Ob/Gyn Intern Orientation and Survival Guide
There is a hierarchy within the residency. It is used to promote progressive decision-making
capabilities while maturing in the training process. It is to be respected and utilized. Although the attending
is ultimately responsible for whatever happens, he/she recognizes the importance of allowing residents the
opportunity to make decisions. Among residents, however, questions and management decisions should
flow from intern to second/third year and then chief. The chief resident may then confer with the generalist
attending, the MFM or ONC attending. This fosters a learning environment and a sense of security. This
flow of information is also bi-directional, and it is often necessary for the more senior resident to "check
behind" the intern. The junior resident will notify the chief of any changes in patient status and will
inform the chief if his/her presence is needed. In the event of an emergency, the junior resident is expected
to directly notify the attending if the chief resident is unable to be reached.
Acronyms and abbreviations
A&P- anterior and posterior repair
BTL- bilateral tubal ligation
BSS- bedside sono
BSO- bilateral salpingoophorectomy
ctx- contractions
EGA-estimated gestational age
EDC- est date of confiment (due date)
FM-fetal movement
EBL- estimated blood loss
EFW- est fetal weight
FHT- fetal heart tracing
GBS-group B strep
GDM- gestational diabetes mellitus
IUFD- intrauterine fetal demise
LMP- last menstrual period
LOF- leakage of fluid
LTCS- low transverse c-section
PID- pelvic inflammatory disease
POC- products of conception
PPROM- premature preterm rupture of membranes
SVD- spontaneous vaginal delivery
VAVD- vacuum assisted vaginal delivery
MVP-maximal vertical pocket
SVE- sterile vaginal exam
SSE- sterile speculum exam
SROM- sponteous rupture of membranes
TAH- total abdominal hysterectomy
TOA- tuboovarian abscess
TVH- total vaginal hysterectomy
Clinic (OB)
Clinic begins at 1pm and runs until all patients are seen.
Prenatal care
§
We have a high-volume of Ob patients, both routine and high risk. High-risk days are
Tuesdays and Thursdays mornings (MFM resident is in charge of this clinic).
§
Schedule for visits for routine care:
§
Q 4 weeks up to 28 weeks
§
Q 2 weeks from 28-35 weeks
§
Q 1 week for 36-41 weeks
§
Biweekly for 41+ weeks- needs NST biweekly and weekly MVP (max vertical pocket)
§
Patients need one nurse interview during their pregnancy- make sure this has been done
§
The first Ob visit: should include a complete H&P, ultrasound to date the pregnancy and
determine viability, Rx for PNV, schedule labs (more on this later), schedule sono if indicated, arrange
MFM referral for high-risk.
§
Dating for a pregnancy should be based on first day of LMP. A first trimester US is the
best way to confirm the EDC or to change her EDC. We can do this in clinic. If she is mid-second
trimester or 3 rd trimester, then she should be sent ASAP to the hospital for a sono.
§
When to change a patient's due date:
<12 weeks- +/- 5 days difference in the LMP and sono
12-24 weeks- 10 days difference in LMP and sono
24-36 weeks- 15 days difference in LMP and sono
>36 weeks- 21 days difference in LMP and sono
TELL THE PATIENT HER DUE DATE AT THE FIRST VISIT- THIS IS HER OFFICIAL
EDC UNLESS TOLD OTHERWISE!!!!!
Routine labs, screens and ultrasounds
·
Prenatal panel- type and screen, RPR, rubella titer, Hep B surface Ag, HIV, H/H, hbg
electrophoresis (if indicated), urine culture. Done at either the first dr visit or nurse interview
·
Pap, GC/Chl- done at the first dr. visit
·
All patients should try to have an official sono ASAP to document IUP and EGA
·
Quad screen (15-23 wk), first trimester Down's screening (11-13wk), cystic fibrosis (any
time)- all optional screens . Needs to be offered. Document if patient declines
·
Early glucola (16-18wk) for risk factors (>200lb, prior hx of GDM in preg, 1 st degree
relative with DM)
·
Fetal movement first felt 16-24 weeks
·
Try to find fetal heart with doptone after 10 weeks
·
Start measuring fundal heights at 20 weeks. A normal fundal height is +/- 3 cm of EGA; if
doesn't correlate or lags or gains on EGA, needs sono to measure growth/MVP
·
Between 12-20 wks, record fundal height in weeks
·
12 weeks at pubic symphisis
·
16 weeks halfway to umbilicus
·
20 weeks at umbilicus
·
28 week panel- antibody screen, hct, RPR and glucola; begin counseling on "kick counts"
(at least 10 fetal movements in 2 hours is reassuring)
·
Rhogam at 28 weeks for all Rh neg without positive antibody screen for Rh
·
One ultrasound for normal pregnancies after 16 weeks (target before 20 weeks)
·
Sign sterilization papers at 28 weeks- make a copy for patient and tell her to keep handy in
case the hospital copy gets lost. Pt must be over 21 years old to sign and must have signed 30 days in
advance for term delivery and 72hrs in advance for preterm delivery. Morbidly obese women may want to
consider another form of contraception since this is very difficult in them.
·
Check position at each visit 36+ weeks by Leopolds and then sono to confirm; if breech,
offer external cephalic version or schedule c-section
·
Counsel on signs/symptoms of labor each visit starting at 36 weeks
Prenatal Assessment Center
Referral center for high risk pregnancies and for genetic counseling. Also does the first trimester
Down's screening.
High Risk Ob
¨
Advanced Maternal Age (AMA)- older than 35 at the EDC. Needs to be offered genetic
counseling and amniocentesis for chromosomes (optional)
¨
Chronic HTN (CHTN)- elevated BP prior to 20 weeks. Also needs baseline PIH labs, 24hr
urine for protein clearance, EKG (if long standing). Biweekly testing at 32weeks
¨
Diabetics- preexisting or gestational. Also needs hbg AIC, 24hr urine for protein and
creatinine clearance, baseline PIH panel; ophthamology, nutrition and diabetic teaching referral; early PAC
sono to r/o anencephaly or other lethal anomalies; monthly US for growth after 24 weeks; fetal
echocardiogram at 20-22 weeks; biweekly testing 28-32 weeks; amnio at 37 weeks for poorly controlled
diabetics and delivery
¨
Previous preterm delivery- try to determine cause; if labor, determine need for cerclage,
progesterone shots or BV screening. Evaluate need for 17 OH-Progesterone
Biweekly testing
One day a week will be NST and amniotic fluid check and another day will be a BPP.
Admitting from clinic
Discuss all admissions with upper level resident/attending prior to sending patient to L&D.
upper level resident on L&D and the charge nurse need to be notified prior to pt going.
The
Scheduled C-sections
ü
Determine how dating established- if adequate, then may post at 39weeks. If poor dating
(3 rd trimester sono, LMP and 2 nd tri sono do not agree, etc), then pt may need amniocentesis for FLM
prior to surgery.
ü
Pt should be scheduled through charge nurse on L&D
ü
H&P and orders should be done by resident who sees the pt for pre-op
ü
ü
NPO after midnight
Discuss BTL prior to surgery. Optimally, pt will have signed tubal papers at least 30 days in
advance but this is not absolutely necessary for c-sections (depends on their insurance)
Hospital Care (OB)
Rounds
§
730 am in the L&D conference room (8 am on Sat and Sun).
§
Be prepared to give a brief overview of the patients you saw in the am (although we
usually just ask if there were any problematic patients): --yo G-P- ppd/pod # s/p SVD/LTCS, doing well
(or having whatever complication). Inform i f a patient is going home that day.
§
-baby's weight, delivering attending and any complications
§
All pts that the interns see must be staffed with an upper level and may need to be cosigned- at least in the beginning
§
All pts, except routine SVDs, should be seen in the evening as well (may start rounding
after 12 noon for pm rounds)
§
Interns usually start with routine SVDs and see progressively more difficult patients, such
as c-sections and gyn patients.
L&D Responsibilities
·
Management of the low-risk laboring patient and triage are the intern's main
responsibilities. This is done under the direct supervision of the upper level OB resident. They should know
everything that is going on.
·
A vaginal exam should NEVER be done without a nurse present, and the 2 nd year resident
should preferably be present also in the beginning.
·
Upper level residents are responsible for preterm (24-37wk) pts. Interns are welcome to see
them, but management should come from the upper level.
·
The upper level resident will be the primary surgeon for primary cesareans, BTLs and
D&Cs.
·
Junior residents are responsible for the ER calls and should be followed by their more
senior resident prior to staffing with the attending.
·
Interns should update the upper level on things that need management. Interns should not
manage gyn onc or antepartum patients without the assistance of an upper level resident- calls can be
redirected to the upper level.
Pound Calls (pager says #3843 for example)
Pt's are instructed to call the Ob Dr. On Call to discuss any questions or concerns they have
outside of regular clinic hours.
§
Obtain the pt's EDC, phone number and where they are seen for their prenatal care
§
Complaints and above info should be recorded in Cerner for legal purposes and reviewed
by the upper level.
§
If the caller is someone other than the pt, ask to speak to the pt directly to obtain the most
accurate information.
§
This is not a 24-hr ob/gyn chat line; pts with routine gyn questions are urged to call clinic
during hours, but if they feel they need to be seen immediately, direct them to the ER
§
Ob pts with concerns should be come to the ER (OB TRIAGE) for decreased fetal
movement greater than 28 weeks, bleeding, cramping, contractions, or leaking fluid. When in doubt, they
should be seen sooner than later.
§
Narcotics are not to be phoned in. If a pt requires this level of pain control, they should be
seen through the ER. Of note, Vicodin and tylenol #3 can be phoned but you should evaluate why the
patient is in pain.
§
Calls should be answered expeditiously, but if you are in the middle of a delivery or
surgery, have the nurse call the operator and hold the calls until later. Remember to call back ASAP. These
calls should not be ignored, and if the operator feels you are not calling back fast enough, your upper level
will be called.
Common Pound-call Questions
Leaking fluid - anyone with possible ruptured membranes should come in. If it leaks only when
she coughs/sneezes, then likely urine. She can wear a pad for a few hours and if it's soaked, then needs to
come in for eval.
Decreased fetal movement - less than 10 movements in 2 hours after 28 weeks. Lie down, eat a
snack, drink some fluid and if above criteria not met, then needs to be evaluated
Bleeding- spotting at term is ok. Bleeding like a period needs to be evaluated immediately. If
first trimester and not accompanied by cramping, may be normal, but monitor for worsening. Explain to pt
that some miscarriages are inevitable, and there is usually nothing that can be done to prevent them, but
should go to the ER if bleeding greater than 1 pad/hr.
Contractions- if preterm and more than 6/hr, then needs immediate evaluation. If less frequent,
she should drink a large glass of water, lie down and monitor ctx. If term, then she should wait until they
are every 3-5 minutes, increasing in intensity and have been occurring for at least an hour. If a pt is unable
to complete sentences while you are talking to her, then it may warrant coming in.
OB Triage
Prior to 20 weeks, they are evaluated in the main ER, but you may be called to evaluate a
pregnant patient down there.
After eval, call the upper level to check out to them.
·
Always verify the pt's EDC by her records; many pts will tell you the wrong due date and
this may change their medical care
·
Labor evaluation includes a digital exam to assess dilation. If she is in latent labor, she may
walk (if reactive NST) or be sent home on therapeutic rest
·
SROM evaluation involves a SSE for pooling, nitrazine (we dont use this anymore- poor
quality control- but some midwives carry it with them ie. Pfaff) and/or ferning. This is performed prior to a
digital exam
·
Bleeding exam involves an ultrasound to verify the position of the placenta prior to SSE
and an SSE if previa is ruled out. The ultrasound also reassures the pt that the baby is ok
·
Decreased fetal movement exam involves an NST
·
Nausea/Vomiting involves a UA to check for dehydration and IVF and antiemetics as
indicated. Once a pt is tolerating po, she may be discharged
Admission Indications
¨
Cervical change (ie labor)
¨
Nonreassuring fetal surveillance
¨
Spontaneous rupture of membranes
¨
Pts who are >40wks- case by case basis
¨
Other preterm patients with problems (high BP, pyelonephritis, bleeding, etc)
Admission H&P
We have preprinted admission forms. The following is the pertinent information to gather:
For laboring patients, the first line is the most important:
--yo (race) G-P- with an LMP of - giving an EDC of --- confirmed by (or changed by) a --week ultrasound, for an EGA of ---. Pt presents with --- (ctx, VB, LOF, decr FM, etc). SROM at am/pm. PNC began at -wks. Pregnancy complicated by ---.
PMH: should include ob/gyn history (paps, STDs, past preg and delivery info)
PSH, Meds, Allergies, Social and family hx
Labs- GBS status
PE: vitals, general
Heart, lungs, abd ( should include fetal lie by Leopold's and EFW!!) , extremities
SVE- dilation/effacement/station/position of fetal head
SSE- pooling, ferning, nitrazine (if available)
BSS- confirm fetal position and fetal weight
Assessment- active labor, ruptured membranes, NRFHTs, etc
Plan: Admit and plan per resident
Review the "routine labor orders" to become familiar with them.
Labor Patients
§
Check patients every 2 hours when in labor; if not in labor yet, needs a note q 2 hours to
document fetal heart tracing, contraction pattern and vitals
§
Check patients if change in FHT- decelerations, variables
§
Check patients if she is feeling rectal pressure or large amounts of bloody show (or if the
nurse asks you to)
§
Effacement refers to the length of the cervical canal; 100% effaced means the lower
uterine segment is the same thickness as the cervix
§
Station is where the presenting part is in the vagina/pelvis. "0" station is when the bony
presenting part is at the level of the ischial spines and + or - refers to distal or proximal to the ischial spines
§
Position is which direction the occiput is pointing. LOA- left occiput anterior is most
common, but may be occiput posterior, or occiput transverse. Difficult to determine at less than 4 cm
dilation.
§
Check your exam with the plastic dilation board at the nurse's station.
§
Epidurals, IV pain meds, pudendal blocks are all acceptable pain control options for
§
Epidurals usually after labor well-established but may be sooner if needed
patients
§
IV meds q 1-2 hr until close to time to delivery (have narcan available for baby if too
close to delivery and narcotics given)
§
Pudendals usually just for pushing (rarely done here)
Labor Note
S: comfortable, unconfortable, etc. Preeclampsia symptoms
O: vitals
FHTs- baseline, presence of accelerations/decelerations, variability
Toco (dynomometer)- frequency and strength of contractions
SVE- dilation /effacement/station/ position
Time of AROM/SROM and color of amniotic fluid; placement of FSE or IUPC should be noted
A: progressing, not progressing, etc
P: expect SVD, proceed to C-section, start pitocin, etc
Delivery
q
Attended by student, intern, upper level, attending and nursery (NICU and chief PRN).
q
A resident should push with the patient and give encouragement
q
The intern is responsible for delivery, assisted by the upper level, unless it is premature and
then the intern will assist the upper level. The student usually gets to deliver the placenta, until the intern
has adequate deliveries, then the intern is responsible for teaching the student how to do a delivery.
q
Try to be as neat as possible and observe sterile technique
q
Nurses appreciate efforts to help them clean up afterwards
Delivery Note - you will often find that an attending has written a comprehensive note on a
patient but it's always a good idea for the delivering resident (or student) to also write a note to show
continuity of care
WE have preprinted delivery notes. If you are to use a blank progress note, you may write the
following:
SVD/VAVD/FAVD of a LFI/LMI at --- weeks from --- position (OA, OT, OP) (If an operative
vaginal delivery was done- VAVD/FAVD- then a reason must be given)
AGPAR/weight/EBL
Resident, attending
Anesthesia/analgesia- epidural, spinal, local (perineal block, pudendal block), IV, none
Perineum- perineal laceraton, MLE, labial laceration and what was used to repair
Placenta- spontaneous vs manual extraction, intact, 3/2 vessels
Complications- shoulder dystocia, 4 th degree laceration, etc
Disposition- mom and baby doing well in room, baby to NICU, etc
NICU/neonatology
Called for the following deliveries:
-OR deliveries, including c-sections
-multiple births
-preterm or postdates (<37wk, >42 wk)
-meconium-stained fluids
-no prenatal care
-per request of delivering doc/nurse, depending on maternal /fetal condition
-at edge of viability- 22-23 weeks; try to contact them as early as possible for consult
Post Partum/Post Op note
S: complaints, amount of lochia, pain, breast/bottle feeding, birth control plan, BM quality (if 3
rd or 4 th degree laceration) or flatus (if C/s)
O: vitals (make sure range of BP for preeclamptics) and Tm/Tc for chorio/post op
Heart/lung/abd- fundus above/below umbilicus, firm/tender, +BS
Wound- clean, dry, intact, no erythema
Extr- pulses, edema, DTR (if preeclampsia)
A: --yo G-P- PPD/POD #, s/p SVD/LTCS secondary to --, doing well
P: continue postpartum/post-op care (or whatever the plan may be)
Operative Note (preprinted)
Pre Op Dx: IUP at -weeks, (indication for c-section)
PostOp Dx: same
Procedure: primary vs repeat LTCS/ classical c-section
Surgeons/attending
Anesthesia- type and dr.
Findings- Normal uterus, tubes and ovaries, APGARs, cord pH, anatomy
Complications
EBL (usually 700-1000ml)
Disposition- mom and baby doing well in recovery, baby to NICU, etc
Review the routine C-section orders to become familiar with them.
Discharge Orders
SVD- 24-48 hr postpartum; c-sections 48-72hr if without complications
v
D/C to home after attending rounds
v
Follow up in 4-6 weeks (4 weeks if BTL planned, 1 week if preeclampsia, 1 week for
incision check or staple removal & 6 w post partum check)
v
Pelvic rest (nothing in vagina) x 6 weeks
v
No lifting anything heavier than baby x 6 weeks (if c-section)
v
Prescriptions on chart (motrin if SVD, add vicodin/percocet for c-sections, avoid Tylenol #
v
Rubella or rhogam if indicated
3)
v
Endometritis precautions: fever greater than 101, chills, abdominal pain, worsening
cramping, heavy foul-smelling lochia
v
Bleeding should last 2-6 weeks but may last longer; quarter-sized clots OK
v
Not breast-feeding- tight bra, cold compresses, cabbage leaves, no stimulation
v
Breast feeding- heating pad, nurse on demand or q 2 hr, pump inbetween to relieve pressure
(engorgement will improve over 2-7 days as mom and baby synchronize)
If coming back for IUD or BTL we strongly encourage an alternate/interim form of
contracpetion. IUDs and BTLs are both done ~8 weeks postpartum (Essure over 12 wks) but pt's need to be
seen before then, and may start ovulating as soon as 2 weeks postpartum if not breastfeeding (and
breastfeeding is not a reliable form of contraception). Depoprovera can be given prior to leaving the
hospital.
Discharge Dictations
The most important patients to have immediately dictated are the transfer patients, however,
interns should not be seeing these patients. Everyone needs a discharge dictation. All discharge dictations
are preferably done the DAY of discharge.
Discharge Dictation
"This is Dr. ___ ____ dictating the discharge summary on Ms. ____ ____ (name, MR#, date of
admission and date of discharge and date of dictation)
DATE OF ADMISSION
DATE OF DISCHARGE
ADMISSION DIAGNOSIS
DISCHARGE DIAGNOSIS
PROCEDURES DONE WHILE IN HOSPITAL
HOSPITAL COURSE
PERTINENT LABS
DISCHARGE MEDICATIONS
Optional:
PAST MEDICAL HISTORY (incl Ob/gyn hx)
PAST SURGICAL HISTORY
FAMILY HISTORY
SOCIAL HISTORY
ALLERGIES
MEDICATIONS
ADMISSION PHYSICAL EXAM
To accomplish a good discharge summary:
1.
Review the whole chart for essential information
2.
Establish all the admission diagnoses- write them down on a scrap of paper
3.
All admission diagnoses must be explained in your H&P summary
4.
Go through the chart and note all the discharge diagnoses
5.
All treatments and procedures that are utilized during the admission must have a diagnosis
6.
Summarize the sequence of events, but do not dictate a series of diagnostic studies that
were done and do not just read the progress notes into the dictation line!
7.
All Dicharge Diagnoses that are Different from the admission diagnoses must have an
explanation in the summary
8.
Don't forget discharge medications
GYN pearls
Post Op Orders
Transfer to 2nd floor, admit to Dr. ---- (attending)
Diagnosis
Condition - guarded, stable, etc
Vitals- q 1 hr x2, q 2 hr x2, then q 4 hours
Allergies
Activity- bed rest
Nursing- foley to gravity, SCDs in place until ambulating, incentive spirometer to bedisde
(please instruct in use)
Call HO for T>100.4, pulse >120, resp >30, urine output less than 60cc/2 hours, BP >160/90,
less than 90/40
Diet- ice chips, may advance to clears (depends on the surgery)
IVF- LR at 150cc/hr
Meds- PCA pump (see separate order form), any home meds that need to be restarted, hormone
replacement if needed
Labs- usually none needed
Post-op check
Done about 4 hours after surgery. If at night (>5pm), the GYN team should check out the
pertinent information to the OB team and what time post op check is needed.
S: Pt alert, nausea controlled, pain controlled
O: Vitals, urine output over X hours
Heart, lung, abd exam. Examine wound bandage to make sure no leaking of blood
A: POD #0 or 1, s/p "procedure"
P: continue post-op care
IVF Primer
Indications for IVF- cannot tolerate PO, immediately post-op, maintain IV access in pt with poor
veins and need for possible IV access, medication dosing
FLUID
Sodium
Potassium
Chloride
Bicarb
Serum
135-145
3.4-4.7
98-108
22-31
NS
154
0
154
0
½ NS
77
0
77
0
¼ NS
38.5
0
38.5
0
3% saline
LR
513
`
130
0
4
513
109
0
28
General fluid management
ü
Initial post-op: isotonic fluid at 100-150cc/hr with intent to fill up vascular space and
losses from NPO/bowel prep/blood loss/intraop fluid losses.
ü
Optional : If s table post-op (>24hr) change to hypotonic fluid with K; ½ NS with 20mEq
KCL at rate to maintain urine output
ü
Continuation of LR or NS may yield metabolic acidosis; most patients correct for this but
be careful in debilitated pts or those with other medical comorbities.
ü
Prolonged NPO (more than 48hr, less than 7d) need D5 added to prevent protein
catabolism: D51/2 NS with 20mEq KCL at 125cc/hr. Watch BMP for evidence of electrolyte imbalances
and correct as indicated
ü
Extended NPO (>7d): assess nutrition status, start TPN if expected return of oral intake not
expected for another 5 days.
ü
Hospitalized with observation: heplock if need continous possible access. If poor veins, can
use lowest rate needed to keep vein open (TKO). Stop all unnecessary IVF when able.
HOPE THIS IS HELPFUL!!!
Jessenia Magua, MD
OB/GYN PGY3
Aurora Sinai Medical Center