Family Centered Maternity Care


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Family Centered Maternity Care

  1. 1. Family Centered Maternity Care August 8-11, 2012 Portland, OR (As of May 14, 2012) Wednesday, August 8, 2012 6:45 a.m. Registration and Breakfast - Moderator: Stephen Ratcliffe, MD 7:30 - 8:30 a.m. Preconception/First Trimester Concerns a. Preconception/Prenatal Risk Assessment - Martha Carlough, MD b. Principles of Women-Centered Care - Sara Shields, MD c. Prenatal Screening: What the Evidence supports in Biomedical Arena - Matthew Cline, MD 1. Review how the provision of preconception care (or the lack thereof) provides the foundation of an initial prenatal risk assessment. 2. Discuss the importance of why a detailed medical history leads to the construction of a tailored prenatal care plan. 3. Distinguish the essential elements of woman-centered maternity care. 4. Apply up to five areas where the evidence supports universal or selective use of screening during the initial prenatal visits. 8:30 - 8:45 a.m. Question and Answer/Panel Discussion 8:45 - 9:00 a.m. Welcome and Overview 9:00 - 10:00 a.m. Basic Prenatal Care a. Genetic Screening - Johanna Warren, MD b. Medication Use in Pregnancy - Amanda Risser, MD c. Infectious Disease Updates - Lee Dresang, MD 1. Use the concepts of pre-test probability, positive and negative predictive values as they apply to testing for fetal aneuploidy. 2. Outline advantages and disadvantages of various approaches to first-trimester and second-trimester screening as well as invasive diagnostic testing for Down syndrome. 3. Summarize the current recommendations for cystic fibrosis testing and the importance of "residual risk". 4. Compare each of the FDA categories for medications in pregnancy. 5. Discuss indicated and unsafe use of over the counter (OTC) medications. 6. Summarize the epidemiology and natural history of common viral infections in pregnancy. 7. Develop evidence-based strategies to prevent, diagnose and manage these infections. 10:00 - 10:15 a.m. Question and Answer/Panel Discussion 10:15 - 10:30 am. Break Page 1
  2. 2. 10:30 - 11:30 a.m. Prenatal and Intrapartum a. Substance Use and Abuse: Current Trends - Larry Leeman, MD b. Management of Category 2 and 3 Tracings - Robert Gobbo, MD c. Pain Management: Expanded Modalities - Judith Rooks, CNM+B91 1. Review the maternal and neonatal effects of substance abuse. 2. Discuss maternal treatment options and for drug-exposed infants. 3. Review updated fetal monitoring classification system from the National Institute of Child Health and Human Development. 4. Explain an alternative "Color Coded" tool currently being used within the Providence Oregon Health System. 5. Identify the three most effective non-pharmacologic methods to help women cope with labor pain, based on strong evidence, and what two kinds of in-the-labor room equipment maximize the effectiveness of non-pharmacologic approaches? 6. List up to the five essential rules for safe use of nitrous oxide labor analgesia? 7. Describe why nitrous oxide labor analgesia is safe for both the mother and the baby? 11:30 - 11:45 a.m. Question and Answer/Panel Discussion 11:45 a.m. - 1:00 p.m. Lunch On Your Own 1:00 - 2:00 p.m. Breakouts (See topics below. One hour in duration. Topics presented four times). #1 Management of Persistent Occiput Posterior (OP) Malposition Stephen Ratcliffe, MD; Helen Welch, MD; Kerry Watrin, MD 1. Describe how to recognize and treat the occiput posterior (OP) position during late pregnancy and during late pregnancy and during the first and second stages of labor. 2. Demonstrate an understanding of belly mapping as a technique to diagnose persistent OP position in the last weeks of pregnancy. 3. List up to three positional changes in labor to assist women with persistent OP position. 4. Discuss non-pharmacologic means, such as intradermal sterile water injections, as strategies to assist women with the "back labor" of the persistent OP position. 5. Demonstrate the proper techniques of manual rotation of the persistent OP position during stage two when the fetus is at a +2 station and vertex presentation. #2 Management of First Trimester Pregnancy Loss Larry Leeman, MD; Amanda Risser, MD 1. Relate the epidemiology and diagnostic criteria of early pregnancy loss. 2. Compare the risks and benefits of expectant management versus medical or surgical intervention. 3. Apply the use of vaginal misoprostol for medical management of miscarriage. 4. Describe the use of manual vacuum aspiration for the early pregnancy loss. Page 2
  3. 3. #3 Non-pharmacologic Management of Pain in Labor: Lessons from Midwifery Kate Pelosi, CNM; Lauren MacKenzie, CNM 1. Describe the nature of pain as it relates to the stages and phases of labor. 2. Discuss psycho-emotional measures that reduce maternal stress in labor. 3. Describe physical comfort measures that reduce maternal stress in labor. 4. Recognize basic physiologic measures that provide comfort for women in labor. 5. Explain 4 non-pharmacologic techniques that can be integrated into your obstetrical practice for reducing maternal stress and pain in labor. #4 Fetal Labor Assessment: Management of Category 2 and 3 Tracings Robert Gobbo, MD; Matthew Cline, MD 1. Describe the fetal physiology and response to stress, medications, hypoxia and academia. 2. Apply updated fetal monitoring classification system from the National Institute of Child Health and Human Development. 3. Apply the mnemonic DR C BRAVADO to help interpret fetal tracings. 4. Explain the alternative "Color Coded" tool currently being used within the Providence Oregon Health System. 5. Develop an appropriate treatment plan based on assessment of maternal and fetal status. 6. Participate in case study fetal assessments. #5a Strategies to Improve Quality and Increase Teamwork (Presented 1:00 - 2:00 p.m.; 2:05 - 3:05 p.m.) Sara Shields, MD; Lee Dresang, MD 1. Critique national and local QI strategies in maternity/newborn care: induction, late preterm birth, corticosteroids in preterm labor, preterm birth prevention, jaundice screening. 2. Compare programs that promote cross-disciplinary teamwork in maternity care. #5b Providing Appropriate and Effective Care to Women Across the Cultural Spectrum (Presented 3:20 - 4:20 p.m.; 4:25 - 5:25 p.m.) Portia Jones, MD; Teresa Gipson, MD 1. Discuss the broad definition of cultures. 2. Review strategies for identifying cross cultural issues in maternity care. 3. Evaluate challenges for multi-cultural providers in maternity care. 4. Discuss a step-wise approach to managing cross cultural issues in maternity care. 5. Apply principles in discussing case examples of specific cultures. #6 Shoulder Dystocia: Update on Prenatal Diagnosis, Anticipation, and Management Johanna Warren, MD; Robert Gobbo, MD; Josh Reagan, MD; Martha Carlough, MD; Lee Dresang, MD 1. Outline existing evidence for prenatal diagnosis of macrosomia and its management. 2. Explain the team management of shoulder dystocia and apply this to your home environment. 3. Develop and demonstrate strategies for emergency management of shoulder dystocia. Page 3
  4. 4. 2:05 - 3:05 p.m. Breakouts Repeat 3:05 - 3:20 p.m. Break 3:20 - 4:20 p.m. Breakouts Repeat 4:25 - 5:25 p.m. Breakouts Repeat 5:25 p.m. Recess Thursday, August 9, 2012 7:00 - 7:30 a.m. Registration/Breakfast: Moderator: Robert Gobbo, MD 7:30 - 8:15 a.m. The Cesarean Epidemic: How it has Occurred and What we can do about it! Aaron Caughey, MD 1. Understanding the factors that have lead to an increase in the cesarean epidemic in the US. 2. Understand how to make interventions to lower cesarean sections in your communities. 3. Describe the improtance of improving the knowledge base and clinical care of obstetricians, mid-wives and family physicians in order to provide safe and effective maternity care. 8:15 - 8:30 a.m. Course Announcements 8:30 - 9:30 a.m. Intrapartum a. Dystocia (Difficult Labor) - Jody Lindwall, CNM b. Stage Two Management - Elizabeth Kavanough, CNM c. Prematurity Prevention/Treatment - Stephen Ratcliffe, MD 1. Recognize labor dystocia that occurs during latent phase and stage one labor and identify likely causes of this dystocia. 2. Identify management strategies to treat labor dystocia. 3. Identify up to four methods of decreasing the need for an operative vaginal delivery or Cesarean Section during stage two. 4. Describe methods of positioning women during stage two that are associated with less perineal trauma and improved neonatal outcomes. 5. Distinguish the cardinal signs and symptoms of preterm labor (PTL) and how to manage this condition based upon gestational age of the fetus. 6. Identify evidence-based approaches to reduce the incidence of preterm delivery. 9:30 - 9:45 a.m. Question and Answer/Panel Discussion Page 4
  5. 5. 9:45 - 10:00 a.m. Break 10:00 - 11:00 a.m. Breakouts (See topics below. One hour in duration. Topics presented two times) #7 Billing and Coding for Maternity Care Kerry Watrin, MD 1. Define physicians' role in appropriate coding and documentation in the maternity care setting. 2. Choose appropriate key items to determine level of patient care coding. 3. Distinguish common coding options for maternity patients during inpatient and outpatient encounters throughout the pregnancy. #8 Circumcision: Update on Evidence, Techniques, and Analgesia Matthew Cline, MD; Portia Jones, MD 1. Provide updated evidence regarding medical indications for newborn circumcision. 2. Relate appropriate information about circumcision to parents to allow for appropriate decision-making. 3. Describe the dorsal penile nerve block and ring block for circumcision anesthesia. 4. Outline the technique for performance of circumcision by Gomco, Mogen, and Plastibell methods. #9 The Basics of Implementing Group Prenatal Care Jody Lindwall, CNM; Stephen Ratcliffe, MD 1. Summarize the evidence supporting the effectiveness of group prenatal care. 2. Provide an outline of a model group prenatal care curriculum. 3. Demonstrate the difference between a group teacher versus facilitative leadership style. 4. Review the practical components of a group prenatal care session. #10 Lowering Risk of Law Suits/What to Do When You have been Sued Robert Gobbo, MD; Sara Shields, MD 1. Develop a plan to work with risk management regarding prevention of malpractice. 2. Review the steps involved in a medical malpractice suit. 3. Formulate a strategy for handling lawsuits. #11 Postpartum Contraception: Strategies and Techniques Teresa Gipson, MD; Larry Leeman, MD; Johanna Warren, MD 1. Compare the new and older methods of contraception. 2. Discuss the merits of these new methods with patient case examples. 3. Apply technical skills for insertion of IUDs, the Implanon system, condoms and diaphragm fitting. Page 5
  6. 6. #12 Maternal Child Health Issues in the Developing World Martha Carlough, MD; Lee Dresang, MD 1. Restate three to four major determinants of maternal child health in the developing world. 2. Describe two to three successful programs that have been associated with sustained improvements maternal/neonatal/child mortality. 3. Distinguish the differences in ALSO Course content and process that are presented in the developing world compared with the curriculum in the developed world. 11:05 a.m. - 12:05 p.m. Breakouts Repeat 12:05 - 1:15 p.m. Lunch On Your Own 1:15 - 2:15 p.m. Breakouts (See topics below. One hour in duration.) #13 Cesarean Section - Training and Privileging (Presented 1:15 - 2:15 p.m.) Larry Leeman, MD; Robert Gobbo, MD 1. Describe ways to obtain training to perform cesarean delivery. 2. Summarize the documentation needed to assembly when applying for privileges. 3. Articulate strategies for negotiating the credential process. 4. Explain the implications of the "Runte" decision. Cesarean Section - Evidence Based and Expert Opinion review of Cesarean Section Techniques, Modifications due to Obesity, Adhesions and Complications (Presented 2:20 - 3:20 p.m.; 3:40 - 4:40 p.m.) Larry Leeman, MD; Robert Gobbo, MD 1. Describe the anatomy and physiology relevant to cesarean delivery. 2. Evaluate risk factors and mitigating approaches to lower morbidity. 3. Summarize strategies for caring for women with morbidly obesity, adhesions, hemorrhage and lacerations. 4. Explain the complications of cesarean delivery. 5. Apply techniques of uterine artery ligation and B-Lynch on simulation surgical models. Cesarean Section for the Assisting and Primary Clinician (Presented 4:45 - 5:45 p.m.) Larry Leeman, MD; Robert Gobbo, MD 1. Analyze indications for cesarean delivery. 2. Evaluate risk factors and mitigating approaches to lower morbidity. 3. Describe the anatomy and physiology relevant to cesarean delivery. 4. Relate steps leading to cesarean delivery of a fetus and the specific role of the assistant. 5. Describe post-operative and post-partum care of the patient who has had a cesarean delivery and the implications for her primary care including future pregnancies and health status. Page 6
  7. 7. #14 Case Studies: Strategies to Avoid and Manage Labor Dystocia to Reduce the Primary Cesarean Birth Rate Helen Welch, CNM; Valerie King, MD; Kate Pelosi, CNM 1. List prenatal strategies that can assist in dystocia prevention. 2. Judge normal and abnormal phases of labor. 3. Discuss evidence-based care of women with non-progressing labor (with a focus on low risk women in first labor). #15 Management of Chronic Medical Conditions (thyroid, epilepsy, headache and asthma) Stephen Ratcliffe, MD; Portia Jones, MD 1. Contrast the natural history of these disorders during and after pregnancy. 2. Discuss the safe use of medications for these chronic conditions. 3. Develop management strategies of these conditions during pregnancy. #16 Clinician Role in the Promotion of Successful Breastfeeding Doris Onnis, RN, IBCLC; Martha Carlough, MD 1. List six health benefits for both mother and baby resulting from breastfeeding to address the issues related to breastfeeding as a public health issue. 2. Describe evidence-based strategies to motivate mothers to choose, initiate and continue breastfeeding. 3. Evaluate the challenges in early breastfeeding and choose appropriate management. 4. Discuss resources for accurate information on the safety of prescription medications, including hormonal contraceptives, during breastfeeding. #17 Stage Two Management Elizabeth Kavanough, CNM, Amanda Risser, MD 1. Integrate into practice an evidence-based approach for management of second stage of labor. 2. Recommend alternative maternal positions in second stage labor that facilitate progress. 3. Determine risk factors during pregnancy and labor which result in an increase in perineal trauma. 4. Design an evidence-based approach for reducing and preventing perineal trauma during the second stage of labor. #18 Vacuum-Assisted Vaginal Deliveries: Focus on Safety and Effectiveness Lee Dresang, MD; Kerry Watrin, MD; Johanna Warren, MD 1. Relate criteria to support safe delivery outcomes. 2. Compare the evidence of safety and effectiveness of forceps versus vacuum assisted vaginal delivery. 3. Summarize strategies to reduce the need for vaginally assisted deliveries. 4. Discuss the indication for forceps and vacuum assisted deliveries. 5. Demonstrate proper techniques in forceps assisted vaginal delivery and vacuum assisted vaginal delivery using the models. Page 7
  8. 8. 2:20 - 3:20 p.m. Breakouts Repeat 3:20 - 3:35 p.m. Break 3:40 - 4:40 p.m. Breakouts Repeat 4:45 - 5:45 p.m. Breakouts Repeat 5:45 p.m. Recess Friday, August 10, 2012 7:15 - 7:45 a.m. Breakfast 7:45 - 8:45 a.m. Care of Common Conditions in Pregnancy a. Major Depression in Pregnancy: Screening/Diagnosis/Management - Lee Dresang, MD b. Gestational Diabetes Update - Teresa Gipson, MD c. Hypertensive Disorders: Recognition/Management/Prevention - Kerry Watrin, MD 1. Discuss the evidence linking the use of antidepressant medication with adverse maternal infant outcomes. 2. Review treatment options of mild, moderate and major depression. 3. Present tools to assist the clinician in making an accurate diagnosis of major depression. 4. Review the current evidence to support the diagnosis and treatment of GDM. 5. Understand when and how to institute insulin therapy. 6. Evaluate alternative approaches to treat GDM using oral agents. 7. Discuss the diagnosis and management of gestational hypertension and pre-eclampsia. 8. Diagnose and treat essential hypertension in pregnancy. 8:45 - 9:00 a.m. Question and Answer/Panel Discussion 9:00 - 9:10 a.m. Course Announcements Page 8
  9. 9. 9:10 - 10:10 a.m. Timing of Delivery a. Using Ultrasound to Manage Pregnancies at Increased Risk - Robert Gobbo, MD b. Prolonged Pregnancy: Prevention and Management - Portia Jones, MD c. Induction Controversies/Techniques - Valerie King, MD 1. Summarize existing methods of using ultrasound to conduct antenatal fetal surveillance and the evidence to support its use to monitor high risk conditions such as hypertensive disorders and Intrauterine Growth Restriction (IUGR). 2. Identify strategies to reduce the need for induction for prolonged pregnancies. 3. Analyze the evidence to support expectant management of the prolonged pregnancy versus induction of labor. 4. Discuss the technique of Active Management of Risk in Patients at Term and its evidence base. 5. Compare techniques of cervical ripening and their relative efficacy. 6. Identify EBM-based techniques to decrease the incidence of prolonged pregnancy. 10:10 - 10:25 a.m. Question and Answer/Panel Discussion 10:25 - 10:45 a.m. Break 10:45 - 11:45 a.m. Labor and Delivery a. Trial of Labor after Cesarean Section (TOLAC) - Larry Leeman, MD b. Role of Support in Labor - Helen Welch, CNM c. Immediate Care of Mother, Infant and Family - Martha Carlough, MD 1. Review current recommendations regarding trial of labor after Cesarean Section (TOLAC). 2. Understand the role of at rained lay birth attendant (Doula) to provide continuous emotional support during labor. 3. Define up to four benefits that a Doula can bring to women in labor. 4. List two benefits conferred to the baby with delayed clamping of the umbilical cord. 5. Identify woman- and infant-centered approaches to promote bonding and successful breastfeeding. 6. Review the evidence supporting Active Management of the third stage of labor. 7. Summarize the initial steps to identify and manage a postpartum hemorrhage. 11:45 a.m. - 12:00 noon Question and Answer/Panel Discussion 12:00 noon - 1:30 p.m. Lunch On Your Own Page 9
  10. 10. Optional Sessions - Separate registration fee required - room location listed on ticket 1:30 - 3:30 p.m. Repair of Vaginal, Cervical and Basic 1st/2nd Degree Perineal Lacerations with an Anatomic and Evidence-based Approach Robert Gobbo, MD; Larry Leeman, MD; Matthew Cline, MD; Stephen Ratcliffe, MD; Teresa Gipson, MD; Johanna Warren, MD; Valerie King, MD 1. Describe the anatomy of the perineum and pelvic floor. 2. Review the indications for episiotomy and demonstrate proper and safe technique. 3. Be able to demonstrate the proper handling of instruments, suture and technique and knot tying for repair of simple 2nd degree, peri-urethral lacerations. 4. Be able to identify lacerations that extend into the rectal sphincter and mucosa, and cervical lacerations and strategies to temporize bleeding and patient discomfort in interim period before consultant arrives. 5. Incorporate cognitive with procedural skills through hands-on participation in a perineal repair model. 4:15 - 6:15 p.m. Perineal Repair: Complex Repairs Including 3rd/4th Degree Repair and Cervical Lacerations Robert Gobbo, MD; Larry Leeman, MD; Matthew Cline, MD; Stephen Ratcliffe, MD; Portia Jones, MD; Johanna Warren, MD; Valerie King, MD 1. Describe the anatomy of the perineum and pelvic floor. 2. Understand the long-term consequences of occult and apparent pelvic floor trauma. 3. Demonstrate the repair strategies for rectal mucosa and rectal sphincter lacerations. 4. Demonstrate repair techniques for complex/stellate vaginal and cervical lacerations. 5. Incorporate cognitive with procedural skills through hands-on participation in 2 perineal repair models. Saturday, August 11, 2012 7:30 a.m. Breakfast 8:00 - 9:00 a.m. Mother-Infant Care a. Postpartum Urgencies - Johanna Warren, MD b. Newborn Respiratory Problems - Matthew Cline, MD c. Neonatal Problems - Kerry Watrin, MD 1. Outline systematic approaches to manage a delayed postpartum hemorrhage. 2. Detail steps to take to prevent venous thromboembolism as well as diagnose and treat this condition. 3. Describe how preeclampsia can present clinically many days post-delivery. 4. List up to four causes of respiratory distress in the newborn and how to diagnose and manage these conditions. 5. Explain a diagnostic and management approach to the following neonatal conditions: congenital hip dysplasia, hyperbilirubinemia, heart murmurs, hypoglycemia and suspected sepsis. Page 10
  11. 11. 9:00 - 9:15 a.m. Question and Answer/Panel Discussion 9:15 - 9:30 a.m. Course Announcements/Wrap-Up 9:30 - 10:30 a.m. The Postpartum Period a. The Postpartum Visit and Family Planning Considerations - Josh Reagan, MD b. Maternal/Paternal Adjustments - Kate Pelosi, CNM c. The Case for Interconception Care - Stephen Ratcliffe, MD 1. Review the evidence based data on the importance of the postpartum visit and the key information to be obtained through the history and physical. 2. Outline some important distinctions in patient selection for effective contraception in the postpartum period. 3. Perform an assessment of immunization status for women receiving postpartum care. 4. Outline the maternal body changes common after a vaginal and cesarean delivery with attention to issues re: body image, vaginal and vulva changes and the impact on sexual health. 5. Provide an overview of common problems affecting couples after birth, including marital discord, infidelity, control and abuse issues and what strategies we can best employ to help families maintain or re-establish healthy relationships. 6. Examine the rationale, evidence and benefits of interconception care (ICC) strategies as it relates to family medicine and the medical home with emphasis on those with a prior adverse pregnancy. 11:00 - 11:15 a.m. Question and Answer/Panel Discussion 11:15 a.m. Course Adjourns Page 11