Obstetrics and Gynecology

Intern Handbook
2010-2011
 SIGNOUT TIMES & IMPORTANT NUMBERS
Mon 0630 – 1830
Tues 0630 – 1730 Gyn Pager 12055
Wed 0630 – 1730 GynOnc Pager 12825
Thurs 0630 – 1730 R1 OB 222-7964
Fri 0630 – 1830 R2/R3 OB 222-7965
Sat 0800
Sun 0800 - 1930

TABLE OF CONTENTS

Day OB and Nightfloat……..…………………….……………....pg 1

Postpartum………………………………………………………..pg 8

Floor Calls…………….……………………….…………………pg 10

Discharges…………………………………………………..…..…pg 12

Conferences……………………………………….………………pg 13

Consenting…………………………………………………….…..pg 14

Gyn Onc………………………………………………………...…pg 14

US/REI…………………………………………….………………pg 18

GYN……………………………………………………………….pg 19

Dictation 101…………………………………………….………..pg 20
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Day OB and Night Float

Daily Schedule and Events

1. Lectures/ Grand Rounds: Mon 7:30 – 11:30 am
2. Fetal Strip Rounds: Wed 7:30 am
3. MFM Journal Club: 3rd Wednesday of each month 7:30
4. GynOnc Journal Club 4th Wednesday of each month 7:30 ( onc R2 presents )
5. NICU conference: Friday @ noon ( off-service intern covers this )

Admit Orders
Remember: ADCVANDIMLS
(Admit, Dx, Condition, Vitals, Activity, Nursing, Diet, IVF, Meds, Labs, Special)

There are pre-checked order sets available in Powerchart. Below are some items that are
already checked off…
- Admit to L&D – you will have to ADD the attending (SWC vs SMC)
- Vitals (per routine) – Ask nurse to cycle BPs at least q1hr for pts with
GHTN/PIH/ PreE
- Activities: bedrest (in active labor)
- Nursing: CEFM x 2, strict I/O’s if on magnesium
- Diet: sips and chips in active labor
- IVF: NS or LR
 See diabetic protocol for IVF
 Pre-eclampsia and receiving Mg → fluid restrict <2400/24 hrs
(100cc/hr) – this is part of PIH/mag order set
- Meds:
 Fentanyl 100 mcg IV Q1hr PRN x maximum of 3 doses
 Induction/augmentation agents (cervidil, miso, or pitocin )
 For Pre-E - Mg 4g loading dose, then 2gm/hr IAL
 For DM – See protocol for insulin regimen
 For GBS+ - Ampicillin 2g IV loading dose, then 1g q4h until
delivery. See section on GBS+ for alternatives
- Labs: CBC on everyone, T&S NEW PROTOCOL; for Pre-E (CBC, uric acid,
AST/ALT, creatinine, UA (straight cath), Urine ptn/cr ratio – this is ordered as
urine protein w/ creatinine in powerchart. **OB PIH labs orderset**
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Laboring Patients
1. Complete H&P preprinted form. Also fill out PP Rx and d/c summary.
2. Confirm fetal presentation with U/S on ALL new admits.
3. Patients need notes every 2 hours while in L&D; if doing an exam, tell the
nurse before or after and write it on the strip. If cervidil or miso & healthy
every 4hr notes is okay
 Make sure all cervical exams are double checked in the first 2-3
months of year.
4. Review the fetal central monitors frequently, if there is any concern, SEE
the patient and ask another resident or the attending to review the strip with
you.
5. For AROM/FSE/IUPC you will always need the nurse present in the room.
6. Update the sign-out on the computer regularly ***
7. Consent patients for vacuum, forceps, c/s – translators are always available
on pager system if necessary, have patient sign pre-printed consent and
write progress note documenting consent – OK to use C/S consent stamp
8. Call upper resident and attending for all deliveries. ***
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9. For vacuum, forceps, preterm, twin deliveries upper years usually get first
dibs – discuss with your team.
10. Get med students involved, - multips (with epidurals & nl –sized baby) are
best for them to follow and deliver – discuss having the med student
involved with the delivery with the attending prior to the delivery.
 All med student notes need to be cosigned.

OB Checks
1. 4 key questions for all patients: Contractions? Vaginal bleeding? Loss of
fluid or ruptured membranes? Fetal movement?
2. Confirm dates – Date by LMP c/w US? When was US?
3. Review pt’s chart! Antepartum issues? Look at BPs. Has the patient had
Pre-E labs?
4. For LOF or VB, sterile speculum first (remember NO digital exam for
previas!)
 SSE with water – no gel
 Look for pool, then swab with nitrazine swab, then use cotton
swab to make slide to check for ferning under microscope.
5. Present the case to the 2nd year and/or chief.
6. If a resident’s continuity patient is to be admitted, notify them (it will have
their name in the front of the chart).
7. Have med students see ob checks too – have them get the history then do
the exam together (or just R1 for SVE)
8. Common OB check issues and treatment:
 UTI: Remember to send Urine for culture and f/u result.
Macrobid 100 mg po bid x 7 days prior to 37 wks
Keflex 500 QID x 7 days any GA
**what # UTI in preg? Do they need daily suppressive abx
after treatment?
 BV: Look for clue cells on wet mount. Grey discharge with +
“whiff test”.
Metronidazole 250 mg PO tid or 500mg PO bid
 Yeast: Monistat 3 or 7 day course
 Decreased FM: If discharged after reactive NST and nml AFI,
Should be set up for NST/AFI in 3-4 days in PDC.
9. ** Make a copy of the OB check note and write what needs to be
followed up on (e.g. UCx, GC/CT) on the top along with the patient’s
phone number – put in blue folder in res room **
10. PUT 24hr urine follow-ups on SIGNOUT, always verify pt’s correct
ph#
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Perinatal Diagnostic Center
1. All formal ultrasounds, NST, AFI, amniocentesis and FLM are done in
PDC.
2. To schedule pt for U/S, NST/AFI fill out PDC requisition and FAX to PDC
– helpful to put pts EDC on form. Can also call PDC ext. 57030 to let them
know if study is STAT.
3. Give copy of PDC form to pt and circle phone # - IT IS THE PT’S
RESPONSIBILITY TO CALL PDC FOR THEIR APPT TIME!

PEARLS → these may vary depending on the patient and the attending so check with
the team prior in writing orders
1. GBS + or GBS bacteruria: Ampicillin 2g IV then 1g q4hr until delivery;
Most attendings want 2 doses (4 hr) of antibiotics on board prior to
delivery. If PCN allergic: Ask about reaction to PCN. If not
anaphylactoid, give Kefzol . If anaphylactiod (inc hives), check for
sensitivities. If sensitive to clinda, give Clinda 900mg IV q8. If not
sensitive to clinda or sensitivities not available, give Vanco 1gm q 12 hr.

2. Maternal fever in labor: +maternal temp >38 WITHOUT fetal or

maternal tachycardia. Discuss with chief and attg (everyone’s different)
but can start Amp/Gent (same protocol as intrapartum chorio) without
“calling chorio” -> different implications per peds for newborn

3. Chorioamnionitis: Maternal fever + maternal tachy and/or fetal

tachycardia, or “foul smelling” fluid.
***CONSENT PT FOR CHORIO STUDY, IF POSSIBLE**
 NSVD - Amp 2g IV q6h + Gent daily dosing 5mg/kg) x 24h
afebrile PP
 if C/S – ADD Clinda 900mg IV q8h to Amp/Gent, x 48h afebrile
PP
 Note: 24 hours begins from first afebrile, not last fever

4. Induction of Labor: assess! Is cervix “favorable?”

How much is the patient contracting? If LESS than 3 UCs / 10min and
cervical ripening necessary….
 Cervidil – Placed in vagina, left in place x 12h
 Miso – Oral: 50mcg po, then 100mcg in 4h if pt still qualifies
(less than 3ctx/10min and less than 3cm);

5. Augmentation of labor (or induction with favorable cervix or frequent

UCs)
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 Pitocin – Order as “Pitocin per protocol”, usually started if >3cm
dilated. Starting dose is 1-2 milliunits. Can do ‘low-dose’ pit, not to
exceed 10milliunits

6. Magnesium Sulfate checks: Review BPs, check reflexes, follow strict

I/O, listen to lungs, follow labs. Remember to ask patient about
headaches, blurry vision, scotoma, SOB, RUQ pain. (Check every 2-4 hr)

7. Diabetes: (See Diabetic management protocol in Powerchart)

 A1GDM: FS q 4 hr in latent labor, q 1 hr in active labor. Do
fasting FS on PP/POD 1. Needs 2hr GTT at 6wk PP visit.
 A2GDM: FS q 4 hr in latent labor, q 1 hr in active labor. Start
insulin drip if FS > 110. Do fasting and AC FS postpartum. Treat
with sliding scale for FS > 200. Needs 2hr GTT at 6wk PP visit.
 Type 2 DM: FS q 4 hr in latent labor, q 1 hr in active labor. Start
insulin drip if FS > 110. Do fasting and AC FS postpartum. Treat
with sliding scale for FS > 200. Consider restarting pre-
pregnancy hypoglycemics, preferable metformin (less risk of
hypoglycemia).
 Type 1 DM: FS q 1 hr during labor. Insulin drip in labor if FS
>70. Start insulin at 1/2 - 1/3 pregnancy dose PP (with chief or
attg guidance) and check fasting, AC, PC and qhs FS. If pt has
insulin pump, usually restart PPD1 or POD1 (when tol reg diet)

SAMPLE NOTES AND DICTATIONS

L&D progress notes: (remember to date and time all notes)

R1 OB PN
S: Comfortable/desires pain meds. If pre-eclamptic, any sxs?
O: TEMP, VS: (If on Mg, also note I/O’s, general, lung exam, DTRs)
FHT: baseline, variability?, presence of accels, if not currently reactive, mention
if previously reactive; decels
Toco: Q X minutes, +/- irritability; Pitocin @ x
SVE: dil / eff / station, position of head if known, +/- caput
Labs: [if on meds, write in column]
A/P: X yo GxPx @ x weeks by LMP c/w x week US, in active labor/induction for ….
(1) MWB: AFVSS; if diabetic, fingersticks; if Pre-E, presence of symptoms,
whether needing BP meds, s/sx MgSO4 toxicity. Can include other
important maternal issues here…(anticoag, cardiac, etc)
(2) FWB: reactive/reassuring tracing; GBS status, time since ROM, ?fetal
anomalies. NICU aware (if necessary)?
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(3) Labor: ?adequate progress; meds being used; next intervention if needed.
Discuss C/S?
(4) Pain: comfortable; epidural/fentanyl
(5) Blood type (+/-)/ Rubella status (RI/RNI) /Varicella status (VI/VNI),
GBS (+/-) ….. or at least include GBS status

Delivery Note:
R1 Delivery Note
NSVD of viable male/female infant, wt= , APGARs=

Pt arrived in active labor/induced/ augmented for…. (may include meds used for labor).
She progressed to complete rapidly /over x hours, and pushed x hours to deliver. (Note
presence of increased BPs, infection, deviations from labor curve, meconium). Infant’s
head delivered in a controlled fashion/precipitously over IP/MLE, under local/epidural/no
anesthesia. Nuchal cord x X (or no nuchal). Anterior shoulder delivered with/without
difficulty (if dystocia, note maneuvers used). Posterior shoulder and body followed easily.
Cord was clamped and cut, infant to mom/RN/peds. Placenta with 3VC delivered
spontaneously and intact/ manually extracted. Describe placental/cord abnormalities, if
present. X degree laceration repaired with x-vicryl/chromic/monocryl in usual fashion.
Describe repair if complicated. If 3rd or 4th degree lac, document rectal exam. (If cord gas
or placenta sent, document why)

Baby to WBN/NICU for … Mom to postpartum floor stable (describe any postpartum
interventions for mom, e.g. Abx, Mg, FS, bowel care for large tears).

EBL=
OBs= Attg, Residents, +/- students
The Attending physician, Dr. X, was present and participated directly in the entire
procedure.
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C/S dictation – use this or the dictation in the Red Book as a guide…

Need to know:
EBL, I/O, Apgars, Weight, +/- Abx, Sutures/Layers Closed, Age/G/P/Weeks

Preoperative Diagnosis:
1. 23 y/o G3P2 @ 40 1/7 wks
2. Arrest of dilation at 6cm x 4hours
3. Non-reassuring fetal heart tracing
Postoperative Diagnosis: Same
Operation: Primary low segment transverse caesarean section
Surgeon: Attending Assistant: you!
Anesthesia: Epidural (or spinal)
Indications: 23y/o G3P2 @ 40 1/7 wks arrived IAL, progressed to 6cm then
experienced an arrest of dilation at 6cm despite pitocin augmentation and
UCs >200MVU as measured by IUPC. Fetal NRFHT also developed, decision was
made to proceed with C/S.
Findings: Male infant in occiput posterior presentation. Thick meconium
(or clear fluid) at amniotomy. APGARs 6/8 at 1/5 minutes. Weight 3980g.
Normal uterus, tubes, and ovaries.
Description of Procedure:
After assuring informed consent, the patient was taken to the operating
room and spinal anesthesia was initiated. The patient was placed in the dorsal, supine
position with leftwardl tilt. The abdomen was prepped and draped in normal sterile fashion.
A Pfannenstiel skin incision was made with a scalpel and carried through
to the level of the fascia. The fascial incision was extended bilaterally with Mayo scissors.
The fascial incision was then grasped with Kocher clamps, elevated, and sharply and bluntly
dissected superiorly and inferiorly from the rectus muscles.
The rectus muscles were then separated in the midline, and the peritoneum was
tented up and entered sharply with Metzenbaum scissors. The peritoneal incision was extended
superiorly and inferiorly with good visualization of the bladder.
A bladder blade was then inserted, and the vesicouterine peritoneum was
identified, grasped with pick-ups, and entered sharply with scissors. This incision was then
extended laterally, and a bladder flap was created. The bladder was retracted using the
bladder blade. The lower uterine segment was incised in a transverse fashion with the
scalpel and then extended bilaterally with bandage scissors.
The bladder blade was removed, and the infant's head was delivered
atraumatically. The nose and mouth were suctioned and the cord was clamped and
cut. The infant was handed off to the pediatrician. Cord gases and cord blood were sent.
The placenta was then removed manually, and the uterus was exteriorized and
cleared of all clots. The uterine incision was repaired with (1-0 chromic) in a running
locking fashion. A second layer of (1-0 chromic) was used to obtain excellent hemostasis.
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The bladder flap was repaired with a (3-0 Vicryl) in a running fashion. The cul-de-sac was
cleared of clots and the uterus was returned to the abdomen. The peritoneum was closed with
(3-0 Vicryl). The fascia was re-approximated with (0 Vicryl) in a running fashion. T
he skin was closed with staples.
The patient tolerated the procedure well. Needle and sponge counts were
correct times two. One gram of Kefzol was given prior to the start of the procedure
Estimated Blood Loss: 800 mL
Specimens: Placenta, Cord gas, Cord blood specimens
Fluids: 2000mL LR, 500cc hespan. Output 300mL clear urine at end of procedure.
Complications: None
Disposition: The patient tolerated the procedure well and was transferred to the
recovery room in stable condition.

The attending, Dr. XX, was present and participated directly in the entire procedure

POSTPARTUM – this is your service….OWN it!

1. OB intern takes all the postpartum calls
2. Round on all SMC, SWC, and private c/s patients (intern on the “easy” rotation can
round on the private c/s patients). OB night float intern prepares the list (see below)
and divides the patients among the Day and Night interns
3. Night float prints list of who to round on and their PP or POD – include labs, pertinent
complications (chorio/endometritis/GDM/preE). This list is divided between DAY,
NIGHT +/- off-service intern +/- NP Bobye Sunday. Also make list for SWC, SMC
attending (highlight their patients)
4. Night float intern should go down to prep at 0430. How to prep:
a. Open power chart, choose the patients by highlighting names
b. Go to task (top menu bar on the left most corner of the screen)
c. Click reports
d. Click postpartum report AND MD teaching encounter and then push print
e. Make sure MD teaching encourter ( attending attestation ) is included with
each progress note

So… Who do you round on?

WEEKDAYS
1. All San Mateo County patients. (SMC)
2. SWC (Stanford) patients:
 Bobye Sunday, NP will round on UNcomplicated NSVD and C/S
 ANY complicated patient needs to be seen by the intern **
** Complicated means DM I or II, PIH currently on Magnesium or
with abnormal labs or BPs, patients on antibiotics, medical problem
requiring closer monitoring or medication ….or anything Bobye
Sundae does not feel comfortable with…
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3. Private C-sections in which a resident assisted (look at delivery summary or OP report
on Powerchart, or red-bordered sheet in chart). Private NSVDs never need to be seen by
interns.
 Proceed with caution when writing orders on private patients (always ask
chief or private attending first if you have questions.)
 Simple orders including Tylenol, Motrin, Benadryl, heating pads (KPads) are
ok
 When called about a fever or BP issue, etc: evaluate the patient, then run it by
an upper resident or call the private to discuss plan for work-up/management

WEEKENDS:
ALL SMC, SWC and private c-sections - No Bobbye Sunday on weekends

So … How do I Round …

1. Night intern: communicate with Bobye about what patients she is comfortable seeing
2. Use postpartum progress note and include physician attestation sheet (MD teaching
encounter)

Wound Care
 Remove staples on POD#3 or #4 if patient being discharged and place steris on top +/-
benzoin. Use caution and talk to upper res if pt obese, diabetic
Vertical staples stay in for 7-10 days: MUST give pt instructions to go to Stanford OB
clinic or SMC or PMD to get staples out. Write this info CLEARLY on discharge summary
 Prolene (blue permanent suture secured with steris: remove POD3-4, simply cut long end
and pull from end with loop to remove….super easy
 Opsite (Tegaderm): placed over subcutaneous sutures, remove prior to d/c. No need to
put anything on top

POSTPARTUM ISSUES

Anemia
-anyone with Hct < 30 gets FeSO4 bid once tolerating regular food.
-give Rx on d/c for Ferrous sulfate as well

Rh Negative
1. Follow up Rhogam studies from delivery and give Rhogam subq as indicated.
2. Nurses are usually good about checking as well but a reminder order is always good

Contraception
If Breast Feeding:
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 Micronor (progesterone-only OCP) 1 tab PO QD, start 2nd Sunday after
delivery. 11 refills. Can switch to regular OCPs when no longer breast feeding.
 Depo-Provera 150 mg IM injection. Tell them that they will need to repeat
every 3 months.
 IUD post-placental or at 6 weeks PP check up
 Implanon during visit or at 6 week PP check up

Vaccinations
1. Rubella non-immune: Order MMR prior to d/c Current guidelines are that patients
should not become pregnant 1 month after receiving vaccine
2. Tdap: Contains new pertussis vaccine for adults. If no tetanus within 2 years
recommend giving this
3. Varicella non-immune: Varivax prior to d/c. Needs booster at 6wk PP visit according to
ID specialist Dr. Aziz

Postpartum tubal ligations – need standard Stanford consent signed by patient and hand
written consent. For medical must have tubal consent signed 30 days prior to delivery, if
preterm (<40wks) only 3 days prior is okay. Remember to document your consent
discussion in the chart! There is a template on the workspace, called R1 BTL

FLOOR CALLS
What to do if they call you for …
**This list should not replace clinical judgment, physical evaluation or attending opinions**

1. Temperature
Most everyone treats >38.5 regardless of mode of delivery. 38-38.5 varies. More likely to
treat if had a temp in labor or if temps have been “almost” high for a while. Often treat
NSVD if >38.0 or if>12-24 hours out of a c-section. You will want to discuss with upper
level or attending.
Questions: Mode of delivery, when did they deliver, was temp repeated, did they get
antibiotics in labor or have chorio.
Patient Evaluation: Does pt look sick? Breast tenderness? Lungs clear? CVAT? Uterine
tenderness? Wound cellulitis? Calf tenderness and swelling (DVTs)?
Possibe studies: CBC, Cath UA and C&S, CXR, Tylenol 650-1000mg PO q6 prn fever

For presumed endomyometritis (temp with fundal tenderness >24h PP):

Gentamicin 5 mg/kg q24h
Clindamycia 900mg IV q8
+/- Ampicillin 2 g IV q6hours
*** Usually treat with antibiotics until afebrile (T<38)>48 hours. This extends
from first time pt documented afebrile, not last fever.
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2. Low HCT
Questions: If you are called with a significantly low Hct (<25) do PE.
Patient Evaluation: Check vitals, tachycardic? orthostatics, urine output, and determine if
patient is symptomatic (are they dizzy when they stand?). Evaluate for source of bleeding,
quantity of blood or hematoma.
Treatment: Consider transfusion (done very rarely), rechecking Hct, and FeSo4 and discuss
with upper level.
- transfusions usually reserved for Hct<20

3. Bleeding
Questions: How much blood, mode of del, EBL, vitals, orthostatics, urine output
Patient Evaluation: May involve looking at quantity of blood yourself, and if concerning
call upper level to do pelvic and possible remove clots, membrane, or maybe to administer
meds.
Treatment: Pitocin, Methergine (if normal BP’s), Hemabate (if not asthmatic), or Miso
buccal/SL. Also consider Keflex 1 gram x 1 if you have done manual extraction of clots on
the floor.

4. UTI Symptoms
Cath UA and C&S -> if pos Tx: keflex 500mg PO QID x 5-7 days

5. No or low UOP
Bolus LR or NS 500-1000mL. (do not bolus pts on Magnesium or with cardiopulm dz),
Strict ins and outs, Watch UOP closely, if low (<30cc/h) or none in 4-6 hours bladder scan
and may place foley to check for urinary retention.

6. Unable to void
If pt has not voided for 4-6hrs s/p Foley removal: bladder scan, best to replace Foley if
urinary retention and keep in place for another 24h of bladder rest. Voiding trial the next
day: if pt fails, may need d/c with foley – don’t forget leg bag teaching and to discuss f/u

6. Magnesium
A. Checks: Questions: Any scotoma, RUQ pain, headache
Check I/Os, DTRs, Lungs, Write brief note
B. Mag Calls:
 Can we decrease frequency of vitals?
Question: How long on Mag and when does it D/C. What have UOP and vitals been like?
If BPs have been good and uop ok then may go from vitals q1 to q2, etc.
 Can we decrease the Mag as the patient is so groggy and feels miserable?
Determine if she is severe Pre-E and what her vitals have been like. What is her UOP and
Cr? Go evaluate patient. May order Mg level and consider decreasing to 1.5/hour or
1/hour, most patients will tolerate Mg at 2g/h for 24h PP if nl renal function.
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7. Elevated BPs
Questions: What are the last several BPs? New onset hypertension or ongoing problem? Is
patient Pre-E and on Mag or was she on Mag.
Treatment: We treat BPs SBP>160 DBP>105. Please note these numbers vary according to
attending. If the BP is new we may want to get PIH labs to evaluate Pre-E.. We treat acute
with Labetalol 10-20mg IV or Hydralazine 5-10mg IV, also can start a patient on
Labetalol 100-200 mg po BID. If HTN refractory to po labetalol consider Nifedipine XL
starting at 30 mg qday. Always communicate and discuss with upper level.

DISCHARGES – this will quickly become your forte!!

Discharging NSVDs
1. Discharge to home on PPD2 athough…..encourage multips to go home on PPD1, as long
as it has been > 24 hours since infant’s birth

2. Discharge Rx:
 Colace 250 mg po bid prn (#60, 3 refills)
 Motrin 600 mg po q6h prn (#30, no refills)

Discharging C-sections
1. Discharge on POD#3 or 4 after passing flatus and tolerating reg food. Remove staples,
prolene or opsite, as appropriate
2. Discharge Rx:
 Colace 250 mg po BID prn (#60, 3 refills)
 Percocet 1-2 tabs po q4-6 hours pm pain (#30, no refills) – MUST go on
formal controlled substance Rx (get from upper level resident)
 Motrin 600 mg 1 tab po q6h prn (#30, 1 refill)

Discharge Summaries
1. Fill out pre-printed form – hospital course is just infant sex, weight, APGARs if
uncomplicated NSVD or c-section.
2. Patients with a complex PP course (antibiotics for chorio/endometritis, poorly controlled
BPs, FSs, etc.), tachycardia, abnl labs or needing special followup MUST be clearly
documented on discharge summary.
3. YOU MUST DICTATE DISCHARGES who receive a transfusion, are hospitalized
longer than standard duration of admission after delivery >PPD2 or >POD4. Use your
judgement – if a patient has a complex course, it is helpful to outside and future providers to
have a clear hospital course, so DICTATE 
4. Patients previously on AP who then are moved to L&D and deliver: AP course will be
dictated by 2nd year – copy d/c summary and put in 2nd year’s box, if they have a
complicated postpartum course – that will need to be dictated separately.
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5. It is very important to always have d/c paperwork CLEARLY filled out, dated and signed
– CYA!!
6. If a patient was transferred from OSH: CC outside MD on discharge summary. Ask R2
if you’re unsure….this is also VERY important!

Signing Out Post-Partum

Sign out complex patients or those with labs or other studies that need to be checked after
sign-out.
-DO sign out: preE, DMtype1 and type 2, chorio/endometritis, PPH, wound
complications
-NOT necessary to signout: FS for A1 or A2GDM, SW, vaccinations: just triple-
check that the order is in

Wed AM Teaching ~730am in OB conference room (3rd floor)

1. 1st, 2nd and 5th Wednesdays are fetal strip rounds, day OB intern prepares
and presents an interesting fetal strip (present case) and another intern reads
the strip. Helpful to make a handout about relevant topic for medical
students
2. Help out fellow interns and pull interesting fetal strips during your shift
and let them know it’s a good one to discuss!
3. 3rd Wednesday of the month is MFM journal club, an intern and MFM
fellow present an article. Coordinate a calendar for the year with fellow
interns and communicate with MFM fellow about which article and hoe to
present.
4. 4th Wednesday is Onc journal club: R2 on onc presents – you’re off the
hook!!

Perinatal Conference
1. This conference is on Friday at noon with the OB and NICU faculty and
residents – conference room on 1st floor Packard by elevators.
2. Intern on an “easy” rotation to prepare and present the case. L&D day
intern takes the responsibility when off service resident on vacation.
3. Fetal strips are not presented in these conferences, simply the prenatal
course leading up to the delivery including interesting maternal disease or
complications (*briefly*). Include US findings and +/- betamethasone
prior to birth. Infant info: only need to present APGARs, cord gases, baby
weight. The peds resident will present the baby’s hospital course.
4. Call NICU fellow on call Wed to get the names of the infant’s being
presented. Number is 19686
5. You are not responsible for presenting information on babies transferred to
LPCH after birth (outborn babies)
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***********************************************
CONSENTING 101

BLOOD TRANSFUSION RISK NUMBERS

HIV less than 1/2,000,000
Hepatitis C less than 1/2,000,000
Hepatitis B 1/500,000

SAMPLE C-SECTION CONSENT

I discussed with the patient the risks, benefits, and alternatives of a Cesarean section. I
explained to the patient there is a risk of infection and damage to internal organs including
bladder, bowel, ureters, blood vessels, and nerves. I also explained to the patient there is a
risk of bleeding which may require a blood transfusion or in rare cases a hysterectomy. I
explained that the risks of a blood transfusion include the risks of the transmission of HIV
(<1/2,000,000), Hepatitis C (<1/2,000,000), or Hepatitis B (1/500,000). The patient
demonstrated understanding and all questions were answered. Consent signed.

SAMPLE BILATERAL TUBAL LIGATION CONSENT

I discussed with the patient the risks, benefits, and alternatives of a bilateral tubal ligation. I
explained to the patient that this is a method of permanent sterilization but does have a
failure rate of 3-5/1000. I explained to the patient that if she does become pregnant after a
tubal ligation she is at increased risk of an ectopic pregnancy and should be evaluated by a
physician immediately. I explained to the patient there is a risk of infection and damage to
internal organs including bladder, bowel, ureters, blood vessels, and nerves. I also
explained to the patient there is a risk of bleeding which may require a blood transfusion. I
explained that the risks of a blood transfusion include the risks of the transmission of HIV
(<1/2,000,000), Hepatitis C (<1/2,000,000), or Hepatitis B (1/500,000). The patient
demonstrated understanding and all questions were answered. Consents signed.

Gyn-Onc

Rounding and Floor Work

1. Responsibilities depend on your chief:
 If individually rounding, the evening before, you will decide with your team
who will see which patients (MOST COMMON)
 If team rounding – collect vitals on all patients prior to arrival of team
 For patients in the ICU – usually an upper level will round and collect vitals
 F/U labs, tests, studies and consults during the day and gather vitals prior to
PM rounds with attending

Admissions and D/C’s

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1. Admissions must have H&P’s, Use gyn-onc order sets and templates in EPIC for
admission
2. For discharges: Use discharge tab in Epic.
 First do general discharge order set. Make sure to include day and night
contact numbers for the patient. Day # 498-6000, Night 723-4000 and ask for
gyn-onc doctor on call (.oncfu)
 Next do discharge summary. You can cut and paste course from sign out into
Hospital course. Change wording to make it understandable (e.g. spell out
abbrieviations). (.gyndischarge)
 Make sure pt has all new meds or refills on meds if needed. Ask what
pharmacy they use and fax….unless Percocet, oxycodone, etc need secure Rx
from upper resident

Clinics (M,W,F)
1. All patients you see in clinic need notes, they can be done either in epic or dictated.
2. Do as much of floor work as possible from clinic: entering orders, F/U labs, getting
patient updates from nurses – this is always the intern’s 1st priority
3. For each patient, you will see the patient first – get history and do brief PE – then present
to the attending (they will do the pelvic/breast exams with you)

Tumor Board (Wed 1pm)

1. Patient’s presented at Tumor Board include those who go to the OR (does not include
patient’s with benign disease or undergoing palliative treatments) and some new patients
who were seen in clinic (the attending will tell you if they want the patient presented).
2. Keep a list and verify with upper levels and fellows frequently.
3. Each patient is presented with their identifying info (age, type of cancer, stage) and a
summarization of their tumor history:
a. Key events – radiology and pathology
b. Surgeries
c. Chemo/Radiation
d. Brief: PMHx, PSHx, Meds, FH, SH
**look at previous TBs and the team will help you too**
4. Pathology slides have accession numbers which are on computer for older studies.
5. For recent pathology (i.e. pt recently had biopsy), call Surgical Pathology (across from
2nd floor escalators), new accession numbers.
 If pathology read is not “final” (give the ‘hot seat’ pathologist the accession
number and they can tell you), just indicate that the pathology is pending and
“for review”
6. Radiology studies not done at Stanford can be found in the work-room (work-room C) at
the Cancer Center. If not there, ask Joanne Halsey if she knows where to find them. (Make
sure to drop of outside films and TB packet to the reading room on Tuesday, prior to
 16
conference.) Better yet, get OSH films uploaded to the Stanford computer system by going
to film library and talking to Jose…

Weekly Schedule

Daily
1. 6:15 AM or earlier: Page Night float, get sign-out and have pager 12825 forwarded to
your pager.
2. Print new signout for your team from OB secure workspace
3. Definitely wear scrubs on OR days, usually we dress up on clinic days…but if you’re
feeling lazy, scrubs are okay too.

Monday (Berek clinic)

1. Grand rounds and lecture 7:30 – 11:30
2. Clinic in Cancer Center, Clinic C, Workroom C for rest of the day
3. Sign-out at 1830

Tuesday (OR Day)

1. Facilitate patients going to the OR:
2. Floor work: update discharge summaries, check labs, etc.
3. For Tumor Board:
 Gather all outside films from clinic and take them to radiology - CT Fellow -
with copy of Tumor Board (including cover sheet). If all films uploaded to
system or SUH – no need to do this
 Email Tumor Board to ONLY to Deirdre Steiglitz – she will distribute the list
in a secure way to the rest of the recipients at the top of the tumor board
 Fax cover sheet of Tumor Board to: Surgical Path, Radiology, Radiation
Oncology, Radiology File Room: NUMBERS on top of TB
4. Always keep checking into OR to see if there is anything else that needs to be done
5. Post-op check patients – all OR patients need post-op checks approx. 4h after completion
of procedure: include vitals, fluids (I/O’s), meds (esp. pain)
6. Start on Tumor Board for the next week: somewhat painful, but so good to be ahead
7. Signout at 1730

Wednesday (Teng Clinic)

1. Strip rounds or journal club 7:30 – 8:30
2. Clinic with Dr. Teng (Cancer Center, Clinic C, Workroom C)
3. Tumor Board at 1 PM in Basement RadOnc classroom, down big stairs in center of
Cancer Center. Turn Lx2 off stairs. Classroom is down on L (basically under the stairs)
4. Signout at 1730
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Thursday (OR Day)
1. Facilitate patients going to the OR:
2. Floor work: update discharge summaries, check labs, etc.
3. Work on Tumor Board – don’t get behind - you’ll hate yourself on Sunday for it!
4. Post-op check patients – all OR patients need post-op checks approx. 4h after completion
of procedure: include vitals, fluids (I/O’s), meds (esp. pain)
5. Signout at 1730

Friday (Hussain Clinic)

1. Clinic with Dr. Hussain (Cancer Center, Clinic C, Workroom C) – she works FAST, get
the important information from the patients and MOVE ON!
2. Signout at 1830

Helpful Hints:
1. Gyn Onc Pager: 12825
2. Chemo patients admitted to FGr or EGr
3. All other patients, it is preferable to go to F3
4. Rounds: irregular with attendings
5. Replacing electrolytes
 Phosphorus: Phos NAK packets
 Magnesium: Mag Sulfate IV 8 meq is 1g, so order “8” or “16”
 Potassium: 10 meq IV over 1 hr  replaced K <4.0
 Calcium: Calcium gluconate 1g IV
6. Hct <30, consider transfusion – discuss with chief
7. IVF: D51/2NS + 20 meq K@ 125 cc/h (routine fluid orders postop or NPO)

Sample Gyn Onc Note –EPIC

** Click the notes tab on the left. Click on new note. Type .gyn and chose gyn progress
note. This will bring up a template and import all vitals, labs, and meds. Make sure to
review these!! Then just add interval history and plan.
R1 Gyn Onc PN POD#1, HD#2

Interval History: ask about pain and look to see how much pain meds they are taking,
flatus, nausea, vomiting, tolerating diet, SOB, etc, as appropriate
O: Filled in by EPIC. Review vitals and pay attention to I/O, drain output, etc.
PE:
Gen: does the patient look uncomfortable, is she alert, awake, and oriented?
Neck: look at the line sites: is there erythema, warmth, bruising?
Heart: rate, rhythm, murmurs…..
Lungs: listen sitting up or patient rolled to side; crackles? Decreased breath sounds?
 18
Abdomen: look for distention, ascites; listen for bowel sounds; check ostomy sites, color of
output
Wound: check site for erythema, warmth, bruising, etc. if would is being packed remove
packing and note granulation tissue, pus, fluid, bleeding, foul smell, etc. (allow extra time
for packing wounds!)
Extremities: check to see that TEDs/SCDs are placed, look for tenderness, edema
Labs: imported by Epic (.rrCBC, .rrBMP, etc)
Radiographic Studies: imported by Epic
Pathology: Look up any pending pathology

A/P: ##yo with [diagnosis] s/p [surgery] etc.

Onc: Brief dx, course, intraop findings – pathology
Pain: note PCA or oral meds
Heme: note pt’s last Hct, if any transfusions needed, epogen; note if pt has
thrombocytopenia
ID: note if pt has temperature spike, work-up involved, day of antibiotics; pending micro
CV: Treatment of HTN, arrhythmias, chest pain, etc
Resp: note saturations and oxygen requirements, and interventions needed for SOB,
effusions, etc
GI: note the patient’s diet, if she is on GI prophylaxis (pepcid), stool softeners, if has NGT,
tx for nausea/vomiting
FEN: note plan for chem., labs, TPN, IVF, etc
Endo: note if diabetic, has thyroid disease, meds
Prophylaxis: note if pt has TEDs/SCDs, heparin, lovenox
Dispo: discharge plan, SW or case manager consult if needed

US/REI WEEKLY SCHEDULE

AM: Round on private post-partum patients. The nightfloat intern will make a list for you and highlight who
you need to see.

  Monday Tuesday Wednesday Thursday Friday

Grand Rounds Planned
AM Resident Ed PDC US REI Parenthood REI
PM PDC US PDC US PDC US PDC US PDC US
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Outpatient Gynecology

During this rotation, you will be traveling to various clinics in order to enhance the depth of
your gynecologic knowledge! Here’s the basic scoop…also see your specific clinic
schedule made by the chiefs to see what attending you are assigned when in Gyn clinic at
Stanford

AM: Arrive to post-partum round on Private C/S PP pts. Transfer GYN pager 12055 to
yours. You will hold the pager unless off-site. Transfer to R2 or R4 if at VA, SMC and
COMMUNICATE with them that you’re doing so

  Monday Tuesday Wednesday Thursday Friday

Grand Rounds Castro Planned
AM Resident Ed GYN Clinic Commons Parenthood Continuity
VA Dr.
PM Cohen GYN Clinic Contraception SMC REI

GYN clinic / Contraception clinic

REI: 900 Welch Road
SMC: 222 W. 39th Avenue, San Mateo, CA 94403
Planned Parenthood: 1691 The Alameda, San Jose, CA

Continuity clinic: OB or GYN every other week

OB: 770 Welch Road
GYN: Blake Wilber, 2nd floor
VA: 3801 Miranda Avenue, Palo Alto, CA 94304
Women’s Clinic is in bldg 5, toward the back of the VA complex

How do I do a consult?
Once you receive a consult, run the consult first by your senior resident. Always ask ED
resident where the pt gets her care!! If PAMF or Menlo clinic – the ER resident must page
the on-call OB/Gyn for that group. If Stanford pt, go see the consult. Formally present the
consult to the attending, once you have your assessment, and create a plan with your attg.
Once clinic is over, the attg will go see the patient with you.
Once you have a plan, make sure you add your consult to the sign-out so that the NF and
day team will know what to follow up on, as you will be in clinic!

If you are in REI: answer the consult, but unless the consult is an emergency, let the primary
team know that someone will be by to see her in the afternoon. Let the R2 know if you have
a consult that needs to be seen and you are at REI clinic!
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ED: They will contact you regarding the schedule

Dictation clues

For Stanford
***use for Gyn Onc and Gyn service ***

Dial 233 or 650 723 6100. For STAT dictation, dial Medical Transcription Services 650 723 5588.
1. Enter ID (same ID as for Centricity or Carecast). Do not enter leading 00s. For eg, 0012enter 12.
2. Enter clinical code followed by the # key.

Enter code: Description:

1 Inpatient
2 ED
3 Outpatient Surgery
Enter Clinical Area Code (To obtain code, call 3- Clinic Visit
5588)
263 Gyn Onc
264 Gyn

3. Enter work type followed by the # key.

Inpatient/Ops Clinic
2 = H&P 32 = New Patient Visit
3 = Inpatient Progress Note 33 = Clinic Visit
4 = Inpatient Consult 34 = Outpatient Consult
5 = Operative Report 35 = Outpatient Procedure
6 = Inpatient Letter 36 = Outpatient Letter
7 = Discharge Summary 37 = Follow-up Visit
8 = Transfer Off Service 38 = CDMS
39 = Off Site SNF Visit
40 = Radiology Report
41 = Non-Patient Doc.
42 = Non-Patient Letter

4. Enter the patient’s 7 digit medical record number followed by the # key.
Do not use check digit (which is the last digit of the record- the number
followed by the dash)
5. Press 6 any time during the dictation to assign a high priority. Then call
Transcription 3-5588 any time to ensure processing.
6. To begin dictation, press 2. To pause, press 2 again.
 7. ***Dictate your first and last name and your title (resident physician)
Attending physician Patient’s first and last nameMRN  Type of report 
Date of service
2 Dictate/ Stop 7 Rewind
3 Short rewind and play 8 New report
4 Fast forward 9 Insert
5 Disconnect and get job no. 44 End of job
6 High priority (STAT) 8# New report, same work type
77 Rewind to beginning with auto playback
Example of common Stanford dictation:
Gyn Onc clinic clinic visit:
Dial 233 ID number  Clinic code 263 Work type 33 for clinic visit  7 digit MR number 
2 to begin  then dictate the beginning patient information (refer to number 7)  8 for new report
or 5 to disconnect (always write down the job number on the clinic note after the dictation)

For LPCH
*** use for discharge summaries***
Dial 78278 or 650 497 8278
1. Enter ID number followed by # sign
2. Press 1 to dictate
3. Enter Clinic Code followed by # sign
4. OB clinic code 270; Inpatient clinic code 1
5. Enter work type followed by # sign
2 H& P 10 Clinic Visit
4 Inpatient consultation 11 EEG
5 Operative Report 12 Clinic Procedure
6 Inpatient Letter 13 Outpatient Letter
7 Discharge Summary 14 Outpatient consultation
8 Transfer Summary 15 Clinic Note (not visit related
Example of common LPCH dictation:
OB discharge summary:
Dial 82278  Dial 1Clinic Code 1 for inpatient Work type 7 for discharge summary
Enter 8 digit MRN (include check digit) 2 to begin  then dictate the patient information
(refer again to number 7 ***)
For Stat press 6 at any time and call 497-8611