Sparrow/MSU Family Medicine Residency Program
Maternity Care Guidelines
These guidelines represent group consensus and generally accepted protocols and comfort levels within the group of faculty that supervise residents for maternity care.
These guidelines were made with current evidence-based information whenever possible, fused with constraints resulting from our patient population, care environment, and teaching milieu. These Guidelines only apply to resident patients.
Attending Physician Responsibilities:
An attending physician must round and write a note on every pregnant or postpartum inpatient or observation patient at least once every 24 hours. Patients who are admitted overnight should be seen by the daytime covering physician who should also write a note.
Attending physicians should be present on labor and delivery:

Whenever requested by residents or nursing

Whenever fetal heart monitor strip is yellow or red (unless core team review determines the attending need not be present)

For all trials of labor after caesarean

When a patient in active labor is 10 cm (nulliparous) or 7 cm (parous).
Attending Sign out:

If the next on call attending must be present at shift change, attending must call them and give verbal sign out 1-2 hours prior to shift change.

Patient in labor but attending does not need to be present - text page is adequate for sign out.

No attending sign out is required if there is no patient in labor.
Faculty rounding on pregnant inpatients and newborns:
1.
2.
A pregnant patient with a medical problem unrelated to pregnancy – inpatient attending rounds
A pregnant patient with a medical problem related to pregnancy
–
3.
4.
inpatient attending rounds if has OB privileges. Otherwise OB coverage attending rounds.
Ill newborns – Inpatient attending rounds if has OB privileges and/or competence with newborns. Otherwise OB coverage attending rounds and communicates clearly with next attending at change of shift.
Well newborns/circumcisions – OB coverage attending EXCEPT on
5.
weekends when, if the rounding attending is competent, the rounding attending should do this work.
In general inpatient attending should be willing to round on all patients for which they are competent to decrease the burden on the OB covering attending.
Consulting OB

1.
Breech Presentation - Persistent Breech after 36 weeks necessitates a consult for version attempt vs. planned C-section.
2.
Diabetes:
 Gestational Diabetes - If diet controlled (controlled = FBS < 105 and
1hr post-prandial < 120) okay to manage without consult. If not diet controlled, high-risk TOC or co-management arrangement.
 Type I diabetes mellitus
– transfer to high risk OB
 Preexisting Type 2 DM – transfer to high risk OB
3.
HIV positive – Transfer to High Risk OB.
4.
Late care: not in and of itself a reason to transfer care or consult.
5.
Maternal Age Limits - no TOC necessary based exclusively on Advanced
Maternal Age or teen pregnancy
6.
Multiple gestation
– transfer to High Risk OB
7.
Obesity (Pre-pregnant weight > 300 lbs or an obese female with a difficult vaginal exam) – Consult OB.
8.
Post-partum Tubal Ligation - Consult OB prior to 36 weeks.
9.
Preeclampsia
– No need to consult for r/o preeclampsia (See Sparrow
Hypertension Protocol). When diagnosed, must consult High Risk OB.
10.
Pregnancy Loss:
 Repeated (>2) 1 st trimester loss
– Transfer to High Risk OB
 History of 2 nd trimester loss – Transfer to High Risk OB
 History of unexplained 3 rd trimester loss – Transfer to High Risk OB
11.
Preterm Contractions – even if not diagnosed with preterm labor, if planning to discharge the patient on any tocolytic medication, consult OB prior to discharge .
12.
Pre-term Labor < 35 weeks consult OB
13.
Pre-term PROM
–
Consult OB
14.
TOLAC (Trial of Labor after Caesarean, AKA VBAC) Consult OB AS
EARLY IN THE PREGNANCY as possible, informed consent must be signed

for TOLAC; no TOLAC after two C-Sections; no oxytocin with TOLAC without consultation. See Sparrow TOLAC policy. FM and OB attending must be in hospital for TOLAC!
Genetic Counseling
1.
2.
All attempts should be made to inform the patient in her first trimester about her options regarding genetic testing.
Nurses who do intakes can give patients information, counsel them, and order prenatal genetic screens (e.g. serum integrated test, CF carrier)
3.
4.
5.
All women should be offered the option of screening vs. diagnostic genetic counseling.
All women should be offered testing for cystic fibrosis.
Document that these tests were offered and were accepted or declined.
Baby’s Physician
1.
Discussion regarding the medical care of the baby in the hospital and for well baby care should be carried out prenatally. Document patient’s wishes in the
"Problem Overview" summary prior to the third trimester.
2.
Family Medicine residents will care for newborns in the hospital for nearly all patients . If the patient’s selected newborn physician personally comes to the hospital and provides care for newborns in the hospital we will assign care to that physician. No newborns that residents deliver should go to
NTS. The delivering resident should examine the baby (while maintaining skin to skin contact) and write an H&P at the time of delivery.
Ultrasounds
1.
Ultrasound for Dates - An ultrasound should be ordered as early as possible
2.
if a patient is at all uncertain of her LMP. The pt should not be pressed into stating a LMP. Nurses at all offices have standing orders to order this ultrasound.
Routine US - All patients will have one US ordered at 18 - 19+7 (Before 20 weeks) for fetal anatomy and placental location.
EDC
EDC should be based on a certain LMP unless an ultrasound before 20 weeks
EGA disagrees. Refer to the ACOG Committee Opinion on Method for Estimating
Due Date as to when one should choose the ultrasound due date instead of
LMP. EDC should be clearly documented in the chart, told to the patient, and reconfirmed at every prenatal visit.

Post-Dates Management
1.
2.
When patient is 40+ weeks schedule induction for post-dates pregnancy.
Induction should be scheduled for the first weekday after 41 weeks . No inductions should be scheduled for post dates prior to 41 weeks. In addition to scheduling induction, the resident should call the attending who will be covering at the time of induction to discuss the plan.
No antenatal testing is required if a patient begins induction by 41 weeks. If patient must go longer due to weekend or other issue, schedule AFI/NST for
3.
at or before 41 weeks.
Induction Protocol - follow the OB keystone protocol, may use misoprostol
(Cytotec) or Cervidil for cervical ripening if needed. See Sparrow Induction policy/boarding pass.
Premature Rupture of Membranes
Term PROM - Labor should be induced at the time of presentation to reduce the risk of chorioamnionitis unless the patient refuses.