OB

HOME BASE: 3200

Labor and Delivery,

3800: Postpartum floor (low-risk and high-risk),

3100: Antepartum floor (mostly high-risk, but some low risk),

Triage area on 3rd floor: where new patients are seen (some may be roomed on L&D, but still considered Triage)

TEAM: You will be on Low Risk and L&D. Low risk team is made up of 1 senior, 1 OB intern, 1 ER intern, +/- FM resident +/- med students. Typically, OB attending 1 covers low-risk postpartum and L&D and OB attending 2 covers triage.

TYPICAL DAY:

5:00am: Show up on 3800. There should be a list of patients sitting on front desk (ask secretary if not) - you can call 3800 around 9PM the night before/ask the night intern to text you/access epic at home to find out how many patients there are the next day so you can get there early enough/potentially sleep in. Usually takes about 7 min a patient but sometimes longer.

**Do not round on private attendings’ patients, FP patients, or people who delivered after midnight**

**Some patients who were "high-risk" antepartum become "low-risk" postpartum, so double check both high and low risk lists to make sure every postpartum patient is accounted for**

Divide the patients up with the OB intern +/- FM resident equally. Prepare all d/c paperwork for pts going home, which includes DC summaries (these should be started by the resident who delivered the patient), patient instructions ("after vaginal birth" or "after a cesarean"), follow-ups, DC med rec and sign all prescriptions EXCEPT for narcotic orders (these need to be signed by the attending). Do NOT put the actual order in to DC patient until after rounding with attending (you can delete DC patient order thru med rec so the prescriptions print and re-do med rec to put the actual DC order in after rounds). This way you never have to physically return to postpartum after rounds. Have your notes signed with co-signer as your attending (ask OB intern or look in MD report room to know who's coming on) and DC paperwork done before sign-out from night team at 7:15am.

7:15am: Sign out: [3rd floor conference room, near triage] attended by night and day teams, both high and low risks, including the attendings. DON'T BE LATE. Night team present all L&D patients, antepartum patients, +/- triage patients, and scheduled cases. Pay attention to all patients as you can deliver some of the high risk patients.

7:45am: Back to 3800 to round with low risk intern/senior/attending.

8:00am - 5:30pm:

L&D: Follow laboring pts. Introduce yourself to all laboring low-risk patients (you never know when you're going to be the only resident physically on the floor to catch the baby and you'd want them to know who you are). Laboring patients need to be checked every 2-3 hours or so (there's a timer on the track board that says how long it's been since last cervical exam). Drop a note every time you check someone. Discuss with senior, may need AROM/pitocin/internal monitoring/other stuff during course. Nurses are happy to double check your cervical exam after you if you want them to. Be aware of who's close to delivering and make sure you don't find yourself stuck in triage when its go time.

Triage: You should also see triage patients throughout the day. You can assign triage intern and L&D intern, but oftentimes you're covering both by yourself or triage blows up and need both interns to do both. It is a good idea to speak with the OB intern/senior after seeing a patient and before doing the vaginal exam, to know what they may want done (FFN, SROM check, cervical check, wet mount), because you don’t want to do the exam and find out they wanted FFN or SROM check and you just ruined it. Triage can be very useful: you see lots of emergent pregnancy-related issues we don’t see in our ED, but we will in the community (PIH, labor checks, clearance of baby s/p trauma etc.). Treat this like the ED - be fast, efficient, and use the OB triage template. Stop seeing triage patients at 5:30pm.

**For both L&D and Triage, update the "OB NICU communication" section under triage/admit tab in epic as you go. That is what shows up on the board for everyone else to see and it's the only way you can communicate with other residents what is going on with each patient, what still needs to be done/pending for discharge.**

Senior OB pager is 9406 (obsenior) and junior is 9407 (objunior), in case you can’t find anyone and want to know what’s going on. You can also check the MD report room near antepartum, residents/attendings like to hang out there.

Fridays: OB resident lecture 8-3 (it lasts until about 2 but you don’t see them until about 3) so you cover L&D and triage with attending +/- FM resident. Introduce yourself to ALL laboring patients who are close.

6:00pm: Day team signs out to night team. You should be there for this, especially if you have triage patients to sign out. If you do, senior might gesture for you to go home after L&D and triage sign-out so you don't have to sit through high-risk sign-out. If you don't have any patients to sign out, senior might let you go before sign-out completely.

CALL: They have a night float system, so no call. You may ask to stay late if you aren’t getting enough deliveries (not usually an issue though).

WEEKENDS: You are on for 2 weekends and 1 weekend day during the month. There will be one OB intern pre rounding with you, who is not the same OB intern from the week. Oftentimes they don't know you're coming to help out, so it's nice to let them know the day before (ask your regular OB intern to let the weekend intern know) so they don't come in at 4am to round on the entire list. Show up around the same time as weekdays. Sign-out is still at 7:15am. You are required to stay and do a full shift until sign-out to night team at the same time, 6:00pm. BUT, if the attending, senior, and OB intern all say you can go early, you can leave because weekends tend to be much lighter without scheduled cases. Obviously don't leave if OB intern needs help.

DAYS OFF: 2 full weekends off and 1 weekend day off (assuming you have the full month rotation)

PAPERWORK:

• Use templates for ALL notes (look under senior's name and steal them):
  • Postpartum progress notes: use postpartum vaginal delivery or postpartum C-section templates
  • Postpartum discharge summary: DC vaginal delivery or DC c-section templates; start this note every time you deliver someone and fill it out as much as you can (don't use the template that auto populates when you open the note)
  • L&D H&P note: use OB L&D H&P template if admitting patient
  • L&D progress note: use labor rounding note template
  • Triage note: OB triage template, write that you "discussed A/P with Dr.***" so the attending doesn't think you discharged someone without speaking to a senior
• Print out your completed notes before you go to sign-out, you won't be able to keep all your patients straight and you can't present off the computer. Your postpartum notes should include (at min):
  • ID: yo G_P_ POD#_/PPD#_ s/p NSVD/C-section delivered at _ wks
  • S: The P’s and B’s --> ask about: Pain/Peeing/pooping/eating/walking/bleeding/Breast feeding/Birth control
  • O: get vitals, Do heart, lung, abdominal, fundus (should be firm/at umbilicus), don’t do a pelvic, check LE for swelling, and focused exam for any complaints. Pre-delivery Hgb, Postpartum Hgb, Rh pos or neg, Rubella status, Tdap status
  • A: Restate ID section and Rh status, Rubella status, Tdap status
  • P: does she need lactation consult, scripts, DC plan, foley out if a C-Section, staples removed, rhogam, MMR vaccine, Tdap, social work if drugs or social problems, etc.
• To discharge a patient: D/C summary, D/C orders, and Med rec, write a script for: Motrin 600 mg PO Q6H, Colace 100 MG PO BID, Norco 5 Q6H (different attendings like to dispense different # of norco, but #60 for C/S and #20 for VD should be ok), FeSO4 325mg PO QDay if postpartum Hgb is below 9 and BID if its between 9 and 10, Micronor (OCP) 1 tab PO QDay same time, every day if pt wants.

​Common presentations:

Triage: labor check, PTL check (work-up may include FFN, wet mount, UA), SROM check (includes speculum exam to look for pooling, ferning, and nitrazine test), anyone over 15 wks GA with other complaints (dysuria, N/V, vaginal d/c, bleeding, etc), blood pressure check/Pre-ecclampsia rule out, NST/AFI. Pts in active labor or positive SROM get admitted to L&D.

**Get access to OBIX (FHT program) before starting your rotation**: call helpdesk before you start your rotation because it takes a few days to get approved. You'll want to have access so you can read your own FHT

​

Review:

• FHT, cervical exam, labor check (pre-term vs term), stages of labor, early/late/variable decels, shoulder dystocia, prolapsed cord, hemorrhage, Tx for chorioamnionitis and GBS+
• Chorioamnionitis: Ampicillin 2g IV q 6hrs, Gentamicin 1mg/kg IV q 8hrs (stop after delivery)
• GBS +: Penicillin G 5 million units IV x 1, then 2.5 million units IV q 4 hrs until delivery

Pearls:

• Give yourself some slack: OB is different than any other field you rotate through. The first few days will be a little rough, but by the end of the month, you’ll know the routine.
• Get help if you need it. Nurses are very nice and supportive.
• SROM check: Sterile speculum, NO LUBE, look for pooling of fluid in the vaginal vault, do nitrazine test (wipe fluid on paper, positive turns blue), ferning (small amount fluid on slide, let it dry, look under microscope, looks like ferns).
• Decreased FM: look at FHT for reactive strip, bedside U/S for AFI. If not reassuring, do BPP (ob residents can show you how to calculate it)
• All TOLACs (Trial of Labor After C-section) must be consented by a OB resident
• Common causes of pre-term cxns: dehydration (give PO fluids), infection (check UA, etc), doing the nasty (ask if they did it recently), full bladder.
• Code to get into room with microscope and sink to put dirty speculums is “12345” (located in hallway on the right when going to L&D)
• Patients may go home day PPD 1 or 2 after vaginal delivery, POD 2 or 3 or 4 after C/S. Ask patients if they want to go home if they are candidates for going home. Insurance covers up to PPD2 and POD4.
• Follow up is in 6 weeks for vaginal births and c-sections. C-sections also get a 2-week wound check (horizontal incision: staples out prior to d/c UNLESS the patient is obese. Vertical incision: leave them in).
• D/C Instructions: Pelvic rest for 6 wks, no driving or heavy lifting for 2 weeks, call MD for fever over 100.4, increased abd pain or vaginal bleeding (> 3 pads/hr), difficulty voiding, red painful swollen breasts.
• Contraception: offer micronor mini pill (take same time every day, switch to regular pill when no longer breast feeding, give rx for 3 packs). Or they can get Depo-provera shot (give 150 mg IM before d/c, needs shot q3mos). Both ok for breast feeding. Some may want IUD, 6-8wks later.
• Give FeSO4 325 PO qday (if Hgb <10), or BID (if Hgb < 9).
• Give PNV (disp 90 with 5 refills) if breast feeding.
• Give everyone Colace 100mg PO BID prn constipation
• Give everyone Ibuprofen 600mg PO q6hrs prn pain
• For C-section patients, Norco 5mg PO q6hrs prn pain (# depends on attending, but up to #60); vaginal delivery patients can also get Norco, if they think they need it. If they do, only give 15-30.
• ACGME requires 10 deliveries for us, LLUMC ER program would like 15.
• Please, whatever you do, don’t drop the baby!!
• Be nice to the nurses - most have been around for a long time, and can really be helpful if you have questions.
• This is a good rotation to take vacation on if you have the 4 week rotation.

If you’re only on the two week rotation, make sure that your seniors know, so they can help you get enough deliveries.

​Abbreviations:

• SVE: sterile vaginal exam
• EGA: estimated gestational age
• NSVD: normal spontaneous vaginal delivery
• VAC: vacuum assisted delivery
• CS: (or “section”) c-section/cesarean section
• rCS: repeat C-section
• NRFS: non-reassuring fetal status
• NRFT: non-reassuring fetal tracing
• FTP: failure to progress
• VBAC: vaginal birth after C-section
• TOLAC: trial of labor after C-section
• OA: occiput anterior (most babies)
• OP: occiput posterior - harder to deliver, there are as many combos as this as possible.
• SROM: spontaneous rupture of membranes
• PROM: premature rupture of membranes (SROM before labor)
• PPROM: preterm premature rupture of membranes (SROM before labor and before 37wks)
• AROM: artificial rupture of membranes (aka go “rupture a patient”)
• PIH: “pregnancy induced HTN;” not a term anymore by ACOG but still used. Proper term is pre-ecclampsia or severe pre-ecclampsia or ecclampsia, but since there are no abbreviations for those things and PIH is so easy to write, that’s what is done.
• NST: non-stress test
• AFI: amniotic fluid index (read about how to do it)
• MVP: Maximum Vertical Pocket
• DVP: Deepest Vertical Pocket
• FFN: fetal fibronectin only can be done if between 24 and 34 weeks, and if there have been no vaginal exams or intercourse or anything in the vagina for >24 hours. Blood will give you a false positive test. Read about it so you know what it’s helpful for. Basically if negative, labor is extremely unlikely to occur in the next 7 days.