OB Days Handoff

EPIC Context: DUH IP OB Virtual

Alternate between two OB Day intern roles: Triage/Circ and Floor/Postpartum.

Need supervision by resident or midwife. Message nurses to ask what time they want to do the circ so they can bring baby to the room.

Have prepared prior to performing circ:

• •Consent form signed (ONLY mom/birthing parent can sign) with baby’s MRN label on the form.
• •Baby added to Circ shared patient list.
• •Circ Handoff completed (.circumcisiontodo).
• •Check infant chart to verify has voided and received vitamin K.
• •If ICN baby, document when ICN reached out to you to schedule circ.
• •When you know for SURE going to do a circ, place the circ order set for baby’s chart the day you’re doing the procedure. Never place circ order early.

Handbook supplement — Forms + workflow detail:

• •Forms location: 5700/5800 cubbies or near HUC at 5300.
• •Naming convention: name on form must match the baby’s sticker — usually “Baby Boy” + mother’s last name.
• •Copy routing: mom gets the yellow copy; white copy is scanned into baby’s chart and kept in 5800 HUC desk.
• •Order meds in BABY’s chart using the NEO Neonatal Male Circ order set.
• •Time-out before procedure: verify Vitamin K given, voided, no medical contraindications.
• •Off-service baby needs a circ? Add baby to circ list, inform the 5800 charge nurse (613-8777), and remind the off-service team to administer Tylenol and accompany baby with lidocaine and Toot-Sweet.
• •Triage intern oversees the circumcision service each day/week.
• •Supervision required: certified APP, upper level (PGY-2+), or faculty. Interns do not perform circs on DWHA infants but can consent the birthing parent.

• •Document using OBHandP templates.
• •Use OBProgress for any further triage progress notes.
• •Before seeing the patient, look up last ultrasound and anatomy ultrasound.
• •Common topics: rupture of membranes rule out, decreased fetal movement, labor, PreE workup, etc.

Intern Survival Guide is a great resource for what labs / exams / orders need to be done for proper workup.

• •Hold PP pager AND go to vaginal deliveries.
• •Write the delivery note and admit postpartum patient to the postpartum service.
• •Admit to postpartum via the transfer tab and put in the order sets.
• •Fill out VTE risk calculator.
• •Start their Handoff: .OBHANDOFF1SUMMARY · .OBHANDOFF2DAYTMN · .OBHANDOFF3XCOVER · .OBHANDOFF4TODO
• •Start their Discharge Summary.

Splitting the list — who is rounding?

• •Weekdays (M–F): (2) LD Day Interns, (±) ED Intern, (1) APP (one of the midwives or NP). DWHA has APP who does all their weekday rounding.
• •Weekends (Sat/Sun): (1) “On-Call” intern, (1) “Swing” intern, (1) Chief (if needed), (±) ED Intern. No APP rounders.
• •Usually three people rounding in the morning. If interns are capped at their max, they should reach out to the chief the night before.

Splitting the list — who do we round on?

• •Weekdays: any non-DWHA patient before midnight. DWHA has APP.
• •Weekends: any non-DWHA patient before midnight + DWHA C-sections before midnight.
• •KEY: night intern, write “AFTER MIDNIGHT” in handoff to help daytime rounders.
• •Remember to always be in “obstetrics” context.

• •Summary/Course: fill out EBL. Pay attention for complications/morbidities.
• •GDM: fasting BG early AM. <120 → can DC glucose checks and stop pregnancy regimen. Check Duke Box for GDM protocol.
• •PPH: CBC early AM.
• •Traumatizing delivery (failed IOL, anxiety, depression): consult Birthing Center + Children’s Clinical Social Work. Put first call as callback information.
• •X-cover To Do auto-populates as A&P for progress note. Tip: use .ppplan to help figure out what to do for your postpartum patient. Put your plan here.
• •Routine postpartum care items:
• ◦Male baby → ask if want circumcision.
• ◦VTE risk → prescribe Lovenox if qualifies. Pay attention to when epidural was placed/removed and how long since delivery — handoff tells you the criteria. If new PreE diagnosis or gets transfused, update VTE risk.
• ◦Immunizations: COVID (if 2 shots, ask if want another; if 3 shots, consider immune). Rubella non-immune → offer MMR (can get prior to discharge). Tdap. Rhogam (order if Rh− mom with Rh+ baby → “RHIG postnatal”).
• ◦Pain: C/S → oxy for breakthrough. SVD → ibuprofen + acetaminophen.
• ◦Contraception plan.
• ◦Everyone gets seen by lactation — do not order a consult unless there’s a specific issue. Include details in the note section of the consult order if you do.
• ◦PT consult as needed — good idea for C/S patients with more pain and 3rd/4th-degree tears so they can get an intro to PFPT in hospital.
• ◦PP follow-up needs (case management makes appts): 3-day BP check, 1-week mood check, 4–6 week postpartum visit, PCP / specialist visits. On weekends, send an internal comm (.internalcomm) to request.

Vitals / Objective:

• •BP: isolated mild range, gestational HTN, preeclampsia ± SF, hypotension, shock?
• •Temperature: >100.4 = febrile. Think about timing in relation to delivery for IAI vs. endometritis. DDx: UTI, mastitis, URI, bacteremia, etc.
• •HR: tachycardia — what was their baseline? Total EBL? Consider CBC / transfusion. Tolerating PO? Consider fluid bolus.

Physical Exam:

• •What is a fundus? Who knows — sometimes habitus is an issue.
• •When do I pull the dressing? POD#2, use spray!
• •HTN: headache, vision changes, dyspnea, RUQ, epigastric pain, edema.
• •Anemia: dizzy, lightheaded, SOB.

• •Weekdays (M–F): meet in DBC Classroom at 7:10 AM. Staff with Chief Resident + Postpartum Attending of the day. Wed: 6:45 AM due to Grand Rounds.
• •Weekends (Sat/Sun): meet in GYN workroom at 7:10 AM. Staff only with chief resident.
• •There’s a system-wide note template under the Notes tab on Epic.
• •KEY: the handoff auto-populates the rounding note template — prechart in the handoff to optimize efficiency with rounding notes in the morning.
• •Keep track of co-intern / APP’s postpartum tasks brought up on rounds on the printed lists.

• •Discharge instructions
• •Order reconciliation
• •HTN monitoring orders as needed (see below)
• •Discharge summary
• •If weekend, send internal comm for PP follow-up scheduling (PP 6-wk, BP check, mood check if indicated).

Discharge tab → order reconciliation:

• •Tylenol, ibuprofen, Colace, ± oxycodone (for C/S).
• •Lovenox: make sure VTE calculator score is filed. Adjust to number of days recommended (3 weeks = 21 days, etc.). Dosage depends on BMI.
• •Be sure you have the right pharmacy. Can call into patient’s room: 681-53XX (XX = patient’s room number).

Hypertensive disorders (GHTN, PreE w/o SF, PreE with SF, chronic HTN) have special discharge tasks:

• •MyChart gestational hypertension flowsheet
• •Nursing communication: “BP cuff prior to DC”
• •Blood pressure monitor
• •Patient instructions: .HTNPOSTPARTUMREMOTE

Patient instructions (can steal from me):

• •.HCKDCCSECTION
• •.HCKDCCSSPAN
• •.HCKDCSVD
• •.HCKDCSVDSPANISH

D/C summaries:

• •Need to be completed within 24–48 hours.
• •Change the date of service at the top to actual day of D/C.

• •Occurs at 9:15 AM with nursing, lactation, social work, peds on 5300.
• •Discuss early discharges or any other concerns you may have.
• •If floor person is in a delivery etc., the other intern can cover.

• •Postpartum Antibiotics by Indication (.abxld) → /resources/knowledge/postpartum-antibiotics
• •Postpartum LARC: Inpatient Eligibility → /resources/knowledge/postpartum-larc
• •Postpartum BTL/BS: Medicaid Paperwork → /resources/knowledge/postpartum-btl
• •Postpartum Vaccinations → /resources/knowledge/postpartum-vaccinations

Check:

• •GPs and GA
• •Last note for pregnancy complications, medical/surgical/social history, allergies
• •Placenta location
• •Delivery history
• •Triage vitals and NST
• •Presentation with BSUS
• •The 4 Q’s: bleeding, cramping, loss of fluid, movement
• •Clean up speculum, ultrasound, and swabs.
• •Exam and confirm presentation.
• •Be ready with a one-liner, brief HPI, exam (including vitals, NST, SVE when appropriate), and your suggestion for plan / disposition.

• •NST — fetal wellbeing (reactive?) / contractions?
• •SVE
• •Ultrasound for fetal position
• •Collect GBS if not on file
• •If patient has history of C-section, determine candidacy/desire for TOLAC — patients who TOLAC will need a separate consent on admission
• •Disposition (talk to team; depends on tracing / other factors):
• ◦<3 cm — home with labor precautions
• ◦2–4 cm — recheck in 1–2 hours
• ◦≥5 cm — admit to labor and delivery

• •Same as term, plus infectious workup: UA, wet prep, GC.
• •Collect GBS.
• •Disposition:
• ◦No contractions / closed cervix → home with return precautions.
• ◦Contractions or cervical change → admit for monitoring.
• •If admitted for concern for preterm labor (discuss with upper level before ordering):
• ◦<32 wks → magnesium for fetal neuroprotection.
• ◦Betamethasone for fetal lung maturation if candidate (see steroid candidacy below).
• ◦NICU consult <34 weeks.
• ◦Ampicillin if GBS unknown.
• ◦Consider tocolytics.

Knowledge: specific steroid windows, GBS prophylaxis dosing, mag neuroprotection regimens, and tocolysis details (indomethacin / nifedipine) → see Preterm Labor: Steroids, GBS, Mag Neuroprotection, Tocolysis at /resources/knowledge/preterm-labor-management

• •Speculum exam (don’t use gel — risk for false positive):
• ◦Pooling?
• ◦Nitrazine (blood and semen can cause false positives)
• ◦Slide for ferning
• •SVE / ultrasound to check for position.
• •If rupture confirmed at term, admit to L&D for induction / augmentation. If history of C-section, assess desire for repeat (TOLAC consent vs. C-section consent).

• •Same as term, plus infectious workup: UA, wet prep, GC.
• •Collect GBS.
• •If admitted for confirmed PPROM:
• ◦34–36w6d — discuss expectant management vs. induction.
• ◦<34 weeks:
• ◦Latency antibiotics.
• ◦<32 wks → magnesium for fetal neuroprotection.
• ◦Betamethasone for fetal lung maturation if candidate.
• ◦NICU consult <34 weeks.
• ◦No tocolytics for PPROM.
• ◦Contraception plan; sign tubal papers if applicable.

Knowledge: exam rule (no DE unless >34w), counseling stats, specific latency abx, and steroid rules → see PPROM: Exam Rules, Latency Antibiotics, Counseling at /resources/knowledge/pprom-management

• •Confirm dating with bedside ultrasound — PGY-2/4 can help with biometry if unsure.
• •Enter OBGYN hx, medical, surgical, family, social history into Epic.
• •Get name + phone, plus secondary contact + phone. Document this in your note.
• •Use OB No Prenatal Care order set to order all routine NOB labs while pt is in triage:
• ◦Type & screen, CBC
• ◦Hep B surface antigen, Hep C antibody, Syphilis Ab, HIV L&D
• ◦Hemoglobin electrophoresis, Rubella antibody, Urine drug screen

• •NST
• •AFI
• •If term, consider delivery.
• •If preterm, consider in-triage monitoring vs. admission (decision based on NST).

• •Vitals: if >140/>90, repeat q15 min BPs during triage evaluation.
• •Lab evaluation: CBC / CMP / P:C (can order before seeing patient).
• •Symptoms: headache, vision changes, chest pain, shortness of breath, RUQ pain.
• •Physical exam: lungs (pulmonary edema), lower extremities (edema).
• •Disposition:
• ◦If no elevated BPs, discharge with return precautions. Ensure patient has home cuff; counsel them to bring home cuff to next appointment to calibrate.
• ◦New diagnosis gestational HTN or preeclampsia without severe features:
• ◦>37 wks — admit for delivery.
• ◦<37 wks — consider 24-hr BP observation vs. home with precautions.
• ◦New diagnosis preeclampsia with severe features:
• ◦>34 wks — start magnesium (preeclampsia dosing), q8h CBC/CMP, admit for delivery. Consider steroids if candidate.
• ◦<34 wks — start magnesium, q8h CBC/CMP. Start magnesium (fetal neuroprotective dosing if <32 wks). Betamethasone for fetal lung maturation if candidate. NICU consult <34 weeks.
• ◦If severe-range BPs: start severe-range BP pathway AND start long-acting medication (usually Procardia 30 mg daily).

Knowledge: severe-features mag protocol (4g + 2g/hr × 24h), Q4–12h labs, and the DUHS OB SEVERE-RANGE BLOOD PRESSURE TREATMENT PATHWAYS order set → see Preeclampsia: Severe-Features Management + Severe-Range BP Pathway at /resources/knowledge/preeclampsia-severe-features. Bedside mag-check reference → /resources/knowledge/mag-checks-bedside.

• •Ask about recent intercourse.
• •ROM workup.
• •Each Fox swab is 5 mL.
• •DDx: UTI, abruption (ask about drug use), ROM, labor, nothing.

Consider: biliary issue, appendicitis, pancreatitis, pyelo, UTI, abruption, labor, round ligament pain.

• •Headache cocktail: Benadryl, Mag oxide, Reglan, Tylenol (lowest dose of all — 650 mg Tylenol).
• •GI cocktail: 30 mL.
• •Chest pain: EKG and Troponin x2 (0 and +3 hrs), BNP.

• •Add to Postpartum list.
• •Delivery note — access through delivery summary tab.
• •Postpartum orders: OB Post Vaginal Delivery order set. Reconcile orders under “Transfer” tab using postpartum order set.
• •Update Handoff with delivery info.
• •Start Discharge summary — speed button in DUH IP OB context “OB Discharge”. Share once started.
• •Add patient to your personal ACGME Log list.
• •Complete VTE risk calculator.
• •Delivery summary tab — lowest priority; ideally completed by end of shift but can do next day.

• •Staff with upper level.
• •Sign H&P.
• •Add to Antepartum list.
• •Start Handoff — .OBAPSIGNOUT2018
• •Admission orders: OB Antepartum Admission order set. Use “Admission” tab.
• •Ask if the patient needs scan and/or CS consent.
• •Tubal consent (consider for preterm patients).
• •Communicate to Antepartum team.

• •Staff with upper level.
• •Sign H&P.
• •Add to Active list.
• •Communicate to Active team and Charge RN.
• •Write Handoff (if not already drafted) — .OBHANDOFF*** phrases (e.g., .OBHANDOFF1SUMMARY).
• •Admission orders: OB Labor and Delivery Admission order set. Use “Admission” tab. Make sure you check for GBS status and history of HSV.
• •Write labor sheet.
• •Scan for presentation.
• •Ask if the patient needs CS or TOLAC consent.

• •Staff with upper level.
• •Discharge orders — use “Discharge” tab.
• •Discharge instructions — .TRIAGEPRECAUTIONS
• •Ensure patient has follow-up appointment scheduled.
• •Communicate plan to patient and Triage nurse.
• •Sign H&P.
• •Handoff:
• ◦.obhandoff1summary — Summary/Course
• ◦.obhandoff2daytmn — Day Team Notes
• ◦.obhandoff3xcover — Anticipatory Guidance
• ◦.obhandoff4todo — X-Cover To-do

Initial course:

• •Single course for all women between 23w6 and 33w6 (earlier GA needs NICU discussion about resuscitative plans).
• •BMZ 12 mg q24h for two doses.

Rescue course:

• •Single rescue course allowed between 24w0d and 33w6d if last course was more than 14 days ago.

ALPS:

• •Single course between 34w0d and 36w6.
• •Contraindications: pre-gestational maternal diabetes, chorio, prior steroids in pregnancy (no rescue).

• •Pitocin: IV 10–40 units per 500–1000 mL as continuous infusion. 10 U IM.
• •Methergine: 0.2 mg IM q2h. HTN relative contraindication.
• •Hemabate: 250 mcg IM, q15m, up to 8 times. Asthma absolute contraindication. Administer with lomotil to mitigate diarrhea.
• •Misoprostol: 600 mcg buccal. Longer onset of action — should not be main response to hemorrhage.
• •Not uterotonic: TXA 1 g (can redose once after 30 minutes).