Charting:
-The templates that I have provided for you are set up in a particular way, and yes - they ask for a lot of numbers (more in baby notes than Mom notes). This is because they are designed to be used for research if needed. So if it’s asking for a number (latch score, number of wet diapers, etc) DO NOT replace with “feeding well” or “voiding appropriately.” We cannot use that for research. Please go to the "Notes" section on the main page for all the details and templates you didn't even know you wanted.
-Please minimize the little ‘pull in’ dynamic texts because it makes your notes long and superfluous - again, they are designed in a specific way so that they are super high yield and aren’t full of fluff. Some of these pull in things bring in an insane amount of useless info (there’s some ‘birth info’ one that I’ve seen used to pull in Apgars, but it also pulls in every single person who went into the patient’s room during labor. Like every nurse, student doctor, etc.) If you don't have enough time to pull in "21yo G3P2 at 36+5WGA by LMP", and you have to pull in the gian EDD smartphrase (which incidentally should already be in the note on the R side), you have time management issues. Please fix your time management issues, don't "fix" my already clear and perfect note templates. No fluff please.
-Whenever you write a note on a patient chart (ANY NOTE, even if only a one liner), please, please, please put a statement about who the attending is that is/has been staffing that patient. This does not mean you have to staff every single note, but a “Dr Turner will be kept updated,” or “will plan to call Dr. Raju with further updates” lets us know who is the staffer, and who needs to sign those notes.
-Triages are documented as H&Ps (can call it "OB triage note" or whatever) and do NOT require a discharge summary - if you are asked for one retrospectively, then the patient wasn’t appropriately placed as “outpatient in a bed” and you can talk to Mindy (Nurse Supervisor) to help fix this. You can write the note and edit as you go, save it to write at the end of the triage visit, or write it and then do a separate progress note if you really want to to give updates on the triage stay.
-YOU MUST DOCUMENT A DIAGNOSIS FOR ALL PATIENTS!!! You do this in the "Problems and Diagnoses" tab on the dark side, and make sure that it's in the top section (the bottom section is forever things, and the top section is problems with this encounter). So if they come in for cramping, bleeding, decreased movement, whatever....make sure that you put a diagnosis in there.
Night Teams: our current goal is to have attending-to-attending sign-outs at 7am and 5pm each day when there are patients on the floor, in the hopes to minimize multiple changes to patients’ plans of care. If nothing changes about the patient medically, nothing should change about the plan, and this will allow us to all be on the same page with any plan changes. This means no stopping pit overnight in inductions if things are progressing and/or patient ruptured (if not doing stuff or if wanting to use more ripening agents, this could be appropriate as long as not ruptured). If you have concerns, contact your chiefs and they will help you manage.
Delayed Cord Clamping: As long as appropriate (ie. mom and baby are both stable), we should be doing delayed cord clamping on all patients. There is ample evidence to show that this helps to prevent postpartum hemorrhage, and increases iron stores in term and preterm infants in the first few months of life. This is done for at least 30-60 seconds (can stop earlier if the cord has stopped pulsing), and it’s important to note that you do NOT need to hold the baby below the mother (gravity will not overpower that awesome high-pressured blood flow). Baby should be placed on Mom’s stomach (starting the skin-to-skin process), and then take a nice big breath before you jump to trying to cut that cord (again, assuming this is a vigorous baby who does not need to be transferred immediately to the warmer). If there is meconium or you have a tricky looking strip, and peds is present, you can still do delayed clamping as long as baby is vigorous – be verbal about this plan so that everyone in the room is on board and not expecting you to take a screaming baby immediately to the warmer. If anyone involved in the delivery (nurses and NICU included) verbalizes concern for the baby after delivery, or requests transfer to the warmer, you should immediately cut the cord and transfer baby over. Remember that this is the first of the three parts of active management of the third stage of labor (AMTSL; should have flashbacks of ALSO here…..think PPH prevention) – the other two parts are Pitocin being started with the anterior shoulder (which can be hard to do at times with staffing in the room – can start as soon as baby is out or very shortly thereafter – just know you don’t have to wait for the placenta to delivery), and cord traction. AMTSL should be practiced with all patients ideally, as some of the worst PPHs you will encounter will be in people without any risk factors. Play the defense and you have a much better chance of winning the game ;-) I will probably pimp you on this at every delivery I attend, just an FYI!
Cord Blood: we should be collecting cord blood at every delivery (rather just when Mom is O+ or Rh-). This is for us to get the direct Coombs on baby, because it’s very possible to get a Coombs positive baby born to someone who isn’t O+ or Rh- (ie. ABO incompatibility). Why do we want Coombs? This helps us to better interpret the bilirubin (see below), and know when to do follow-up testing, when to see that baby in clinic, and when to start lights.
Monitoring Bilirubin: (note - this is a current EBM committee topic, so this could change in the near future.) When looking at bilirubin, you need first to determine baby’s “risk group” – using bilitool (www.bilitool.org) or an equivalent app, you can see that there are three risk groups, all with different light levels for treatment. Baby’s bilirubin should be documented and reported as (for example) “9.6@36 hours, high-intermediate risk (or HIR) with LL 13.6.” It is important to note that the high-intermediate/low-intermediate/low risk designations must be taken with a grain of salt when you have a baby who is not in the low-risk group for neurotoxicity risk – as an example, if a baby was 37+5 with Coombs positive, that bili reported above (that is HIR), is actually potentially AT light level. Please see the “How to Use Bilitool” document that explains how to use bilitool (in case you have not yet used it). Please read it, every if you think you know what you’re doing, because I’ve found several people aren’t exactly clear on the risk groups (because they ARE confusing). Using this will not only help us make sure babies are being treated appropriately, but as well can help us predict when bili might be an issue after discharge. Should we send home with a bili blanket? See a day earlier? This will help you make those decisions. As well, note that bilitool should be our final word here - it’s been noted that some of the phone apps don’t use the same cut offs, and given that bilitool is an AAP app, it will be the final word. So if your phone is telling you that a baby needs lights, double check on the computer!
Reporting Baby’s Size and Gestational Age Range: Every baby born should be checked to see where their percentile weight lays on a gestational age normogram (attached, and will be in the call room and the binder previously mentioned), and they should be reported in sign out, in notes, and to attendings as “a preterm/early-term/full-term SGA/AGA/LGA” baby. You can also find the exact percentiles on the peditools website (see useful websites tab on main page), but you do not need to report the exact percentile if using the chart (rather document “<10th” or “25-50th”). This again is helping us to identify risk factors (for hyperbilirubinemia, hypoglycemia, weight loss, poor feeding, etc), so that we can best plan for and identify issues that may arise, and determine the best follow-up care for these babies. When you have a baby who is SGA, you should also be looking to see if they are symmetric or asymmetric (look this up if you don’t know), because one of these could potentially require further work-up while they’re in the hospital (again, if you don’t know what I’m talking about, look it up!) Now if you are missing a measurement, do not put "not done" - go find out from the nurse what the measurement is and make sure that it gets put into the computer. We've had too many babies discharged who did not get an HC. Not acceptable.
Weight Loss: when looking at baby’s weight loss, it’s important to look at more than just the number – certain babies (ie. those born by cesarean, after long inductions, or to Moms with preeclampsia) tend to lose more weight, and a lot of that is in the first 24 hours. When you think that “excessive weight loss” can be a reason some Moms will stop breastfeeding (either because they’re inappropriately advised to switch to formula, or because they feel like they don’t have enough milk and are starving their baby), our interpreting weight loss becomes that much more important! When you have a baby who seems to be losing more weight than normal, look at their labor and delivery – do they have one of those risk factors? If so, then look at the weight loss from their weight from DOL#1; often times when you do this you see a much more “normal” weight loss. Now when a baby DOES have more weight loss than normal, and Mum is breastfeeding, encourage her to start pumping immediately (and frequently – at least every 3 hours, around the clock!). Have them evaluated by lactation, and make sure that if there are latching difficulties, that there’s not something we can fix (like a tongue tie). She should be keeping baby at the breast, and then pumping and feeding whatever she pumps (this is called “triple-feeding”). If baby needs supplementation, see about donor milk before switching to formula. True decreased milk supply isn’t as common as people think it is, so support and encourage these women in those first few days – it’s the most important time for them in establishing their breastfeeding relationship!
Nursing Staff:
-Do yourself a favor and learn the names of the nurses on L&D - obviously there are a bunch of them, and you won't be able to memorize them all, but at the least learn the names of the nurses taking care of your patients, and introduce yourselves as well. You would be surprised how much that little act will gain their respect and show them that you are a team player.
-Be helpful. Get your own gloves, get your own gowns, get your patient a warm blanket or a drink or whatever (assuming you aren't late for clinic). Again, we are a team, and not only do the nurses really appreciate this kind of gesture, but the patients do too! Shows that you care, and that little things like that aren't "beneath" you. You are not a waiter, but neither are the nurses, so it's fair that if you can, you help.
-Many of the nursing staff have been doing what they've been doing for many more years than you have been in post-grad education. And even those who haven't have lots of experience that they can share with you. They have so much knowledge to share with you, so if they bring concerns to you please listen! Discuss things with them and see their side (and let them see your side). This is not to say that you have to agree with them or do what they say, but I would highly caution you against dismissing their concerns and not addressing them head-on. Again - we are a team. It's great to explain to them what you're thinking, what your plan is, and why your plan is what it is. Listen to them and their concerns. Validate them, and take them into consideration. They are advocating for their patients as much as you are, and they deserve to be heard.