Time to be
A
Second Year Resident
Stanford Department of OB/Gyn
Stanford Hospital and Clinics
May 2011
1
Table of Contents
I.
II.
a)
b)
III.
a)
b)
c)
d)
IV.
a)
b)
V.
VI.
a)
b)
c)
Introduction
Obstetrics
Antepartum
Continuity Clinic
Gynecology
Preop Conference
Beta Book
Follow up
i) Resident mailboxes
Clinic
Gynecologic Oncology
OR
Clinic
Emergency Department
Miscellaneous
Night Float
OR scheduling
Phone Triage
Created by Sarah Waller June 2006
Additions by Inna Landres May 2007
Additions by Brooke Friedman and Amy Wong 2008
Additions by Pauline Chang and Jess Kassis 2009
Additions by the ladies of 2013 and 2014
Welcome to Second Year! Congrats on finishing intern year and moving up
in the world. Second year is much different than intern year and brings its
own challenges, but it’s rewarding too! You will have lots more
independence this year, but don’t hesitate to ask for help and explanation
when things just don’t seem to make sense.
Most of all, remember we are all part of a team, always ask for help and
advice if you need it.
2
Obstetrics
I.
Antepartum:
a. Admissions: The Basics
1. Reasons to Admit:
1. Hyperemesis gravidarum
2. Diabetes
3. Pre-Eclampsia/Hypertension
4. PPROM
5. PTL
6. VB: Abruption/Previa
7. Pyelonephritis
8. Non-reassuring fetal status or other fetal indication
2. Talk to your chief, then the fellow (daytime), and then the MFM
attending to staff the admission. At night you will generally tell
both the in-house attending as well as the MFM back up (at home).
3. For all transfer patients, update the primary MD at least weekly,
after delivery, and at time of discharge (if undelivered). Document
your phone calls in PowerChart, especially if you leave a message.
1. Have D/C summary sent to primary OB (if transfer pt)
4. All viable patients will need NICU and Anesthesia consults.
5. All viable patients should be consented for c-section on admission.
Consent for classical c-section prn early GA, IUGR, position. Also
sign BTL and VBAC consents on admit if applicable.
II.
AP Orderset Tips (to avoid endless pages):
a. See T&S guidelines (intern handbook, at L&D front desk, resident room)
b. Type & Cross is ordered as “Type & Screen” and then “Red Blood Cells”
for “x” units.
c. Change default is for daily weight— q week or on admit only
d. Make sure fetal monitoring is ordered appropriately. Default is CEFM.
e. Check orders for Massage, PT/OT and SCDs if patient is planned to have
an extended stay. If stable, write RN communication for “Wheel Chair ride”
as well.
III.
Hyperemesis:
a. For ED patients, ask for a urine dip (for ketones) and D5 and aggressive
anti-emetics (they may need specific recommendations).
b. Admission Criteria:
1. Failure of standard anti-emetics, evidence of severe dehydration,
electrolyte abnormalities, ketones in urine.
2. Labs: TSH/fT4, βHCG, CMP, UA, C&S, check UA dip for
ketones.
3. Studies: Dating US (if none available), also to r/o molar pregnancy
4. Rx:
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1. Bolus 1L NS then D51/2NS + 20K @ 125cc/hr
2. VitB6 25mg po tid
3. Anti-emetics (Zofran, Phenergan, Reglan), consider
Compazine PR.
4. Ativan 0.5-1 mg q6
5. Stagger scheduling of anti-emetics and Ativan (order meds
q6hrs, and ask nurse to stagger.)
6. Consider steroids in very refractory patients (usually not on
admit)
5. Diet: May start with clears but generally “whatever the pt wants”
6. Daily weights for these patients! Remind the RN.
7. Follow symptoms and urine dip for ketones. Okay to go home if no
ketones.
8. Adjuvant Tx: Consider Acupuncture (Dr. Samuel LaBaron),
ginger, and a Psych consult. Remeron is often recommended by
Psych.
IV.
Diabetic Control
a. HPI: Type I vs II? What meds? Oral vs Insulin? FS?
1. Consider endocrine consult if unsure of true diagnosis, they will
likely order c-peptide level, insulin antibodies
b. Labs: TSH/FT4, PNL (if not done), HbA1c, 24h urine for total protein
excretion and creatinine clearance, baseline pre-eclampsia labs, consider
Chem 7 (r/o DKA) with creatinine to evaluate kidney function
c. Studies: Dating US (* confirm viability *), EKG, ECHO
d. Consults:
1. Genetics
2. Nutrition
3. Diabetic teaching
4. Ophtho Consult
e. Orders: IVF, Diabetic diet (2200 Kcal), Finger sticks: fasting, pre/post
meal (1hPP), qhs, 2 AM
1. Goal: fast < 95, 1pp <135
Patient:
90Kg
f. Start Insulin (daily dose):
1st Tri (0.7)
st
1. 1 tri: 0.7/kg/d
Total
2. 2nd tri: 0.8/kg/d
Insulin: 63
units
3. 3rd tri: 0.9 /kg/d
42 Units in
AM
(2/3)
28u NPH
(2/3)
14u
Humalog
(1/3)
21 Units in
PM
(1/3)
10u NPH
qhs
(1/2)
10u
Humalog
qdinner
(1/2)
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4. Cover with ISS (mild to moderate to start)
5. Increase insulin by ~ 20% daily
V.
PPROM
a. SSE x 3 (Do NOT digitally examine.)
b. Bedside US for position, consider EFW as well. Rescan if admit who
goes into labor … position can change during admission!
c. FWB: initially CEFM/Toco, (if breech, usually patient will be on
continuous monitoring.) NICU consult. PDC scan for formal EFW.
d. Anesthesia consult
e. Labs: GBS, GC/CT (urine GC/CT okay), urinalysis
f. Rx:
1. BMZ 12mgIM q24hr x2 (Transfers may receive Dexamethasone
6mg IM q12hr)
2. PPROM Antibiotics:
1. Amp 2g IV Q6 x 48hr, then Amoxicillin 250mg po Q8 x5d
2. Azithromycin 1gm q24hr x 48, then Erythro 330mg po Q8
x5d
3. If PCN allergy: Clinda: 900 IV q8 x 48 then 300 BID x 5
OR Vancomycin 1g q12 x48 hours if GBS is unknown
g. Tocolysis: (if sxs of PTL, continue until BMZ complete – 72h - only)
1. Magnesium sulfate 4g IV bolus then 2g/hr
2. Nifedipine 10mg SL q20 min x3, then 20mg q6hr (or 10mg q4hr)
3. Indocin: An effective agent, but some attendings have hesitance
because of concerns over exacerbating oligo. Discuss w/your team.
h. If pre-viable either IOL or expectant management (abx depend on
attending
VI.
Preterm Labor
a. SSE as above with cultures and FFN, wet mount (r/o BV, yeast), then:
b. SVE
c. Bedside US, position +/- EFW
d. Rx:
1. Tocolysis (choices are attending/GA dependent):
1. Magnesium Sulfate 4g IV bolus, then 2g/hr
2. Nifedipine: 10mg SL Q20 x 3, then 10-20 mg po Q4-6hr
hold for BP < 90/50 (if low BP or sx, decrease dose or
frequency)
3. Indocin: Ok if < 28 wks (28-32 wks depends on attending),
50 mg po x 1 then 25 mg po q8 x 48-72 hrs
2. BMZ 12mg IM q24h x2
e. Recurrent PTL: consider re-tocolyze if < 30wks (attending dependent)
f. Antibiotics: No evidence for antibiotics for exposed membranes and some
studies show adverse effects, however some attendings still want them.
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VII.
Pre-Eclampsia, HELLP
a. Labs: CBC, creatinine, uric acid, AST/ALT, ± coags, urine
protein/creatinine, urinalysis (on admit, and repeat daily, twice weekly, or
weekly depending on stability)
b. 24h urine collection
c. PDC US (Growth/IUGR)
d. Strict I/Os
VIII. Vaginal Bleeding: Abruption, Previa, Accreta
a. SSE: Confirm absence of previa prior to vaginal exam and assess for
active bleeding, quantity, color
b. Pad count
c. CBC, KB, T&C, Coag panel,
d. Place two large bore IVs if concerning
e. Anesthesia consult ASAP
f. Abruption:
1. Tocolysis for UCs (ask attending)
2. Deck US – r/o large bleed
3. PDC US
g. Previa
1. Consent for ceasean and c-hyst PLUS Calif. hysterectomy consent
2. Consider Gyn-Onc consult
3. Deliver if near term (>35 wks, attending dependent)
h. Accreta, Increta or Percreta
1. PDC US, consider MRI (Inpatient MRI are scheduled through
LPCH radiology. Get Dr. Barth involved  he reads these scans.)
2. Consent for c-hyst PLUC Calif. Hysterectomy consent
3. Consult Gyn-Onc, Urology (if percreta), +/- IR consult
IX.
Pyelonephritis
a. Labs: CBC, UA, Urine culture, blood cultures, GC/CT
b. Meds:
1. Ampicillin (2g IV q6h) and Gentamicin (1mg/kg IV q8h) OR
2. Ceftriaxone 1g IM/IV q24h
3. Treat x 48h afebrile then discharge home with po antibiotics for 10
days total. Check culture sensitivities!
c. Suppression therapy
1. Macrobid100 mg po qhs
2. Consider switch to Keflex 500 mg QD at 36+ weeks
6
OB Float
Monday:
7:30am Resident Lectures
11:30 am-6:30pm L+D covering for chief who is in continuity clinic. During this time the
AP R2 usually continues to be first call for AP. The float helps with C/S, triage and the
board.
Monday night: Prep charts for Tuesday pm clinic (if not done already).
Tuesday:
7-8:00am: Finish prepping charts if not done already
8:00am-12:00pm PDC (May be pulled for L+D if busy)
1:00pm-5:00pm MFM clinic (you should get a list of the Attendings you cover each
month; email the admin chief and/or the MFM service fellow if you don’t know)
5:00- First, finish your clinic notes. Then it’s nice to check in with L&D chief, and prep
charts for Wednesday.
Wednesday:
7:30am Strip rounds or Journal club
9:00-12:00pm MFM clinic
1:00-5:00pm PDC July-Dec (may be pulled to L+D); then covering L&D Jan-Jun (once
interns start Continuity Clinic)
5:00- Finish your clinic notes. Then it’s nice to check in with L+D, then prep charts for
Thursday.
Thursday:
AM: RESEARCH time! Technically we are supposed to be available for back up on
L&D, so if you don't live within 15 min of the hospital, come in around 7:30 and work in
the library, F3 workroom, etc. You can register your laptop with Stanford University
Wireless network by calling 5-8000.
1:00pm-5:00pm MFM clinic. As usual, finish your notes and then check in with L+D.
Friday:
Ask chief what time you should come in (usually around 7:45 AM). Cover for AP R2
who is in Continuity Clinic. You may become first call for AP during this time (carry the
R2's pager and phone), but your chief should help out since you are less familiar with the
service and your colleague may prefer to keep their pager. Just communicate with your
Chief and co-R2 what the best system is on any given day.
1:00pm (or when scheduled) your Continuity clinic
Check in with L+D after continuity clinic. Consider prepping charts for next week. TGIF!
How to prep notes:
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1. Go to the Obstetrics Welch Rd master schedule book in Powerchart. This is in the
same place that you find the OB surgery schedule book.
2. Within the Obstetrics/Welch Rd schedule go to the MFM schedule book.
3. You will always cover the Tues PM, Weds AM, and Thurs PM clinic, and will work
with the same three attendings all month. Confirm with your Admin Chief or Fellow
which attendings you are working with in a given month.
4. To see the list of scheduled patients each day, go to Provider Schedule and look under
the attending's name. This will also give you a shortcut to the chart.
How charts should be prepped:
 There is are MFM Clinic Note templates in Powerchart which you should use.
 Make sure to change note dates and GA if you are prepping notes ahead of time.
The general format is the same as for our continuity OB pts, but generally the MFM pts
have more problems.
ID: age, parity, dating, problems
Subjective:
Objective: Per flow sheet (fundal height, doptone etc)
A/P IUP @ x wks
Problem list. Generally list each problem separately. Include FWB as a problem unless
already extensively covered in another problem (eg a cardiac anomaly).
Tips--Look back at previous notes as a guide.
-Always look up any pending studies, ultrasounds, consults and make sure printed copies
are in the chart for easy review during the visit.
-Don't forget about routine OB: Rh status, GTT, vaccinations, GBS, tubal papers, etc.
-Anticipate if pts will need an ultrasound (eg multiples, cervical length)
-New transfer pts, 1 time consults and preconception consults generally need to be
dictated as a letter to the referring provider. Dictate through LPCH as an outpatient clinic
letter. LPCH dictation guide: http://links.stanford.edu/hims/dictation1.htm
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Gynecology
I. Preop Conference (Mondays after Chariman’s Rounds in Dept. Conference
Room)
a. Prepare pre-op conference weekly.
1. Preop conference consists of a discussion of the upcoming cases for the
week. You don’t have to prepare anything formal, but have a general idea
of the cases and some idea of which ones would be interesting to discuss.
2. On Epic, use SDS to get case list for the week. Remember to check for
new cases added during week (check OFTEN!)
3. Include any add-on cases performed during week, from ED, etc.
b. Email preop conference to GYN attendings by Friday PM
c. Read about diagnoses/surgeries  you will be asked questions about choice
of surgery, appropriateness
1. Good reading sources: Compendium, Up-to-Date, texts (Williams
Gynecology)
II. Clinic Preops
a. Preop ONLY if you’re working with your assigned attending
b. Prepare Preop Packets, similar to ONC:
1. Helpful “dot phrases”: .gynpreop, .hystconsent, .genconsent,
.slingconsent
2. Pre-op Orders: pre-op labs, abx ppx (usually kefzol 1gm, discuss
alternatives with attdg if PCN allergic), SCDs, heparin?
3. Give copy of consents to patient and the completed packet to Delilah to fax
to Pre-op SAU.
4. If pts don’t have preop appt, have them get labs done that day – place
orders only encounter
III. “Beta Book”
a. Place beta f/u on sign-out. Remember to place a telephone encounter on Epic.
b. Send certified letters if needed (unable to reach patient after 2-3 honest
attempts)—Fill out sheet and give to Rodelia to send out.
c. If no insurance, refer to SMC, SCVMC, etc
IV. Obtaining Follow-up
a. Get correct patient phone numbers!!
b. Call Gyn clinic schedulers to schedule. If any question regarding insurance,
go through Shareeta.
c. Route EPIC messages and info for when you want the patient to follow-up to
Samantha Abraham, RN. (overnight calls, ED follow-ups, etc)
d. If pt to follow up at SMC email Dr. O; if Ravenswood, email Dr. Detata and
this individual: MMartinez@ravenswoodfhc.org.
GYN Continued
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Basic schedule
Monday: Grand rounds and teaching AM; Chairman’s Rounds at 1130 and pre-op
Conference at 1215, then GYN clinic PM.
Tues: Urogyn OR (Sokol, Chen)
Wed: Minimally-invasive / General Gyn OR (Jacobson)
Thurs: GYN clinic AM; Admin time PM – if you need it, time to work on preop conference,
OR schedule
Fri: GYN clinic/OR cases (REI or Family planning) and your continuity clinic PM
ER Basics
Call back ASAP –
Great first questions include:
•
Patient’s Attending (SUH vs. PAMF, should be able to see on patient’s main tab at
top of screen). We DO NOT seen PAMF, Menlo or other private GYN MD’s
patients.
•
Is the patient ONC or postpartum? If so, direct them to correct service
•
Pregnant?
•
Stable or not stable?
•
Get the story & request that the ED physician perform a pelvic and order
labs/imaging if appropriate and not yet done
•
Run consult by Chief!
•
Go see consult
•
Review imaging with radiology!!!
•
Depending on attending, you might involve them for initial exam (EX: Dr Jacobson
and Hillard usually like to be present for pelvic exam)
OR Basics
•
•
•
Meet patient in pre-op. Mark abdomen if necessary. Write Rx if outpt procedure.
Go to OR with patient, help with positioning, shaving, set up, etc.
Be NICE to circulators and scrubs – they can make your life so much easier if they
like you….
•
Be involved, interested and pay attention but realize that especially during your first
month, you may not get to do much.
•
Ask Attg if they want anything special postop. Don’t be afraid to ask specifics: pain,
diet, labs, etc for postop orders
•
Accompany pt to PACU. Do immediate post-op note and either same day d/c
orders or floor orders.
•
If you anticipate just a quick overnight stay admit to “23 hour obs”, and consider C1
outpt observation unit (don’t have to do discharge summary!)
•
Don’t forget 4hr postop checks if not an outpt/same day procedure
•
Signout format is similar to ONC. Don’t forget about out-there patients: ectopics,
phone calls, etc. And sign these out to your weekend team if they need follow up before
Monday!!
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Gynecologic Oncology
You don’t have to carry the pager anymore! 
I. OR
a. Discuss with chief how cases to be divided (often R2 will go with the fellow)
b. Your main job as the R2 is making/updating the spreadsheet with upcoming cases
i.
Read about patients prior to surgery
ii.
Print out H&Ps at least the day before and make copies for the team
iii.
Check labs (does patient need to be transfused prior? Type & Screen done
UTI? Double check SUH reads on outside path and make sure it is
agreement. Generally, there can be no surgery without internal review of
pathology) If in doubt, check with your fellow, attending, chief, etc.
iv.
Make sure there is a copy of consent (surgical and CA hyst if needed).
v.
Prep next month’s OR schedule as much as you can for the upcoming
team and upload it to the workspace.
II. Clinic
a. Prep New Pt charts and pre-ops ahead of time if possible. Upload file onto secure
workspace.
b. Clinic procedures: Colpo, LEEP, EMB, etc.
III. Floor
a. Help intern with floor tasks
b. Prepare discharge orders and discharge summary
IV. Tumor Board
a. Help prepare each week
b. Make sure you TELL the intern about any patients that need to go on Tumor
Board from clinic, the OR, or just randoms that the Attendings tell you about. It isn’t
as obvious as it may seem 
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Emergency Department
- Confirm patient’s primary MD (Privates see their own pts. We do not see Nezhat’s pts.)
- Request and await appropriate tests/imaging prior to seeing patient, unless unstable.
- Run all consults by chief resident before presenting to the attending
- Review the images with radiology before seeing the patient.
Coverage:
DAY: Check amion (password: stangyn).
NIGHTS/CALL: If pregnant, post-partum or first tri SAB - OB attending; Non-pregnant
or r/o ectopic: Gyn attending. If active REI pt, notify REI fellow on call first.
Common Consults:
1. r/o Ectopic
- Labs: BHCG, CBC, T&S – Ask RH status. (LFTs, BUN/Cr if MTX anticipated)
- Studies: TVUS
- F/up: If Beta < 2000 and no IUP  repeat Beta in 48 hrs, add to sign out.
If Beta >2000, no IUP and stable, set up for repeat Beta and US 48 hrs
Or consider MTX if high suspicion / undesired pregnancy (50mg/m2)
Stable, Beta < 6500, no CA, mass <3.5cm, reliable f/up
If unstable or relative contraindications for MTX  OR
2. Vaginal bleeding
- Hx: Pad count, Hct drop, sx.
- Imaging: consider U/S (thickened endometrial lining, polyp, fibroids)
- Rx: Admit if severe anemia, heavy active VB, risk factors
Estrogen: IV Premarin 25mg q4 x 24 or until decrease vb
Progesterone: IM or Megace
OCP taper (any 35mcg): tid x3d bid x3d qd (also Rx give anti-emetics)
D&C
- Outpt Rx: OCP taper, Progesterone
- F/up: Gyn Clinic or PMD, EMB as outpt if needed
3. Ovarian “mass”
- Studies: TVUS, CT if concerning for malignancy or poorly visualized
Discuss study directly with radiologist, confirm flow to ovary
- Incidental vs. Symptomatic—criterion for admission
4. PID
- Admit: TOA, failure of outpt abx, immunodeficiency, non-adherent or PO intolerant
- Labs: CBC, UA C&S, Blood Cx, GC/CT, full STI screen
A. Cefotetan (2g q12) or Cefoxitin (2g q6) and Doxy (100mg q12IV or PO) x 48 afebrile,
then Doxy 100mg bid po x 14d. If TOA, add Flagyl/Clinda.
B. Gent/Clinda x 48, then Doxy 100mg bid po x 14d
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5. True ER Emergencies: Ruptured ectopic, hemorrhage, ovarian torsion
- Notify attending ASAP!
- Call OR control desk and anesthesia attending
- Make sure T&C done
- Consent pt to OR
- May need to wheel pt to OR yourself
Miscellaneous
I. Night Float
a) Gyn/Onc/ED is priority … but let your chief know where you are 
b) Post op checks can be seen whenever you are free, unless there is a specific
concern that makes them high priority
c) Cover board ~ 5am for pp rounds
d) Sign out to Day teams. Courteous to keep the sign outs updated, highlight new
changes in far right or indicate in text somehow.
II. OR scheduling
a) Routine cases:
i) Schedule through Delila in Gyn or Kim in Onc
ii) Add on: M-F prior to 2PM on day prior to OR  do as above. After 2PM,
must call OR control desk yourself, may need to talk with anesthesia
(especially if urgent/emergent)
b) Emergencies
i) Call control desk—Tell them how urgent (Rolling patient up from ED as
you’re calling? Vs. Stable but shouldn’t wait until tomorrow?)
ii) Ask to speak to anesthesia attending in charge
iii) May need to facilitate transport from floor/ED yourself … especially if
unstable pt.
III. Phone Triage
a) Obtain full story, refer to previous notes. Okay to phone a friend (e.g. your chief!)
if you aren’t sure what to do.
b) Document, document, document. If you tell them to come to the ED, write it! If
you review ED/return precautions, write it! CYA!
c) For GYN/ Gyn Onc triage: Telephone encounter in Epic. Close encounter under
attending name (whoever sees that patient in clinic). Forward message to
Samantha Abraham if Gyn f/u is required as attending may not see for some time.
d) For OB triage: Create “Telephone Encounter” in PowerChart.
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