NSVD Module©

Goals, Objectives and Competencies:

Goal: To understand the role of the family physician in the complete care of a pregnant woman and
her family throughout a hospitalization for a Normal Spontaneous Vaginal Delivery.

Objectives:
The learner will:
1. Perform appropriate evaluation and documentation, from admission through birth and
discharge, of a woman with a term singleton pregnancy who presents to Labor and Delivery in
labor (ACGME Competencies A,B,D).
2. Describe and integrate the philosophy of family centered birth (A,B).
3. Provide appropriate patient education and anticipatory guidance to women in labor and their
families (A,D).
4. Provide culturally competent care to pregnant women and their families (D,E).
5. Provide support and encouragement for woman to breastfeed during the postpartum period
(A,B,D,E).
6. Utilize existing support systems, including consultation, in the hospital and community to
provide optimal care and follow-up of women and their newborns (D,E,F).
7. Evaluate controversial topics in Obstetrics and select a specific topic from within the evidence-
based literature to present in Journal Club (B,C,F).
8. Evaluate and investigate patient care practices by using data from the learner’s clinical practice
site and/or the training hospital to implement best practices and improve patient care (C).
9. Evaluate progress in learning by evaluation of knowledge and skills by self-report, examination
and by others, including preceptors, support staff and patients (C,E).

Objective 1: Perform appropriate evaluation and documentation, from admission through birth and
discharge, of a woman with a term singleton pregnancy who presents to Labor and Delivery in labor.

Competencies:
1. Perform an antepartum evaluation, including:
Calculate Estimated Date of Delivery by Nagle’s Rule, “The Wheel,” and Ultrasound
Determine risk of delivery: high vs. low
Describe the evaluation for “rule out rupture of membranes”
Describe the evaluation for “rule out labor”
Describe and explain bishops scoring
Perform appropriate physical exam to presenting history
Order and evaluate appropriate laboratory studies as indicated
Order and evaluate appropriate imaging studies as indicated
Order or perform and evaluate appropriate fetal assessments
Assess social support for birth and the postpartum period
Assess social support dynamics
2. Manage a NSVD of a term singleton pregnant woman:
Identify and describe each stage of labor:
Stage1: Cervical Dilatation
Define the components of active labor
Sketch and explain Friedman’s Curve
Describe and explain relevant pelvic anatomy and landmarks
Describe and explain rules of engagement
Describe and explain cervical dilatation and effacement
Describe the different presentations of the fetus at term
Compare and contrast the difference in three stages of a woman’s labor who is
Nulliparous v. multiparous

© 2005 Francesco Leanza, Alice Fornari, Janet Townsend, All Rights Reserved
 Explain the role of “Artificial Rupture of Membranes” in labor management
Describe the different options for Analgesia/Anesthesia for obstetrical patients
Explain how to prevent perinatal Group B Streptococcal disease
Explain the role of a provider as labor coach
Explain the role of a Doula
Explain how to determining completion of cervical dilatation
Stage2: Pushing and birth
Describe and sketch positioning and descent of the fetus
Describe indications for surgical delivery
Describe indications for Episiotomy
Explain and describe how to control the fetal head during birth (i.e. “Where to
put your hands”)
List what should be on the delivery tray
Explain the role of provider as labor coach
Stage 3: Delivering the placenta
Describe the different presentations of the placenta
Explain how to exam the placenta
Describe the different types of vaginal lacerations and how to repair them
Describe the different degrees of perineal lacerations and how to repair them

3. Explain the role of Fetal Monitoring

Describe indications for external and internal fetal monitoring
Describe reassuring patterns of Fetal Heart Rate (FHR)
Describe non-reassuring and ominous patterns of FHR
Describe interventions for non-reassuring and ominous patterns of FHR
Assess the evidence behind medical decision making in intervention based on FHR

4. Describe how to manage these common post partum issues:

Postpartum Hemorrhage
Endometritis
Perineal care
Lactation
Feeding- breast vs. bottle
Family planning
Resuming pregnancy prevention
Concerns and issues around discharge (see objective 3: anticipatory guidance)

5. Perform appropriate documentation, from admission through birth and discharge, of a woman
with a term singleton pregnancy who presents to Labor and Delivery in labor.
Perform and Document an appropriate Antepartum note
Perform and Document an appropriate Admission History and Physical
Perform and Document an appropriate Delivery Note
Perform and Document an appropriate Post Partum Note
Perform and Document an appropriate Discharge Summary
Document and analyze appropriate laboratory studies and imaging studies throughout the patient’s
admission

Objective 2: Describe and explain the philosophy of Family Centered birth.

Competencies:
Describe the concept of “Pathology of Pregnancy”
Compare and contrast the concepts of high tech/low touch delivery and low tech/high touch birth

© 2005 Francesco Leanza, Alice Fornari, Janet Townsend, All Rights Reserved
Objective 3: Provide appropriate patient education and anticipatory guidance to women in labor
and their families.
Competencies:
Assess all patients for barriers to understanding patient education including: literacy level,
comprehension of English and/or any physical impairment(s).
Provide appropriate services for these patients
Explain in layman’s terms how labor progresses
Explain in layman’s terms the various options for Anesthesia and Analgesia
Natural Birth
Non-pharmacologic interventions
Pharmacologic interventions
Epidural
Explain in layman’s terms the issues around common postpartum issues:
Postpartum Hemorrhage
Endometritis
Perineal care
Lactation
Feeding- breast vs. bottle
Family planning
Resuming pregnancy prevention
Explain what you would say to patients regarding these issues for anticipatory guidance:
Baby care
Breast Feeding
Changes at Home
Sibling relationships
Resuming sexual activity
Sleep
Post Partum Depression
Follow-up care
Public Health Nurse

Objective 4: Provide culturally competent care to pregnant women and their families.
Competencies:
Assess social support for birth and the postpartum period
Assess social support dynamics during birth
Assess all patients for barriers to full participation in the birth process including: literacy level,
comprehension of English and/or any physical impairment(s).
Provide appropriate services for these patients
Investigate and describe cultural differences around birthing babies and women’s experiences:
Some examples might be:
What are the specific cultural practices around pregnancy, birth and the post-
partum period of the women and their cultures that your primary care site
serves? Are there specific rituals? Diets? What is the woman’s role within her
family- immediate or extended? Are there any limitations placed on the woman?
What are the differences in experience of women who give birth in the US
compared to their birth experiences in other countries?
What is the physician’s role in repairing lacerations incurred after birth in
women who have had Female Genital Mutilation?

Objective 5: Provide support and encouragement for woman to breastfeed during the postpartum
period.
Competencies:
Describe advantages and disadvantages of breastfeeding
Describe strategies of counseling women on breastfeeding, include:
Patient education
Prenatal

© 2005 Francesco Leanza, Alice Fornari, Janet Townsend, All Rights Reserved
 Admission for birth
Post-partum
Early contact
Positioning and Latch-on
Effects of intrapartum analgesia and anesthesia
Effects of cesarean delivery
“Rooming in”
“Nipple confusion”
Activities:
Follow the Lactation consultant
Attend a class with moms
Breastfeeding Curriculum with Joon Lee

Objective 6: Utilize existing support systems, including consultation, in the hospital and community
to provide optimal care and follow-up of women and their newborns.
Competencies:
Describe when you would consult an OB/Gyn, lactation consultant, Public Health Nurse, Social
Worker
Explain various issues around coding and billing around birthing

Objective 7: Evaluate controversial topics in Obstetrics and select a specific topic from within the
evidence-based literature to present in Journal Club.
Competencies:
Apply evidence-based research to patient care
Possible topics:
Electronic Fetal Monitoring
Epidural anesthesia
Labor positioning
Perineal massage
NPO orders during birth
Blood screening in laboring patients
Episiotomy
The role of support during birth, including Doula’s
The role of ultrasound in prenatal care

Objective 8: Evaluate and investigate patient care practices by using data from the learner’s clinical
practice site and/or the training hospital to implement best practices and improve patient care.
Competencies:
Investigate the maternal morbidities and mortalities for Montefiore and FHC or WB respectively.
Some examples might be:
Evaluate the Cesarean rate for these practices
How many prenatal visits does it take to improve infant and maternal M & M?
Most common M&M for these practices
Investigate what QI initiatives exist at Montefiore,FHC or WB?
Attend a meeting
Can you apply what you see to your practice?

Objective 9: Evaluate progress in learning by evaluation of knowledge and skills by self-report,

examination and by others, including preceptors, support staff and patients.

N.B. Dear Learner: This is a “living curriculum.” Without active and current input from you, this
curriculum will not survive. To that end we welcome suggestions and improvements. Please let us know
what we can do to improve your learning…

© 2005 Francesco Leanza, Alice Fornari, Janet Townsend, All Rights Reserved