Fellowship Handbook

The UAMS Regional Center Rural Track Family Medicine Residency Program in El Dorado endeavors to recruit, train, equip, and retain family medicine physicians who will practice the full scope of family medicine in rural Arkansas and other medically underserved areas. Graduates of the program are prepared to provide independent, comprehensive, patient centered care to families through all stages of life. The program aims to recruit physicians who feel called to serve rural Arkansas communities and provide service to those in the greatest need despite the challenges this path may bring, thereby enhancing the quality of healthcare and accessibility for families and communities for generations to come.

The UAMS Family Medicine Surgical Obstetrics (FM OB) Fellowship Program in El Dorado is dedicated to developing expertise in the comprehensive care of women, with a particular emphasis on maternity care and reproductive health. This one-year fellowship is designed to equip fellows with the clinical, educational, and leadership skills necessary for independent practice in family medicine obstetrics and gynecology. Fellows will gain extensive experience in the management of both low and high-risk pregnancies, as well as surgical obstetric training. The program offers a dynamic learning environment, allowing fellows to participate in patient care across a diverse, varied patient population while working closely with obstetrics colleagues on labor and delivery and in the operating room for gynecologic procedures. Through a combination of hands-on experience, multidisciplinary collaboration, and mentorship from experienced attending physicians, the fellowship aims to prepare fellows for independent, full-spectrum family medicine practice.

Participating Sites

Fellows should expect to train with South Arkansas Women’s Clinic FM OB Physicians and OB/GYNs, UAMS Family Medical Center El Dorado FMOB faculty physicians, and faculty physicians at Baptist Health Medical Center El Dorado.

Our fellows will provide care at the following sites:

• UAMS Family Medical Center El Dorado (FMC)
• South Arkansas Women’s Clinic (SAWC)
• Baptist Health Medical Center El Dorado Women’s Center

As professionalism is a vital part of a fellow’s job and appearance sets the tone of that professionalism with patients, it is important that our fellow adheres to a professional dress code. The following list is not intended to be all inclusive but covers the main points of interest.

• Clean, appropriately fitted clothing or professional attire such as dress pants and button-up shirts are acceptable. Neat, wrinkle-free scrubs can be worn in the clinic if anticipating urgent call for OB care.
• White coats with name tags visible are to be worn at all times in the clinic when caring for patients and in the hospital (excepting surgical suite and during procedures).
• Hats are not acceptable to be worn, excepting religious headwear.
• Clean, groomed hair and personal hygiene are required.
• Fingernails may not extend beyond the fingertips.
• No excessive scented products such as perfume, cologne, or body sprays.
• Hoodies, jackets, sweaters, fleeces, vests are not to be worn while providing direct patient care.
• UAMS logo’d jackets/vests may be worn in the clinic.
• Clean shoes free of odor must be worn at all times. Sneakers are acceptable to wear with scrubs.
• Clothing must be free of any provocative or political statements or images, including pins, lanyards, or badges.
• Official ID badges as provided by the program/hospital must be worn at all times while on duty, in a visible location above the waistline. Badges worn at waist level are not allowed.
• Apparel examples that are NOT approved for duty within any clinical site: leggings, sweatpants, joggers, shorts, flip-flop/thong style sandals, t-shirts (unless UAMS logo’d and approved), beanies, mini-skirts, tank tops, etc.
• The Program Director will make individual judgment calls as necessary on professional dress; if deemed not to meet the program’s standards, the fellow will be required to change.

Timeliness

Fellow should arrive at least 15 minutes before the start of their shift.

Communication

The Fellow has a mailbox/in-basket (both clinic and fellowship), a dashboard in each EMR, a UAMS email account, and virtual folders on their clinic team. Each fellow is assigned a mailbox/in-basket (clinic and fellowship), dashboards within each EMR, a UAMS email account, and virtual folders on their clinic team. The fellow is expected to check these regularly throughout the day and respond within 24-48 hours.

UAMS email is an official means of communication between UAMS administration and fellows. Each fellow is responsible for regular checks of his/her email. Failure to do so may result in loss of critical information, dropped responsibilities, poor job performance, and/or job termination. Fellows should not have an expectation of privacy on workplace computers and UAMS email addresses.

Deadlines, policy changes, and program updates are often communicated via UAMS email, and it is the fellow’s responsibility to maintain knowledge of these notifications. Additionally, notifications and updates may be reflected in the program’s management software New Innovations; likewise, fellows must maintain constant knowledge of any information located there.

• Fellows must sign all verbal orders within 24 hours.
• Fellows must complete all daily notes before leaving their shift.
• Fellows must complete all history and physicals before leaving their shift.
• Fellows must complete all discharge summaries before leaving their shift.

Learning Objectives

Fellow should be able to:

• Read assignments to prepare for both inpatient service and outpatient clinic
• Begin by developing a broad base of knowledge and then layer details as the year progresses
• Review and evaluate journal articles to support or change published data
• Develop an evidence-based approach to management and treatment of obstetric related concerns
• Maintain a continuing checklist of relevant evidence-based articles in obstetrics and women’s health to support lifelong learning

Fellow is suggested to attend:

• AAFP Family Centered Maternity Care Conference (recommended)
• ALSO Provider Course (required)
• ALSO Instructor Course (recommended)

Methods

• Discussion of articles/chapters
• Viewing of selected prerecorded lectures/videos/audio recordings
• Participation in and leading of hands-on simulations
• Completion of interactive modules through ACOG

Texts

• Cunningham and Gilstrap’s Operative Obstetrics
• Gabbe et al., Obstetrics: Normal and Problem Pregnancies, 8th edition
• Gabbe’s Obstetrics Study Guide
• Obstetrics and Gynecology Comprehensive Handbook, 3rd Edition
• Williams Obstetrics

Websites / Podcasts / Recorded Lectures

• SMFM, ACOG, AAFP
• OBG Project
• AAFP Maternity Care Conference Lectures

Journals for Journal Club

• The Green Journal – ACOG
• AAFP Journal

Additional GYN/Newborn Topics

• D&C
• Cervical cancer: PAP, colpo, LEEP
• Contraception
• Menopause
• NRP topics

Education resources and references available at the University of Arkansas for Medical Sciences Regional Centers Rural Training Program – El Dorado Library:

• Obstetrics and Gynecology Comprehensive Handbook, Zheng T, 3rd Edition, 2022
• Williams Obstetrics 26e: Cunningham F, Leveno KJ, Dashe JS, Hoffman BL, Spong CY, Casey BM (eds), McGraw Hill, 2022

UAMS Library Online Resources

• Virtual Reference Collection: libguides.uams.edu
• Current Diagnosis and Treatment, Maxine Papadakis, McGraw-Hill, Current Edition

Online Resources

• UpToDate
• Angel Guidelines – UAMS Institute for Digital Health & Innovation High Risk Pregnancy Program website (also available as an app): angelsguidelines.com

Additional topics will be assigned by the Program Director as needed.

July

• Evidence based c-section articles
• Clark et al., Prevention of 1st c-section
• Tools and suture
• Sterilization techniques
• GBS guidelines
• Postpartum hemorrhage
• Operative complications

Participating Sites: SAWC, Baptist El Dorado

August

• Hypertensive disorders
• Diabetes
• Hemorrhage chapters and hands on
• Shoulder dystocia
• Triple I / chorio / endometritis
• Normal and abnormal labor
• Cervical cancer screening

Participating Sites: SAWC, Baptist El Dorado

September

• Prenatal care
• Postpartum care
• Antepartum fetal evaluation
• Induction of labor
• Breech presentation
• Contraception

Participating Sites: SAWC, Baptist El Dorado

October

• Prematurity complications
• PROM/PPROM (Gabbe chapter)
• Post term
• VBAC
• Infant loss / IUFD
• Early pregnancy loss: medication and surgical management
• Genetic testing

Participating Sites: SAWC, Baptist El Dorado

November

• Placental disease
• Fluid disorders
• Alloimmunization
• Breastfeeding
• Depression
• Anemia in pregnancy

Participating Sites: SAWC, Baptist El Dorado

December

• OB ultrasound chapter
• FGR/IUGR
• Infections in pregnancy
• Pain control in pregnancy
• Evaluation of recurrent pregnancy loss

Participating Sites: SAWC, Baptist El Dorado

January

• Maternal physiology
• Cardiac disease
• Respiratory disorders
• Skin diseases in pregnancy
• Thyroid
• Multi-gestation

Participating Sites: SAWC, Baptist El Dorado

February

• Infections (bacterial, viral, TORCH)
• Hepatitis
• Thromboembolism
• Cervical insufficiency

Participating Sites: SAWC, Baptist El Dorado

March / April / May / June

To be determined – additional topics assigned by Program Director as needed.

Prepared to practice in:

• Rural communities
• Academic institutions

By achieving competency in:

1. Management of normal and abnormal labor, including:
   • Cesarean sections
   • Operative vaginal deliveries
2. Management of early pregnancy failure through:
   • Medical intervention
   • Surgical procedures
3. Post partum tubal ligation
4. Sterilization at time of Cesarean Section, including tubal ligation
5. Initiating newborn care and stabilization for transfer
6. Women’s Health

Patient Care

Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and promotion of health.

• Provide caring, compassionate, and respectful patient care utilizing effective communication techniques.
• Demonstrate appropriate knowledge and skills to counsel and educate patients regarding diagnosis and all available management options.
• Demonstrate the ability to work with other members of a medical staff to provide patient focused care.
• Display understanding of ethical principles related to maternity care.
• Demonstrate appropriate use of diagnostics and technology to develop and implement patient care management plans.
• Display expertise in preventative medicine as it relates to maternity care.

Medical Knowledge

Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

• Demonstrate the ability to diagnose and manage conditions pertaining to pregnancy and women’s reproductive health.
• Demonstrate comprehension of established principles and evolving clinical data in the field of maternity care.
• Display understanding of the physiology of pregnancy and the postpartum state.
• Display proficiency in obtaining a focused history of a patient presenting with a pregnancy or gynecologic complaint.
• Confidently perform a focused, comprehensive exam for a maternity or gynecological complaint.
• Observe and learn common obstetric and gynecologic procedures.

Interpersonal & Communication Skills

Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals.

• Exemplify respectful, productive behaviors for functioning as a member of a health care team.
• Demonstrate therapeutic and compassionate relationships with patients.
• Demonstrate optimal listening and history taking skills and promote effective education and communication between the fellow and the patient.
• Communicate intelligently, thoughtfully, and respectfully with patients presenting with pregnancy or women’s health complaints.

Professionalism

Fellow must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles, and sensitivity to patients of diverse backgrounds.

• Demonstrate dependability, respect, commitment, compassion, and ethical principles in carrying out the professional responsibilities which accompany this position.
• Demonstrate responsiveness to the needs of the patient and society that supersede self-interest.
• Display sensitivity and responsibility to patients regardless of age, socioeconomic status, or disability.
• Engage in activities that foster professional growth as a physician.
• Arrive promptly for all rotation activities and remain until the clinic, lecture, or session is complete.
• Dress appropriately and professionally for required activities.
• Demonstrate research skills including critical appraisal of obstetric and gynecologic literature, appropriate research models, writing styles, and publishing and presentation techniques.
• Display proficiency with utilization of information, technology, and on-line medical information to support personal education.
• Obtain and utilize information from assigned patient population to improve individual patient care.

Practice Based Learning and Improvement

Fellows must demonstrate the ability to investigate and evaluate their care for their patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.

• Demonstrate the ability to identify strengths and deficiencies in surgical skills, critically evaluating performance in procedures such as cesarean delivery and operative vaginal delivery, using surgical logs and faculty feedback to set and achieve measurable improvement goals.
• Engage in Morbidity and Mortality review and evidence-based quality improvement activities, analyzing complications and unexpected outcomes, and incorporating current literature to refine clinical decision-making and surgical technique.
• Incorporate mentorship and structured feedback into daily practice by actively seeking, receiving, and applying formative guidance from OB/GYN and Family Medicine faculty to enhance technical proficiency, efficiency, and patient outcomes.
• Demonstrate the ability to appraise and apply scientific evidence by regularly reviewing current obstetric and gynecologic literature and integrating new knowledge into patient care.

System-Based Practice

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

• Illustrate an awareness of the system in which we function and the relationship of that system to the global health care environment.
• Demonstrate understanding of how the fellow’s professional practices affect other agencies and other aspects of health care.
• Advocate for quality patient care and assist the patient as they negotiate complex medical systems.
• Recognize when referral is appropriate and facilitate the encounter between consultants.

Fellow duty hours will be entered into a spreadsheet for review by the fellowship coordinator and program director and will be continuously monitored. Work duty hours may be entered daily or weekly. Fellow schedules are designed in most cases not to exceed 80 hours per educational work week.

Fellow call requirements:

• One weekend per month (consists of Thursday-Monday)
• One night per week

Additional call may be required to solidify experience as unique cases present and/or for continuity

experience.

FM OB Fellows will be allowed to moonlight at the discretion of the Program Director as long as it does not interfere with their basic responsibilities toward the fellowship training requirements. Moonlighting is considered to be any activity (practicing medicine or otherwise) outside of the fellowship program that is done by a fellow for personal remuneration.

Our program, in partnership with UAMS Regional Programs, is charged with helping the fellow find meaning in being a physician as well as addressing work compression and workplace safety that might impact fellow well-being. Fellows must be allowed to attend all healthcare appointments and should be given tools to address burnout, depression, suicidal ideation, and substance abuse. We are also tasked with developing a system in which fellows may be absent due to fatigue, illness, family emergencies, and parental leave without fear of negative consequences. Additional details of the Fellowship Well-Being may be found in the program’s Policy for Fellow, Fellow, and Faculty Member Well-Being.

The fellow will meet with the Program Director quarterly for a formative formal evaluation of his/her progress. At this meeting, she/he will discuss how the program is working for her/him; identify and document any difficulties and/or any issues with completion of the goals and objectives, faculty difficulties, and/or programmatic issues that need to be addressed by the Program Director. Part of these meetings should include a self-assessment and/or progress on individual learning plan. The fellow will be evaluated by each faculty member with whom he/she works.

The Program Director will provide a summative evaluation of the fellow’s performance upon completion of the program. The evaluation will become a part of the fellow’s permanent record and will be maintained by the institution. The fellow will have access to review his/her record.

Continuous Evaluation and Improvement

• Formal Assessments: Fellows are regularly evaluated on their medical knowledge, skills, and professionalism.
• Feedback Loops: The program provides feedback to fellows to improve their performance.
• Remediation Plans: If a fellow’s performance is below expectations, a remediation plan is developed.

360-Degree Assessment

The 360-degree feedback provides the fellow feedback on his/her performance by the raters or evaluators working with the fellow during his/her training. This assessment involves the evaluation of the performance of the FM OB Fellow in the areas of the ACGME six core competencies by peers with knowledge of a similar scope of practice, co-workers from the allied health professions, office staff, and patients. The resulting information is presented to the FM OB Fellow with the aim of helping him/her to gain a better understanding of their skills and development areas. Each source can provide a different perspective on the FM OB Fellow’s skills, attributes, and other relevant characteristics, thus helping to build a richer, more complete, and accurate picture than could be obtained from any one source. The FM OB Fellow will be assessed by the following in this 360-degree process:

Fellow Assessment by Faculty

1. Faculty Physician: FM OB Fellow is to be evaluated by faculty physician(s) observing their patient interactions.
2. Patient Evaluation: FM OB Fellow is to be evaluated by patients from FMC, SAWC, and Baptist El Dorado L&D. Requirement: four (4) total evaluations of the FM OB Fellow per year completed by patients.
3. Office Staff: FM OB Fellow is to be evaluated at their clinic. Requirement: evaluations of the FM OB Fellow will be completed by different front office staff during the year.
4. FM OB Self-Assessment: The FM OB Fellow will fill out a self-assessment. Requirement: four (4) evaluations will be completed by the FM OB Fellow each year.

Faculty Assessment by Fellow

The FM OB Fellow will evaluate the faculty/physician(s) on their contribution to the fellow’s medical knowledge, medical skills, clinical judgment, nurturing of scholarship, availability, humanistic qualities, teaching time, time for patient care, and an overall evaluation. Requirement: evaluations will be completed on all faculty/physicians working with the fellow.

All procedures should be recorded regularly. Procedures may be entered daily or weekly.

Fellows have 15 vacation days plus 6 sick days per academic year. Vacation time should be submitted to the coordinator and program director no less than 90 days before the planned absence. Fellows should notify the program director, associate program director, and coordinator in the event that they are ill and cannot attend their regular fellowship responsibilities. Absences requiring time out of the Family Medical Center should be scheduled at least one month in advance or they will not be approved. Emergencies are excluded from the one-month notification process.

Vacation (PTO)

1. 3 weeks (15 days) of vacation are available during the fellowship year.
   • Ideally, those weeks are taken in the second half of the year.
   • Can be taken throughout the year with prior approval to allow for adequate clinical and event coverage.
2. Adequate lead-time is required for time off (vacation, job interviews, etc.).
   • Notice for absences requiring time out of the fellowship should be made at least one month in advance or it will not be approved (emergencies are excluded from the one-month notification process).

Sick

1. If you are ill, notify the Program Director, Associate Program Director, and the Coordinator immediately.
   • You should also notify the attending physician you are scheduled to work with.

Antepartum and Postpartum Care

• Management of gestational diabetes
• Management of pre-eclampsia/gestational hypertension
• Management of preterm labor
• Management of chronic medical conditions in pregnancy
• Management of trial of labor after cesarean (TOLAC)
• Management of postpartum time and fourth stage
• Management of postpartum hemorrhage
• Stabilization and management of neonate

Expected to Become Competent in the Following Obstetrical Procedures

• Cesarean section
• Postpartum care
• Operative vaginal delivery
• Spontaneous vaginal delivery
• VBAC
• External cephalic version
• Repair of 1st and 2nd degree laceration
• Repair of 3rd and 4th degree laceration
• Obstetric ultrasound

Gynecology Experience

• Sterilization procedures
• Medical management of early pregnancy loss
• Surgical management of early pregnancy loss (D&C)
• Contraceptive counseling
• Management of abnormal cervical cytology: colposcopy/LEEP/cryotherapy

Outpatient

Clinic with Faculty/Adjunct Faculty – Family Medicine Center: two one-half-day sessions per week.

Quality Improvement

• Clinical Quality Improvement Project for L&D or Outpatient Obstetrical Care
• Participate in monthly QI meetings
• Participate in Perinatal Safety Meetings with OB department

Structured Study

• Arrange and present at weekly Friday morning Strip Review/High Risk Case Review meetings with FM and OB staff
• Complete reading list provided by faculty, Dr. Watson, and give weekly lectures to residents from the reading list
• Participate in monthly Journal Review
• Friday half-day Strip Review/High Risk Case Discussions/Admin time
• Friday half-day didactics development
• Participate in simulations
• ALSO certification
• Complete AAFP Women’s Health KSA/SAM Women’s Care

Teaching

• Supervise and teach medical students and residents, including supervision of L&D admissions, triage patients, vaginal deliveries, and inpatient rounds when scheduled on L&D
• Present at and attend monthly L&D M&M
• Attend Family Medicine Didactics and present monthly

• Quarterly reviews by Fellowship Director
• Procedure evaluation forms submitted for each C-section and procedure, to be signed by the attending physician
• Specific criteria to move to the next level

• Fellows will have an academic appointment through the UAMS Department of Family Medicine.
• Fellows will develop a manuscript/case review for submission required for completion of the fellowship.
• Fellows will demonstrate competency in the procedural skills required to practice independent operative obstetrics.
• Fellows will demonstrate competency in resuscitation and stabilization of the neonate appropriate for delivery of maternity care in an underserved setting.

Oversight

Dr. Donya Watson, Fellowship Director

Faculty

Physicians with C-section privileges, including OB/GYN adjunct faculty.

Content

Fellowship faculty, with support from the FM GME Office.

Didactics & Clinical Education

Provided by physicians with C-section privileges, including OB/GYN adjunct faculty.

Evaluations

• Conducted by the Fellowship Program Director
• Procedure evaluation forms required for each completed C-section and procedure, signed by the attending physician
• See the Evaluations section for further detail

1. Triage and Laboring Patients

Fellows must review each assigned patient’s chart and examine each assigned patient before morning and evening rounds and shortly after any transfer of care. Separate notes will be generated after morning and evening rounds.

At a minimum, the fellow must know:

• Status and plan for any current medical and obstetrical concerns
• Patient’s pertinent past obstetrical, surgical, medical history, and social history
• Abnormalities noted during pregnancy and antepartum period, including pertinent labs and other test findings
• Current exam with an emphasis on:
  • Current vital signs
  • Pertinent neurological findings
  • Pertinent cardiopulmonary exam
  • Stage of labor
  • Fetal activity and fetal monitoring history
  • Status of current anesthesia/analgesia (primarily laboring patients)
  • Identification of risk factors
• Current laboratory and other testing findings
• Delivery plan, including patient awareness of potential for operative delivery
• Laboring patients must be seen and personally examined at least hourly, more often as indicated. Vaginal exam need not occur hourly unless indicated.
• Progress notes are expected every four hours during latent phase, every two hours during active phase, every 15-30 minutes during second stage, and with any significant event, unless events preclude writing a note.

Fellows must inform attending faculty of:

• Any significant change in patient’s exam or other findings
• Completion of first stage of labor
• Failure to progress according to expectations based on gravidity and other factors
• Patient status at a minimum of every two hours or as otherwise required by faculty attending; every report must include vital signs and a focused physical exam
• The current state of L&D management on a frequent basis (suggested at least every two hours)
• Notify the FM attending of the following:
  • Patients in triage at the time of presentation and nature of presenting problem
  • Admissions to L&D
  • Status of laboring patients and any high-risk conditions of patients on L&D, including impending deliveries and risk factors for each delivery
  • Significant events at the time of those events
  • Consultations in ED
  • Consultations with OB/GYN

2. Post-Partum Patients (As Above, Except Where Highlighted)

• Fellow must review each assigned patient’s chart and examine each assigned patient before morning rounds and shortly after any transfer of care
• Status and plan for any current medical and obstetrical concerns
• Patient’s pertinent past obstetrical, surgical, medical history, and social history
• Conditions noted during pregnancy with change of care (antepartum, intrapartum, and post-partum periods), including pertinent lab, sono, and other test findings (e.g., gHTN, PPH, gDM)
• Current exam with an emphasis on:
  • Current vital signs
  • Pertinent neurological findings
  • Pertinent cardiopulmonary exam
  • Status of current anesthesia/analgesia
  • Uterine firmness, volume of lochia
  • Breast tenderness or redness
  • If post C-section: status of wound and urine output
• Current laboratory and other testing findings
• Current/future plans:
  • Birth control
  • Breastfeeding
  • Resumption of intercourse
  • Mental status (post-partum depression, etc.)
  • Home safety/social work update (infant care, potential for partner or child abuse, food insecurity, etc.)
• Post-partum patients should be seen daily by each assigned fellow (e.g., daily and at relief post call)

1. Leadership

Faculty member and fellow are responsible for patient care while assigned to L&D.

• Must be aware of and personally see each patient:
  • Must receive detailed report from off-going faculty and assigned fellows at time of relief, before 8 AM morning rounds and 5 PM attending-to-attending hand-off
  • Laboring patients within one hour of completion of report at beginning of assignment, including 8 AM morning rounds and 5 PM attending-to-attending hand-off
  • Post-partum patients within two hours of completion of report at beginning of assignment, including 8 AM morning rounds and 6 PM evening fellow hand-off (preferably on 8 PM evening rounds)
  • Triage patients within 30 minutes of arrival
  • Emergent patients, immediately
  • Continue awareness and management of all FM patients in L&D according to condition, and assist attendings performing continuity deliveries as requested
• Special instructions for fellows:
  • Morning rounds are run by the supervising fellow under supervision of the FM or OB faculty attending
  • All patients are assigned to the supervising fellow
  • Fellows must inform the supervising fellowship faculty member about the current state of L&D management on a frequent basis (suggested at least every two hours)
  • Fellows are responsible for notifying the FM attending of patients in triage, admissions to L&D, status of laboring/high-risk patients, significant events, and consultations in the ED or with OB/GYN
  • Fellows are to follow the instructions of the supervising fellowship faculty member
  • Should issues arise with the instruction or performance of fellows on the service, the fellow is to inform the supervising fellowship faculty member and the residency office

2. Management of Stages of Labor (All Faculty Attendings with L&D Privileges)

1. First Stage:
   • Receive fellow report on patient, assessing and assuring quality of fellow review and examination of patient
   • Develop and review plan for labor, including presentation/station of fetus, likelihood of C-section delivery, anticipated need for OB/GYN help, and assurance that the fellow understands their role
   • Personally see patient as soon as possible after evaluation and report
   • Assure fellow, nursing, or personal appropriate, timely, and ongoing quality review of vital signs, physical/maternal-fetal monitoring, and other tests
   • Review with fellow progress of the patient at least every two hours; recommended the patient be personally seen at this time as well
   • Intervene where needed should fellow plan and care need correction
   • Discuss care with nursing staff and be certain they are aware of means to contact you
2. Second Stage:
   • Assure personal, fellow, and/or nursing presence in room at all times during second stage
   • Assure appropriate, timely, and ongoing quality review of vital signs, physical/maternal-fetal monitoring, and other tests
   • Limit vaginal and cervical exam to the minimum appropriate for the patient’s progress and condition; limit perineal trauma
   • If not in the room during second stage, remain in the L&D unit to enable presence at delivery
   • If fellow delivering, assist fellow in adequate control of neonate’s head during delivery
   • Control bleeding
3. Third Stage:
   • Assess neonate at birth for need of emergent intervention (FM faculty only)
   • Assist fellow in delivery of placenta
   • Inspect placenta for completeness of missing cotyledons
   • Control bleeding
   • Assess cervix, vagina, and perineum; plan for any necessary repairs and initiate consultation when appropriate
   • Assist fellow in any necessary vaginal, cervical, or perineal repairs
   • Assure appropriate instigation of post-partum measures
4. Post-Partum Care:
   • Attending present at the time of continuity delivery remains responsible for post-partum care unless there is an agreed upon hand-off to another faculty member

3. Special Instructions for Faculty Attending Supervising Fellow Continuity Delivery

(Instructions to faculty attendings designated as fellows are noted above.)

• Should issues arise with the instruction or performance of fellows on the service:
  • Inform the Fellow-in-Charge
  • Inform the Faculty-in-Charge
  • Inform the residency office
• Faculty attendings will be primary participants in the evaluation of fellow performance during continuity deliveries and are required to complete appropriate assessment of performance

4. Attending Faculty with Operative Delivery Privileges

• When fellows are present, attending faculty with operative delivery privileges are expected to:
  • Delegate faculty supervision of residents and students on L&D
  • Support the fellow in their teaching and supervision roles
  • Anticipate the need for additional help, participate directly with the fellow in the management of patients with complications, encourage collegial early consultation when the need arises, and where operative delivery is required, utilize the fellow as primary learner
• When fellows are not present in L&D:
  • Faculty directly assume teaching and clinical supervision responsibilities for residents and students
  • Faculty directly assume management of FM patients in L&D
  • Faculty are primary surgeons for FM patients requiring operative delivery; primary surgeons may invite other physicians to participate in operative delivery at their discretion

PGY-4 (FM Maternity Care Fellow)

Fellows are part of a team of providers responsible for patient care. The team includes an attending and may include other licensed independent practitioners, other trainees, and medical students.

Fellows are physicians-in-training. They learn the skills necessary for their chosen specialty through didactic sessions, literature review, and provision of patient care under the direct supervision of the medical staff (i.e., attending physicians). As part of their training program, fellows and residents are given progressively greater responsibility according to their level of education, ability, and experience.

Trainees who have completed a residency in Family Medicine are referred to as fellows. Fellows are engaged in a program of study intended to qualify them for independent, autonomous obstetrics practice.

Fellows evaluate patients, obtain medical history, and perform physical examinations. They are expected to develop a differential diagnosis and problem list. Using this information, they arrive at a plan of care or a set of recommendations in conjunction with the attending. They will document the provision of patient care as required by hospital/clinic policy.

Fellows may write orders for diagnostic studies and therapeutic interventions as specified in the medical center bylaws and rules/regulations. They may interpret the results of laboratory and other diagnostic testing, request consultation for diagnostic studies, evaluation by other physicians, physical/rehabilitation therapy, specialized nursing care, and social services. They may participate in procedures performed in the operating room or procedure suite under appropriate supervision. Fellows may initiate and coordinate hospital admission and discharge planning.

Fellows discuss the patient’s status and plan of care with the attending and the team regularly. Fellows help provide for the educational needs and supervision of any junior trainees, residents, and medical students.

Resident

A physician who is engaged in a graduate training program in medicine and who participates in patient care under the direction of attending physicians as approved by each review committee. Note: the term “resident” includes all residents and fellows, including individuals in their first year of training (PGY-1), often referred to as “interns,” and individuals in approved subspecialty graduate medical education programs who historically have also been referred to as “fellows.”

As part of their training program, residents are given graded and progressive responsibility according to the individual resident’s clinical experience, judgment, knowledge, and technical skill. Each resident must know the limits of his/her scope of authority and the circumstances under which he/she is permitted to act with conditional independence. Residents are responsible for asking for help from the supervising physician for the service they are rotating on when they are uncertain of diagnosis, how to perform a diagnostic or therapeutic procedure, or how to implement an appropriate plan of care.

Attending of Record (Attending)

An identifiable, appropriately credentialed, and privileged attending physician who is ultimately responsible for the management of the individual patient and for the supervision of fellows involved in the care of the patient. The attending delegates portions of care to fellows based on the needs of the patient and the skills of the fellows.

To ensure oversight of fellow supervision and graded authority and responsibility, the following levels of supervision are recognized:

1. Direct Supervision: the supervising physician is physically present with the fellow and patient.
2. Indirect Supervision:
   • With direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide direct supervision.
   • With direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care but is immediately available by telephonic and/or electronic modalities and is available to come to the site of care to provide direct supervision.
3. Oversight: the supervising physician is available to provide review of procedures and/or encounters with feedback provided after care is delivered.

Clinical Responsibilities

The clinical responsibilities for each fellow are based on patient safety, fellow education, severity and complexity of patient illness/condition, and available support services. The specific role of each fellow varies with their clinical rotation, experience, duration of clinical training, the patient’s illness, and the clinical demands placed on the team. Fellows must comply with the supervision standards of the service on which they are rotating unless otherwise specified by their program director. Progressive responsibility will be delegated at the discretion of the Program Director and documented regularly with the Program Coordinator.

Attending of Record

In the clinical learning environment, each patient must have an identifiable, appropriately credentialed, and privileged primary attending physician who is ultimately responsible for that patient’s care. The attending physician is responsible for assuring the quality of care provided and for addressing any problems that occur in the care of patients, and thus must be available to provide direct supervision when appropriate. The availability of the attending to the fellow is expected to be greater with less experienced fellows and with increased acuity of the patient’s illness.

The attending must notify his/her team of when he/she should be called regarding a patient’s status, including all situations that require attending notification per program or hospital policy. The primary attending physician may at times delegate supervisory responsibility to a consulting attending physician if that consultant recommends a procedure. This information should be available to fellows, faculty members, and patients.

The attending may specifically delegate portions of care to fellows based on the needs of the patient and the skills of the fellows, in accordance with hospital and/or departmental policies. The attending may also delegate partial responsibility for supervision of residents to fellows assigned to the service, but must assure the competence of the fellow before supervisory responsibility is delegated. Over time, the fellow is expected to assume an increasingly larger role in patient care decision making; the attending remains responsible for assuring appropriate supervision and is ultimately responsible for the patient’s care. Fellows and attendings should inform patients of their respective roles in each patient’s care.

The attending, fellow, and/or resident are expected to monitor competence of more junior residents through direct observation, formal ward rounds, and review of the medical records of patients under their care. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each fellow and delegate to him/her the appropriate level of patient care authority and responsibility.

Supervision of Invasive Procedures, Maternity Care Fellows

In a training program, as in any clinical practice, it is incumbent upon the physician to be aware of his/her own limitations in managing a given patient and to consult a physician with more expertise when necessary. When a fellow requires supervision, this may be provided by a qualified member of the medical staff. In all cases, the attending physician is ultimately responsible for the provision of care by fellows. When there is any doubt about the need for supervision, the attending should be contacted.

Procedures Performed with Indicated Level of Supervision

1. Direct Supervision Always Required:
   • Cesarean sections
   • Operative vaginal delivery
   • Third and fourth degree perineal and all vaginal or cervical lacerations
   • External versions
   • Management of early pregnancy failure, surgical (D&C for retained placenta)
2. Direct Supervision Required Until the Fellow Is Deemed Competent to Perform Independently:
   • Obstetrical Care Competencies:
     • Triage precepting
     • Labor admission
     • Induction admission
     • Postpartum rounding
     • Postpartum discharge
     • Antepartum rounding
     • Antepartum discharge
     • Labor management
     • Attending-to-attending sign-out
     • Perineal laceration repair, first or second degree
     • Prenatal clinic visit
     • Induction request review
     • Limited obstetric ultrasound examination (fetal position, amniotic fluid index, placental location, cardiac activity)
     • Performance and interpretation of non-stress and stress tests
     • Management of category 2 and 3 tracings
   • Newborn Care Competencies:
     • Newborn rounding
     • Newborn circumcision
     • Maintain NRP certification
   • Inpatient Care Competencies:
     • Inpatient admission
   • Gynecology Competencies:
     • MCC IUD insertion/removal
     • MCC Nexplanon insertion/removal
     • Colposcopy

Emergency Procedures

It is recognized that in the provision of medical care, unanticipated and life-threatening events may occur. The fellow may attempt any of the procedures normally requiring supervision in a case where death or irreversible loss of function in a patient is imminent, an appropriate supervisory physician is not immediately available, and waiting for the availability of an appropriate supervisory physician would likely result in death or significant harm. The assistance of more qualified individuals should be requested as soon as practically possible. The appropriate supervising practitioner must be contacted and apprised of the situation as soon as possible.

Supervision of Consults

Fellows may provide consultation services under the direction of faculty. The attending of record is ultimately responsible for the care of the patient and thus must be available to provide direct supervision when appropriate. The availability of the attending should be appropriate to the level of training, experience, and competence of the fellow and is expected to be greater with increasing acuity of the patient’s illness. Information regarding the availability of attendings should be available to residents, faculty members, and patients.

Fellows performing consultations are expected to communicate verbally with their supervising attending at regular time intervals, typically on the same day as the consultation. Any fellow performing a consultation where there is credible concern for patient’s life or limb requiring immediate invasive intervention MUST communicate directly with the supervising attending as soon as possible prior to intervention or discharge, so long as this does not place the patient at risk. If communication is delayed due to ensuring patient safety, the fellow will communicate with the supervising attending as soon as possible. Fellows performing consultations will communicate the name of their supervising attending to the services requesting consultation.

Additional specific circumstances requiring communication with appropriate supervising faculty include:

• Informing the supervising fellowship faculty member about the current state of L&D management on a frequent basis (suggested at least every two hours)
• Notifying the FM attending of:
  • Patients in triage at the time of presentation and nature of presenting problem
  • Admissions to L&D
  • Status of laboring patients and any high-risk conditions of patients on L&D, including impending deliveries and risk factors for each delivery
  • Significant events at the time of those events
  • Consultations in ED
  • Consultations with OB/GYN

Supervision of Hand-Offs

Each program must have a policy regarding hand-offs. This policy must include expectations of supervision with each type of hand-off situation. As documented in the ACGME’s common program requirements, programs must design clinical assignments to minimize the number of hand-offs and must ensure and monitor effective, structured hand-off processes to facilitate both continuity of care and patient safety. Programs must ensure that residents and fellows are competent in communicating with team members in the hand-off process.

Circumstances in Which the Supervising Practitioner MUST Be Contacted

If the attending of record is not available for urgent matters in any of the below circumstances, another faculty member with similar privileges and/or an OB/GYN attending physician could be contacted to provide supervision:

• Significant events or changes in patient status
• Admissions and discharges
• Presence of patient in triage

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the Program Director and faculty members. The Program Director and faculty must evaluate each fellow’s abilities based on specific criteria and the program milestones:

Direct Supervision (Barring Obtaining Privileges)

1. Cesarean sections
2. Operative vaginal deliveries
3. Management of early pregnancy failure, surgical
4. Sterilization at time of Cesarean Section, including tubal ligation and salpingectomy
5. Performance of D&C for retained placenta
6. External cephalic version

Direct Supervision

1. Vaginal deliveries
2. Morning rounds
3. Afternoon 6 PM hand-offs
4. Labor management
5. All admissions, discharges, and discharge of triage patients
6. Management of common intrapartum problems (malpresentation, unanticipated shoulder dystocia, manual removal of placenta)

Conditional Independence

1. Vaginal deliveries
2. Morning rounds
3. Afternoon 6 PM hand-offs
4. Labor management
5. All admissions, discharges, and discharge of triage patients

Progressive Authority

1. Discuss management of routine and complex OB patients with confidence with attendings, surgeons, and other consulting physicians
2. Present lectures and presentations confidently in front of peers and faculty
3. Discuss relevant topics in OB literature and ways to improve patient care
4. Manage more complicated patients and perform more complicated procedures
5. Teach residents and students routinely

Transitional Independence

1. Demonstrates increasing ability to singularly handle a full day of new and established patients in clinic
2. Routinely demonstrates the ability to manage established patients who are either worsening or not improving
3. Ability to make clinical decisions based upon historical, physical, laboratory, imaging, and consultation becomes routine
4. Demonstrates a “commanding presence” with residents, nursing staff, etc.

The fellowship program uses a multifaceted assessment process to determine a fellow’s progressive involvement and independence in providing patient care. Fellows are observed directly by the attending staff throughout clinical training. Supervising physicians provide formal assessments. Fellows are evaluated on their medical knowledge, technical skills, professional attitudes, behavior, and overall ability to manage the care of a patient.

In addition, fellow performance is discussed at faculty meetings on a regular basis. Direct feedback regarding the fellow’s performance is provided by the fellowship program director on a structured quarterly basis, and additionally on an as-needed basis.

The attending staff evaluate trainees continuously. If, at any time, their performance is judged to be below expectations, the Fellowship Program Director (or designee) will meet with the trainee to develop a Remediation Plan. If the trainee fails to follow that plan, or the intervention is not successful, the trainee may be dismissed from the program. If a trainee’s clinical activities are restricted (e.g., they require a supervisor’s presence during a procedure, when one would not normally be required for that level of training), that information will be made available to the appropriate attending and hospital staff.

Fellowship programs must provide faculty development and fellow education on best practices around supervision and the balance of supervision and autonomy. One best practice to consider is the SUPERB SAFETY model.

SUPERB Model – For Attendings

Attendings should adhere to the SUPERB model when providing supervision. They should:

1. Set Expectations: set expectations on when they should be notified about changes in patient’s status.
2. Uncertainty is a time to contact: tell fellow to call when they are uncertain of a diagnosis, procedure, or plan of care.
3. Planned Communication: set a planned time for communication (i.e., each evening, on call nights).
4. Easily available: make explicit your contact information and availability for any questions or concerns.
5. Reassure fellow not to be afraid to call: tell the fellow to call with questions or uncertainty.
6. Balance supervision and autonomy.

SAFETY Acronym – For Fellows

Fellows should seek attending physicians’ input using the SAFETY acronym:

1. Seek attending input early.
2. Active clinical decisions: call the attending when you have a patient whose clinical status is changing, and a new plan of care should be discussed. Be prepared to present the situation, the background, your assessment, and your recommendation.
3. Feel uncertain about clinical decisions: seek input from the supervising attending when you are uncertain about your clinical decisions. Be prepared to present the situation, the background, your assessment, and your recommendation.
4. End-of-life care or family/legal discussions: always call your attending when a patient may die or there is concern for a medical error or legal issue.
5. Transitions of care: always call the attending when the patient becomes acutely ill and you are considering transfer to the intensive care unit (or have transferred the patient to the ICU if patient safety does not allow the call to happen prior to ICU involvement).
6. You need help with system/hierarchy: call your supervisor if you are not able to advance the care of a patient because of system problems or unresponsiveness of consultants or other providers.

AAFP Reprint No. 261 – Recommended Curriculum Guidelines for Family Medicine Fellowship Maternity Care. This appendix is endorsed by the American Academy of Family Physicians (AAFP) and is provided for informational purposes only.

Introduction

This AAFP Curriculum Guideline defines a recommended training strategy for family medicine fellows. Attitudes, behaviors, knowledge, and skills that are critical to family medicine should be attained through longitudinal experience that promotes educational competencies defined by the Accreditation Council for Graduate Medical Education (ACGME), www.acgme.org. The family medicine curriculum must include structured experience in several specified areas. Much of the fellow’s knowledge will be gained by caring for ambulatory patients who visit the family medicine center, although additional experience gained in various other settings (e.g., an inpatient setting, a patient’s home, a long-term care facility, the emergency department, the community) is critical for well-rounded residency training. Fellows should be able to develop a skillset and apply their skills appropriately to all patient care settings.

Structured didactic lectures, conferences, journal clubs, and workshops must be included in the curriculum to supplement experiential learning, with an emphasis on outcomes-oriented, evidence-based studies that delineate common diseases affecting patients of all ages. Patient-centered care and targeted techniques of health promotion and disease prevention are hallmarks of family medicine and should be integrated in all settings. Appropriate referral patterns, transitions of care, and the provision of cost-effective care should also be part of the curriculum.

Program requirements specific to Family Medicine with Obstetrics Fellowship may be found on the ACGME website. Current AAFP Curriculum Guidelines may be found online at www.aafp.org/cg. Note: the term “manage” occurs frequently in AAFP Curriculum Guidelines and is used broadly to indicate that the family physician takes responsibility that optimal and complete care is provided to the patient – it does not necessarily mean that all aspects of care must be directly delivered personally by the family physician, and may include appropriate referral to other providers.

Preamble

While the scope of practice for family physicians continues to evolve, competency in providing high-quality, evidence-based, consistent care to women throughout their lifetimes, including during pregnancy, continues to be an important objective of fellowship training. Maternity care experience varies widely among training programs, but acquiring a core set of knowledge and skills is required by both allopathic and osteopathic fellowship accreditation councils and is recommended to ensure family physicians can offer maternity care in their practices.

Family physicians generally offer a unique model of prenatal and intrapartum/postpartum care in which physicians attend the majority of their own patients’ deliveries, and both the woman and her baby often continue to see their family physician for ongoing women’s health, medical, and well-child care. This experience must be underpinned by competency in history taking and physical examination skills, knowledge of the physiologic and psychosocial aspects of caring for women, and specific hands-on procedural skills. Even family physicians who do not include maternity care in their scope of practice should be comfortable with and competent in the care of medical issues in women during pregnancy and lactation, as well as management of contraception and preconception counseling.

Due to the unique model family medicine offers for maternity care, family physicians often provide care in the immediate neonatal period to newborns they deliver, supporting a well-child population in the continuity clinic and interconception care to mothers.

Competencies

At the completion of fellowship training, FMOB fellows should be able to:

• Communicate effectively with female patients of all ages, demonstrating active listening skills, a respectful approach to sensitive issues, and collaborative care planning with the patient
• Perform comprehensive physical examinations of female anatomy, with appropriate screening tests for pregnant women, and perform obstetrical procedures
• Develop and implement treatment plans for common pregnancy complications (prenatal, intrapartum, and postpartum) and utilize community resources when indicated
• Demonstrate effective primary care counseling skills for psychosocial, behavioral, and reproductive issues in women, as well as comprehensive wellness counseling based on age and risk factors
• Consult and communicate appropriately with OB/GYNs, maternal-fetal medicine specialists, and allied health care professionals to provide optimum health services for women
• Act as patient advocate and coordinator of care for female patients across the continuum of outpatient, inpatient, and institutional care

Attitudes and Behaviors

The fellow should develop attitudes that encompass:

• A caring, compassionate, and respectful approach to the female patient’s role as an informed participant in her own health care decisions and those affecting her family
• Recognition that a woman’s health and childbearing is affected not only by medical problems, but also by family, career, life cycle, relationships, and community
• A patient-centered approach to prenatal care, labor management, and postpartum care that is respectful of the wishes of women and their families for their birth experience, while ensuring safe, evidence-based care
• Recognition that major depression is common throughout the prenatal and postnatal time frames, particularly for women in low-income, poorly supported environments, and that serial screening, diagnosis, and treatment is recommended
• Recognition of the impact of addiction on pregnancy outcomes, and a compassionate, supportive approach to women struggling with addiction during pregnancy
• Awareness of issues facing heterosexual, lesbian, bisexual, and transgender patients, particularly regarding reproductive health
• Awareness of the widespread and complex health effects of psychological, physical, and sexual abuse on women, including on their subsequent experience of pregnancy and the birth process
• Awareness of issues related to female circumcision/female genital mutilation when caring for women from cultures that support such practices

In the appropriate setting, the fellow should demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, and demonstrate the ability to apply knowledge of the following areas of Family-Centered Maternity Care.

A. Preconception Counseling and Planning

• Nutrition, including for women with eating disorders and all classes of obesity
• Contraception and identifying chronic medical conditions in which certain contraceptives are contraindicated (e.g., thrombophilia with estrogen-containing contraception, Wilson’s disease with copper IUD)
• Understanding and utilizing the quick-start method for initiation of contraception, as appropriate
• Prevention of birth defects with peri-conceptional folic acid/multivitamins and limiting known teratogenic medications
• Optimization of health prior to conception (e.g., euglycemic control in type 2 diabetes prior to conception)
• Identification of chronic mental health conditions to optimize treatment and avoid known teratogens
• Identification of women with addiction disorders to arrange multidisciplinary treatment and support
• Assessment of immunization status and appropriate vaccinations
• Screening for preconception genetic counseling
• Exercise, particularly in women who are overweight or obese
• Occupational hazards assessment
• Anticipatory guidance regarding realistic expectations about work during the antenatal and postnatal period

B. Antenatal Care: First Trimester

• Diagnosis of pregnancy, including differentiation and management/referral of abnormal gestations (e.g., gestational trophoblastic disease, ectopic pregnancy)
• Initial prenatal history and evaluation, including clinical assessment of gestational age and accurate dating with ultrasound
• Obtaining baseline laboratory testing:
  • Maternal blood type and Rh, rubella titer, varicella IgG (if status unknown)
  • QuantiFERON and lead levels (if risk factors present)
  • Urine culture (at 11-16 weeks)
  • STI testing: hepatitis B surface antigen, RPR, gonorrhea, chlamydia, HIV, hepatitis C antibody (if risk factors present)
• Assessment and management of first-trimester complications and symptoms:
  • Spotting/bleeding
  • Pelvic pain
  • Hyperemesis gravidarum
  • Multi-fetal gestation
  • Musculoskeletal changes and discomforts
  • Body image changes
  • Life cycle stresses and changes in family dynamics
• Risk-factor screening:
  • Counseling to help patients make personal decisions regarding risk factor screening
  • Options for early screening for chromosomal abnormalities (nuchal translucency/PAPP-A, combined or sequential screening, cell-free DNA testing, AFP/quad marker testing)
  • Cystic fibrosis, Tay-Sachs disease, and hemoglobinopathy screening, if indicated
  • Referral for genetic counseling regarding other genetic diseases
  • Referral for amniocentesis or chorionic villus sampling, when indicated
• Counseling for prevention/treatment of substance abuse and STIs:
  • Tobacco cessation counseling in pregnancy
  • Alcohol abuse risks and fetal alcohol syndrome
  • Opiate abuse and referral for treatment (methadone/buprenorphine), counseling on neonatal abstinence syndrome
  • Other substances of abuse and pregnancy risks
  • Risk factors for STIs (including viral hepatitis and HIV) and their impact on pregnancy and fetal outcome
• Prenatal nutrition counseling:
  • Vitamin D, iron, and folic acid supplementation as needed; counseling on appropriate weight gain based on pre-pregnancy BMI
  • Screening/treatment of eating disorders
• Psychosocial stressors of pregnancy:
  • Counseling and support of the patient and family through the adjustments of pregnancy, including referral to psychological support services as appropriate
  • Longitudinal screening, diagnosis, and treatment for depression throughout pregnancy and the postnatal period
• Counseling for unintended pregnancy (including options of adoption and termination of pregnancy)
• First trimester pregnancy loss:
  • Diagnosis and differentiation of failed pregnancies (threatened, incomplete, complete, embryonic demise), and recognition/referral of ectopic pregnancies
  • Management of uncomplicated spontaneous abortion (expectant, medical, aspiration, surgical evacuation)
  • Referral for surgical intervention when complicated by infection, retained products of conception, or other high-risk situations
  • Counseling regarding grief in the event of any first trimester loss
  • Counseling regarding risk factors, common causes, and appropriate interpregnancy interval
  • Appropriate medical evaluation for recurrent early pregnancy loss
• Breastfeeding: early promotion and support, and support in decision making throughout pregnancy
• Adolescent pregnancy: special considerations regarding nutrition, confidentiality, and social/psychological needs, with awareness of community resources
• Substance abuse in pregnancy: special consideration for prenatal monitoring/testing and anticipating pain management/withdrawal needs across pregnancy, intrapartum, and postpartum periods
• Counseling regarding and promotion of appropriate immunizations in pregnancy

C. Antenatal Care: Second and Third Trimester

• Counseling, assessment, and management regarding discomforts of and adjustments to the growing pregnancy
• Second and third trimester screening and risk assessment for:
  • Gestational diabetes (including first trimester screening for pre-gestational diabetes when indicated)
  • Sexually transmitted infections
  • Vaginal infections
  • Group B beta-hemolytic strep screening
  • Asymptomatic bacteriuria, UTI, and pyelonephritis
  • Iron deficiency anemia
• Gestational diabetes: management with appropriate counseling and referral for nutritional care, glucose testing, oral medication or insulin management, antenatal fetal surveillance, and obstetrical consultation, if indicated
• Obstetrical complications – assessment and management, including indications for consultation or transfer of care:
  • Preterm labor
  • Preterm prelabor rupture of membranes (PPROM)
  • Intrauterine growth restriction (IUGR)
  • Malpresentation
  • Placental abruption
  • Trauma/deceleration injuries
  • Blood factor iso-immunization
  • Hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, preeclampsia with severe features, HELLP syndrome, eclampsia; note preeclampsia may present postpartum up to six weeks after delivery)
  • Intrahepatic cholestasis of pregnancy
  • Poly- and oligohydramnios
  • Fetal demise
  • Collaboration in management of high-risk patients with obstetric consultation and timely referral to maternal fetal medicine specialists
• Medical complications during pregnancy, with appropriate consultation or referral:
  • Asthma
  • Pyelonephritis and renal calculi
  • Thyroid disease (hypo and hyper)
  • Chronic kidney disease
  • Epilepsy
  • Autoimmune disease (e.g., lupus)
  • Cholelithiasis and acute cholecystitis
  • Preexisting hypertension or diabetes
  • Thromboembolic disease/thrombophilia
  • Dilated cardiomyopathy
  • Chronic pulmonary hypertension
  • Valvular heart disease
  • Obesity
  • History of bariatric surgery and pregnancy

D. Peripartum Care: Labor and Delivery

• Normal labor and delivery:
  • Understand the physiology of the three stages of labor and demonstrate effective management, including contemporary normal/abnormal labor curves and active management of the third stage
  • Appropriate utilization and interpretation of external electronic fetal monitoring
  • Appropriate obstetric analgesia and anesthesia, including family presence and labor support methods (e.g., Lamaze, Bradley)
  • Anticipate and plan for special populations (e.g., opiate-dependent patients, extreme obesity)
  • Non-pharmacologic pain control methods (ambulation, hydrotherapy, position changes, counterpressure, self-hypnosis, TENS units, sterile water injections)
  • Understand the evidence supporting doula use to improve birth and postpartum outcomes
  • Methods for protecting the perineum during second stage; indications for episiotomy
  • Normal course of the third stage and steps to prevent excessive bleeding/reduce postpartum hemorrhage risk (ALSO active management techniques)
  • Support and counsel patients regarding breastfeeding in the immediate postpartum period
• Complications during labor and delivery:
  • Fetal malpresentation: fetal-pelvic relationships and importance of early detection
  • Understand that latent phase labor lasts until 6 cm dilation and patience is warranted absent maternal/fetal jeopardy
  • Active phase labor dystocia: risk factors, prevention, recognition, and management (including IUPC placement to titrate oxytocin)
  • Post-term pregnancy: indications and risk assessment for induction, cervical ripening, Pitocin induction, AROM, and Bishop scoring
  • Premature and prolonged rupture of membranes: interventions including induction/augmentation and prophylactic antibiotics
  • Role of fetal malposition (OP/OT) in active phase and second stage dystocia
  • Meconium: awareness of need for appropriate personnel at delivery and intrapartum management
  • Emergencies: recognize signs/symptoms of life-threatening peripartum emergencies and utilize appropriate resuscitative techniques; co-manage placental abruption/hemorrhage, preeclampsia, eclampsia, amniotic fluid embolism, and DIC with obstetric consultation
  • Postpartum hemorrhage: recognition, diagnosis, and management, including medication side effects and comorbidity considerations
  • Category 2 and 3 tracings: early signs of fetal compromise and appropriate interventions (position change, tocolytics, maternal fluids, oxygen, amnioinfusion), with timely consultation
  • Shoulder dystocia: risk factors, prevention, recognition, and management using ALSO protocols
  • Assisted deliveries: indications for and appropriate use of vacuum extractor and forceps per ALSO protocols
  • Cesarean section: indications, risks/benefits, and need for timely intervention and surgical consultation
  • Stillbirth: management options and psychological support for patients and families
  • Neonatal resuscitation: maintain PALS and/or NRP-NALS certification; experience as first responder for neonates requiring resuscitation

E. Postpartum Care

• Routine postpartum care: normal lochia patterns, fluid shifts, perineal care education, support of breastfeeding and maternal-child bonding, and postpartum contraceptive counseling
• Recognition and management of postpartum complications in the hospital:
  • Delayed postpartum hemorrhage
  • Postpartum fever and endometritis
  • Pain associated with normal uterine involution, episiotomy/laceration repair, epidural/spinal anesthesia-related pain or headache, and musculoskeletal injury from labor
  • Thromboembolic disease
  • Recognition that preeclampsia may present as a new disorder in the first six weeks postpartum
  • Lactation difficulties in the newborn period
  • Postpartum depression and other mood disorders
• Later postpartum follow-up:
  • Normal and abnormal postpartum lochia and bleeding patterns
  • Breastfeeding difficulties (milk supply, latch, nipple soreness/cracking, blocked ducts, engorgement, mastitis)
  • Continued screening, assessment, and management of postpartum mood disorders
  • Postpartum intimate relationships and family dynamics
  • Parenting education and resources
• Interconception care: counseling on child spacing and risks related to prior pregnancy outcomes (e.g., gestational diabetes, pregnancy induced hypertension, prior preterm labor/birth, thromboembolic disease), with knowledge of risk reduction for preterm birth prevention

F. Newborn Care

See AAFP Curriculum Guideline No. 260 – Care of Infants and Children.

G. Consultation and Referral

• Understanding of the roles of the obstetrician, gynecologist, and subspecialist
• Recognition of resources in women’s health care delivery systems (e.g., WIC, Planned Parenthood)
• Regionalized perinatal care for high-risk pregnancies
• Collaboration with other health care professionals (childbirth educator, lactation consultant, certified nurse midwife, nutritionist/dietician, parenting educator, social services, HHS, mental health, and addiction professionals)

Section II, Gynecology, is addressed in AAFP Curriculum Guideline No. 282 – Women’s Health and Gynecologic Care.

I. Core Skills

In the appropriate setting, the fellow should demonstrate the ability to independently perform the following skills (when not available or appropriate, the resident should have exposure to practice these skills).

A. Pregnancy – Independent Performance

• History, physical examination, counseling, and laboratory/clinical monitoring throughout pregnancy
• Assessment (general impression, not formal measurements) of pelvic adequacy
• Assessment of estimated fetal weight and position by Leopold maneuvers
• Performance and interpretation of non-stress tests and stress tests
• Limited obstetric ultrasound examination (fetal position, amniotic fluid index, placental location, cardiac activity)
• Management of labor with accurate assessment of cervical progress and fetal presentation/lie
• Induction and augmentation of labor, including artificial rupture of membranes
• Placement of fetal scalp electrode
• Placement of intrauterine pressure catheter
• Amnioinfusion
• Local anesthesia
• Spontaneous cephalic delivery
• Active management of the third stage of labor
• Episiotomy
• Repair of episiotomies and lacerations (including third-degree)
• Neonatal resuscitation

B. Pregnancy – Exposure and Practice

• Vacuum extraction
• Emergency breech delivery
• Management of common intrapartum problems (e.g., malpresentation, unanticipated shoulder dystocia, manual removal of placenta)
• Pudendal block anesthesia
• First assisting at cesarean delivery
• Vaginal birth after previous cesarean delivery
• Dilation and curettage for incomplete abortion (may be an “advanced skill” at some programs)

Sections C (Gynecology) and D (Family Planning and Contraception) are addressed in AAFP Curriculum Guideline No. 282 – Women’s Health and Gynecologic Care.

II. Advanced Skills

For family medicine fellows planning to practice in communities without readily available obstetric-gynecologic consultation, additional, intensified experience is recommended, tailored to the needs of the fellow’s intended practice and agreed upon by the maternity operations committee.

A. Pregnancy

• Ultrasound-guided amniocentesis during mid-trimester and third trimester
• Conduction anesthesia and analgesia (not routinely taught by OB-GYNs)
• Management of early preterm labor or preterm rupture of membranes
• Management of multiple gestation
• Management of planned breech delivery
• External cephalic version
• Operative vaginal delivery (vacuum and forceps)
• Fourth-degree laceration repair
• Management of severe preeclampsia or eclampsia
• Management of complications of vaginal birth after previous cesarean delivery

B. Surgery

• Performance of cesarean delivery
• Performance of dilation and curettage (D&C) for management of retained placenta
• Postpartum tubal ligation with and without cesarean delivery

Sections C (Gynecology) and D (Family Planning and Contraception) are addressed in AAFP Curriculum Guideline No. 282 – Women’s Health and Gynecologic Care.

Implementation

Core knowledge and skills should require a minimum of two months of experience in a structured obstetrics educational program, with an additional one month dedicated to gynecologic care. Adequate emphasis on both ambulatory and hospital care should be provided. The fellow will obtain substantial additional maternity care experience throughout the year of continuity practice. Ideally, fellowships should have several core family medicine faculty members skilled in performing and teaching comprehensive maternity care, in addition to OB-GYN specialists in a supportive role.

Programs for family medicine residents should have a collaborative relationship between family medicine faculty and OB-GYNs at the training institution. It is recommended that an operational committee be established for the practice of maternity care at any institution involved in graduate medical education, with membership representing both family medicine and OB-GYN departments as well as community family physicians who practice maternity care. This committee should develop objectives aligned with the training program’s goals, monitor resident experiences, and assist in evaluating faculty teaching skills.

This AAFP Curriculum Guideline is intended to aid residency directors in developing curricula and to assist residents in identifying areas of necessary training. These guidelines are designed as guidelines rather than residency program requirements and are not intended to serve as criteria for hospital privileging or credentialing; the assignment of hospital privileges is a local responsibility based on training, experience, and current competence.

The AAFP recognizes the United States Breastfeeding Committee (USBC) for their work in developing Core Competencies in Breastfeeding Care and Services for All Health Professionals, which provided a framework for this guideline.

Resources (Selected Bibliography)

• American Academy of Family Physicians. Preconception care. Position paper. 2016.
• American Academy of Pediatrics & American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 8th ed. Elk Grove Village, IL: AAP, 2017.
• American College of Obstetricians and Gynecologists. Bariatric surgery and pregnancy. ACOG Practice Bulletin No. 105. Obstet Gynecol. 2009;113:1405-1413.
• American College of Obstetricians and Gynecologists. Early pregnancy loss. Practice Bulletin No. 150. Obstet Gynecol. 2015;125:1258-1267.
• American College of Obstetricians and Gynecologists. Report of the ACOG task force on hypertension in pregnancy. Obstet Gynecol. 2013;122(5):1122-1131.
• American College of Obstetricians and Gynecologists. Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. Obstet Gynecol. 2014;123:693-711.
• Chang PC, Leeman L, et al. Family Medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008;40(5):326-332.
• Coutinho AJ, Cochrane A, et al. Comparison of intended scope of practice for family medicine residents with reported scope of practice among practicing family physicians. JAMA. 2015;314(22):2364-2372.
• Creasy RK, Resnik R, et al. Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice, 7th ed. Philadelphia, PA: Saunders; 2013.
• Cunningham FG, Leveno KJ, et al. Williams Obstetrics, 24th ed. New York, NY: McGraw-Hill Medical; 2014.
• Deutchman M, Tubay AT, et al. First trimester bleeding. Am Fam Physician. 2009;79(11):985-992.
• Dresang LT, Yonke N. Management of spontaneous vaginal delivery. Am Fam Physician. 2015;92:202-208.
• Farahi N, Zolotor A. Recommendations for preconception counseling and care. Am Fam Physician. 2013;88(8):499-506.
• Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility, 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
• Gabbe SG, Niebyl JR, et al. Obstetrics: Normal and Problem Pregnancies, 7th ed. Philadelphia, PA: Saunders; 2016.
• Hartling L, et al. Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the USPSTF and NIH. Ann Intern Med. 2013;159:1.
• Hofmeyr GJ, Lawrie TA, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014;(6):CD001059.
• Kelly BF, Sicilia JM, et al. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):398-404.
• LeFevre ML, U.S. Preventive Services Task Force. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia. Ann Intern Med. 2014;161(11):819-826.
• O’Connor E, Rossom RC, et al. Primary care screening for and treatment of depression in pregnant and postpartum women. JAMA. 2016;315:388-406.
• Riley L, Wertz M, et al. Obesity in pregnancy: risks and management. Am Fam Physician. 2018;97(9):559-561.
• Zakrzewski L, Sur D. Immunizations in pregnancy. Am Fam Physician. 2013;87(12):828-830.
• Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014;89(3):199-208.

Web Sites

• Agency for Healthcare Research and Quality – Guidelines and Measures: www.guideline.gov
• American Academy of Pediatrics: www.aap.org
• American Congress of Obstetricians and Gynecologists: www.acog.org
• American Family Physician (AFP): Labor, Delivery, and Postpartum Issues – www.aafp.org/afp
• American Family Physician (AFP): Prenatal Care – www.aafp.org/afp
• Association of Maternal & Child Health Programs: www.amchp.org
• Centers for Disease Control and Prevention – Health Equity, Advancing Women’s Health and Safety: www.cdc.gov/women
• Centers for Disease Control and Prevention – Reproductive Health, Maternal and Infant Health: www.cdc.gov/reproductivehealth
• World Health Organization: www.who.int

Curriculum guideline revision history: Published 07/80. Reformatted 07/88. Revised/Retitled 03/98. Revised 2/08. Revised 11/09 by Hinsdale Family Medicine Residency. Revised 09/12 by Eastern Maine Medical Center Family Medicine Residency. Revised/Retitled 06/14 by Bayfront Health St. Petersburg Family Medicine Residency, FL. Revised 08/16 by Lancaster General Family Medicine Residency, Lancaster, PA. Revised 08/18 by Phelps Family Medicine Residency Program, Sleepy Hollow, NY.

This joint statement was developed by a joint task force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists.

Access to maternity care is an important public health concern in the United States. Providing comprehensive perinatal services to a diverse population requires a cooperative relationship among a variety of health professionals, including social workers, health educators, nurses, and physicians. Prenatal care, labor and delivery, and postpartum care have historically been provided by midwives, family physicians, and obstetricians. All three major caregivers remain today. A cooperative and collaborative relationship among obstetricians, family physicians, and nurse midwives is essential for provision of consistent, high-quality care to pregnant women.

Regardless of specialty, there should be shared common standards of perinatal care. This requires a cooperative working environment and shared decision-making. Clear guidelines for consultation and referrals for complications should be developed jointly. When appropriate, early and ongoing consultation regarding a woman’s care is necessary for the best possible outcome and is an important part of risk management and prevention of professional liability problems. All family physicians and obstetricians on the medical staff of the obstetric unit should agree to such guidelines and be willing to work together for the best care of patients, including a willingness on the part of obstetricians to provide consultation and back-up for family physicians who provide maternity care. The family physician should have the knowledge, skills, and judgment to determine when timely consultation and/or referral may be appropriate.

The most important objective of the physician must be the provision of the highest standards of care, regardless of specialty. Quality patient care requires that all providers practice within their degree of ability as determined by training, experience, and current competence. A joint practice committee with obstetricians and family physicians should be established in health care organizations to determine and monitor standards of care and proctoring guidelines. A collegial working relationship between family physicians and obstetricians is essential to provide access to quality care for pregnant women in this country.

B. Practice Privileges

The assignment of hospital privileges is a local responsibility, and privileges should be granted on the basis of training, experience, and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, to ensure the provision of high-quality patient care.

Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies. The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice. Provisional privileges in primary care, obstetric care, and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented. All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. These principles should apply to all health care systems.

C. Interdepartmental Relationships

Privileges recommended by the department of family medicine shall be the responsibility of the department of family medicine. Similarly, privileges recommended by the department of obstetrics-gynecology shall be the responsibility of the department of obstetrics-gynecology. When privileges are recommended jointly by the departments of family medicine and obstetrics-gynecology, they shall be the joint responsibility of the two departments. (1998; 2014 April BOD)

Reference chapter mapping to Gabbe’s Obstetrics: Normal and Problem Pregnancies, for use alongside the curriculum outline and reading assignments above.

Additional topics referenced throughout Gabbe (chapter numbers vary by edition; consult the current edition’s index): tobacco/alcohol/environmental exposures, depression, antenatal testing, maternal disease, maternal anemia and sickle cell disease, ITP, autoimmune disease, antiphospholipid antibody syndrome, inherited thrombophilias, cardiac disease, peripartum cardiomyopathy, thromboembolism, renal disease, obesity, diabetes mellitus, thyroid disorders, acute/chronic hepatitis, asthma, epilepsy, chronic hypertension, CMV/herpes/rubella/syphilis/toxoplasmosis, influenza/West Nile/varicella-zoster/TB, malaria, HIV, parvovirus B19, GBS, acute abdominal pain, gallbladder/fatty liver/pancreatic disease, first trimester vaginal bleeding, cervical insufficiency, nausea and vomiting, fetal death and stillbirth, abnormal amniotic fluid volume, preeclampsia, FGR, Rh and other blood group alloimmunizations, preterm labor, PROM, indicated late preterm and early preterm deliveries, prevention of cerebral palsy, amnionitis, third trimester bleeding, amniotic fluid embolism, induction of labor, intrapartum fetal heart rate monitoring, breech delivery, VBAC, placenta accreta, shoulder dystocia, twins/triplets and beyond, postpartum hemorrhage, and evaluation of fetal health and defects (appendix).