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Hard Work Beats Talent When Talent Doesn’t Work!Welcome to OB RotationGoals: Deliver babies, learn management of common problems in L&D1) Before your first day please read Pages 145-181 (Research Family Medicine Residency Survival Guide)Day Shift6:00 am Arrive: Everyone including medical students arrive for check out with night float After checkout notify OB Goppert attending of labors, inductions,PPNotify Newborn Goppert attending of circs/newborns (Newborn Resident should call nursery to determine how many circs there are for the day)RIC divide patients (must be seen with note written before 9am rounds)Medical student must see at least 2 PP patients per day6:30am-7:45am See patients and write notes Night floatstays to see triage, do C-sect/ induction H&P and deliveries if they have been following a patient overnight(if no triage, H&P needed or deliveries may leave at discretion of team)7:45 am Nurses huddle-every one attends (except night float)Night float leaves8-9 amFinish notes- all notes are to be done in computer before work rounds 9-10:30 amRounds –You will be responsible for presenting all patients on floor See next page for examples of how to presentDon’t forget you need to know about Goppert patients Continutiy residents need to have notes written in computer (or fill out checkout template)And checked out to team Newborn resident will also be responsible for knowing about and presenting Goppert babies that are in the NICU-talk with NICU nurses/NNP each morning and establish a good relationship with them so we can begin increasing our knowledge of neonatal care/management.Longitudinal- residents are required to read assigned article and fill out study sheet for each article on daily basis. The didactic portion of rounds will focus on hands on learning of the topic of the day. On Friday’s we will do board question review.2 days before the end of rotation a written test will be given. This should help residents assess their own knowledge of OB/NB10am-6pmDeliver Babies (Yippee hope you deliver a lot!)Do triage6:30pm Check out Page GTFM faculty with update (inductions/labors )Ensure the list is updated with accurate and thorough information (see the guidelines for updating the list in the rounding room above the computer, this make rounding and presenting patients much more efficient!)Current Helpful Hints:Divide the listOn Call – see Antepartumand PostpartumNewborn – see babies and postpartumMedical student - write at least 2-3 paper notes in the morning assigned by residents If one person is done early please help the otherTriage – On call resident should triage new patients but if overwhelmed newborn resident must help. Triage has an order set(called OB-ED Triage)which has labs and medicines which must be on CPOE-All triage patients MUST be admitted through the OB ED triage order set, but you still fill out the PAPER H&P form when evaluating all triage pts.Remember that when you enter orders on CPOE it needs to coorespond to the time that the nurse faxes the admitting order to admitting. So note that time and change your orders to that timeAll orders must be entered into the computer on CPOE, however you may still give verbal orders to the nurses--don’t be afraid to ask them to take a verbal order from you if you have your hands full but help them out and put in orders if you aren’t doing anything at that moment.There is a pink notebook which has sample CPOE orders (and preferences per provider) so check this out and use it.Location :Goppert drawer Checkout all your triage patients to the correct attending (SBAR)Goppert patients to continuity resident then Goppert attending (unless emergency). You should have an imp/plan on check out. Midwest patients to their PCP unless after 5pm or before 9am then notify the on call docResidents like to be called on all their patients at all times-they will then tell you if they want you to continue coordinating with them or if they want you to coordinate with the on-call docResidents must determine which patient is stable enough for medical students to evaluate but medical student must see stable triages before the resident.AdmissionsUse the PAPER H&P form you filled out to dictate from (only pts who are actually getting admitted need an H&P dictated)Admit under doctor you discussed admission withAll Inductions need US for fetal positioningUse the OB orders sets when admitting a pt. on CPOE (OB-Vaginal admission, OB preterm admission, etc.) Remember when admitting a late preterm infant that you need to use that order set. Make sure you mark yes to pre-admitting baby on the CPOE admission order setsNST’s need an order in CPOE, then fill out the paper form for the dx, and interpretation.Laboring PatientMonitor heart tones if non-reassuring contact physician immediatelyNotify attending of progression or questions you may haveRemember the attending has to be notified for change in status (ie give an epidural, give blood pressure meds, a patient has rapid progression).I have only seen problems when residents are not communicating enough!Progress note every 2 hours in any labor patient(OB-Intrapartum note in PDOC)Remember you are responsible for all patients on floor (so you should know if an induction is going into labor, or an antepartum has a changing status)Goppert continuity residents should arrive when:Multigravida – 6 cm dilationPrimigravida – 8 cm dilationOr if patient has any change in status which is worrisomeAlways notify the Goppert continuity resident when their patient arrives in triage, in labor or for previously scheduled IOL or C/SPostpartumAssign medical students to round on postpartum patientsUse OB – Postpartum PDOC progress note template in computerCo-SignEven if he didn’t deliver the patient but they are PCPOther docs assign to whoever the delivering physician wasTHIS MAY CHANGEDischarge – Use OB – discharge templateLeave discharge order incomplete but fill out everything else in RED including med reconciliation-you will d/c that patient later in the day after faculty has rounded on them and has approved dischargePrint new scripts using script printer closest to youAntepartumUse OB – Antepartum templateAssign to doctor rounding on patientDeliveriesDictate deliveries and if swope patient CC swopeMake sure to put your procedures into my evalsTransfer patient to postpartum unit in ordersOn service resident should attend all Goppert deliveries…may do infant careContinuity Residents should notify OB Coordinator about deliveries by filling out form and faxing (located in drawer)Name of patientDate of deliveryGender of newbornType of deliveryBreast or bottle feedingContraceptionNewbornNew born resident notify attending again at 7AM on admissions and circs including NICUAfter a baby is born, ask nurses if they will be followed by us (Goppert) or by Pediatrician on-call; if they are our patient ask nurses to print out Newborn H&P form (paper). This should be filled out within one hour of baby being born-Newborn resident should do this if baby is born in the morning, but on-call resident (or continuity resident) should do this if born in the afternoonAdmit H&P is on paper,Do newborn progress note(Well baby progress note on PDOC)Discuss and sign circ consent with parents (Do this while rounding on mom or baby prior to circ day so that it is done)Use to check bilirubin levelsInfants need blood sugars if <10% or >90% on growth chart, or mother with DMIf called with Coomb + test-order CBC with diff, reticulocyte count, Neonatal Bili stat , these results should be immediately called to attending when availableCan use Ballard if not sure if appropriate for gestational ageMedical Student should perform at least one circGive discharge pamphlet/booklet to parentsPOLY-VI-SOL D 1 (cholecalciferol) 400U dropper full poqday for the first 12months of lifeFax H&P/Discharge Form to Deb Law 816 276 7992—if baby will be followed at GoppertCan print and give to unit secretary to Fax Discharge Form to Swope 816 922 7685Also print a copy of discharge summary for the patient to take to physicianCall Deb Law and Swope (816 922 7645 ext 6261) to make follow up appointmentsdischarge summary in PDOC-add physical exam, and Hepatitis immunization, discharge weight/%loss (subject to change)Please uncheck glucose monitoring and then check high risk glucose monitoring on admission order sets. NSTPlease call other attending for NST unless told not to.Needs order for NST in CPOE, written interpretation and diagnosis okMiscellaneous Info:ALWAYS ask any Levine pt if they are a continuity patient of Genna SeimensContinuity residents are responsible for being involved in the triage of their patients. They are also responsible for being at every delivery (this isn’t always possible), and for doing the mother’s H&P, the Baby’s H&P and for rounding on their patients at least one day while they are admitted. Responsible for discharging their patients and ensuring appropriate follow up. They should also be in touch with the OB team each day in regards to the management of their patients. The OB team is responsible for presenting all newborn patients as if they had seen them. Please get in touch with OB continuity to get all info or to present.Examples of CPOE orders filled out can be found in pink notebook in Goppert drawer at nurses stationSwope babies- ask mom to call Swope and make follow up appt for no later than 48 hours after discharge. (think ahead if its going to be a weekend) IF they do not have an appt by PPD#2 Call Peds LPN 816-923-5800 Ext 4240 to make appt. On discharge print 2 discharge summaries and give 1to patient to take to their appt, and 1 to unit secretary to fax to SwopeOB triage and home call instructions.PLEASE NOTE:? In an emergency, call the faculty first!!? Please ask Dr. Tramp or myself if you have any questions.OB pager home calls:?All home calls are first checked out to the continuity resident following the patient, and then to the OB faculty on call.? The OB faculty on call is the person listed in the amion schedule.? The continuity resident should suggest a plan and a plan should be suggested to faculty when you call.? Home calls in the night time can be checked out to the faculty on call.? (10pm-6am).? For continuity residents working night float, phone calls during the day can be checked out to faculty (8am-4pm).? If the plan made includes the patient coming to triage, you can wait to call the continuity resident until the patient is present in triage.An ECW? telephone encounter should be created for ALL home calls.? A brief description of the question and plan should be charted, and the telephone encounter assigned to the continuity resident as FYI.? Make a telephone encounter even if the plan is for the patient to come to triage.? If the patient doesn’t show up, we still have a record of the phone call.To figure out who the continuity resident is, look in the ECW OB flowsheet.? It should be the first thing on the problem list.? Patients at the outreaches and inreach often say their doctor is the faculty at their track site, so you have to look for the resident if the patient doesn’t know their name.? (The faculty are listed on all appts, all labs, all ultrasounds – frequently the patients don’t realize their doctor is not the name on all their paperwork!)? Here’s an example of the flowsheet listing the continuity resident.?For reference sake, the OB track sites are:Harrisonville Lifechoice.? Faculty:? Tieman, Residents:? Stefanovic and MincherLees Summit.? Faculty:? Philgreen, Residents:? Argubright and BrouwerLevine at Midwest Women’s, Resident:? ColaneseInreach at GTFC.? Faculty:? Tramp, Residents:? Westhues, , Zarrabi, GaultAny patient who say they belong to the above faculty, please also ask who their resident is.? ?All patients must be checked out within 30 minutes of seeing the patientFirst check out to the continuity resident and make a plan, then call the OB faculty on call with the proposed plan.? (This is the faculty listed in amion.)? In an emergency, call the faculty first!Continuity residents are to be called for all triages, regardless of time of day.Under no circumstances should a patient be sent home from OB triage without the OK of the facultyPostPartum SVDThis is a __yo G__P__ now P__who is Postpartum D#___after SVD. PNC was complicated by_____. Her Labor and delivery course were uncomplicated/or complicated by (ie postpartum hemorrhage requiring methergine and cytotec, 4rth degree, or PIH)S: She is doing ____ Lochia is (minimal/heavy)(if heavy comment if she has lightheadedness/sob) .She is voiding_(well) and ambulating (without difficulty) Breast/bottle feeding ___(without difficulty).O: She is afebrile, BP –range (numbers), Pulse-range, UO- Fundus_(firm)__and __(2)finger breadths below umbilicus, Ext-without edema/homansPre Hgb ____/PP Hgb___Imp:1) S/P SVD PPD#__, doing well2) any other prob (ie. PIH/Rh-needs rhogam, needs rubella)Plan: She will use ______for contraception( tubal papers signed on chart,etc), She will be d/c with __(Ibuprofen, Tylenol #3, PNV, FeSo4) _____(today/tomorrow), and Follow up on __________.PostPartum OVDThis is a __yoG__P__nowP__who is PPD#__ s/p __(Forceps/vacuum)__ assisted delivery secondary to _____. A episiotomy was/was not cut. A ___degree perineal laceration was repaired. Labor and delivery course was otherwise complicated/uncomplicated. Her PNC was complicated by _______.S: She is doing ____. Lochia is (minima/>than heavy period). She is voiding__(well)__ and ambulating (with/without) difficulty. Breast/bottle ( with/without) difficulty. O: Afebrile, BP-range, Pulse-range, UO-Uterus-firm __fingerbreadths below umbilicus, Ext-with/without edema/(+/-) Homans, vaginal exam-laceration healing well ,no hematoma (check for 3rd/4rth degree tears)Pre Hgb__/Post Hgb__Imp: S/p OVD PPD #__, doing wellPlan: She will use _____for contraception, To keep stools soft she will use (miralax/colace) for next 4 weeks, D/C meds are _________. She will follow up ____________ with ____________.High Risk Antpartum__yo G__P__ with EGA(by LMP/U/S) admitted with__________________ PNC otherwise complicated by_______HPIPMH/POBH /PSh including prenatal care/FH/SH/Meds/ALLROS based on clinical presentationPELABSIMPPLAN(Betamethasone, Procardia, mag US, fetal presentation, prior OB history, consents, results of culture (GBS/GC/CHL/urine,etc)PostPartum C-SectPt is a __yoG__P__now P__ who is POD#__s/p a (primary/repeat) (low transverse) CSECT secondary to __________(failure to progress/breech/fetal reasons).L&D course was otherwise ____________(complicated by/uncomplicated) Prenatal care was complicated by____________. S: She is doing well this AM,( Breast/bottle ) feeding(with/without) difficulty. Lochia (minimal/heavy if heavy –lightheaded/sob) Foley (removed/present). Pt (has/has not) voided.(Has/Has not ambulated. Eating PO without difficulty. Pain is controlled on ______.O: afebrile, BP-range, P-range, I/OUterus-firm and below umbilicus, incision- clean /dry and intact (with dressing intact), ext-(+/-) edema, (-) homansPreHgb__/PPHgb__Imp: s/p Csect POD #__doing wellPlan : D#1-d/c foley/increase ambulation D#2-increase ambulation D#3-remove staples, place steri-strips, d/c homeShe will use ______for contraception. D/c meds will be (norco/Percocet/Pnv/FeSo4/Miralax). She will follow up with ____in __weeks. Newborn PresentationBaby (boy/girl)_____ is a __wk infant born via (csect/ovd/svd) yesterday to a __yo G__P__ with Prenatal labs as follows: GBS (+/-), Blood type/aby, HBSag (+/-), HepC Aby (+/-), HIV (+/-), RPR (non-reactive), GC/Chl (+/-). Pregnancy was c/b (gest dm, PIH, preterm labor, etc). ROM occurred __hrs before delivery. Delivery was complicated by (tight nuchal cord, Category 3 tracing, etc) Infant weighed _____gm and had Apgars of __/__. Normal resuscitation (or Resuscitation consisted of ____________)Today infant is doing well, (breast /bottle) feeding without difficultyS: Weight today / ____% wt loss, ___voids/___stools Exam : pertinent positives. –skin rashes, jaundice, murmurs, clicks, etcLab: bili ____ (risk zone), Blood sugars _____, Preductal/postductal Pox, hearing test resultImp:1)DOL# __, doing well 2) any issues (poor feeding, erythema toxicum, jaundice, sga,hypoglycemiaetc)Plan: Continue supportive care for feeding, (address each issue as brought up), Hep B immunization (was/was not) given, Home health (poor feeding/follow up jaundice), F/u _____Delivery SummaryDate of admission:Date of delivery:Attending physician:PCP:Pre-delivery diagnosis: (e.g pre-term/term/post-dates intrauterine pregnancy, suspected LGA, labile HTN, GDM, etcPost-delivery diagnosis: same as pre-delivery dx; delivery of viable term M/F infant, Apgars __ and __Procedure(s): Pit induction, AROM, SVD, etcDelivery physician(s):Anesthesia: Epidural vs. IV vs. none Findings: Term SGA/AGA/LGA M/F infant, Apgars __ and __, complete 3 vessel placenta (oligo, etc)Description of procedure: Ms. ___ is a __ yo F, G__nowPxxxx at __._ wga delivered a term viable M/F infant weighing ___. Apgars were __ and __ at 1 and 5 minutes of age. Prenatal course (was unremarkable/consisted of/etc.) The pt presented to the L&D floor on __/__/__ with SROM/bleeding/etc, (underwent Pit induction/AROM/SROM/etc). Epidural was placed at __ cm. Stage 1 of labor lasted __ hours __ min. Stage 2 of labor lasted __ min. Nuchal cord present? (Pit infused with delivery of anterior shoulder?) Infant was bulb suctioned at the time of delivery. Cord was doubly clamped and cut and infant was handed to a waiting nurse/NICU team. Cord blood (and cord gases?) sent for analysis. Intact placenta with 3 vessel cord delivered spontaneously at __ hours. Stage 3 of labor lasted __ mins. Pitocin infused (now, or with delivery of anterior shoulder?). Uterus, cervix, vagina, and rectum were explored and __ degree perineal/introital/periurethral/etc lac was repaired in the normal fashion with __ suture. EBL __. Pt and infant remained in room in stable condition. Dr. Attending present for stages 2 and 3 of labor. Sponge, lap, and instrument count correct x 3. ................
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