OB (R3)

Curriculum Background

Family Physicians must be prepared, especially in the military, to practice full spectrum obstetrics including obstetrical emergencies, prenatal counseling, family planning, antenatal, intrapartum, and postpartum care.  Medical knowledge of many basic topics, performing basic procedures during the pregnancy and postpartum periods is the core of this curriculum.  Understanding the role of the obstetrician as consultant is also key in one’s practice. 

Curriculum Goals

The ACGME has outlined six core competencies for all residents in training. The primary goal of the Maternity Care experience is for residents to develop the following 6 competencies in the context of evaluating and treating prenatal, antenatal and postpartum patients

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 sciences, as well as the application of this knowledge to patient care.

3. Practice-based learning and improvement that involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvements in patient care.

4. Interpersonal and communication skills that result in the effective exchange of information and collaboration 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 patients of diverse backgrounds.

6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Key Rotation Specific Milestones

1.  Patient Care 5: Management of Procedural Care

2.  Medical Knowledge 1: Demonstrates Medical Knowledge of Sufficient Breadth and Depth to Practice Family Medicine

3.  Medical Knowledge 2: Critical Thinking and Decision Making

4.  Interpersonal and Communication Skills 1: Patient – and Family-Centered Communication

5.  Interpersonal and Communication Skills 2: Inter-professional and Team Communication

Rotations

PGY-1 and 2

Obstetrics—1 month of obstetrics on Labor and Delivery, triage, postpartum ward, and clinic.  Evaluate, diagnose, and treat obstetric patients through the spectrum of care. 

PGY-3

Obstetrics —1 month of obstetrics on Labor and Delivery, triage, postpartum ward, and clinic.  Evaluate, diagnose, and treat obstetric patients through the spectrum of care.  Senior OB Watch.

Other Learning Activities

Didactics— longitudinal curriculum of lectures over 18 months and topics covered specifically

by OB/GYN providers on each of the rotations. (PGY 1, 2, 3)

Simulator training—obstetric urgency/emergency training drills during the rotation utilizing the

MOES trainer (PGY 1, 2, 3)

Ultrasound Course ( PGY 2 or 3)

ALSO Course (PGY 1, 2, or 3)

OB test at each year group (PGY 1, 2, 3)

EBM Obstetric lecture (PGY 1)

FM Clinic—longitudinal prenatal care over 3 years

Obstetrics Repair Workshop (PGY 1)

______________________________________________________________________________

ACGME Program Requirements for Maternity Care:

www.acgme.org – Family Medicine RRC requirements

Administrative Information:

Last review: November 2021

Family Medicine Coordinator: Carrie Nichols, MD

Obstetrical Coordinator:  LDCR Erin Shiv

Length of rotation:  1 month

Number of months to be completed: PGY1; PGY 2; and PGY3.

Maximal time away alloweed from rotation:  none

Number of half days in FM clinic: PGY1 – 1/wk; PGY2 –1/wk ; PGY3 – 31/wk  

Preferred clinic times: TBD

A.M. Report attendance required: Yes

Thursday afternoon conference attendance required: Yes

FM call required: Yes

Responsible for hospitalized FM panel patients: Yes, a supplementary note must be completed

Responsible for OB panel patients: Yes

Selected Rotation Specific Objectives by ACGME Competency Category:

The following is a listing of selected knowledge, skills and attitudes (K.S.A.s) that residents are expected to gain competency in during their rotations on the Obstetrical rotation.  It is understood that not all the K.S.A.s will be attained on a single rotation, but they will be developed and attained throughout the 3 years of residency; specific K.S.A.s that are not developed on the Obstetrical rotation will be developed during the other rotational experiences, or longitudinally in didactic presentation and Family Medicine clinic.

The rotation-specific objectives will be reviewed with each resident prior to rotating on the obstetrics service in order to clarify which objectives the resident is trying to attain. The resident will hold onto the curriculum, and use it as a reference point for areas to focus on during the rotation. At the end of the rotation, the rotation specific objectives will be reviewed with their advisor, and those attained will be checked. This review will be kept in the resident’s file, in order to document the resident’s progress.

Maternity Care Objectives

Patient Care:

Gather essential and accurate information about their patients:

PGY-1

___ Complete accurate history, physical at new OB visit

___ Complete routine obstetrical visits through an uncomplicated pregnancy (9 visit pathway)

___ Understand, analyze and interpret fetal monitoring strips

___ Recognize and be able to stage the degree of laceration

___ Identify, manage shoulder dystocia

___ Recognize retained placenta and placental products

PGY-2

___ Recognize multiple gestation pregnancy

PGY-3

___ Recognize when episiotomy should be and can be executed

Perform competently all medical and invasive procedures considered essential for the area of practice: Proficiency will be determined by several factors including understanding of indications, total attempted, total completed, skill level, confidence and outcome of procedure

PGY-1

___ Perform a spontaneous vaginal delivery

___ Be able to recognize when to perform and show competence performing the following basic obstetric procedures:

              ___ Amniotomy

              ___ Amnioinfusion

              ___ Fetal scalp electrode placement

              ___ Intrauterine pressure catheter (IUPC) placement

PGY-2

___ Perform the following ultrasounds during pregnancy:

              ___ Amniotic Fluid Index (AFI)

___ Biophysical Profile (BPP)

___ 1st Trimester US for dating

___ Perform laceration repair of 1st and 2nd degree repair

PGY-3

___ Perform operative delivery - vacuum and/or forceps

___ Perform manual extraction of retained placenta

___ Perform episiotomy

___ Perform as 1st assist during LTCS

Medical Knowledge

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

The resident should gain understanding of pathophysiology, presentation, initial evaluation, inpatient management and appropriate follow-up of patients who have the following included (but not limited to) conditions:

PGY-1

___ Recognition of preterm labor, gestational diabetes mellitus, and pre-eclampsia

___ Recognition and treatment of post partum hemorrhage

___ Management of pregnancy loss

___ Identify, work up, and treatment of ectopic pregnancy

___ Recognition of postpartum depression

___ Recognize and diagnosis of mastitis, chorioamnionitis, and endometritis

___ Know indications for Rhogam

PGY-2

___ Management of preterm labor

___ Management of pre-eclampsia

___ Recognition, work up, and treatment of placental abruption

___ Recognize indications for induction of labor and agents used

___ Manage and treat mastitis, chorioamnionitis, and endometritis

___ Recognition, diagnosis, and treatment of placenta previa

PGY-3

___ Management of prenatal, intrapartum, and postpartum gestational diabetes mellitus

___ Genetic counseling for Integrated/Quad screen and Cystic Fibrosis testing

___ Management of postpartum depression

___ Know indications, when to initiate, and frequency for antenatal testing

___ Trial of Labor After Cesarean (TOLAC) counseling and knowledge of its management and

                 complications

___ Knowledge of post termination complications

___ Understand and being able to counsel patients about breast feeding.

Practice-Based Learning and Improvement

Use information technology and on-line medical information to support education:

PGY-1

PGY-2

PGY-3

___ Utilize hospital’s evidence-based medicine resources (Up To Date; Ovid; Medical Letter; Prescribers Letter; Other resources on Clinical Portal) to obtain current information on patient management

Identify strengths, deficiencies, and limits in one’s knowledge and expertise; and set learning and improvement goals:

PGY-1

PGY-2

PGY-3

___ Set specific learning goals at the beginning of the rotation based on knowledge and skill gaps

Analyze practice experience and perform practice-based improvements:

PGY-1

PGY-2

PGY-3

___ Develop time management skills to increase efficiency in patient care

Facilitate the learning of students and other health care professionals

PGY-1

PGY-2

PGY-3

___ Residents will participate in teaching team members on relevant topics of patient care

Interpersonal and Communication Skills

Work effectively with others as a member or leader of a health care team or other professional group

PGY-1

PGY-2

PGY-3

___ Communicate effectively with physicians, other health professionals, and health related agencies

___ Interactions with other physicians and health care professionals will be collaborative with the patients’ interests held foremost

___ Communicate bad news to patients                 

Provide information using effective nonverbal, explanatory, questioning and writing skills

PGY-1

PGY-2

PGY-3

___ Demonstrate skills for complete, concise and relevant patient presentations to staff attendings and consultants

___ Complete daily progress notes on all assigned patients 

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.

PGY-1

PGY-2

PGY-3

___ Residents will be on-time to all work-related events, will complete all administrative work within hospital/departmental policies and will present themselves with an appropriate/professional appearance/demeanor at all times

Systems-Based Practice

Demonstrate an awareness of and responsiveness to the larger context and system of health care.

PGY-1

___ Ability to complete WIC forms

___ Counsel patient on family planning options available, including after delivery and during lactation

PGY-2

___ Appropriate referral for high risk pregnancy

PGY-3

___ Know and prescribe appropriate immunizations during pregnancy

___ Residents will gain an understanding of the larger context of inpatient care within the existing military and civilian healthcare organizations within the region.  This will be accomplished via discussions with faculty, direct consultation with medical services at other centers, and facilitation of transfers of care when appropriate to other centers.

­­­___ Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate by utilizing applying EBM principles and utilizing EBM databases

Specific Expectations of Residents:

PGY-1

1.  Complete laceration repair with simulation kit

2.  Complete end of rotation written OB test with 80% or greater

3.  Participate in MOES Obstetric drills (Code Purple) for OB emergencies

4.  Be present for all daily OB lectures given by OB providers.

5.  Present EBM OB lecture assigned to them to OB provider.

PGY-2

1.  Complete and pass Advance Life Support in Obstetrics (if on out-rotation will complete in 3rd year)

2.  Attend and complete Ultrasound course

3.  Complete end of rotation written OB test with 80% or greater

4.  Participate in MOES Obstetric drills (Code Purple) for OB emergencies

5.  Be present for all daily OB lectures given by OB providers

6.  Complete ’Humanism in Medicine’ Essay

PGY-3

1.  Need to complete minimum of 70 vaginal deliveries and 10 continuity deliveries

2.  Complete ultrasound course if not done in PGY-2 year

3.  Complete and pass Advance Life Support in Obstetrics (if on out-rotation during 2nd year)

4.  Complete end of rotation oral OB test with 80% or greater

5.  Participate in MOES Obstetric drills (Code Purple) for OB emergencies

6.  Be present for all daily OB lectures given by OB providers

For PGY 1, 2, 3

1.  Record all procedures in New-Innovations in a timely manner and assign a supervising physician

2.  Complete rotational evaluation on New Innovations within 2 weeks of completion of rotation

3.  Complete curriculum review within 2 weeks of completing the rotation with resident advisor; denote on the curriculum areas where competency was attained

4.  Required attendance at:

a.   Morning report

b.  Academic conferences

5.  Routine call responsibilities

6.  Coverage on OB panel patients and deliveries

7.  Family Medicine clinic as scheduled

Evaluation: 

Resident Evaluation:

Daily evaluation

The Obstetric attending should provide daily and weekly oral feedback to the residents on progress and performance. Attendings will also provide feedback on the quality of written communication by critically reviewing resident chart entries

Mid-rotation feedback:

With Obstetric attending at completion of week 2. Resident must ensure time is scheduled with staff.  Written feedback required if resident is failing at mid-rotation evaluation or at any other time.  A copy of this written feedback will be provided to the Program Director.

Final Evaluation

All attendings should be sent an evaluation by the resident via New Innovations. Evaluations should be completed within two weeks after rotation.

Methods of Evaluation:

Written OB test during PGY-1 and PGY-2 OB Rotations

Oral OB test during and PGY-3 OB rotation

MOES simulation (Code Purple)

ALSO course

Ultrasound course

Direct supervision

Lecture attendance

100% chart review

Portfolio:

The following items will be entered in the residents training record by the GME coordinator:

-Procedures documented in New Innovations

-Resident New Innovation evaluation

-Rotation specific objectives completed (pages 3-6 of this document)

Staff Evaluation: (the staff is evaluated by the resident)

-Residents evaluate staff using the annual New Innovations staff evaluation

Rotation Evalutation: (the rotation is evaluated)

-Resident assesses quality of the rotation by completing the New Innovations standard rotation evaluation form. Evaluations should be completed within two weeks after rotation.

Recommend reading list:

It is expected that residents will read, at a minimum, Up To Date articles on the conditions of the patients they are following. They will check off in the knowledge portion of the goals and objectives those conditions they have seen. They should check off each of the specific conditions they have gained knowledge in, and they should have checked off all the knowledge specific objectives by the time they have completed their final Obstetrics rotation.

References:

1.  Program Requirements for Graduate Medical Education in Family Medicine; effective July, 2014.

2.  AAFP’s Residency Solutions: Recommended Curriculum Guidelines for Family Medicine Residents: http://www.aafp.org/online/en/home/aboutus/specialty/rpsolutions/eduguide.html; the following curriculum guidelines were referenced in delineating specific objectives for the Maternal Care Curriculum.

3.  ACOG Compendium

4.  Gabbe, SG, Niebyl, JR, Simpson, JL. Obstetrics: Normal and Problem Pregnancies.

(5th edition).  Churchill Livingstone,  2007.

5.      Hacker, NF, Gambone, JC, Hobel, CJ.  Hacker & Moore's Essentials of Obstetrics and

Gynecology. (5th Edition).  Saunders, 2010.

6.  Cunningham, FG, Gant, NF, Levano, KJ.   Williams Obstetrics (21st edition). McGraw-Hill

2001. 

7.  Gordon, JD, Rydfors, JT, Druzin, ML, Tadir, Y.  Obstetric Gynecology and Infertility,

Handbook for Clinicians 6th edition.  Scrub Hill Press, 2007.