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27 Teaching Maternal Health Care
289
• Implement Interprofessional Training: Integrate inter- professional training experiences into obstetrical rota­tions to leverage the expertise of nurses, midwives, obstetricians, and other healthcare professionals. Collaborative learning experiences promote teamwork, communication, and shared decision-making among healthcare providers while maximizing learning opportu­nities for residents in obstetrical care.
• Leverage Simulation Training: Develop simulation­based training programs focused on obstetrical emergen­cies, procedural skills, and clinical scenarios. Simulation training allows residents to practice managing obstetrical complications in a controlled environment, rene proce­dural skills, and enhance clinical decision-making under the guidance of experienced faculty or simulation educators.
• Explore Innovative Teaching Modalities: Embrace innovative teaching modalities such as online modules, virtual reality simulations, interactive case-based learn­ing, and ipped classroom approaches to supplement tra­ditional didactic instruction. These modalities offer exibility, accessibility, and opportunities for self­directed learning, particularly without sufcient obstetri­cal faculty.
• Promote Resident Autonomy and Graduated Responsibility: Gradually increase resident autonomy and responsibility in managing obstetrical patients under appropriate supervision and mentorship. Providing resi­dents with opportunities to lead prenatal visits, manage low-risk deliveries, and participate in collaborative decision- making processes fosters condence, indepen­dence, and readiness for clinical practice.
• Advocate for Institutional Support: Advocate for insti­tutional support and resources to address the shortage of obstetrical faculty within family medicine residency pro­grams. Collaborate with hospital administrators, depart­ment chairs, and academic leaders to prioritize obstetrical education, recruit additional faculty, secure funding for faculty development initiatives, and invest in infrastruc­ture to support resident training in obstetrics.
Addressing Residents Uninterested inObstetrical Medicine
Family medicine maternity care is a eld that many health­care providers are passionate about. However, it’s important to recognize that family medicine covers a wide range of areas, and not all learners will be interested in learning or practicing maternity care. It’s crucial to respect the views of our learners, even though residents trained under family medicine physicians who practice obstetrics are more likely
to include maternity care in their practice. It’s worth noting that there is a correlation between residents’ interests before their postgraduate training and their plans to include mater­nity care in their practice upon graduation. The majority of residents who are not interested in practicing maternity care usually do not change their minds by the time they graduate from residency.
Dierential Scheduling Based onResident Interest
Differential scheduling of obstetrical experiences based on residents’ interest in practicing maternity care can be a valu­able strategy for family medicine residency programs to optimize resident education and enhance workforce develop­ment in obstetrics. Tailoring maternity care rotations to align with residents’ career goals and interests not only promotes engagement and enthusiasm but also maximizes learning outcomes and retention of skills. Here’s how family medi­cine residency programs can implement this approach effectively:
• Early Identication of Interest: Encourage residents to express their interest in obstetrics early in their training. Conduct regular assessments, surveys, or one-on-one meetings to gauge residents’ career aspirations, prefer­ences, and level of interest in practicing obstetrics. Identifying residents with a genuine interest in maternity care allows programs to tailor their educational experi­ences accordingly and adjust rotation schedules as needed.
• Customized Rotation Experiences: Offer exible scheduling options and customized rotation experiences that cater to residents’ varying levels of interest and pro­ciency in obstetrics. Residents who are highly motivated to pursue maternity care as part of their future practice can be assigned to extended or intensive obstetrical rota­tions, allowing them to gain comprehensive exposure to prenatal care, labor management, deliveries, and postpar­tum care. Meanwhile, residents with less interest in maternity care can participate in shorter or more focused rotations that emphasize core competencies and basic skills in obstetrical care.
• Individualized Learning Plans: Develop individualized learning plans for residents based on their career goals, prior experience, and learning needs in obstetrics. Collaborate with faculty mentors and preceptors to tailor educational objectives, clinical experiences, and proce­dural training to align with each resident’s career inter­ests. Individualized learning plans may include elective rotations, advanced skills workshops, scholarly projects, or mentorship opportunities tailored to residents’ specic career goals.
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• Mentorship and Guidance: Provide mentorship and guidance from experienced obstetrical faculty to residents interested in practicing maternity care. Assign dedicated mentors or preceptors who can offer personalized sup­port, career counseling, and professional development opportunities to residents pursuing careers that include obstetrics. Mentorship relationships foster rapport, facili­tate skill development, and provide valuable insights into the realities of practicing obstetrics in various clinical settings.
• Regular Feedback and Assessment: Implement regular feedback mechanisms and assessment tools to monitor residents’ progress, performance, and satisfaction with maternity care rotations. Solicit feedback from residents regarding the quality, content, and structure of obstetrical experiences, and use their input to rene and improve educational offerings in obstetrics. Encourage residents to reect on their experiences, identify areas for growth, and set goals for further skill development in maternity care.
• Promotion of Work-Life Balance: Recognize the impor- tance of promoting work-life balance and wellness among residents pursuing careers that include obstetrics. Address potential challenges, stressors, and burnout risks associ­ated with obstetrical practice through initiatives such as exible scheduling, peer support networks, stress man­agement workshops, and access to mental health resources. Emphasize the importance of self-care, resil­ience, and holistic well-being for residents engaged in demanding maternity care rotations.
• Fellowship Opportunities in Maternity Care: In cir­cumstances where the volume of vaginal and operative deliveries does not support independent practice and/or advanced obstetrical knowledge is desired, family medi­cine residents may elect to pursue additional training through fellowship programs. Family Medicine residency programs should aim to identify residents interested in acquiring advanced obstetrical skills and training by way of fellowships as soon as possible. In this way, their time in residency can be tailored such that the resident will be competitive for their application. While fellowships in maternity care are not accredited by the ACGME, all have formal educational curricula and a select number are eli­gible for the Board of Certication in Family Medicine Obstetrics (BCFMO) should the trainee opt to complete the certication exam [5].
Training WithanObstetrics andGynecology Residency Program
Many have debated whether or not maternity care training for family medicine residents is enhanced or hindered by having an obstetrics and gynecology residency program
operating in the same hospital. Coordinating with the obstetrics and gynecology residency program director, coordinator, and administrative staff to align schedules and optimize resources can be helpful in health care settings with both family medicine and obstetric residency pro­grams. Shared didactic sessions, simulation labs, and inter­disciplinary case conferences can enhance the educational experience for both family medicine and obstetrics and gynecology residents. It is key, however, to establish clear communication channels to address any overlapping responsibilities or concerns regarding patient care between the family medicine and obstetrical departments. Facilitating collaboration with other healthcare profession­als involved in obstetrical care, including obstetricians, midwives, nurses, and social workers may provide rich interprofessional experiences. Such experiences foster a holistic understanding of maternal-fetal medicine and pro­mote effective teamwork.

Maternity Care Curricular Elements

The following sections of this chapter are intended to guide family medicine educators who may be designing a curricu­lum through the various components of maternity care in accordance with the requirements set forth by the ACGME (see Box 27.4). Rather than being a comprehensive review of current clinical recommendations for preconception and maternity care, this section highlights elements of screening, disease management, prenatal imaging, inpatient obstetrical care, and care during the fourth trimester of pregnancy that should be included in a curriculum. Social determinants of health and their impact on maternity care will also be high­lighted [1].
Box 27.4
Subsections b through f of section IV.B.1.b).(1).(a). (xii) of the 2024 ACGME requirements state that FM residents receive education and training for the provi­sion of low-risk prenatal care including diagnosing and managing pregnancy and its complications (i.e., ecto­pic pregnancy, pregnancy loss, and options education for unintended pregnancy) and caring for common pregnancy-related problems and comorbid conditions. These subsections further describe requirements for training on spontaneous vaginal delivery, obstetrical emergencies, and the provision of postpartum care, including screening for postpartum depression, breast­feeding support, and contraception.
27 Teaching Maternal Health Care
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Preconception Care

Preconception care, and the management of chronic health conditions, is a critical component of maternal health to opti­mize maternal and fetal outcomes. A curriculum in precon­ception care should foster resident knowledge of current clinical guidelines and best practices while also facilitating resident opportunity to utilize such knowledge in the clinical management of patients. Elements that a program may con­sider including in a curriculum could include:
• The role of multidisciplinary collaboration to optimally address and manage chronic health conditions [6].
• Elements of a comprehensive assessment, including a review of chronic conditions such as diabetes, hyperten­sion, thyroid disorders, and autoimmune diseases. Similarly, a review of immunizations may be critical to ensure that all vaccinations are up to date prior to preg­nancy [6, 7].
• How to conduct an appropriate and thorough medical review to minimize possible teratogenic effects of medi­cations [6].
• Optimal goals for blood glucose control for patients with pre-existing diabetes mellitus to reduce the risk of con­genital anomalies and maternal complications [6, 8].
• Optimal goals for blood pressure control and appropriate medication management for patients with hypertension [6].
• Current recommendations for folate supplementation to reduce risk of neural tube defects [9].
• Counseling and medication options to assist women to achieve a healthy weight before conception as obesity is associated with increased maternal and fetal risks [6].
• The role of genetic counseling for women with chronic conditions with a hereditary component [6].
• Counseling on lifestyle modications, including smoking cessation, alcohol avoidance, and maintaining a balanced diet, to optimize maternal health [6].
• How to appropriately screen for and address mental health concerns such as anxiety and depression that can adversely impact preconception and pregnancy outcomes [6].
• Establishing an appropriate follow-up schedule to moni­tor chronic conditions and continue to optimize during the preconception period [6].

Prenatal Care

Whether or not a resident intends to practice maternity care throughout their career, caring for patients during pregnancy provides the opportunity to help residents master communi­cation skills during what may prove to be challenging cir-
cumstances. For example, family physicians play a critical role in providing comprehensive options counseling for indi­viduals facing unintended pregnancies [10].
Family medicine residents should therefore be trained on discussing, in an open and non judgmental way, the available choices, including continuing the pregnancy, considering adoption, or terminating the pregnancy. By offering a patient­centered approach, family physicians empower individuals to make informed decisions about their reproductive health while respecting their autonomy and emotional well-being.
Acquiring skills in diagnosing and managing ectopic pregnancy and miscarriage is essential to ensuring the safety and well-being of patients [11]. However, providing empa­thetic care, emotional support, counseling, and follow-up care to help patients navigate the physical and emotional aspects of miscarriage or ectopic pregnancy is equally criti­cal to ensuring their holistic well-being of patients during this challenging time.
In addition to the communication and interpersonal skills that residents must master while caring for obstetric patients, the medical knowledge and patient care components of a maternity care curriculum should include discussions of screening, immunization, conditions which may complicate maternity care, breastfeeding, and the role of ultrasound.
Screening Studies inPregnancy
Family physicians should be familiar with the interpretation of necessary screening studies that identify conditions that may pose risk to the obstetric patient or developing fetus. A curriculum should discuss the rationale behind screening for the following conditions
• Alloimmunization: The risk of developing alloimmuniza-
tion for an RhD-negative pregnant individual carrying an
RhD-positive fetus is up to 2% in the setting of spontane-
ous abortion and up to 5% with dilation and curettage and
reduced by up to 90% with Rho (D) immune globulin
(RhoGam) [12].
• Anemia: Iron deciency anemia is associated with an
increased risk of preterm labor, fetal growth restriction,
and perinatal depression [13].
• Asymptomatic bacteriuria: All pregnant individuals
should be screened for bacteriuria between 12 and
16 weeks gestation with a urinalysis as asymptomatic
bacteriuria complicates up to 15% of pregnancies in the
United States of which 30% will progress to symptomatic
urinary tract infection if left untreated [14].
• Cervical cancer: Cervical cancer screening should occur
at recommended intervals based on the patient’s age, the
results of previous cervical cytology, and the presence of
high-risk human papillomavirus (HPV). Should the risk
292
Table 27.1 Testing recommendations and treatment of STIs during pregnancy [24, 25]
Infectious agent Testing Treatment Pregnancy-related risks Bacterial vaginosis Testing is only indicated in the symptomatic
patient
Chlamydia Universal screening Azithromycin,
Genital herpes Testing is only indicated in the presence of
lesions. Consider culture or polymerase chain reaction testing of lesions.
Gonorrhea Universal screening Ceftriaxone Chorioamnionitis, preterm birth, low
Hepatitis B Universal screening Active and passive
Hepatitis C Universal screening Treatment is not approved
Human immunodeciency virus Syphilis Universal screening with automated treponemal
Trichomonas Testing is only indicated in the symptomatic
Universal screening Antiretroviral therapy Vertical transmission
test (i.e., enzyme-linked, chemiluminescence, or multiplex ow immunoassay).
patient.
Metronidazole Preterm delivery, premature rupture of
membranes, acquisition of HIV, gonorrhea, and chlamydia.
Preterm birth, congenital eye erythromycin, amoxicillin, clindamycin Acyclovir or famciclovir prophylaxis starting at 36weeks’ gestation
immunization of the fetus
during pregnancy
Penicillin G benzathine Congenital syphilis
Metronidazole Preterm birth, premature rupture of
infections and pneumonia
Vertical transmission
For patients with active lesions or
prodromal symptoms at delivery,
Cesarean section is indicated.
birth weight, congenital eye infections
Vertical transmission
Vertical transmission
membranes, low birth weight
M. D. Hartman et al.
of cervical intraepithelial neoplasia grade 3 be greater than 4%, colposcopic examination is indicated and can safely be performed, without endocervical sampling, by the family physician during pregnancy [15].
• Group B Streptococcus (GBS): In the United States, GBS is the leading cause of infection in the rst 3months of life, and 25% of all pregnant individuals are GBS carriers [16]. Increased screening and treatment with intrapartum antibiotics decreases neonatal mortality [17].
• Inherited conditions and neural tube defects (NTDs): Screening for aneuploidy in early pregnancy is encour­aged, and individuals older than 35 years of age are at increased risk [18]. If a screening test is positive, chori­onic villous sampling (CVS) or amniocentesis should be recommended, which have similar rates of fetal loss [19]. Family physicians often play a pivotal role in educating patients about the benets and potential risks associated with CVS and amniocentesis, facilitating informed decision- making, and assisting in coordinating the proce­dure when indicated. Providing comprehensive informa­tion and emotional support during the decision-making process is essential in ensuring patients can make informed choices regarding these invasive genetic tests during prenatal care.
• Rubella: Pregnant women should be screened for rubella immunity during the rst prenatal visit, and if nonim­mune, offered vaccination postpartum to prevent congeni­tal rubella syndrome in subsequent pregnancies [20].
• Sexually transmitted infections: Sexually transmitted infections which can affect a fetus should also be screened for routinely during pregnancy and are summarized in Table27.1 [21].
• Thyroid disease: While evidence is lacking that universal screening for thyroid disorders improves pregnancy out­comes, thyroid-stimulating hormone (TSH) levels should be measured if there is a history of thyroid disease or dis­ease symptoms in pregnancy [22].
• Varicella: Maternal varicella can have signicant fetal effects and there is some evidence to support assessing the mother’s varicella history at the rst prenatal visit, with serologic testing for those with a negative history. Individuals who test negative for immunoglobulin G should avoid exposure to varicella during pregnancy and be offered vaccination postpartum [23].

Immunizations

Pregnant individuals should receive a diphtheria, tetanus, and pertussis (Tdap) vaccine as early as 27weeks’ gestation for antibody response and passive immunity to the fetus [26]. Tdap is recommended for each pregnancy [27]. Pregnant people are at increased risk of intensive care unit admission, preterm labor, stillbirth, and maternal death with either Inuenza or COVID-19 infection [28, 29]. Family medicine
27 Teaching Maternal Health Care
293
residency programs should incorporate the recommendation that people who are pregnant, as well as household contacts, become vaccinated against inuenza and COVID-19 [28,
29]. RSV vaccination in pregnancy is encouraged between
32 and 36weeks as passive immunity confers a protective benet to the infant through its rst 6 months of life [30] (Box 27.5).
Box 27.5
COVID-19 infection almost doubles the risk of devel­oping preeclampsia. For these patients consider initiat­ing low dose Aspirin (81mg) after 12weeks’ gestation as preeclampsia prophylaxis [31].

Common Conditions Which Complicate Pregnancy

A residency curriculum should ensure that residents are familiar with common conditions which may complicate pregnancy. For example, gestational diabetes (GDM) com­plicates up to 14% of pregnancies in the United States, 67% of which will develop type 2 diabetes mellitus (T2DM) in their lifetime, with racial/ethnic minorities being at highest risk [47, 48]. Residents should be familiar with screening for and management of pregnancies complicated by GDM. A robust maternity care curriculum also offers the opportunity to ensure that residents are well versed in how to manage women throughout their lives who present remote from preg­nancy with a history of GDM. Similarly, residents should learn how to diagnose and treat the common hypertensive disorders of pregnancy, which include chronic hypertension presenting before 20weeks gestational age and gestational hypertension and preeclampsia presenting after 20 weeks gestation. In addition to understanding the pathophysiology, screening and diagnosis of common complications of preg­nancy, residents should understand the indications for ante­natal testing in the third trimester to monitor the well-being of both the mother and the developing fetus during the later stages of pregnancy. It may include a variety of tests, such as non-stress tests, biophysical proles, or Doppler ultrasound assessments, depending on the clinical indication.

Breastfeeding

Setting aside time for breastfeeding education is recom­mended during the initial prenatal visit as a positive correla­tion exists between breastfeeding education and exclusive breastfeeding [12]. Simply providing a recommendation to
breastfeed has increased breastfeeding initiation and dura­tion rates [32]. Breastfeeding has been shown to reduce the risk of various health issues, such as childhood obesity, asthma, urinary tract infections, and sudden infant death syn­drome. In addition, it also has the added benets of decreas­ing the risk of obesity, ovarian and breast cancer, and cardiovascular disease. However, studies have shown that only half of family medicine physicians feel adequately trained in lactation medicine [12]. Programs with more grad­uates practicing prenatal and newborn care typically dedicate more time to breastfeeding education. As a result, their grad­uates feel more comfortable counseling patients regarding lactation medicine [12].
A lactation curriculum should include discussion about
the physiology of lactogenesis, how to help neonates with an appropriate latch, how to promote breastfeeding in a manner that increases a patient’s decision to nurse their newborn suc­cessfully, standard infant feeding patterns and joint problems such as low milk supply, engorgement, and mastitis. Additionally, being familiar with how culture and social determinants of health care can impact breastfeeding is also important. Residents may benet from a curriculum that includes didactic education as well as observed patient inter­actions to improve resident ability to assist patients with common challenges that may arise. A well-educated resident typically feels more comfortable approaching the subject with their patients [12, 13, 33].
Role ofUltrasound inMaternity Care
Obstetrical ultrasound can provide valuable information in maternity care. All family medicine residency programs should have time dedicated to the instruction of basic obstet­ric ultrasound. Programs may vary with respect to the com­plexity of ultrasound skills that residents are taught with some programs only teaching detection of fetal heart tones or assessment of fetal lie and others choosing to teach skills to allow for accurate pregnancy dating or the completion of an anatomy scan to detect fetal structural defects and placental anomalies. Still other programs may choose to complete bio­physical proles or assessment of amniotic uid index utiliz­ing ultrasound within the ambulatory clinic as both a patient service and an educational opportunity for resident physi­cians. An ultrasound curriculum should not replace teaching residents’ robust physical examination skills such as Leopold maneuvers. Having residents routinely assess fetal lie using Leopold maneuvers beginning at the 36th week of pregnancy allows residents to gain experiences gathering vital informa­tion about fetal presentation when ultrasound is not immedi­ately available [20]. Encouraging residents to do both Leopold maneuvers and ultrasound, when time permits, to
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assess fetal lie may provide real-time feedback to help improve both physical examination and imaging skills in learners.
A dedicated curriculum that includes both didactic and hands-on training with an experienced provider can prepare residents to utilize ultrasound effectively [34]. For many family medicine residency programs, maternity care pro­vides an opportunity to teach important ultrasound skills that may be transferrable to other point of care ultrasound applications.
Social Determinants ofMaternity Care
In keeping with the ACGME requirements, family medicine residents must understand the impact social determinants of health (SDoH) play on maternity care and the overall health of the mother-baby dyad [1]. This is further highlighted by the fact that 80% of the factors directly impacting the health of an individual are SDoH [35]. Healthy People 2030 identi­es access and quality of healthcare and education, social and community context, economic stability, neighborhood, and built environments as critical areas of SDoH.Access to quality prenatal care is foundational to achieving good peri­natal outcomes. Nearly two million of the ve million people born female in the United States of childbearing age live in maternity care deserts where obstetrical care facilities and providers are absent [36]. Additionally, the COVID-19 pan­demic amplied gender-based health disparities, with people born female being less likely than those born male to seek healthcare and experiencing increased stress related to social, nancial, and emotional stressors [37, 38].
As maternity care providers, family physicians play a critical role in helping to mitigate the burden SDoH plays on maternal and child health without compromising the overall quality of care received [3]. The United States has the highest number of pregnancy-related deaths in the developed world. Black maternal care disparities in the United States continue to worsen, highlighted by their three times higher risk of pregnancy- related death than their White counterparts [39].
once per trimester; validated tools include intervention ser­vices or a referral for positive screens is recommended [40,
42]. Family physicians should be aware of the signs of abuse
(e.g., frequent sexually transmitted infections, repeated requests for pregnancy tests when pregnancy is not desired, fear of asking a partner to use a condom), the effect of vio­lence on health, and the increased risk of child abuse after delivery [40].

Substance Use

Polysubstance use while pregnant increases the risk of fetal growth restriction, preterm delivery, stillbirth, fetal malfor­mations, and death [43]. The use of prescription opioid pain relievers complicates approximately 7% of pregnancies in the United States, 20% of which report misuse of those med­ications [44]. Opioid use in pregnancy rose by 131% from 2010 to 2017 in the United States, and the incidence of babies born with withdrawal symptoms in that time increased by 82% [45, 46]. Additionally, fetal alcohol exposure is the leading cause of preventable neurodevelopmental disorders in the United States, yet 14% of pregnant individuals report current drinking and 5% binge drinking in the past 30days [47, 48]. By screening and offering treatment for substance use during pregnancy, family physicians can have positive impacts on women, children and families. As such, including polysubstance screening and intervention techniques in a maternity care curriculum would be prudent.

Food Insecurity

Maternal food insecurity increases the risk of low birth weight and preterm birth, gestational diabetes, hypertension, post-partum depression, and some birth defects [49–52]. Universal screening for food insecurity has been recom­mended, and tools like the 2-Item individual Hunger Vital sign screening tool may be used [53, 54].
Depression andAnxiety

Intimate Partner Violence (IPV)

IPV during pregnancy increases the risk of spontaneous abortion, placental abruption, premature rupture of mem­branes, low birth weight, and prematurity [40]. IPV-related homicide is the leading cause of death in pregnancy in the United States [41]. The USPSTF recommends IPV screening for women of childbearing age at the initial prenatal visit and
One in 10 pregnant people in the US experience depression while pregnant, and this rate increases to 1in 5 for minori­tized pregnant people (54% of Latinas, 28% of Black women) [55]. People who are non-White, 24 years or younger, or 12years or less of education, lower socioeco­nomic status, or a history of intimate partner violence or sexual trauma are at higher risk [55–57]. Left untreated, depression can result in preeclampsia, preterm delivery, low
27 Teaching Maternal Health Care
Table 27.2 Screening for depression and anxiety-related disorders [55]
Condition Validated tool Sensitivity (%) Specicity (%) Anxiety Generalized Anxiety Scale-7 (GAD-7) 73 67
Bipolar disorder
Depression Edinburgh Postnatal Depression Scale (EPDS) 81 88
a
Screening for bipolar disorder should be done before initiating treatment for anxiety or depression
b
The PHQ-9 contains questions about anxiety and depression
a
State-Trait Anxiety Inventory 81 78 Composite International Diagnostic Interview 69–100 98–99 Mood Disorder Questionnaire (MDQ) 44–90 61–92
Patient Health Questionnaire-9 (PHQ-9)
b
88 88
295
birth weight, and maternal suicide [58, 59]. With a deep understanding of the biopsychosocial model and experience treating mental health concerns, family physicians are well prepared to have a positive impact on prenatal patients with concomitant depression and anxiety. Screening is recom­mended at least once during each trimester by the US Preventive Services Task Force (USPSTF), the American College of Obstetricians and Gynecologists, the American Psychiatric Association, and the American Academy of Pediatrics; see Table27.2 for validated tools that may be used [55].
Encouraging aHealthy Lifestyle
Family physicians are in a unique position to make a positive impact on the lifestyle considerations of individuals before, during, and after pregnancy, especially considering that almost 90% of individuals do not meet the recommendations for healthy nutrition and almost 30% are considered obese prior to conception [60]. The increased demands of preg­nancy and the number of healthy calories consumed starting in the second trimester are very important. For Individuals carrying one fetus, an extra 340 calories is encouraged; for those carrying twins, an extra 600 calories is encouraged [60]. The MyPlate food-planning guide, informed by the Dietary Guidelines for Americans 2020–2025, offers person­alized plans based on the individual’s pre-pregnancy BMI and level of physical activity [61]. Together with general dietary guidelines for pregnant individuals highlighted by Ramírez, 2023, the MyPlate food-planning guide can serve as a good tool for family physicians while counseling preg­nant individuals on healthy nutrition [20].

Inpatient Obstetrical Care

The inpatient maternity care unit provides an opportunity for residents to develop important skills in interpreting fetal telemetry and tocometry as well as procedural skills such
as placement of an intrauterine pressure catheter (IUPC) or perineal laceration repair. Each new intern comes from a different learning environment, which may lead to incon­sistent experiences in their preparation for postgraduate obstetric training. There can be gaps in their training, caus­ing some learners to feel uncomfortable providing obstetric care [62]. Early review of the stages of labor and appropri­ate interventions for emergency situations is key to promot­ing resident condence. Incorporating simulation training and case-based learning to supplement clinical experiences as well as emphasize the importance of interdisciplinary collaboration and consultation with obstetric specialists can help residents when managing both straight forward as well as more complex cases. Similarly, incorporating simu­lations into the resident curriculum early in training can help new residents feel more comfortable with examination skills, which could cause patients discomfort, such as ster­ile cervical examinations [63]. Ensuring adequate supervi­sion and support for family medicine residents managing obstetrical patients is essential, particularly early in train­ing when residents may have variable condence and competence.
The American Academy of Family Physicians provides the Advanced Life Support in Obstetrics (ALSO) course, which helps learners acquire and demonstrate skills required during obstetrical emergencies [62]. Further, the ALSO course emphasizes how to handle emergencies as part of a medical team, a valuable skill for residents to apply across settings. A study that compared groups of residents who learned management of obstetric emergencies in a didactic setting versus those in the ALSO course showed improved clinical judgment, skills, and communication in the ALSO course group [62]. It is recommended that all family medi­cine residents take part in the Advanced Support in Obstetrics (ALSO) course, as it offers both theoretical and practical training in managing obstetric emergencies in a simulated environment. Residency course directors should consider adding this course to the standard orientation for residents in the family medicine department, as it could prove to be a valuable addition.
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The ALSO course provides learners with opportunities to practice hands-on clinical skills with models while instruc­tors offer individualized feedback to each student. Using models helps in forming the necessary hands-on skills used in practicing obstetrical medicine. Models and simulations need not be expensive to be effective. One residency pro­gram reported increased resident comfort and competency after completing a simulated cervical examination where the model was constructed from easy to obtain, everyday materi­als [63]. Likewise, using beef tongues, as demonstrated in an online video by the Lisa Society of Gynecologic Surgeons, as a model for perineal repairs allows residents to acquire frequently utilized suturing skills in an environment without concern for possible patient harm and a more lenient time frame than with a patient on labor and delivery [63, 64].
Dealing withDicult Situations
Providing maternity care can bring immense joy to residents as they witness the growth of a family and experience the satisfaction of a job well done. However, not every preg­nancy has a positive outcome, and fetal loss is a possible scenario. In such cases, it is essential for residents to be equipped to address the questions, concerns, and frustrations of the patients and their families in a professional and com­passionate manner [65]. Policies must be in place to support not only the patients and their families but also the resident and other members of the medical team who may be impacted by the experience. It is important to recognize that residents will also be affected by such experiences and should be con­sidered the second victim. Faculty should train residents to effectively communicate with patients and families dealing with poor outcomes [65]. Learning about a poor birth out­come or dealing with a serious maternal complication can come as a shock. Patients may need several meetings before they fully understand the scope of their clinical situation [65]. Residents should communicate with other members of the involved medical team. Reviewing the care plan with the nursing staff is especially useful as they are at the bedside and frequently receive patient queries [65].
Experiencing a poor outcome can be a traumatic experi­ence for any physician. During residency, dealing with such situations often involves struggling with guilt, fear of medical- legal actions, and isolation [65]. Physicians may also question their management of the case. In these situa­tions, it is important for physicians to receive support from both their colleagues and peers. Providing feedback should be done within 48 hours of incident and last for at least 10minutes [66]. Attendings should approach the learner in a supportive manner that helps the learner feel safe and begin the process of healthy closure [65].
Postpartum Care (aka TheFourth Trimester)
Family physicians have the unique opportunity to provide a connective role in the care for the birthing person and new­born in the postpartum period due to the ability to care for each member of the dyad individually and as a unit. The fourth trimester is another name used for this period as it continues the care beyond the initial three trimesters of the pregnancy. Postpartum care should be approached as a con­tinuum, bridging the immediate inpatient care to the outpa­tient clinical environment and through to a nal comprehensive postpartum visit after a 12-week postpartum period [67]. Key elements of a resident curriculum include hospital discharge planning, lactation support, contraception, and mental health screening in the postpartum period. The transition from pregnancy care to general adult or adolescent well care should be completed after 12weeks postpartum.

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