Family Planning Handoff

PGY-1: Family Planning Clinic — Duke Clinic Gynecology (1J + clinic surgical days).

PGY-2: DUH 4200 (Duke North, 4th floor, 4200 unit) — Epic Context: DUKE HOSPITAL 4200 GYNECOLOGY OUTPATIENT CLINIC. Clinic 8:30 AM – 4:00 PM.

Note templates:

• •.ABORTION — notes for any type of abortion visit
• •.MISCARRIAGE — miscarriage cases
• •.FPABORTION
• •.FPCONTRACEPTION — contraception counseling visit
• •.FPIUDREMOVAL
• •.FPIUDINSERTION
• •.FPNEXPLANON
• •.FPNEXPLANONREMOVAL
• •.gynminorprocedure — procedure notes (IUD removal, etc.)

Order dot phrases:

• •.diaimg4 = US OB (use for TAUS and TVUS)
• •.diaimg6 = gyn US

Epic AVS dot phrases (steal from Jasmine Arrington):

• •.FPMODSETPTINSTRUCTIONS — IV moderate sedation
• •.JAAVSPILLINITIATION — OCP pills initiation
• •.JAAVSPOPINITIATION
• •.JAAVSCONTINUOUSBC — continuous contraception with pills, patch, ring
• •.JAAVSIUDHORMONAL
• •.JAAVSIUDCOPPERINITIATION
• •.JAAVSRINGINITIATION
• •.JAAVSPATCHINITIATION
• •.JAAVSDEPOINITIATION

After med or surg ab → abortion navigator → fill out case report.

• •Use .fpcontraception note. Discuss options! Most will end up being a same-day IUD or Nexplanon unless they want moderate sedation for IUD.
• •You’ll have some IUD moderate-sedation consults over video — talk through mod sed, normal IUD counseling, expectations (NPO, driver/support person, they will still be awake and feel things but idea is to have less discomfort), basic risks of mod sed, other options like paracervical block only (which we usually do with mod sed anyway).

For IUD orders:

• •Use order set for ambulatory LARC.
• •If getting sedation, order toradol and zofran (see surg ab orders).

• •Confirm dating (place order within patient’s chart).
• •72-hour consent (medical and surgical) — can be signed by RN, MD, PA, NP; every page needs a sticker; write “Duke University Hospital.”
• •Hematocrit (>30).
• •Talk about future contraception.
• •Schedule surgical (usually nurses have done this already but check).

Pre-procedure rules:

• •NPO 8h, clear liquids OK up to 2h pre-op.
• •For moderate sedation visits: .fpmodsed in the Wrap Up tab.
• •Make a copy of consent (original + patient copy).
• •Medical vs surgical consent differ only in the risks table (infection/bleeding higher with meds) — frame as “in case you change your mind or need the other.”

Instructions / forms:

• •Green forms — for med Ab.
• •White forms — for mifepristone consent and then outside-of-state form.
• •Purple forms — for surgical Ab.
• •Attending signature form for both medical and surgical abortions.

Orders:

• •Mifepristone 200 mg in clinic
• •Phenergan 12.5 Q6 × 12
• •Ibuprofen 800 mg Q6 × 30
• •Miso 200 mcg × 4 (= 800 mcg total) vaginal or buccal.

Counseling (also .fppreopmisoinstructions for patient instructions):

• •Do not send miso to Walmart! They won’t fill.
• •Sign two forms, then have attending sign third form.
• •Mife: stops pregnancy, primes body for miso.
• •800 mcg Miso 24h after first pill — wait for it to dissolve 30 min.
• ◦Buccal — 2 pills each cheek, after 30 min, swallow with water. Only say this if more than 1 dose.
• ◦Vaginal — place as far up as you can, allow 30 minutes. Less nausea.
• •Should bleed in next 1–24 hours. Call if no bleeding in 24 hours — not working.
• •Bleeding, cramping normal — will send ibuprofen and nausea meds. Should improve over time.
• •Abnormal: multiple pads in an hour, fever, chills → call this number on sheet.

Pre-procedure meds:

• •Give miso 400 mcg 2 hours prior to procedure for >10 weeks.
• •Order set: Surgical abortion.

Consents:

• •.OBGYNCONSENT for the e-consent (SIGN BEFORE MEDS).
• •Consents + purple sheet + abortion form + telehealth f/u in 2 weeks.

Procedure orders:

• •Bedside ultrasound for >10 weeks during procedure.
• •Order zofran 4 mg IV, toradol 15 mg IV, azithromycin 500 mg PO.
• •Lidocaine: 10 cc and 10 cc injected at 4 and 8 o’clock (nurses order lido).

Notes for surg Ab:

• •Pre-sedation note (sign before procedure!!)
• •Procedure note
• •Progress note

Procedure Note: Plan > Smartset > Ambulatory Gyn Outpatient MVA (also EMB, IUD) = procedure note.

• •We use Denniston dilators.
• •Post-procedure dx: s/p completed abortion.
• •40 mL of 0.5% lidocaine.
• •Add in extra things like silver nitrate.
• •Add in preop sedation to note.

Counseling:

• •Heart, lungs, Mallampati.
• •Surgical abortion risks:
• ◦Bleeding — will you accept transfusion?
• ◦Infection — we give abx; will give more if needed; keep eye out for fever, chills.
• ◦Uterine perforation — should heal on its own. If we use suction and there’s a possibility for damage to surrounding structures, we will stop.
• •Moderate sedation: will breathe on own, but will help with pain. Allergy. Too much sedation → pneumonia, aspiration, hypoxia. Medical risks like clots — DVT, PE.
• •Contraception?
• •Want support person in there?

Consents: Go to consents > blank consent. Dot phrase: .gynconsent

• •Bimanual exam.
• •Insert speculum.
• •Do swabs if indicated (GC/CT under 25).
• •Inject lidocaine (1–2 mL) into anterior lip.
• •Place tenaculum — wrist up!
• •Inject at 2 o’clock and 10 o’clock (or 4 and 8 if you can see) with 20 mL lidocaine. Go in 3 cm, pull back first, inject as you come out.
• •Put on sterile gloves.
• •Dilate — first thing is 5 and goes up by one after. Go past cervix; should be fast/smooth. Dilate to # of weeks for abortion, # of weeks at time of EPL dx if EPL. Round to completed weeks.
• •Prep suction — click shut, pull back, put top on.
• •Insert into cervix and go to fundus, then click open suction. First motion is twisting — then up and down and twisting.
• •Come out, remove tip, expel syringe.
• •RELOAD — click shut, pull out, put tip on.
• •Repeat until you feel rough uterine “cry”, then draw out.
• •Look for bleeding from os.
• •Remove tenaculum, apply pressure if site is bleeding — may use silver nitrate.
• •Remove speculum.
• •Grab POC to look at them.

• •Add to abortion history under Abortion tab (extra triangle carrot).

• •When did you take mife and miso?
• •How was the experience? When did you bleed? How much did you bleed?
• •How are you now — still bleeding?
• •Contraception.
• •Make sure G’s and P’s are updated.
• •+/- US.

• •Dot phrase: .attesttele
• •Confirm name, DOB.

• •DNA extract and hold
• •SNP chromosomal microarray
• •Chromosome analysis

• •Usually two surgical abortions a day: 8:30 AM and 12:30 PM.
• •You perform abortions both in clinic and the OR this rotation. You decide how much or little you want to participate in operative abortion and communicate your comfort level to the attending.
• •In NC, must complete 72h counseling before performing abortions, plus ultrasound requirement. You’ll perform a lot of TVUS in clinic for this and follow-up medication abortions, in addition to surgical abortion problem visits.
• •D&E: come to clinic day before procedure for placement of laminaria / dilapan.

Insurance status is very important in this clinic. Know your patient’s payer status to understand what you are/aren’t able to offer them:

• •Medicaid: contraception covered. Abortion and abortion follow-up — pay out of pocket (package pricing).
• •National Abortion Federation: funding source for abortion and 1 abortion follow-up visit for patients without abortion insurance coverage.
• •Private insurance: often covers abortion, but some plans may not. Cover sheet in patient folders will have information on this.

• •Mostly SWU clinic and Digoxin injections for fetal anomalies (>20 wk), laminaria / dilapan placement.
• •Place pre-op orders for cases as you see patients for their SWU.
• •Includes labs for cytogenetics (microarray, chromosome analysis, DNA extract and hold) and cabergoline for lactation suppression.

Recommend making Epic “Family Planning OR” schedule including those two sites for the following attendings:

• •Alfonso
• •Gray
• •Hagey
• •Jones
• •Swarz
• •Thomason

Paperwork for abortions:

• •Bring paperwork for attending to sign day of surgery.
• •At DRH: collect folders from clinic day prior to surgery.
• •At DUH: pick up folders day of surgery.
• •After cases, return folders to clinic to be scanned.
• •List of paperwork based on type of indication for D&C or D&E and gestational age at time of procedure (guide located in clinic).
• •Responsible for completing the Abortion Navigator in Epic after cases (link within op-note templates).

Mementos: you help to collect footprints per patient request.

• •DRH: ink will be in the OR with cards (do not need to supply).
• •DUH: go to L&D newborn nursery outside nursing station on 5700 to get ink pad. Blank cards in FP clinic work room.

• •Offer Ativan and TXA.
• •Pre-op H&P then place in the Prep for surgery tab → orders.
• •Consent for lams and D+E.
• •Plan for genetics.
• •Disposition of fetus.
• •Cabergoline (offered in any second trimester) — 1 mg dose in PACU. Side effect: increased nausea.
• •Footprints.
• •22–24 weeks → KCl injection with MFM.
• •>20 weeks: can offer digoxin injection (70% efficacy if injected intrafetal; still effective if intraamniotic).
• •Pre-op orders: DNA extract and hold, karyotype, SNP chromosome microarray.

• •Prep all patients.
• •.1Jepacnew
• •.1Jepacreturn
• •You will receive access to a Box folder with weekly reading for early pregnancy / miscarriage / abortion evaluation and management.

Once a person has an IUP, resolve the episode to no longer be in Beta Book. Reference email from Susan with how-to documents.

Adding patient to the Beta Book:

• •Find episodes of care in the upper right hand corner of EPIC (or search it).
• •Create a new episode.
• •Name: PUL
• •Type: Ectopic / Molar Pregnancy

Setting up follow-up:

• •New encounter → internal communication to 1J triage → “Please schedule a beta MD appointment in 2 days. She has been added to the beta book.”
• •Order beta (STAT). Reason: pregnancy of unknown location.

Managing the Beta Book:

• •Search “My Reports” in Epic within the Duke Clinic Gynecology context.
• •Search “beta” under Library → click “DUHS Betabook Has Active Episode” — brings in everyone with an active Ectopic / Molar episode to review.
• •Favorite this report so you can find it more quickly.

Do Beta Book twice a week:

• •If not already done, write a 1-liner about the patient.
• •Put newest data at the top (like Cervix Clinic results).
• •If following molar pregnancy: “downtrending beta in setting of mole, following to zero” + most recent beta.
• •Partial mole: follow to <5, then HCG q1 month <5 before can resolve.
• •Complete mole: follow to <5, then HCG q1 month for 3 months at <5 before can resolve.
• •If have gestational sac with a yolk sac, resolve Episode of Care (following until IUP, not until viability).
• •Day of missed appointment, send internal communication to 1J Triage to call patient for scheduling. Click Priority before sending. Title: “Beta book follow up attempt #”.
• •A week later, send another internal communication to call patient.
• •Third contact, ask to call again and send certified letter → close Beta Book encounter.
• •Don’t resolve Episode of Care until nurse confirms letter sent.

Pro Tips:

• •If following at DWHA or OSH, can resolve episode if another provider is performing PUL care.
• •If patient is scheduled directly by ED for PUL follow-up, make sure there is STAT beta ordered.
• •For younger patients with molar pregnancies, consider calling directly to counsel.
• •Tell patient someone from our team will contact them, and if not, to reach out to the 1J numbers (.1javs).

Susan’s 3-strike rule for Beta Book contact:

• •1st time (first 2–5 days of initial encounter): document as internal communication what the patient needs (beta vs beta/MD), forward to 1J triage RN. Order the beta MD as STAT. Highlight the priority. You should receive closed-loop comm from the triage nurse when this is completed.
• •2nd time (within 1–2 weeks): same as above. Consider referral to Duke Well.
• •3rd time (after 3 weeks): forward internal communication to 1J triage nurses and ask them to issue a certified letter. Remove from the Beta Book.

• •400 miso — 3 hours before D&C for teenagers.
• •Beta Book — tracks everyone who needs b-hCG. New episode → molar / PUL.