Obstetrics
I. Rationale
Pregnancy and childbirth are an important part of the family life cycle. The family physician, as the provider of primary care to individuals and families, is uniquely qualified to guide and deliver comprehensive, evidence-basedmaternity care to the pregnant patient and her family. The Emory Academic Health Center and clinical affiliates expose the resident to a breadth of obstetrical experiences with diverse patient populations.
This Family MedicineObstetrics curriculum is offered to residents over the three years of training in both didactic and clinical settings. The clinical phase consists of two components: the focused rotations at Grady Memorial Hospital (PGY1) and Emory University Hospital Midtown (PGY2) in obstetricsand family medicine inpatient service, and the longitudinal component which takes place over time in the family medicine outpatient clinics and on other rotations where obstetric-related continuity care is provided.
The primary goal of the obstetrics curriculum is to prepare residents with the knowledge, skills, and professional attitude to be competent in the provision of evidence-based, effective reproductive health care to patients.
II. Competencies
Patient Care
Goals:
- To communicate effectively and demonstrate caring and respectful behaviors interacting with
patients and their families when gathering essential and accurate reproductive health information, counseling, and be able to apply this knowledge to the care of the individual patient.
- To demonstrate the ability to effectively interview and evaluate patients for reproductive health promotion and treatment using appropriate techniques and skills to enhance the doctor-patient relationship.
- To demonstrate sensitivity to and knowledge of the emotional, psychosocial, and cultural aspects of reproductive health, pregnancy, labor and delivery and parental care of the newborn.
- To develop and implement patient managements plans using health information technology to support patient care decisions and patient education.
Objectives:
A. Demonstrate knowledge of and/or ability to perform:
1. New obstetric patient assessment, including history, physical, diagnostic andscreening
studies and patient education
2. Estimates of gestational age
3. Risk assessment protocols
4. Routine obstetrics visits, including gestational age specific testing and anticipatory guidance
5. Biophysical profiles
6. Pre-conceptual, anti/intra/postpartum counseling
B. Provide counseling to patients and their significant others regarding family planning,
including:
1. Different methods of birth control
2. Child spacing
3. Role of family members in pregnancy, delivery, and child care
4. Impact on family members, including spouse-spouse relations, sibling-parent
relations and sibling-sibling relations
C. Provide counseling in a non-judgmental manner to patients and their significant others regarding various options for managing an unwanted pregnancy, recognizing that there are multiple religious, ethical, and moral considerations in this counseling, and if unable to provide comprehensive counseling, be able to refer to a provider who can.
D. Communicate with a family, the news of fetal loss or congenital anomaly, recognizing the stages of grief, and appropriately scheduling the family back for follow-up.
E. Provide clear explanatory information and obtain consent on all patients undergoing diagnostic or therapeutic procedures in a manner understandable to the patient.
F. Discuss the pregnancy, treatment plan, anticipatory guidance, and lactation issues with the patient and her family in a manner understandable to all of them.
G. Review questions with patients and their families and elicit any concerns they may have.
Learning Activities: (check all that apply)Attending Rounds / Research Conference / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient Care
Grand Rounds / Specialty Conference / Resident Seminar
Subspecialty Conference / Noon Conference / Journal Club
X / Morning Report / X / Faculty Supervision / X / Critical Appraised Topics
Other (specify) / X / Self-study OB Monographs / Faculty facilitated self-critique of videotaped patient encounter
Evaluation Methods: (check all that apply)
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report: Senior Resident/Faculty
X / Program Director
Review / X / In-Training Exam / X / Supervision and Feedback
360° Evaluation / x / Oral Report / X / Record Review
Medical Record document review
X / Other (specify) PALS and Neonatal Resuscitation Course exams / X / Case presentation
Medical Knowledge
Goals:
- To provide comprehensive antepartum care, utilizing assessment tools and screening methods for pregnant patients.
- To identify common antepartum complications and know how to manage these complications.
- To deliver appropriate intrapartum care for pregnant patients.
- To identify common intrapartum complications and know how to manage these complications.
- To provide appropriate postpartum care for pregnant patients.
- To identify postpartum complications and appropriately manage these complications.
- To provide effective care of the normal newborn.
- To perform neonatal resuscitation.
- To recognize ectopic pregnancies and manage them effectively.
Objectives:
A. Demonstrate knowledge of and assist in the performance of:
1. New obstetric patient assessment, including history, physical, diagnostic and screening studies and patient education
2. Estimates of gestational age
3. Risk assessment protocols
4. Routine obstetrics visits, including gestational age specific testing and anticipatory guidance
5. Biophysical profiles
6. Pre-conceptual, anti/intra/postpartum counseling
B. Demonstrate knowledge of the following ante partum complications and their managements,
assisting in the management of those that present in the clinical setting:
1. First trimester bleeding
2. Third trimester bleeding
3. Gestational diabetes
4. Pregnancy-induced hypertension, pre-eclampsia, eclampsia
5. IUGR / macrosomia
6. Premature rupture of membranes
7. Pre-term labor
8. Abdominal trauma
9. Advanced maternal age
10. Abnormal AFP
11. Anemia
12. Abdominal pain
13. Sexually transmitted infections
14. UTI/ pyelonephritis
15. Positive group B strep
16. Oligohydramnios
17. Polyhydramnios
18. Abnormal lie
19. Hyperemesis gravidarum
20. Post-date pregnancy
21. Size-date discrepancy
C. Demonstrate knowledge of and/or ability to perform under faculty supervision:
1. Pudendal/local block anesthesia
2. Normal vaginal delivery
3. Placement of Fetal scalp electrode
4. Placement of intrauterine pressure catheter
5. Vacuum/forceps delivery
6. Episiotomy and repair
7. External fetal monitoring
8. Analgesia during pregnancy
9. Determination of rupture of membranes
10. Leopold maneuvers
11. Determination of cervical dilatation, effacement, presentation, station
12. Use of Ultrasound to determine presentation
13. Stages of labor, and normal labor curve
14. First person assist in Cesarean Section
D. Demonstrate knowledge of the following intrapartum complications and their managements, managing or assisting in the management of those that present in a clinical setting under faculty supervision:
1. Prolonged rupture of membranes
2. Abnormal presentation, position
3. Fever
4. Active herpes
5. Labor disorders
6. Meconium
7. Vaginal/cervical lacerations and repair
8. Vacuum delivery
9. Breech delivery
10. Retained placenta
11. Shoulder dystocia
12. Abnormal fetal tracking
E. Demonstrate knowledge and display skills under faculty supervision to perform:
1. Manual extraction of placenta
2. First assist of tubal ligation and hysterectomy
F. Demonstrate knowledge and displays skills in the management of post-epidural complications under faculty supervision for:
- postpartum hemorrhage
- postpartum infection
- postpartum PIH
- amniotic fluid embolism
G. Demonstrate knowledge of care of the normal newborn including:
1. Estimating gestational age by Dubowitz criteria
2. Initial physical examination
3. Initial prophylactic medications
4. Initial feeding of the infant in the delivery room
5. Ability to perform circumcisions under faculty supervision
H. Demonstrate knowledge of and skills in neonatal resuscitation by passing the course and performing correctly in the clinical setting.
I. Describe typical signs and symptoms, the work-up, and management of an ectopicpregnancy.
Learning Activities: (check all that apply)x / Attending Rounds / Research Conference / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / x / Direct Patient Care
Grand Rounds / Specialty Conference / Resident Seminar
Subspecialty Conference / Noon Conference / Journal Club
x / Morning Report / x / Faculty Supervision / x / Critical Appraised Topics
x / Other (specify)
Self study Ob modules / x / Ambulatory Care Clinic / x / Neonatal Resuscitation and PALS courses
Evaluation Methods: (check all that apply)
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report: Senior Resident/Faculty
X / Program Director
Review / X / In-Training Exam / X / Supervision and Feedback
360° Evaluation / x / Oral Report / X / Record Review
Medical Record document review
X / Other (specify) PALS and Neonatal Resuscitation Course exams / X / Case presentation
Practice-Based Learning and Improvement
Goals:
- To understand the need for and engage in continuing self-education about updates in obstetrics using information technology and other modes for learning evidence-based care.
- To identify gaps in obstetrics knowledge and skills and set learning and self improvement goals.
- To develop a vision for whether obstetrics may be part of future practice.
Objectives:
- Discuss the value of including Obstetrics in the practice of Family Medicine.
- Accept and respond positively to constructive feedback for self- improvement.
- Construct an educational experience that allows for additional training in obstetrics as indicated, based on self-identified personal knowledge and skills gaps to be prepared for on anticipated future practice including obstetrics. If obstetrics are not to be part of a future practice, describe how the family physician may interact with the pregnant patient and her family to help ensure the most gain from the experience.
- Participate in a quality improvement/practice management project to assess the degree of compliance with an evidence-based or best practice clinical guideline related to Obstetrics, and report the findings and plans for improvement.
- Identify sources to which residents may turn for more information or continuing education on family-centered obstetrics.
Learning Activities: (check all that apply)
Attending Rounds / Research Conference / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / Direct Patient Care
Grand Rounds / Specialty Conference / Resident Seminar
Subspecialty Conference / Noon Conference / Journal Club
Morning Report / X / Faculty Supervision / Critical Appraised Topics
Other (specify) / Portfolio development / QI Project
Evaluation Methods: (check all that apply)
X / Attending Evaluation / Directly Supervised Procedures / Morning Report
Program Director
Review / In-Training Exam / X / Faculty Supervision and Feedback
Quality Improvement
Project presentation
Other (specify)
Interpersonal and Communication Skills
Goals:
- To learn to communicate efficiently and effectively with obstetric patients and their families, the health care team and obstetric consultants.
- To communicate and document clearly and completely using written and verbal methods.
- To demonstrate sensitivity to patient and family cultural, lifestyle, race, gender, age, disability issues.
- To develop effective interpersonal and teaching skills for participation in the healthcare team and for support of maternity patients and their families including use of language translators.
Objectives:
- Prepare a consultant referral form which contains a complete and succinct summary of the patient’s diagnosis, accurate description of the problem, the question for the consultant, and other information pertinent to the referral.
- Utilize, and facilitate the communication of accurate information effectively with other members of the health care team, patients and their families in a timely manner.
- Present patient cases accurately and effectively.
- Effectively, accurately, efficiently document obstetric patient encounters in the medical record.
- Communicate effectively with obstetric patients and their families.
- Communicate effectively verbally and in writing with community healthcare partners.
Learning Activities: (check all that apply)
x / Attending Rounds / Research Conference / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / x / Direct Patient Care
Grand Rounds / Specialty Conference / Resident Seminar
Subspecialty Conference / Noon Conference / Journal Club
Morning Report / x / Faculty Supervision / Critical Appraised Topics
Other (specify)
Videotape patient encounter and self-critique / Ambulatory Care Clinic / x / Focused observation of faculty professional role models
Evaluation Methods: (check all that apply)
x / Attending Evaluation / x / Directly Supervised Procedures / Morning Report:
Program Director Review / x / In-Training Exam / x / Supervision and Feedback
Senior Resident/Faculty
360° Evaluation / x / Checklist evaluation of Patient interaction videotaped performance
Other (specify) / x / Patient surveys
Other (specify) / x / Videotape review of patient encounter
Professionalism
Goals:
- To develop a commitment to carrying out professional responsibilities
- To adhere to ethical principles
- To develop sensitivity to a diverse patient populations
Objectives:
- Displays behavior that is patient-centered, team-oriented, compassionate, ethical and sensitive to patient culture and beliefs.
- Demonstrate personal responsibility for compliance with residency program policies and procedures, for responsible management of patient records, follow-up on diagnostic study results, patient phone requests for information, clarification, and medication.
- Displays behavior that reflects initiative, punctuality, dependability and responsibility.
- Completes charting in a timely manner, and maintains up-to-date duty hour, delivery volume and obstetric procedure documentation.
- Demonstrate attention to detail and appearance that reflects respect for self, the profession, patients and families.
Learning Activities: (check all that apply)
Attending Rounds / Research Conference / Outpatient Clinics
Multidisciplinary
Rounds / Ethics/Comm Conference / x / Direct Patient Care
Grand Rounds / Specialty Conference / Resident Seminar
Morning Report / Noon Conference / Journal Club
Other (specify)
Prepare an EBM Case Review / x / Faculty Supervision / Critical Appraised Topics
Self critique patient interaction videotape / x / Observe behavior of faculty role models
Evaluation Methods: (check all that apply)
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report
Program Director
Review / In-Training Exam / X / Faculty Supervision and Feedback
X / Other(specify)
360° Evaluation / Portfolio
X / Other(specify)
Videotape review and facilitated critique
Systems-Based Practice
Goals:
- To understand the value of obstetrical care in the practice of family medicine and the positive impact on patients and families.
- To identify and utilize community and system resources to support effective and efficient maternity care.
- To learn to bill appropriately for services and procedures.
- To utilize a team approach to patient care and quality improvement practices.
Objectives:
- Participated effectively in team-based, patient-centered approach to comprehensive health care for female patients and their families
- Meet patient needs or arrange for the comprehensive reproductive health promotion and management services
- Fully utilize community and system resources to optimize high quality reproductive health management.
- Demonstrated the interest in teaching less experienced learners how to provide high quality, patient centered obstetrical care within the healthcare system and community.
- Utilize appropriate coding and billing procedures and clinic resources for efficient, effective, patient centered reproductive health services and practice management.
- Demonstrate sensitivity to cost containment, patient safety, best practices guidelines, and comparative effectiveness in clinical decisions.
- Compare and contrast the patient satisfaction, provider satisfaction, practice cost/revenue and obstetric patient health outcomes in Family Physician practices that offer or choose not to offer obstetrical services
- Participate in a practice management project on a healthcare systems topic.
Learning Activities: (check all that apply)
x / Attending Rounds / Research Conference / x / Outpatient Clinics
Multidisciplinary
Rounds / Ethics/Comm Conference / x / Direct Patient Care
Grand Rounds / Specialty Conference / x / Resident Seminar
Subspecialty
Conference / Noon Conference / x / Journal Club
Morning Report / x / Faculty Supervision / x / Critical Appraised Topics
x / Other (specify)
Practice Management project
Evaluation Methods: (check all that apply)
Attending Evaluation / Directly Supervised Procedures / Morning Report
x / Program Director Review / In-Training Exam / x / Faculty Supervision and Feedback
Other(specify) / Portfolio
Other(specify) / Project presentation
III. Instructional Strategies (see above)
A. Observation of obstetrics preceptor role models and upper level resident’s assessment
of actual patients in labor and delivery
B. Management of actual patients in continuity clinic case discussions
C. Ambulatory care conference and core obstetric readings
D. Associated rotations: family medicine, pediatrics, and newborn nursery
IV. Evaluation Strategies (see above)
A. Observation of resident by obstetric preceptor (PC, K, PBL, CS, P, SBP)
B. Observation of resident clinical performance and medical record documentation by
clinic preceptor (PC, K, CS, P)
C. Procedure/diagnosis documentation. (PC, K, CS, P)
D. End of rotation evaluation (forms: all competencies)
E. Performance on the Obstetrics section of the in-training exam and mini-quizzes (K)
F. Evaluation of case presentation PC, K, PBL, CS, P, SBP)
V. Implementation Methods
The PGY1 resident is scheduled for the Obstetric core rotation at Grady Memorial Hospital, where he/she joins the team of an OB intern and an OB PGY3 resident, who assumes responsibility for the team under the supervision of OB/GYN faculty. The team is responsible for the triage area. The Family Medicine resident and the OB intern share responsibility for seeing all patients coming through the triage area, and all patients are signed out to the OB PGY3 resident. The Family Medicine resident primarily sees term patients (=/> 37 weeks gestation), except when the OB intern is unable to handle the volume of pre-term patients and beginning the patient evaluation to rule out the need for emergency measures. The Family Medicine resident is expected to attend morning report, the Grady OB/Gyn didactic sessions, and will participate in the labor, delivery and C-section activities. Each Family Medicine resident should have the goal of doing and documenting at least 30 vaginal deliveries by the end of this rotation.
The obstetric curriculum has several components. During all training years, the didactic teaching sessions includes obstetrics-related presentations. In the PGY-1 year the resident rotates through the Ob-Gyn department of Grady Memorial Hospital for four weeks. The resident is responsible for triage of all patients that present to this clinic along with the OB intern. In addition the resident will be called to all deliveries during the shift. The rotation consists of 12 hour shifts (7pm-7am) Monday through Friday. The resident is required to read the following monographs (pregnancy care and medical conditions of pregnancy) and to score >90% on the written exam. It is required that on at least three occasions during this rotation that the supervisor rechecks the examination of the cervix to document competency in cervical examination.