The Department of Ob/Gyn delivers approximately 4,200 patients per year at University Hospital. In February, 2010 all obstetric services moved into the new UAB Women and Infants Center of University Hospital. These deliveries arise from patients in an eight county region around Birmingham and from maternal-fetal transports from the entire state of Alabama.  The majority of women deemed to be at lower risk receive prenatal care in clinics run by the UAB Division of Maternal and Femfmtal Medicine located at the Jefferson County Health Departments. High-risk patients are seen in the Complications Clinic (see high-risk obstetrics section).  The system provides an excellent opportunity for residents to participate in both normal and high-risk obstetrical care under the supervision of the faculty of the Division of Maternal and Fetal Medicine (MFM). The Division consists of nine MFM specialists, all of whom are boarded in MFM with one doubly boarded in MFM and Genetics. There are currently four MFM fellows who serve as junior faculty, one of whom is doing a combined Genetics/MFM fellowship.

Inpatient obstetric patients are managed at University Hospital. Residents from all four PGY levels rotate through the University Obstetric service. Seven residents comprise this rotation including one PGY4, one PGY3, two PGY2’s and three PGY1’s. One PGY2 and one additional PGY3 go to the OB Complications Clinic each day on an ambulatory rotation. Resident physicians directly participate in all clinical aspects of the University Obstetrics service including ambulatory care as well as evaluation and management of patients in several areas of care. These areas of evaluation and management of patients include:  

  1. patients presenting to the Maternity Evaluation Unit (MEU),
  2. intrapartum patients in labor and delivery,
  3. maternity transports,
  4. obstetric patients admitted to the antepartum inpatient service,
  5. patients on the postpartum service, and
  6. hospital consults.

In this system, resident physicians deliver routine obstetric care for low risk women through outpatient prenatal clinics, MEU, labor and delivery and the postpartum service. Resident physicians perform all major obstetrical procedures according to graduated level of experience (i.e., PGY1’s perform primary cesarean sections, etc., PGY2’s perform repeat cesarean sections, low forceps and vacuum assisted deliveries, etc., PGY2's and above perform operative vaginal deliveries, PGY3’s and 4’s first assist cesarean sections, perform cesarean hysterectomies, cervical cerclage, postpartum bilateral tubal ligations, etc.).

Educational activities are structured around daily inpatient teaching rounds with the on-service MFM attendings. The attendings discuss all patients on the labor ward each morning with the residents on service and all scheduled surgical cases are reviewed. During sit-down rounds, the residents present all patients to the attendings and management plans are formulated. All residents and medical students not directly providing care in labor and delivery or in the MEU are present for sit-down rounds where teaching occurs daily in a case-based format.

Weekly interactive didactic sessions are held each Wednesday morning for all residents and students on the obstetric service, including residents on the night float rotation. These sessions are typically conducted in a case-based format followed by short didactics to reinforce key concepts. Core OB topics are covered over the course of two years. One Wednesday morning each month is dedicated to an Ob Journal Club in which a classic, or important recent, obstetric article is discussed. This session augments the resident education in evidence-based medicine provided in the departmental journal club EBM curriculum. A list of required reading by PGY level has been developed for the Obstetric service as an educational guide. 

Experience in high-risk obstetrics occurs primarily on the University Obstetrics rotation and the OB Complications Clinic. MFM faculty provide phone consultations for statewide physicians and from these consultations approximately 600 high-risk maternal-fetal transports are referred to the University Hospital Labor and Delivery unit each year.  Residents manage these patients on University Obstetrics rotations as described in the normal obstetrics section. 

Prenatal care for high-risk patients is provided in the University Obstetrics Complications Clinic. All high-risk patients from an eight county district as well as from outlying counties are referred to this clinic, which meets nine times per week. Residents at PGY 1-3 levels from the University Obstetrics rotations attend this clinic. The Complications Clinic has over 16,000 out-patient visits each year. An MFM attending and/or fellow staffs each clinic. Residents and nurse practioners are the primary providers in this clinic while the MFM staff is present to review all charts, discuss management plans, and see patients for additional counseling if needed. Facilities for NST/CST and routine and targeted ultrasound are provided. Amniocenteses for all indications are performed.  The availability of and close proximity to the high-risk testing unit allows the resident an appropriate avenue to learn how to use these tests and procedures. The clinic is also staffed with four social workers and a full time dietician with special expertise in the management of diabetes in pregnancy.  The residents work regularly with these staff in managing the high risk patients.

Each year, PGY2’s have an amniocentesis didactic session and a simulated experience in the technique of ultrasound guided amniocentesis using a gelatin model. These sessions are conducted during Friday afternoon protected time by the MFM faculty and provide opportunity for repeat practice of the procedure with immediate feedback.

Educational activities are structured around daily in-patient teaching rounds with the on-service MFM attendings as described in the Normal Obstetrics section above.  Teaching conferences are also described in the Normal Ob Section.  In addition, residents on the Obstetric service are invited to participate in the monthly MFM-Neonatology Fellows conference where complicated maternal-fetal cases are presented and discussed with MFM and Neonatology faculty.  Invited faculty from other specialty services (pediatric cardiology, pediatric surgery, etc.) also participate in these conferences for the benefit of the fellows and residents. 

The attending physician, who is physically present during each clinic, reviews all charts in the Complications Clinic.  Patient encounters provide unique opportunities for learning and direct interaction with the attending physician. Online evidence based guidelines have been developed and are updated frequently by the MFM Division for management of common problems permitting independent self-study opportunities for the residents (OBCC Clinic Practice Guidelines).  Computers with internet access are readily available in clinic and in the hospital for access to these guidelines and for documentation in the electronic health record. 

All residents are educated in the evaluation of patients and fetuses either with or at risk for genetic disorders. Under direct supervision of the Maternal-Fetal Medicine faculty, residents are provided with the opportunity to observe and participate in genetic counseling, ultrasound evaluation for congenital anomalies, genetic amniocentesis, and the care of pregnant women with genetic disease. Genetic counseling and prenatal diagnosis are carried out in partnership with the Department of Genetics. Patients are referred to our prenatal genetics clinic from care providers throughout the state for consultation regarding advanced maternal age, risk of aneuploidy based on screening tests, or personal/family history of genetic disease. During each session, the patient meets with a genetic counselor who obtains a detailed family history and constructs a pedigree. The residents are directly involved in this interview process. Following this, if indicated, the patient has a targeted ultrasound and amniocentesis performed by one of the MFM faculty. The resident is directly involved in this entire process. In our prenatal ultrasound clinics, patients are referred for evaluation of abnormal ultrasound findings. Each of these clinics is staffed by both a senior ultrasound technician and an MFM faculty with special expertise in prenatal ultrasound and diagnosis. During each session in this clinic, the patient receives a targeted ultrasound as well as extensive counseling regarding the diagnosis, prognosis, and management options.  

As part of our formal Ultrasound Curriculum, residents participate in these clinics as observers. However, in our OB Complications Clinic, similar services are provided for local patients and the resident has the opportunity to perform these procedures under direct faculty supervision in that setting. During the third year of residency, the resident spends ½ day per week during a 7-8 week rotation attending either the prenatal ultrasound or genetics clinic. As discussed in the ultrasound section, as part of the ultrasound curriculum, residents receive both didactic as well as hands-on training using a simulator for the performance of amniocentesis. The resident also has the opportunity to attend clinics focused on the provision of first trimester screening for fetal aneuploidy. Residents observe the performance of nuchal translucency assessment and the counseling involved in discussing screening versus diagnostic testing. The volume of patients in all of the above clinics is plentiful, so there is a wide array of diagnoses seen.  

In addition to these clinics structured toward obstetric genetic issues, the REI and Oncology clinics also provide care for patients with hereditary disease. In the setting of these clinics residents are directly involved in the care provision and counseling for patients with family cancer syndromes, endocrinologic disorders, and other problems affecting fertility (e.g. translocation carriers, disorders amenable to pre-implantation genetic diagnosis).

Throughout the year, a number of lectures are given on genetics and genetic disorders. Topics include basic genetic principles, prenatal screening, preconception counseling, ethnic-based testing, and common anomalies/genetic disorders. In addition to the lectures, on the obstetric, as well as, the oncology and endocrine services, lectures addressing particular disorders and their relation to genetics (e.g. common cancer syndromes) are provided.  Furthermore, each patient with one of these disorders provides an opportunity to use case-based learning to reinforce the principles learned in the lecture setting. The ethics of genetic testing is a focus of lectures as well as journal club discussions.