family Centered Maternity Care Conferences
Family Practice faculty meet with residents on obstetrics to review material and discuss a family practice approach to maternity care.

Call
Two residents alternate days covering Labor and Delivery during the day.  At night the on-call intern covers Pregnancy Care Center deliveries and helps the Senior on-call with medicine.  Alternate days are spent in the Pregnancy Care Center and at the AFP office.  The Maternity Care residents take turns rounding on weekend mornings.

Other Teaching Resources

We highly recommend the annual Family Centered Maternity Care Conference sponsored by the AAFP in July every year.  See the AAFP web site.

Altoona Family Physicians
Obstetrics

Competency-based Goals and Objectives

 Resident Year:                        PGY1, PGY2 and PGY3

 AFP Faculty Contact:            Laura Siems, MD
                                                Terry Ruhl, MD            

 Rotation description and general goals: 

 Obstetrics is frequently the entry point for new families into the medical care system, as well as the point at which a family doctor is most able to support or alter a living pattern about to repeat in another generation.  More significantly, the dynamics of a family change with childbirth, creating challenges that are best handled through the family physician’s awareness of different family members and family situations. 

 The obstetrics rotation provides the resident with the knowledge and experience needed to deliver family centered maternity care in a multi-specialty environment.  Residents learn how to provide appropriate preconception counseling, recognizing patients at risk for obstetrical and associated medical complications.  Residents become comfortable with routine prenatal care, intrapartum assessment, non-operative vaginal deliveries, assistance with operative vaginal deliveries, and immediate newborn care and resuscitation, as well as post-partum management. 

The residents spend two months on the obstetrics rotation in their PGY1 year and one month each in the PGY2 and PGY3 years.  Elective time in the PGY3 year may also be used to further a resident’s experience in obstetrics, either at the Altoona Hospital or at an outside institution.  The residents at Altoona Family Physicians spend a total of four required months on the obstetrics service during their residency with additional elective time if they choose. 

 The Altoona Family Physicians experience in obstetrics includes both inpatient obstetrics as well as outpatient prenatal and postpartum care at the Pregnancy Care Center.  After completing their first month of obstetrics, residents will be assigned their own continuity OB patients from their assigned primary care center (AFP or WBG).  A minimum of 10 continuity patients will be assigned to each resident in their three years of residency.  The bulk of the obstetrics experience will be with patients from the Pregnancy Care Center and patents of attending obstetricians at the Altoona Hospital. 

DUTIES OF THE INTERN/RESIDENT ON THE OBSTETRICAL ROTATION

The Intern/First Year and Senior Resident on OB will alternate coverage of 1) inpatient obstetrics and nursery and 2) outpatient obstetrics and AFP office. They will alternate weekend coverage of rounds and nursery.

Inpatient Duties

The OB resident will staff the Labor and Delivery Unit from 7:00 am to 9:00 pm, Monday-Friday, going to other areas of the hospital only for brief periods for in-hospital meals or conferences, when no one is in active labor. A call room on the labor floor has been provided. If there is no activity on the floor at 8:00 p.m., and the intern is available and willing to receive sign out, the OB resident can notify the desk and the operator and leave one hour early.

The OB resident will receive sign out from the night intern at 7:00 am on Tower 9.

The OB resident will answer after-hours phone calls from all Pregnancy Care patients and any calls referred from the nursing staff. Calls will be documented on the call slip and faxed to PCC the next morning after discussion with the team.  If the PCC does not receive any slips, they will page. 

The OB resident will evaluate all Pregnancy Care Center, BMOG, Littlejohn and O’Brien patients, on arrival to the unit immediately following evaluation by the nurse. The resident will immediately write a note and call the attending to discuss the plan for that patient.

The OB resident will be available to evaluate any patient on admission to the unit at the request of an attending or the nursing staff. The resident will immediately write a note and call the attending to discuss the plan for that patient.

The OB resident will make regular evaluations of Pregnancy Care Center, and admitted BMOG, Littlejohn and O’Brien patients, write frequent notes and actively manage their labor and delivery under the supervision of the attending.

The OB resident, at the permission of an attending, will be available to do regular evaluations of any patient and actively manage their labor and delivery with regular communication with the attending.

The OB resident will keep track of all patients on the floor, even if not actively involved in their care.

The OB resident will call the appropriate attending

·         any time an initial evaluation is done,

·         before discharging a patient,

·         any time there is any concern (by resident or nursing staff) with a patient or a monitor strip,

·         when a patient's labor is not progressing appropriately,

·         when ordering labs or medications (if not previously discussed)

·         at a regular basis (as discussed with the attending at the initial contact), and

·         when a patient is nearing delivery so as to allow the attending to be present.

An OB resident will follow, visit and write a note on all postpartum patients that residents have delivered.

The OB resident will attend all deliveries, either to assist the obstetrical provider or to attend to and resuscitate the baby if necessary.

The OB resident will perform an initial evaluation on every child born on the unit and notify the child's attending physician of any concerns. The resident will perform initial evaluations on any children born overnight that the intern did not do.  The resident will notify the AFP OB attending on call for the day of all overnight AFP nursery admissions.

The OB resident will be available to perform an evaluation on any child in the nursery at the request of nursing, and then communicate immediately with the child's attending. There will be no delay in notifying of the attending in the case of a potentially ill child.

The OB resident, after hours, will regularly evaluate any sick children in the nursery and communicate as appropriate with the attending physician.

The OB resident will, when available, read and provide appropriate documentation on all NST's performed on the unit (unless the attending is present) and communicate the results with the attending.

The OB resident will assist with Cesarean sections and tubal ligations when not imminently needed for a delivery.  If two deliveries are occurring simultaneously, the resident will choose the vaginal delivery and clearly communicate to the attending what duties cannot be covered.

The OB resident will be available to perform obstetrical procedures such as internal monitor placement on any patients at the request of and under the authority of the attending.

The OB resident will be available to evaluate any postpartum patients at the request of the attending or nursing staff. The resident will communicate the findings and recommendations to the attending.

The OB resident will document carefully any contact with a patient or communication with an attending.

The OB resident may assist on GYN surgeries if the activity on the labor unit allows.

The Pediatric resident when available will make nursery rounds with AFP,  BMAP and DMAYY physicians.

The OB resident, when available, will perform circumcisions and any other procedures under the supervision of the attending.  The senior Pediatrics resident may also do this.

The OB resident on rounds for the weekend will start at 7:30 am on Saturday and Sunday with sign out from the intern on call. The OB resident will complete rounds and write notes on all laboring patients, postpartum patients that were delivered by residents, any sick nursery patients or night nursery admissions lacking a newborn physical as well as all AFP nursery patients. The resident will participate in any deliveries and procedures in the morning. The resident will stay until all rounding activities are complete. If all these responsibilities are complete, the resident may leave any time after 11:00 am, after signing out completely to the intern on call. If residents are working on a morning after a 24 hour call, they may not admit new patients.

The OB resident on rounds for holidays will start at 7:30 a.m. with sign out from the intern on call.  The OB resident will then complete rounds and write notes on all laboring patients, postpartum patients that were delivered by residents, any sick nursery patients or night nursery admissions lacking a newborn physical as well as all AFP nursery patients. The resident will stay until all rounding activities are complete.  If all these responsibilities are fulfilled, the resident may leave after signing out completely to the intern on call.  The OB resident may not delegate any rounding activities to the intern on call.

The OB resident will complete all documentation forms for the rotation, including the Competency-Based Curriculum Requirements for Maternity Care.

Outpatient Duties

The OB resident will attend all scheduled sessions of the Pregnancy Care Center, providing care under the supervision of the attending physician. The resident is expected to be on time for PCC office and is allowed to go home after the PCC office hours are completed.

The OB resident will call or fax the information on any complicated patients to the inpatient OB resident.

The resident will be assigned AFP office hours on this rotation.

The resident is expected to complete AFP patient calls and charting duties even if not assigned to AFP office hours.

 OB DUTIES OF THE NIGHT FLOAT INTERN ON CALL

The Intern/First Year on call will cover a broad range of duties in cooperation with the Senior Night Float and under the supervision of Faculty and Attendings.

Obstrical Duties:

The FM intern on call will staff the Labor and Delivery Unit from 9:00 pm to 7:00 am. An appropriate call room on the labor floor will be provided.  

The FM intern on call will receive complete sign out on every patient from the OB resident at 9:00 pm on Tower 9. The FM intern will immediately see any patients in labor or with issues. The outgoing resident may personally introduce the incoming resident to the patient to improve continuity.

The FM Intern on call will answer after-hours phone calls from all Pregnancy Care patients and any calls referred from the nursing staff. Calls will be documented on the call slip and faxed to PCC the next morning after discussion with the OB resident.

The FM intern on call will evaluate all Pregnancy Care Center patients.  BMOG, Littlejohn and O’Brien patients will be evaluated by the resident if they require admission to the labor and delivery unit.  The resident will immediately write a note and call the attending to discuss the plan for that patient.

The FM intern on call will be available to help with private OB patients at the request of the attending.

The FM intern on call will make regular evaluations of Pregnancy Care patients, write frequent notes and actively manage their labor and delivery under the supervision of the attending.

The FM intern on call will call the appropriate attending

·         any time an initial evaluation is done,

·         before discharging a patient,

·         any time there is any concern (by resident or nursing staff) with a patient or a monitor strip,

·         when a patient's labor is not progressing appropriately,

·         when ordering labs or medications (if not previously discussed)

·         at a regular basis (as discussed with the attending at the initial contact), and

·         when a patient is nearing delivery so as to allow the attending to be present.

The FM intern on call will attend deliveries to resuscitate the baby if requested.

The FM intern on call will be available to perform an evaluation on any child in the nursery at the request of nursing, then communicate immediately with the child's attending. This should not be allowed to delay the notification of the attending in the case of a potentially ill child.

The FM intern on call, after hours, will regularly evaluate any sick children in the nursery and communicate as appropriate with the attending physician.

The FM intern on call will be available to perform obstetrical procedures such as internal monitor placement on any patients at the request of the attending.

The FM intern on call will be available to evaluate any postpartum patients at the request of the attending or nursing staff. The resident will communicate the findings and recommendations to the attending.

The FM intern on call will document carefully any contact with a patient or communication with an attending.

The FM intern on call is not to do rounds on the weekend, but may take over other responsibilities at 10:30 so the OB resident can complete rounds.

The FM intern on call will completely sign out all patients to the OB resident at 7:00 am on Tower 9. The intern will attend morning report if other duties allow.

The FM intern on call is not allowed to admit patients the next day, but can only finish other duties due to work hours rules..

The FM intern on call will go home after lunch conference the day after being on call. If in an emergency some activity could interfere with adherence to the Work Hours Rules, the intern will discuss it with the Program Director or designee. 

 Teaching Methods:   The obstetrics rotation offers many opportunities for learning, including:

Supervision: 

 Resident Evaluation:

 Each resident on the obstetrics rotation is evaluated using a competency-based evaluation tool at the end of the rotation.  These evaluations are reviewed by the family medicine faculty quarterly and reviewed with the resident at their quarterly advisor meeting.  If immediate feedback is necessary, the resident may be given on the spot feedback by the OB attending or faculty, the resident’s faculty advisor, or the program director.  Specific evaluations include:

    SAMPLE SCHEDULE:  PGY1

SAMPLE SCHEDULE:  PGY2

SAMPLE SCHEDULE:  PGY3 

 AFP – Altoona Family Physicians, a Dept of Altoona Hospital

WBG – Williamsburg Family Practice, a Dept of Altoona Hospital

AH – Altoona Hospital; Tower 9

PCC – Pregnancy Care Center – a Dept of Altoona Hospital

FCMC – Family Centered Maternity Care
 

 PGY2 and PGY3:

 PGY2 and PGY3:

  PGY2 and PGY3:

o       Work efficiently in the context of an obstetrical care team

o       Clearly communicate patient sign-out, both when giving and receiving sign-out

o       Notify fellow residents, via the electronic medical record, phone, face-to-face, or pager,  if their private obstetrics patients called or presented to the labor and delivery unit

o       Notify the Pregnancy Care Center of any after hours phone calls received

o       Contact the inpatient OB resident via phone, pager, or fax regarding any complicated prenatal patient or any patient instructed to present to the labor and delivery floor

o       Work efficiently with the support staff in the care of the pregnant patient

 Required Reading

 PGY1

 PF Essentials 292: Pregnancy Care

PF Essentials 291: Healthy Newborn

 PGY2 or PGY3

 FP Essentials 316:  Medical Conditions in Pregnancy

Additional Resources

ALSO course syllabus

Ratcliffe, et. al.  Family Medicine Obstetrics

Williams Obstetrics

Gabbe, et. al.  Obstetrics: Normal and Problem Pregnancies