updated july 2014 - university of alabama at birmingham · updated july 2014 mfm curriculum goal:...
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Updated July 2014
MFM Curriculum
Goal: The overall goal of the MFM/Obstetric rotations at the University of Alabama at Birmingham is to train resident physicians (PGY1-4) to have the knowledge base and clinical expertise to manage the full range of obstetric care, including the medical and surgical complications of pregnancy, experience in the management of critically ill patients, and surgical intervention where appropriate. The clinical curriculum includes competency based goals and objectives for each PGY level as well as diagnostic and interventional/surgical procedural skills as described below.
All obstetric training occurs in the UAB Women & Infants Center inpatient and outpatient facilities and in the Obstetrical Complications Building (OBCC, 1500 6th Avenue South). Residents provide patient care under the supervision of the MFM faculty and fellows as described in the Resident Manual. Details of the Obstetric service organizational structure and resident responsibilities at each PGY level are provided in the Resident Manual. Clinic schedules are available in the Resident Handbook.
Regular didactics addressing Obstetric objectives occur each Wednesday morning 6:30-7:00am in the Hauth Conference room and during Friday didactics with OB M&M Conference and selected faculty lectures. The Wednesday MFM didactics follow the objectives below (based on the CREOG objectives, 9th ed) and the MFM reading list (available on the residency web site). A monthly journal club is also held during the Wednesday morning session.
Abbr: PC: Patient Care, MK: Medical Knowledge, PBL: Practice-based Learning, ICS: Interpersonal & Communication Skills, P: Professionalism, SBP: Systems-Based Practice
Goal: To develop an understanding of the Basic Science principles and Mechanisms of Disease underlying normal and complicated pregnancy.
PGY Level PC MK PBL ICS P SBP
Objectives
Describe the major physiologic changes in each organ system during pregnancy. 1,2,3,4 x
Evaluate symptoms and physical findings in a pregnant patient to distinguish physiologic from pathologic findings. 1,2,3,4 x x
Interpret common diagnostic tests in the context of the normal physiologic changes of pregnancy. 1,2,3,4 x x x
Describe the muscular and vascular anatomy of the pelvis and vulva. 1,2,3,4 x
Updated July 2014
Describe the anatomic changes in the mother caused by normal physiologic adaptation to pregnancy. 1,2,3,4 x
Describe the anatomic changes that occur during the intrapartum period, such as cervical effacement and dilatation. 1,2,3,4 x
Describe the anatomic changes that occur during the puerperium, such as alterations in the breast and uterine involution. 1,2,3,4 x
Describe the role for nutritional supplementation in pregnancy (e.g., iron, folic acid). 1,2,3,4 x
Describe the impact of pregnancy on serum and tissue drug concentrations and drug efficacy. 3,4 x
Describe the factors that influence transplacental drug transfer. 3,4 x
Describe the possible teratogenic effects of prescription drugs in pregnancy, such as: Tetracycline, Angiotensin-converting enzyme inhibitors and angiotensin antagonists, Quinolone antibiotics, Lithium, Isotretinoin, Seizure medications, Depression and anxiolytic medications
2,3,4 x
Describe the possible teratogenic effects of nonprescription drugs, such as: Alcohol. 2,3.4 x
Describe symptoms and physical findings suggestive of malignancy in the pregnant patient. 3,4 x
In consultation with a medical or gynecologic oncologist, counsel a patient about treatment options and their impact on pregnancy and the timing of delivery. 3,4 x x x
Describe how the maternal immune response is altered by pregnancy. 2,3.4 x
Describe the association between genital tract infection and adverse perinatal outcomes, such as: Preterm labor, Preterm premature rupture of membranes, Neonatal infection, Maternal infection.
2,3,4 x
Updated July 2014
Goal: To develop competency in the antepartum care of normal pregnancy.
PGY Level PC MK PBL ICS P SBP
Objectives
Preconception care:
Perform a thorough history, assessing historical and ongoing risks that may affect future pregnancy.
1,2,3,4 x x
Counsel a patient regarding the impact of pregnancy on maternal medical conditions. 2,3,4 x x x x
Counsel a patient regarding the impact of maternal medical conditions on pregnancy. 2,3,4 x x x x
Counsel a patient regarding appropriate lifestyle modifications conducive to favorable pregnancy outcome. 2,3,4 x x x x
Counsel a patient regarding appropriate preconception testing. 2,3,4 x x x x x x
Counsel a patient regarding pregnancy-associated risks and conditions, such as: Advanced age, Hypertension, Diabetes, Genetic disorder, Prior aneuploid or anomalous fetus/newborn.
2,3,4 x x x x
Genetic counseling:
Elicit a history for inherited disorders, ethnic- or race specific risks, and teratogen exposure.
1,2,3,4 x
Describe the clinical significance of heritable diseases, such as cystic fibrosis, Tay-Sachs disease, and hemophilia. 2,3,4 x
Updated July 2014
Counsel patients about the techniques for and implications of testing for heritable diseases. 3,4 x x x
Describe the clinical significance of karyotype abnormalities, such as: Trisomy (13, 18, 21), Polyploidy, Monosomy, Sex chromosome abnormalities, Deletions, Inversions, Translocations, Mosaicism
3,4 x
Discuss treatment and surveillance options for patients or newborns with genetically derived disease. 2,3,4 x x
Describe the concepts of penetrance and variable expression and their impact on prognosis for a given genetic disorder. 3,4 x x
Distinguish between various forms of genetic inheritance: Autosomal dominant, Autosomal recessive, X-linked, Mitochondrial, Genomic imprinting 1,2,3,4 x
Counsel patients about the manifestations of common genetic disorders. 3,4 x x
Describe the indications for, and limitations of, noninvasive diagnostic tests for fetal aneuploidy and structural malformations (e.g., ultrasonography, serum analytes). 2,3,4 x x x
Counsel a patient and her family after adverse pregnancy outcome about such factors as recurrence, future care, and possible interventions. 3,4 x x x
Counsel a patient about the genetic implications of advancing maternal and paternal age. 3,4 x x
Prenatal care:
Perform a comprehensive history and physical examination. 1,2,3,4 x x
Order and interpret routine laboratory tests and those required because of risk factors during pregnancy. 1,2,3,4 x x x x
Updated July 2014
Counsel patients about lifestyle modifications that improve pregnancy outcome. 1,2,3,4 x x x
Counsel patients about appropriate immunizations during pregnancy. 2,3, 4 x x x x
Counsel patients about warning signs of adverse pregnancy events. 1,2,3,4 x x
Counsel patients about the risks and benefits of various methods of invasive fetal testing, such as: Chorionic villus sampling, Amniocentesis, Cordocentesis, Pre-implantation genetic testing
2,3,4 x x x x
List ultrasonography findings that are often associated with genetic disorders: Duodenal atresia, Omphalocele, Nuchal translucency/nuchal skin fold, Echogenic bowel, Heart defects, Diaphragmatic hernia, Ventriculomegaly
2,3,4 x
Counsel a patient with an abnormal fetus regarding management options. 3,4 x x x x
Schedule and perform appropriate antepartum follow-up visits for routine and high-risk obstetric care. 1,2,3,4 x x x
Describe the indications and uses for umbilical cord stem cells and counsel patients on the advantages and disadvantages of umbilical cord blood banking. 4 x x x x
Counsel a patient and other health care professionals about fetal effects from exposure to various pharmacologic agents or to indicated diagnostic studies utilizing ionizing radiation.
2,3,4 x x
Counsel patients about the benefits of breast feeding. 1,2,3,4 x x x
Antepartum fetal monitoring:
Describe the indications, contraindications, advantages, and disadvantages of antepartum diagnostic tests, such as: Nonstress test, Contraction stress test, Biophysical profile, Vibroacoustic stimulation test, Doppler velocimetry.
1,2,3,4 x x x x
Updated July 2014
Perform and interpret antepartum diagnostic tests accurately and integrate the interpretation of such tests into clinical management algorithms. 3,4 x x x x
Goal: To discuss and participate in the management of common Medical Complications of pregnancy.
PGY Level PC MK PBL ICS P SBP
Objectives
Diabetes mellitus:
Classify diabetes mellitus in pregnancy. 1,2,3,4 x
Interpret screening tests for gestational diabetes. 1,2,3,4 x x x
Monitor and control blood sugar in the pregnant patient with diabetes mellitus. 1,2,3,4 x
Assess, recognize, and manage fetal and maternal complications such as: fetal malformations, disturbances in fetal growth and diabetic ketoacidosis. 2,3,4 x x
Counsel patients with diabetes regarding future reproduction and the long-term health implications of their medical condition. 2,3,4 x x x
Diseases of the urinary system:
Evaluate signs and symptoms of urinary tract pathology in pregnant patients. 1,2,3,4 x
Describe the indications for the common diagnostic tests for renal disease in pregnancy. 1,2,3,4 x x
Interpret the results of common diagnostic tests for renal disease in pregnancy. 2,3,4 x x x
Counsel patients about the possible adverse effects of diseases of the urinary tract on fetal and maternal outcome, such as: intrauterine growth restriction, prematurity, 2,3,4 x x x
Updated July 2014
perinatal mortality, hypertension.
Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of a patient with renal disease. 3,4 x x x x x
Infectious diseases:
Perform a focused history and physical examination in pregnant patients who have known or suspected infectious diseases.
1,2,3,4 x
Choose and perform laboratory tests to confirm the diagnosis of infection. 1,2,3,4 x x x x
Assess the severity of a specific infection and its potential maternal, fetal, and neonatal impact. 2,3,4 x
Describe the possible adverse maternal and fetal effects of antibiotics administered during pregnancy. 2,3,4 x x x
Manage specific infections in consultation with other specialists, as indicated. 3,4 x x x x x
Hematologic disorders:
Evaluate possible causes of anemia, thrombocytopenia, deep vein thrombosis, and coagulopathy in pregnancy.
1,2,3,4 x x
Institute appropriate acute and chronic management plans for these conditions, including prophylaxis to minimize recurrence risk. 2,3,4 x x
Counsel patients about the fetal and maternal impact of hematologic disorders in pregnancy. 2,3,4 x x
Cardiopulmonary disease:
Describe symptoms and physical findings suggestive of cardiopulmonary disease in pregnancy.
1,2,3,4 x
Updated July 2014
Describe the indications for and interpret the results of common diagnostic tests for cardiopulmonary disease in pregnancy. 1,2,3,4 x x x
Classify maternal cardiac disease in pregnancy and describe the associated maternal and fetal risks. 2,3,4 x
Order appropriate fetal evaluation in patients with congenital heart disease. 2,3,4 x x x
Counsel patients about the impact of pregnancy on cardiopulmonary disease and the impact of these diseases on pregnancy. 2,3,4 x x
Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with cardiopulmonary disease. 3,4 x x x
Gastrointestinal disease:
Perform a history and physical examination for the diagnosis of gastrointestinal disease in pregnancy.
1,2,3,4 x
Describe the indications for and interpret the results of common diagnostic tests for gastrointestinal disease in pregnancy. 2,3,4 x x x x
Diagnose and provide initial management of common gastrointestinal diseases in pregnancy. 2,3,4 x x
Counsel patients about the impact of gastrointestinal disease on pregnancy and the impact of pregnancy on gastrointestinal disease. 2,3,4 x x
Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with gastrointestinal disease. 3,4 x x x
Neurologic disease:
Perform a focused history and neurologic examination in pregnant patients with a known or suspected neurologic disorder.
1,2,3,4 x
Describe the indications for and interpret the results of common diagnostic tests for neurologic disease in pregnancy. 2,3,4 x x x
Updated July 2014
Counsel pregnant patients regarding the impact of pregnancy on neurologic disease and the impact of the disease on pregnancy. 2,3,4 x x
Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with neurologic disease. 3,4 x x x
Endocrine disorders (excluding diabetes mellitus):
Perform a focused history and physical examination in pregnant patients with a known or suspected endocrine disease.
1,2,3,4 x
Describe the indications for and interpret the results of common diagnostic tests for endocrine disease, such as: thyroid function tests, adrenal function tests, pituitary function tests, imaging studies.
2,3,4 x x x
Counsel patients about the impact of an endocrine disease and its treatment on pregnancy and the impact of pregnancy on the endocrine disorder. 2,3,4 x x
In consultation with other specialists, develop a comprehensive plan for the perinatal management of patients with an endocrine disorder. 3,4 x x x
Collagen vascular disorders:
Perform a focused history and physical examination in pregnant patients with known or suspected collagen vascular disease.
1,2,3,4 x
Describe the indications for and interpret the results of common diagnostic tests for collagen vascular disease in pregnancy, such as: serologic tests for rheumatoid factor, Anti-DNA antibodies, antinuclear antibodies, lupus anticoagulant, anticardiolipin (antiphospholipid) antibodies, Anti-Ro, Anti-La.
2,3,4 x x x x
Counsel patients regarding the impact of collagen vascular disease and its treatment on pregnancy and the impact of pregnancy on collagen vascular disease. 2,3,4 x x
Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with collagen vascular disease. 3,4 x x x
Psychiatric disorders:
Updated July 2014
Perform a mental status examination. 1,2,3,4
x
x
Describe the symptoms of common psychiatric disorders in pregnancy. 1,2,3,4 x
Assess the risk of psychiatric disorders such as bipolar disorder, schizophrenia, depression, and the safety of psychiatric medications in the patient and her fetus. 2,3,4 x x
Identify patients who require referral for psychiatric consultation. 2,3,4 x x
Emergency care during pregnancy:
Perform a diagnostic history and physical examination in pregnant patients with a medical or surgical emergency.
1,2,3,4 x
Order and interpret diagnostic tests, such as CT or MRI scan, lumbar puncture, and x-rays, to assess for adverse effects of emergency conditions on the developing pregnancy.
2,3,4 x x
Initiate therapy, in consultation as necessary, and describe the impact of the condition on the pregnancy as well as the impact of the pregnancy on the emergent condition. 3,4 x x
Describe the timing of delivery in obstetric patients with emergent conditions. 3,4 x
Substance abuse in pregnancy:
Describe behavior patterns suggestive of substance abuse. 1,2,3,4 x
Perform a thorough history and physical examination in patients suspected of substance abuse in pregnancy. 1,2,3,4 x
Counsel patients about the impact of substance abuse on the fetus/neonate. 2,3,4 x x
Assess the fetus for adverse effects of substance abuse, such as congenital anomalies or growth restriction. 3,4 x
Updated July 2014
Refer patients with known or suspected substance abuse for counseling and follow-up. 2,3,4 x x
Goal: To discuss and participate in the management of common Obstetric Complications of pregnancy.
PGY Level PC MK PBL ICS P SBP
Objectives
Second-trimester pregnancy loss:
Describe the usual symptoms and clinical manifestations of a second-trimester abortion. 1,2,3,4 x
Describe the risk factors for, and etiologies of, second-trimester pregnancy loss. 2,3,4 x
Perform a physical examination and order diagnostic tests to identify the site of genital tract bleeding, assess cervical effacement and dilatation, and evaluate uterine contractions. 1,2,3,4 x
Perform diagnostic tests to assess patients with threatened second-trimester pregnancy loss, such as: ultrasonography, genital tract cultures. 1,2,3,4 x x
Implement appropriate medical and surgical management (including cervical cerclage) for patients with threatened second-trimester abortion. 3,4 x x
Manage the complications of second-trimester pregnancy loss, such as: chorioamnionitis, retained placenta, uterine hemorrhage. 3,4 x x
Counsel patients who have experienced second-trimester pregnancy loss about recurrence risk 3,4 x x
Preterm labor:
Updated July 2014
Describe the multifactorial etiology of preterm labor. 2,3,4 x
Obtain a complete obstetric history in patients with preterm labor. 1,2,3,4 x
Perform a thorough physical examination to determine uterine size, fetal presentation and fetal heart rate, and to assess cervical effacement and dilatation. 1,2,3,4 x
Perform and interpret biophysical, biochemical, and microbiologic tests to assess patients with suspected preterm labor. 2,3,4 x
Recognize the indications for, and complications of, interventions for preterm labor, such as: antibiotics, tocolytics, corticosteroids, amniocentesis, cerclage, bed rest. 2,3,4 x x x
Describe the expected frequency and severity of neonatal complications resulting from preterm delivery, and describe the survival rates for preterm neonates based on age and weight.
2,3,4 x
Appropriately counsel patients about management options for the extremely premature fetus. 2,3,4 x x x
Counsel patients about recurrence risk and preventive measures for preterm delivery. 3,4 x x x
Bleeding in late pregnancy:
Describe the etiology of bleeding in late pregnancy. 1,2,3,4 x
Describe the factors that predispose to placenta previa and abruptio placentae. 1,2,3,4 x
Perform a focused physical examination in patients with bleeding in late pregnancy. 1,2,3,4 x
Interpret diagnostic tests, such as: hematocrit, platelet count, coagulation profile, Kleihauer-Betke test. 1,2,3,4 x
Perform the following diagnostic tests:
• Abdominal ultrasonography to localize the placenta and evaluate for possible placental separation.
1,2,3,4
x
Updated July 2014
• Endovaginal or transperineal ultrasonography to localize the placenta. 3, 4
x
Determine the appropriate timing and method of delivery in patients with bleeding in late pregnancy. 3,4 x x x
Manage serious complications of abruptio placentae and placenta previa, such as hypovolemic shock and coagulopathy. 4 x
Counsel patients about the recurrence risk for placenta previa and abruptio placentae. 2,3,4 x x x
Hypertension in pregnancy:
Describe the possible causes of hypertension in pregnancy. 2,3,4 x
Describe the usual clinical manifestations of chronic hypertension, gestational hypertension, and preeclampsia. 1,2,3,4 x
Perform a physical examination pertinent to patients with hypertension. 1,2,3,4 x
Perform tests to differentiate chronic hypertension from preeclampsia and gestational hypertension and to assess the severity of chronic hypertension, gestational hypertension, and preeclampsia.
1,2,3,4 x x
Assess fetal well-being in patients with hypertension in pregnancy (see Antepartum Fetal Monitoring). 2,3,4 x x
Treat hypertensive disorders of pregnancy. 2,3,4 x
Recognize and treat possible maternal complications of hypertension in pregnancy, such as: cerebrovascular accident, seizure, renal failure, pulmonary edema, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, abruptio placentae.
3,4 x
Counsel patients about recurrence risk for gestational hypertension and preeclampsia in a subsequent pregnancy. 3,4 x x x
Multiple gestation: 2,3,4 x
Updated July 2014
Describe the factors that predispose to multiple gestation.
Describe the physical findings suggestive of multiple gestation. 1,2,3,4 x
Confirm the diagnosis of multiple gestation by performing an endovaginal or abdominal ultrasound examination. 2,3,4, x
Describe, diagnose, and manage the maternal and fetal complications associated with multiple gestation. 3,4 x x
Perform tests to assess the general well-being of the fetuses of a multiple gestation. 2,3,4 x x
Counsel patients as to the antenatal testing and delivery plans for multiple gestations. 3,4 x x x
Intrauterine growth restriction:
Describe the factors that predispose to fetal growth restriction. 1,2,3,4 x
Assess uterine size by physical examination and identify size/date discrepancies. 1,2,3,4 x
Evaluate the patient for causes of intrauterine growth restriction. 1,2,3,4 x x
Perform an accurate ultrasound examination to assess fetal growth. 1,2,3,4 X
Monitor a fetus with suspected growth restriction (e.g., with antepartum heart rate tests, ultrasonography, and Doppler velocimetry) to determine the appropriate time and method of delivery.
3,4 x x
Counsel patients about the recurrence risk for intrauterine growth restriction. 3,4 x x
Isoimmunization and alloimmune thrombocytopenia:
Describe the major antigen–antibody reactions that result in red cell isoimmunization or thrombocytopenia.
2,3,4 x
Updated July 2014
Interpret serologic assays that quantify antibody titers. 2,3,4 x x
Describe the appropriate indications for determination of paternal antigen status. 2,3,4 x x
Describe the major fetal complications of isoimmunization and alloimmune thrombocytopenia. 2,3,4 x
Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with isoimmunization and alloimmune thrombocytopenia. 3,4 x x x
Post-term pregnancy:
Determine gestational age using a combination of menstrual history, physical examination, and ultrasound examination.
1,2,3,4 x
Describe the potential fetal and neonatal complications of post-term pregnancy, such as: macrosomia, meconium aspiration syndrome, oligohydramnios, hypoxia, dysmaturity syndrome, fetal demise
2,3,4 x
Perform and interpret surveillance tests for the postterm fetus including: antepartum fetal heart rate testing, ultrasound examination 3,4 x x
Describe appropriate indications for delivery in the postterm pregnancy. 2,3,4 x
Premature rupture of membranes:
Describe the possible causes of premature rupture of membranes (PROM) in preterm and term patients.
2,3,4 x
Perform diagnostic tests to confirm rupture of membranes. 1,2,3,4 x x
Assess patients with PROM for lower and upper genital tract infection. 1,2,3,4 x
Describe the indications for, and complications of, expectant management in preterm and term patients with PROM. 2,3,4 x x
Updated July 2014
Describe the indications for, and complications of, induction of labor in preterm and term patients with PROM. 2,3,4 x x
Describe the role and possible complications of the following interventions in patients with preterm PROM: tocolytics, corticosteroids, antibiotics, amniocentesis 2,3,4 x x
Fetal death:
Describe the clinical history indicative of fetal death. 1,2,3,4 x
Describe the possible causes of fetal death. 1,2,3,4 x
Confirm the diagnosis of fetal death by ultrasound examination. 1,2,3,4 x
Interpret the results of diagnostic tests to determine the etiology of fetal death. 3,4 x
Select and perform the most appropriate procedure for uterine evacuation based on considerations of gestational age and maternal history. 3,4 x x
Describe and treat the principal complications of a retained dead fetus. 3,4 x
Describe and treat the major complications of surgical and medical uterine evacuation. ( 3,4 x
Describe the grieving process associated with pregnancy loss and refer patients for counseling as appropriate. 2,3,4 x
Counsel patients about recurrence risk for fetal death. 3,4 x x
Goal: To develop competency in the intrapartum care of normal pregnancy.
PGY Level PC MK PBL ICS P SBP
Objectives
Updated July 2014
Intrapartum fetal assessment:
Perform and interpret the following methods of fetal monitoring: Intermittent auscultation, electronic monitoring, fetal scalp stimulation, vibroacoustic stimulation.
2,3,4 x
Interpret the results of umbilical artery Doppler velocimetry. 4 x
Describe the possible causes for, and clinical significance of, abnormal fetal heart rate patterns including: bradycardia, tachycardia, variability,early decelerations, variable decelerations, late decelerations, sinusoidal waveform.
1,2,3,4 x
Implement appropriate interventions, such as operative vaginal delivery and cesarean delivery for fetal heart rate abnormalities. 3,4 x x
Labor and delivery:
Obtain an accurate history, describing onset of uterine contractions and ruptured membranes.
1,2,3,4 x
Describe appropriate indications for induction of labor. 2,3,4 x x
Perform a pertinent physical examination to assess: status of membranes, presence of vaginal bleeding, fetal presentation, fetal position, fetal weight, cervical effacement, cervical dilatation, station of the presenting part, clinical pelvimetry, uterine contractility.
1,2,3,4 x
Describe appropriate indications for, and complications of, cervical ripening agents. 2,3,4 x x
Describe appropriate indications for, and complications of, labor-inducing agents. 2,3,4 x x
Describe the normal course of labor. 1,2,3,4 x
Assess the progress of labor. 2,3,4 x
Describe the risk factors for abnormal labor. 1,2,3,4 x
Updated July 2014
Identify abnormalities of labor including: failed induction, prolonged latent phase, protracted active phase, arrest of dilatation, protracted descent, arrest of descent. 2,3,4 x
Describe the appropriate role for, and complications of, the following interventions for abnormal labor: analgesia/anesthesia, augmentation of labor, uterine contraction monitoring, episiotomy, operative vaginal forceps/vacuum delivery, Cesarean delivery.
2,3,4 x
Recognize and appropriately evaluate abnormal fetal presentations and positions. 1,2,3,4 x
Select and perform the most appropriate procedure for delivery. 2,3,4 x
Counsel patients about the prognosis for abdominal versus vaginal delivery in a subsequent pregnancy. 2,3,4 x x
Labor and delivery:
Obtain an accurate history, describing onset of uterine contractions and ruptured membranes.
1,2,3,4 x
Describe appropriate indications for induction of labor. 2,3,4 x
Perform a pertinent physical examination to assess: status of membranes, presence of vaginal bleeding, fetal presentation, fetal position, fetal weight, cervical effacement, cervical dilatation, station of the presenting part, clinical pelvimetry, uterine contractility.
1,2,3,4 x
Describe appropriate indications for, and complications of, cervical ripening agents. 2,3,4 x
Describe appropriate indications for, and complications of, labor-inducing agents. 2,3,4 x
Describe the normal course of labor. 1,2,3,4 x
Assess the progress of labor. 2,3,4 x
Updated July 2014
Describe the risk factors for abnormal labor. 1,2,3,4 x
Identify abnormalities of labor including: failed induction, prolonged latent phase, protracted active phase, arrest of dilatation, protracted descent, arrest of descent. 2,3,4 x
Describe the appropriate role for, and complications of, the following interventions for abnormal labor: analgesia/anesthesia, augmentation of labor, uterine contraction monitoring, episiotomy, operative vaginal forceps/vacuum delivery, Cesarean delivery.
2,3,4 x
Recognize and appropriately evaluate abnormal fetal presentations and positions. 1,2,3,4 x
Select and perform the most appropriate procedure for delivery. 2,3,4 x
Counsel patients about the prognosis for abdominal versus vaginal delivery in a subsequent pregnancy. (ICS, P) 2,3,4 x x
Vaginal birth after cesarean delivery:
Document an accurate history of a patient’s previous operative delivery. (PC) 1,2,3,4 x
Counsel a patient about risks and benefits of vaginal birth after cesarean delivery (VBAC). 1,2,3,4 x x
Describe the appropriate criteria for, and contraindications to VBAC, including criteria for anesthesia and hospital policies. 2,3,4 x x x x
Recognize and treat possible complications of VBAC, such as scar dehiscence, hemorrhage, fetal compromise, and infection. 3,4 x
Anesthesia:
Describe the types of anesthesia that are appropriate for control of pain during labor and delivery including: epidural, spinal, pudendal, local infiltration, general, intravenous analgesia/sedation
1,2,3,4 x
Describe appropriate indications for, and contraindications to these forms of anesthesia/analgesia. 2,3,4 x
Updated July 2014
Recognize and treat maternal and fetal complications of anesthesia and analgesia. 3,4 x x
Goal: To develop competency in the postpartum care of normal pregnancy.
PGY Level PC MK PBL ICS P SBP
Objectives
Evaluation of the newborn:
Perform an immediate assessment of the newborn infant and determine if resuscitative measures are indicated.
1,2,3,4 x x
Resuscitate a depressed neonate: 4 x
Assign Apgar scores. 1,2,3,4 x
Describe the indications for cord blood gas analysis and interpret the test results. 3,4 x x
Obtain cord blood for the following purposes: blood gas analysis, cetermination of fetal blood type, cord blood storage. 3,4 x
Describe the rationale for administration of topical antibiotics to prevent neonatal ophthalmic infection. 1,2,3,4 x
Counsel parents about the advantages and disadvantages of circumcision. 4 x x
The puerperium:
Perform a focused physical examination in postpartum patients. 1,2,3,4 x
Updated July 2014
Identify the most common maternal complications that occur in the puerperium: uterine hemorrhage, infection, wound dehiscence (abdominal incision and episiotomy), bladder instability, postoperative ileus, injury to the urinary tract, breast engorgement and mastitis, pulmonary embolism (including amnionic fluid), deep vein thrombosis
1,2,3,4 x x
Treat the most common maternal complications that occur in the puerperium as listed above. 3,4 x
Recognize, treat, and refer as appropriate, postpartum affective disorders. 2,3,4 x x x x
Prescribe methods of reversible contraception. 1,2,3,4 x
Counsel patients about permanent sterilization. 1,2,3,4 x x
Perform postpartum surgical sterilization. 3,4 x
Counsel patients about the advantages of and answer questions related to breast feeding. 1,2,3,4 x x
Counsel patients regarding future pregnancies. 2,3,4 x x
Obstetric Procedures
The following table lists the procedures pertinent to obstetric care and summarizes the level of technical proficiency that should be achieved by PGY level and at graduation. The resident should either understand a procedure (including indications, contraindications, and principles) or be able to perform it competently under supervision (direct for OR procedures and operative vaginal delivery, others indirect with direct immediately available) by faculty or fellows (procedures listed as ‘understand and perform’ are expected to be performed independently by the graduate of the program).
Procedure Understand Understand and Perform
Antepartum
Updated July 2014
Amniocentesis—genetic diagnosis (2nd trimester) 2,3,4 Amniocentesis—assessment of fetal lung maturity (3rd trimester) 2 3,4 Cervical cerclage—transabdominal 3,4 Cervical cerclage—transvaginal 3,4 Chorionic villus sampling 3,4 Cordocentesis 3,4 Fetal Assessment
Biophysical profile 1,2 3,4 Contraction stress test 1,2 3,4 Nonstress test 1,2,3,4 Vibroacoustic stimulation 1,2,3,4
Intrauterine transfusion 3,4 Ultrasound Assessment
Endovaginal 1 2,3,4 Abdominal, basic 1,2,3,4 Abdominal, advanced anatomy 1,2 3,4 Color Doppler 2,3 4 Three-dimensional 3,4 Doppler velocimetry 3,4
Version of breech, external 1,2,3 4
Procedure Understand Understand and Perform
Intrapartum Amnioinfusion 1,2,3,4 Amniotomy 1,2,3,4 Anesthetic/analgesic procedures
Administration of parenteral analgesic/sedative 1,2,3,4 Administration of narcotic antagonists 1 2,3,4
Updated July 2014
Epidural/spinal 2,3,4 General anesthesia 2,3,4
Cesarean delivery Classical 1 2,3,4 Low Transverse, primary 1 2,3,4 Low Transverse, repeat 1,2 3,4 Low vertical 1 2,3,4
Cesarean hysterectomy 2,3 4 Compression suture for uterine atony/postpartum hemorrhage 1,2,3 4 Curettage for retained placenta 1 2,3,4 D&E for 2nd trimester fetal death 3,4 Episiotomy and repair (2nd degree) 1 2,3,4 Episiotomy and repair (3rd/4th degree) 1,2,3 4 Fetal heart rate monitoring (internal/external) 1 2,3,4 Forceps delivery, outlet 1,2 3,4 Forceps delivery, low 1,2,3 4 Induction of labor (prostaglandins, oxytocin) 1 2,3,4 Manual removal of placenta 1 2,3,4 Suction evacuation for first trimester fetal loss 1 2,3,4 Uterine artery ligation 2,3 4 Vacuum extraction, outlet 1,2 3,4 Vacuum extraction, low 1,2,3 4 Vaginal delivery, breech 2,3,4 Vaginal delivery, breech extraction second twin 2,3 4 Vaginal delivery, spontaneous 1,2,3,4
Procedure Understand Understand and Perform
Postpartum
Updated July 2014
Circumcision, neonatal (with anesthesia) 4 Hematoma evacuation, vulvar/vaginal 2,3 4 Neonatal resuscitation, immediate 1,2,3 4 Repair of genital tract lacerations
Cervical 1,2 3,4 Perineal, 1st/2nd degree 1,2,3,4 Perineal, 3rd/4th degree 1,2,3 4 Vaginal 1,2 3,4
Sterilization 1,2 3,4 Wound care (abdominal)
Debridement 1 2,3,4 I&D abscess, hematoma 1,2 3,4 Repair of dehiscence 1,2 3,4 Secondary closure 1,2 3,4
Wound care (perineal) Debridement 1,2,3 4 Repair 2,3 4 Secondary closure 3,4