Antepartum / NF Handoff

• •Arrive around 6 AM, can start ~5:30 AM to be a resource for PGY-2.
• •Sign out at 7:10 AM in the classroom.

• •6 (8 block 2) for PGY-3
• •6 (8 block 2) for PGY-2
• •Then add APP
• •PGY-3 should round on complex / non-straightforward patients.
• •PGY-2 should round on bread-and-butter patients (PPROM, PreX, hyperemesis, vasa previa, s/p cerclage, etc.).

Sub-I — up to 4 patients to round on:

• •See quality of their notes before giving them responsibility.
• •Teach them from the ground up.
• •Don’t add Sub-I to APP rounding assignments — should be with a resident.
• •Sub-Is can round on PPROM or PreX. Eventually can do patients that don’t already have an established note.

Day 1: teach sub-I how to do EPIC handoff, have them watch sign out first day. Can sign onto the pager at 7 AM and stay until sign out. Sub-Is will be gone at times for ultrasound with JoAnn.

Meet with team / Fellow to get updates on patients you missed while at didactics, so have most updated information.

• •Write 1–2 liner on every patient to summarize their clinical situation.
• •Have last growth / AFI available if relevant to patient clinical situation.
• •Goal: for everyone on MFM to discuss patients on AP with a focus on atypical patients for consensus on management / delivery.
• •Fellow will be active participant in conference; they’ll add things when you present.
• •Dr. Kuller asks questions sometimes.

Example format:

Tip: run through atypical people with Fellow so you’re thoughtful about how you present people.

• •Keep Handoffs updated.
• •Dot phrase for AP Handoff: .OBAPSIGNOUT2025
• •Have general sense of what is going on with all the patients.
• •Be aware of direct AP admits.
• •Write a brief progress note with AP updates throughout the day that are important for patient course. Also helpful to write a brief note when transferring a patient to Active service or accepting a patient from Active to AP service.
• •If getting handoff from Active, have them start from the beginning and tell full story.
• •Keep an eye on Triage. Take over AP people to help keep things moving.
• •Pre-rounding on patients covered by Sub-Is — never spend more than 2 minutes in a room if you can help it. Just pop head in and see if they have questions / repeat exam if relevant.
• •Let the PGY-2 split the list for rounding on Thursday. Try to get PGY-2 home at 5 PM if nothing pending.
• •Everyone on AP should have a consent for c-section unless a good reason not to.
• •Give routine prenatal stuff to Sub-I to do (vaccinations counseling, postpartum contraception plan, etc.).

How to schedule an induction / c-section:

• •Send InBasket message.
• •IOL/CS: DUH IP L&D PROCEDURE SCHEDULING
• •Dot phrase: .JAOBSCHEDIOLCS (Jasmine Arrington)

Now that triage is an OB ED, it will have an APP dedicated to triage 24/7. The intern will still come to staff patients with an upper level resident. First block of NF, have chief staff with intern when they are around. PGY-3 should step into this role in subsequent blocks as the floor allows.

• •Ask Attending how they want you to check in regarding staffing before discharge — people have a variety of preferences and may change throughout the year.
• •Can ask chief to un-double scrub to help with triage / L&D.
• •Have consistent person staffing patients (don’t switch).
• •Run triage list throughout the night with intern so are aware for AM sign out.
• •For uncomplicated people, try to get them out in 2 hours.

Try to meet all the patients, including DWHAs. If there is an operative delivery you’ll already have had a touchpoint with the patients.

• •TOLAC
• •Concerning Cat II strips
• •Preeclampsia on magnesium (pregnant or postpartum)
• •Breech PPROM
• •Vasa previa / placenta previa
• •Ongoing postpartum hemorrhage protocols / Jada / Bakri / vaginal packing
• •Severe maternal cardiac or fetal cardiac patients with special needs / strict monitoring plans

Tips:

• •Be proactive about managing labor.
• •Consent concerning Cat II strips for c-section.
• •It is OK to back call SVE.
• •Consider repeat foleys if people <3 cm.
• •If notice labs not collected, message nurse to handle it and get it done.
• •For acute patient situations, it’s OK to ask for more people in the room early and often.
• •Make sure orders put in are correct — especially relevant for triage admits / AP to active.
• •Reference L&D protocols from Duke Box.
• •Communicate with Charge Nurse for c-sections, risky AROM, and high acuity patients.
• •Helpful resource for OB algorithms: https://www.mombaby.org/ob-algorithms/
• •Teach medical students to do magnesium checks.

• •Can free hand notes, don’t have to use template for documentation.
• •E.g., “Cat I strip, contracting q X, continue labor”
• •Expectations:
• ◦Q4h strip check in latent labor
• ◦Q2h strip check in active labor
• ◦Q4h magnesium check note
• •Write at least 1 progress note a night where you use template and go through their MFM note. Catch things that are missing. Only include labor-relevant things in plan.

Dot phrases:

• •Category II strips: .JAOBCAT2 (Jasmine Arrington)
• •IUFD Induction: .JAIUFDIOL (Jasmine Arrington)

Midwives work 6 PM – 6 AM, so they’ll hand off patients to you before 6 AM.

• •Highly recommend setting expectations with APPs at the beginning of shift with how you want them to help you. Should also split the list of patients. You are responsible for knowing all the patients and signing them out, including who they manage, so check in throughout the night.
• •If there are very few patients, feel free to hold all the sheets.
• •Examples: “My goal is for my intern to start an induction and do AROM, so please let them know when you are doing those tasks…” or “I want to walk my intern through vaginal repairs…”
• •Residents should be present at every delivery. Can have APPs present to supervise so do not need to call Attending for delivery. Send Delivery Summary to APP in these circumstances.
• •This is new and everyone is still transitioning into this new structure. If you have concerns, give feedback to your Attending or APPs directly as you feel comfortable.