Inpatient Obstetrics
Case: Mary Smith is a 27-year-old G2P1 woman at 38-weeks gestation presents to the labor and delivery department complaining of lower abdominal pain.
Milestones: OB 2, OB 4, OB 5, PB 2, PR 1
EPAs: EPA 1, EPA 4, EPA 7
Knowledge: BCS Pelvic Examination, BCS Sterile Technique
Basic Clinical Skills:
- Pelvic Examination
- Sterile Technique
- Demonstrates knowledge of routine uncomplicated Intrapartum care including normal labor
- Demonstrates basic surgical principles, including use of universal precautions and aseptic technique
- Performs basic procedures, including speculum examination and cervical examination
- Performs initial warming and drying of a non-depressed infant
- Has a commitment to self-evaluation, lifelong learning, and patient safety
- Understands the importance of compassion, integrity, and respect for others
- Demonstrates sensitivity and responsiveness to patients
- EPA 1: Gather a patient history and perform a physical examination
- EPA 4: Enter and discuss orders and prescriptions
- EPA 7: Form clinical questions and retrieve evidence to advance patient care
- EPA 10: Recognize a patient requiring urgent / emergent care and initiate evaluation and management
- EPA 12: Perform general procedures of a physician
Develop a differential diagnosis for abdominal pain in a pregnant woman
Milestones: OB 2
EPAs: EPA 7
Learner Task: Develop a differential diagnosis for abdominal pain in a pregnant woman.
Educator Checklist: Differential Diagnosis for Abdominal Pain in a Pregnant Woman
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Labor | ||
| Latent Labor | ||
| Gastroenteritis | ||
| Placental abruption | ||
| Cystitis |
Obtain a medical history in a pregnant woman with abdominal pain
Milestones: OB 2
EPAs: EPA 1
Learner Task: Obtain a medical history in a pregnant woman with abdominal pain.
Educator Script: Provide the following pertinent patient history of a pregnant woman with abdominal pain as asked by the learner:
- HPI: Gravida 2, Para 1, 38 weeks plus 3 days by LMP and US dating. Patient is in town for her sister’s wedding and noticed leakage of clear fluid 4 hours ago. Patient complains of non-radiating lower abdominal pain that began 2 hours ago. Pain is intermittent, every 4-5 minutes, each episode lasting for 30 seconds. Nothing makes the pain better or worse. +FM, No VB. Denies nausea, vomiting, pain/burning on urination. Patient is a non-smoker, denies hx of drug abuse or trauma.
- PMH: None
- PSH: None
- Meds: Prenatal Vitamins
- Allergies: Penicillin>anaphylaxis
- P Ob Hx: NSVD-female infant weighing 6 pounds, 12 oz. She was in labor for 36 hours and pushed for 3 hours. Baby spent one week in NICU for GBS infection.
- Prenatal Labs: O+, antibody negative, RPR-NR, Rubella Immune, Hep B Surface antigen negative, HIV negative, GC negative, Hemoglobin electrophoresis AA, CF screen negative, Pap test negative for malignancy, 50 gm Oral Glucose Challenge Test 115, GBS+.
- First and second trimester ultrasound: Unremarkable, c/w LMP.
- P Gyn Hx: Menarche at age 13, menstrual cycles q28-30 days lasting 4-6 days, denies dysmenorrhea or dyspareunia, coitarche at age 17, 5 lifetime male partners, denies history of sexually transmitted infections or abnormal Pap test.
Educator Checklist: HPI
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Onset of pain | ||
| Frequency of contractions | ||
| Vaginal bleeding | ||
| Leading fluid, to include clear/meconium staining | ||
| Fetal movement | ||
| GI symptoms: nausea, vomiting, bowel movements | ||
| Urinary complaints: dysuria, hematuria, urgency, frequency | ||
| Social: trauma, cocaine |
Educator Checklist: History Taking
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| PMH | ||
| PSH | ||
| P Ob Hx | ||
| Prenatal Labs | ||
| P Gyn Hx | ||
| Medications | ||
| Allergies |
Perform a focused physical examination on a pregnant woman with abdominal pain
Milestones: OB 4
EPAs: EPA 1, EPA 12
Learner Task: Perform a focused physical examination on a pregnant woman with abdominal pain.
Educator Script: Provide the following details of focused physical examination as asked by the learner:
- Vital Signs: BP 124/84, P 101, Resp 22, afebrile, EFW 3200 grams
- General: awake, alert and oriented x3 in moderate distress with contractions
- Heart: Nl S1 S2, RRR, no murmurs, rubs or gallops
- Lungs: bilaterally CTA, no wheezes, rales, or rhonchi
- Abdomen: +BS, gravid, fundal height 36, non-tender to palpation, no guarding, no rebound
- Speculum: no blood, +pooling, +nitrazine
- Pelvic: vulva/vagina: normal external genitalia
- Cervix: 4/50/0/vertex, wet mount performed
- Extremities: no clubbing, cyanosis, or edema
- Microscopic examination of vaginal fluid shows:
Educator Checklist: Physical Examination
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Abdominal exam: fundal height and tenderness between UCs | ||
| Leopold/fetal lie | ||
| Performs speculum exam and collects specimen | ||
| Performs intrapartum examination | ||
| Identifies positive nitrazine and ferning |
Educator Checklist: Intrapartum Examination
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Describes the benefits, risks and indications for cervical assessment | ||
| Describes the technique of properly assessing dilation, effacement and station | ||
| Explains procedure to patient | ||
| Puts on gloves in a sterile fashion | ||
| Uses lubricant on two fingers that will be used to perform vaginal examination | ||
| Uses non-dominant hand to separate labia | ||
| Uses two fingers of the dominant hand to assess the cervix | ||
| Assesses presenting part | ||
| Accurately assesses cervical dilation | ||
| Accurately assesses cervical effacement | ||
| Demonstrates appropriate sterile technique throughout examination |
Interpret a fetal heart tracing
Milestones: OB 2
Learner Task: The attending is finishing a procedure in another room and asks if there is anything concerning about the fetal heart rate tracing pictured below. Report the fetal heart rate findings and discuss fetal heart rate features which could be concerning.
Fetal Monitoring Strip
Educator Checklist: Fetal Heart Rate Tracing
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Identifies baseline heart | ||
| Identifies accelerations | ||
| Identifies contractions | ||
| Discusses types of decelerations and FHR tracing without accelerations |
Develop an appropriate treatment plan and write orders
EPAs: EPA 10, EPA 12, EPA 4
Learner Task: The nurse asks for the plan and orders for Ms. Mary Smith. Develop an appropriate treatment plan and write orders.
Educator Checklist: Treatment Plan/Order
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Admits to L&D | ||
| Diagnosis: active labor | ||
| Condition: stable | ||
| Vitals: routine | ||
| Allergies: penicillin | ||
| Activity: as per hospital protocol | ||
| Nursing: routine | ||
| Diet: NP | ||
| Start IV | ||
| Blood type and Rh screen | ||
| CBC | ||
| Recognizes need for IV antibiotics | ||
| Pain management |
Demonstrate compassion, integrity, and respect for others
Milestones: PR 1
Learner Task: Two hours later, the patient is asking questions as to how long her labor will be and what she should expect this time. She appears anxious and is concerned regarding prior GBS-affected baby. Address the patient’s concerns/issues.
Educator Checklist: Professionalism
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Acknowledges patient’s anxiety | ||
| Addresses patient’s concerns | ||
| Asks about additional questions or concerns |
Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement
Milestones: PB 2
Learner Task: The cross-covering nurse has the IV bag labeled with penicillin for Jane Smith. She asks is it okay to administer the antibiotic to your patient Jane Smith for her GBS+ status. Address this nursing concern.
Educator Checklist: Patient Safety
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Recognizes allergy could affect antibiotic choice | ||
| Seeks out the information he/she is lacking from acceptable sources | ||
| Identifies wrong patient for medication |
Identify normal/abnormal labor progress, stages of labor and cardinal movements of labor
Milestones: OB 2
Learner Task: Discuss the patient’s labor progress, stages of labor and the cardinal movements of labor, and any future labor management actions with the attending.
Educator Checklist: Labor
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Describes stages of labor | ||
| Identifies normal and abnormal labor progress | ||
| Describes the cardinal movements of labor | ||
| Student re-examines patient |
Demonstrate appropriate management of labor
Milestones: OB 4, OB 5
EPAs: EPA 10, EPA 12
Learner Task: Two hours after admission, the patient is found to be 7 cm dilated and requests an epidural. The patient receives an epidural. Two hours later the nurse calls you because your patient is complaining about pressure. Patient is FD/100% effaced/+1 station. Discuss future management of labor.
Educator Checklist: Delivery
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Describes the three stages of labor | ||
| Describes the cardinal movements of labor | ||
| Describes the steps of a normal vaginal delivery | ||
| Assesses initial fetal station | ||
| Assesses initial fetal position | ||
| Protects perineum | ||
| Delivers the fetal head | ||
| Watches for restitution | ||
| Assesses for nuchal cord | ||
| Delivery of the anterior shoulder | ||
| Delivery of the posterior shoulder | ||
| Delivery of the torso and legs | ||
| Clamps and cuts umbilical cord | ||
| Initiates warming and drying of depressed infant | ||
| Delivers the placenta | ||
| Checks placenta | ||
| Examines cervix and perineum for lacerations | ||
| Massages fundus appropriately (before or after placenta) | ||
| Delivery type (NSVD) | ||
| Infant weight | ||
| Apgars at 1 and 5 minutes | ||
| Delivery position | ||
| Presence or absence of nuchal cord | ||
| Description of amniotic fluid (presence or absence of meconium) | ||
| Delivery of placenta | ||
| Description of placenta and cord | ||
| Description of lacerations (presence or absence) | ||
| Estimated blood loss |
Educator Checklist: Neonatal Warming and Drying of Non-Depressed Infant
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
| Included =1 | Not Included =0 | |
| Dries infant | ||
| Places baby skin-to-skin with mother |