Objectives

1. To create a supportive infrastructure for expanded OB and pre- and post-conceptual care in Family Medicine.

   1. Family Medicine residents are offered experience in perinatal care in urban, rural, and community clinic settings. Urban inner-city patients are seen at the Family Medicine Residency Program (FPRP) clinic site in Gainesville. With the participation of local physicians, community perinatal care experience is provided at Lake Shore Hospital, a community hospital in Lake City, Florida. The rural perinatal care training was established this year by adding a family physician faculty member in Williston, Florida, an underserved community.

   2. The FPRP clinic is well equipped. The ultrasound machine is used with prenatal patients for detecting early pregnancy complications, dating, confirmation of position, and other indications. An electronic fetal monitor is available for evaluating fetal well-being.

2. To increase the number of OB practicing family physician faculty.

   1. Currently, we have six Family Medicine physicians and one midwife caring for OB patients and training residents at the Residency Program clinic site. Until 1998, there were no Family Medicine faculty members providing perinatal training to residents.

   2. A comprehensive OB track curriculum was designed for re-training Family Medicine physicians in perinatal care. This curriculum is available to any faculty physician who wants to pursue professional development in perinatal care. To date, two Family Medicine faculty physicians have been re-trained.

3. To train Family Medicine residents in prenatal care, to conduct low-risk deliveries, and provide postpartum care.

   1. The Family Medicine OB faculty train the residents in perinatal care. The residents are required to carry a minimum number of continuity of care patients and participate in their delivery and postpartum care. This family-centered perinatal care program provides the necessary training for residents to practice as true family physicians.

4. To increase the number of OB-practicing family physicians.

   1. An OB track curriculum was designed for training Family Medicine residents who wish to develop advanced clinical management skills in prenatal and perinatal care. This curriculum includes three additional months of OB training (2 months in a community-based hospital and one month of high risk obstetrics in a tertiary care center). The residents are required to manage additional continuity of care patients and are required to attend the monthly OB meetings. Residents are responsible for preparing and presenting topics of clinical interest at the monthly meetings. They are evaluated periodically and complete a comprehensive examination prior to graduation from the program.

   2. Three residents have been trained under this comprehensive program. Currently, four additional residents are being trained in this advanced curriculum.

5. To provide additional perinatal educational programs.

   1. A monthly OB meeting, chaired by Dr. Samraj, is conducted with the OB faculty, the midwife, the chief resident in OB, and other residents to discuss progress and plan strategies for this program, and also provides 90 minutes of educational activities in perinatal care.

   2. As an ongoing educational activity for the Family Medicine Residents, approximately 15 to 20 talks per year on the principles of OB medicine are conducted at the Noon Conference series.

   3. Educational programs are provided to community-based agencies, such as "Healthy Start" and "Healthy Families," to help coordinate care for the under-served population.

6. Provide continuity of care (prenatal, intrapartum and postnatal care) for Family Medicine patients.

   1. We have established and expanded our prenatal care program. Total patients enrolled in the program January 2000-October 2002 is 229. Prior to the initiation of this program, the enrollment was 5-10 patients per year. Also, there are 12 patients in the rural clinic at Williston, Florida.

Charting OB Care

The OB faculty and residents use the tool "MOMCARE," provided by the American Academy of Family Physicians (AAFP), to document patient care. This package is a system of practice guidelines, documentation forms, and patient and physician education materials developed and pre-tested by AAFP members. The initial package includes prenatal documentation forms; visit flow sheets, a prenatal program guide, and a resource list of patient education materials. The "MOMCARE" program is renewed and an in-service is conducted annually.

OB Curriculum for all Family Medicine Residents

The Family-Centered Perinatal Care team has developed a training curriculum for all residents. This includes readings on perinatal topics, specific rotation schedules, and collaborative arrangements for faculty trainees to participate in an adequate number of labor and delivery sessions. The curriculum for perinatal care re-training is modeled on the curriculum components mapped out by the Society of Teachers of Family Medicine Working Group on Family-Centered Perinatal Care. Pre-conception care curricular components include evaluation and advice regarding the patient's health and habits as they relate to a healthy pregnancy, e.g., weight; nutrition; exposures; family stressors; psychosocial issues; lifestyle issues, including prevention of drug abuse and counseling in smoking cessation; genetic risks assessment; review of medical conditions; and immunizations. Prenatal care curriculum components include counseling to reinforce healthy behaviors, childbirth and postpartum preparation, prenatal routine and elective screening tests, risk assessment, referrals for high-risk patients, and fetal assessment. The midwife provides initial counseling, and the resident, the faculty member, and the midwife are available for subsequent counseling. Normal labor and delivery components include fetal heart rate monitoring, contraction monitoring and augmentation, infant position during delivery, infant assessment, placental delivery, and intrapartum analgesia and pain management. The curriculum incorporates the management of acute complications in pregnancy, including abruption of the placenta and bleeding in pregnancy, spontaneous rupture of membranes and assessment of reduced fetal movements, and labor ward triage. The residents also provide postnatal care and follow-up for the mother and baby in the clinic and through home visits.