Friday, April 15, 2005

Guidelines for OB report etc.

Obstetrics and Gynecology is a clerkship in a class all its own. You are usually caring for young, healthy patients, have a fair amount of responsibility, get to do procedures on your own, do deliveries, and participate in some surgery. In addition, in this clerkship you'll rarely have trouble making a diagnosis. Patients usually present appearing pregnant, feeling pregnant, and smelling pregnant. Yep, you got it - they are pregnant.

As in most other clerkships, you'll start of with an orientation: "Welcome to OB-GYN. In this clerkship you are graded on technical skill as well as knowledge. Therefore, when you are delivering babies, you are not to drop them." You'll also get a brief demonstration on scrubbing and sterile gown and glove techniques. While this works well in theory, you'll soon discover that occasionally from the time the mother is transferred into the delivery room to the time you have to be in position to catch the baby, there are often only a few seconds - not much time for perfect sterile technique. If, as you are racing to the delivery room, you should happen to spill a glass of water and get your fingertips wet, you will probably be considered sufficiently "scrubbed." Almost without exception, though,, there IS time to wear a gown, gloves, and mask with a fluid shield. Plan for this each time you are part of a delivery and it will become second nature. This is a part of OSHA (Occupational Safety and Health Administration) regulations that have been mandated for your safety Don't take unnecessary risks - it isn't worth it!

Some general advice for OB

Tips: Get to know the nurses working during your shifts. They are typically your lifeline to deliveries and a fantastic resource. Let them know that you would like to do the cervical checks, but remember not to check a pt after SROM without asking your intern or resident. Be sure to give the nurses your pager #. If they like you, you will be called when things start moving, if not... NOT.

Carry a standardized copy of each type of note . Since many of the cases in OB are relatively routine, the write ups are fairly standard - this includes admission notes, delivery notes, postpartum notes, and discharge papers. The residents will be impressed with you if you do this. See the attached Copy Me! pages or use the format used by the residents in your rotation.

As in surgery, practice your knot tying. OB-GYN's tend to be less forgiving when a student asks to do some suturing and hasn't at least practiced tying knots. If you don't know how yet, ask! The residents will be happy to show you how. The one-handed tie is used more often in OB relative to the surgery rotation.



University Medical Center Students divide themselves into 3 groups, in which they spend 3 weeks on OB and 1 _ on GYN and 1 _ on GYN-ONC. Call is approximately every fourth night depending on the number of students on the rotation. Hours are approximately 6:3OAM-6:30 PM on both services. On OB, you are in clinic every morning and on Tuesday through Friday afternoons (Tuesday and Thursday afternoons are spent at the St. Elizabeth Clinic-Bring a Spanish/English dictionary if you are not bilingual). Basically, you will spend all day in OB Clinic, unless you are on call, then you are "on the deck" admitting patients and catching babies. Don't check cervix without intern being present. On GYN, students are in clinic in the afternoons, with the rest of the time for surgery, rounds, and studying. Generally speaking, at UMC you'll see a lot of high-risk patients on OB. Don't expect as much direct involvement in surgery as you had, or will have, in general surgery. You will learn more by showing interest. You will get less deliveries than in Phoenix but if you pay attention, you will get to do a lot. On GYN-ONC you pre-round, round with residents, scrub for the surgeries and do clinic (pre-op, follow-up, oncology).

The residents/interns are for the most part very good and really enjoy teaching. The main complaint at UMC is there are fewer deliveries than other sites, but most students get to do 2 to 8 on their own. Be assertive! UMC usually affords students more GYN experience than the other sites, so students usually become proficient at the pelvic exam. It doesn't hurt to ask the Thomas-Davis and Cigna attendings if you can assist if things are slow. Many times they will let you do the delivery if their patient doesn't mind.


Maricopa Medical Center- While doing OB-GYN at Maricopa, you may be confused for the entire 6 weeks, but when it's over, you'll realize you have a great deal of confidence when it comes to examining women and delivering babies. This place is a baby factory! You will have the opportunity to deliver many babies on your own, repair several episiotomies, and assist on all kinds of GYN surgery. The best piece of advice we can give is to be assertive (can you see a theme developing?) - they really do believe in "see one, do one, teach one." Also, don't, whatever you do, cross the nurses. They have the power to make or break the rotation. At Maricopa you'll work hard. Twelve hour days are the norm. Call is every 3rd to 5th night for 8 calls in six weeks. You can count on going without sleep, but the post call team tries to go home by noon. You may want to review clinical GYN in your "spare time." Be aware that the long hours leave minimal time for studying. In addition, those of you wishing to work with a Spanish-speaking population will have a terrific opportunity to do so at MMC. All in all, Maricopa is a great place to learn "hands-on" OB-GYN. The experience, confidence, and skill you'll gain are well worth it. It your goal is to deliver lots of babies... this is the place. Dr. Glen Kishi is a very enthusiastic teacher and a valuable resource.

St. Joseph's Hospital and Medical Center - As the residencies are combined, the MMC and St. Joe's experiences are similar, although it tends to be a little less hectic here "on the deck." The main difference is the droves of private attendings that care for patients. Many of them will be more than willing to let you catch their patient's kids. Others are less receptive. Again, be assertive. The worst that can happen is that they'll say NO! Call is the same as at Maricopa but students make their own schedule. The clinic experiences are much more limited at St. Joe's that at the other Phoenix sites. There is however, plenty of opportunity for GYN surgery.

Good Samaritan Regional Medical Center- GSRMC is a regular baby factory. It's not unusual for a student to deliver 10-20 babies in 6 weeks. The rotation is split between L&D, GYN, Clinic and subspecialty. Call is every fourth to fifth night, and you must do 8 nights with a couple of weekend days. Students make their own call schedule here, as well. Call nights take place in L&D and are extremely valuable. This is when you'll catch most of your babies and assist in C-sections. Some students have commented that it is easy for a student to be "ignored" when on L&D and on-call, because there is so much going on. The nurses here are great about waking you up to check on patients - but you have to ask! Assertiveness is important. Tip - check the triage board (there are TV monitors to do this with) and anticipate when a normal patient is coming up to L&D, then SNAG IT! It might pay to follow the second-year resident around as well. For some reason this is not encouraged, but this is where you'll work the ER, do some cross-cover and maybe watch some high risk OB. You will meet with your personal preceptor once a week. You will attend lectures (which are excellent) and conferences with the residents almost every afternoon. The evaluations of the students are often short and generic. An honors grade is difficult, but possible. GSRMC has a lot going for it - the residents are friendly, the teaching is outstanding, and the food is plentiful. Just be ASSERTIVE!!!

OB Exam

The final is an NBME exam which is challenging, but passable. Get in as much studying as you can, using lecture notes, handouts, and the books you may have. You may actually get the day off before this exam. The department is changing the required text for the rotation and will likely have it to borrow as they did with this year's book.

Pearl Books OB-GYN
Obstetrical Pearls, A practical Guide for the Efficient Resident
(Benson). ESSENTIAL. READ THIS BOOK BEFORE YOU START THE ROTATION. The hours it takes to read it will be invaluable!! Borrow or buy it. An excellent practical guide to being on the OB-GYN rotation.
PRE-TEST - Obstetrics and Gynecology Great overview of OB-GYN. Helpful for the NBME exam.
NMS and Board Review Series were also helpful for exam preparation and NMS can be borrowed from the OB office.

Copy Me!

OB/GYN history and physical

H&P for Labor and Delivery, actual format

ID/HPI: Patient is a 24 yo. G2PlOOl African-American female with an EDC of 07/05/93 by U/S (07/06/93 by L.M.R) Gestational Age is 39 3/7 weeks. Patient presents with uncomfortable contractions since 06/30/93 at q 10 minutes. Patient presented to triage today with painful contractions (ctx's) q 4'. Patient denies any SROM (spontaneous rupture of membranes), bloody show h/a (headache), epigastric pain, edema, visual changes, N/V/ F/C. Patient intends to bottle (vs. breast) feed. Pediatrician is Dr. Moreno. (Optional: Birth control method used during conception, pregnancy was planned/unplanned) (You may add a paragraph here describing any significant complications during the pregnancy)

Prenatal Hx: First prenatal visit on 01/05/93 at 16 weeks gestation. Patient received prenatal care at the office of Dr. Mary King. Ultrasound was performed at 18 and 24 weeks and demonstrated a singleton fetus without abnormalities. Patient was diagnosed with a yeast infection which resolved with administration of Metronidazole ointment on 3/23/93.
Labs: Blood Type A pos, H&H 14.3/41.9 on 5/25/93.
Antibody screen neg., G.C. neg, RPR non-reactive,
Chlamydia neg., Rubella reactive, Pap smear negative,
HBsAg neg., Glucola 89, serum AFP not performed.
Amniocentesis not performed.
OB Hx:
(1) 1990 - S.V.D. of an 8# 4.5 oz. male at 40 weeks gestation, without
complications. Midline episiotomy performed.
(2) Current
GYN Hx: No history of abnormal Pap smears. Denies any history of STD's (you will want to specifically ask patient if she's had chlamydia, syphilis, gonorrhea, HPV, trichamonas or exposure to HIV)

PMH : Denies Asthma, DM, HTN, Immunological deficiencies, Cancer
Allergies: NKDA
Meds: PNV (Prenatal vitamins) with Fe 325 mg QD
Past Surgical Hx: Appendectomy, 1988, St. Joseph's
Hospital, Phoenix, Arizona
Fam Hx: Maternal grandmother with Breast Cancer, otherwise no significant family history. Denies fam Hx of DM, Immunological deficiency HTN, CHD, twins, mental illness, stillborns, or congenital or chromosomal anomalies.
Soc Hx: Denies TOB, Denies ETOH, 1 cup coffee QD. Patient is married x 3 years. At Maricopa always ask about hx of sexual abuse. Drugs.
ROS: Denies chest pain, visual changes, HA, edema, N/ V/F/C, calf pain, back pain.

PE: A WDWN African-American Female with apparent discomfort during contractions.
BP 11 6/71 HR 77
HEENT No thyromegaly
Breasts: Not engorged
Lungs: CTA Bilateral
Heart: Sl and S2 normal, without murmur, gallop, or rub
FHt 38 cm. Leopold's with vertex position. FHT's 150's and reactive.
Ctx's q 4-5 min.
VE: 6/80%/O (that's 6 cm dilated, 80% effaced, 0 station - always ask a
resident or nurse to check after you)
Ext: No edema, calf tenderness. DTR's 2/4 bilat patellar (Don't forget DTR's!),
no clonus.

A/P: TIUP 39 3/7 weeks with ctx's x 1 day and no SROM.
(1) Admit to L&D with monitoring
(2) Expectant managemnt ( you'll write this ALOT)
(3) Consider artificial rupture of membranes (this is not
always indicated)
(4) Discussed with Dr. Montis

Prenatal H&P - Initial visit

This H&P is similar to the one above, with the exception that you won't be as rushed as you are in Labor and Delivery. The HPI is essentially the same - you may want to ask the patient about things like low back pain and constipation (iron in prenatal vitamins is a major culprit), visual changes, vaginal discharge, and head aches. In the Gyn history, ask about age at menarche, information about menstrual periods (length, regularity or lack thereof, days of heavy/light flow). You will also want a more complete sexual history, including number of partners, whether they are "men, women, or both" and STD's. One way to elicit accurate information about STD's is to ask, "Have you ever had any bumps, rashes, sores, ulcers, etc......" Under Social History, get information about occupation. Your physical is much more complete, and the clinic may have a form for you to fill out. Make sure and find out the pregestational weight. You will be performing a pap and pelvic on the first visit. You will also want to perform a thorough breast exam, as many women receive their primary care at these visits. Remember DATING (of the pregnancy, that is) IS KEY! ALWAYS recalculate dates on every prenatal visit, even if gestational dates are listed in the chart!

Copy Me!

OB/GYN delivery Note
OB/GYN Post partum note

A controlled spontaneous vaginal delivery over an intact perineum (or midline episiotomy anesthetized with 5% lidocaine) of a viable male/female infant, weight 6 pounds 1 0 oz, apgars 9/9. Bulb suction on the perineum. Clear amniotic fluid. Spontaneous expulsion (or manual extraction) of an intact placenta with a 3VC (3 vessel cord make sure there are 3 vessels in the cord - a 2VC is associated with abnormalities 18% of the time). Cervix, vagina, and side walls inspected and intact with no tears appreciated.

Episiotomy repaired with 3-0 vicryl. EBL 300 cc. No other complications. Blood type is A pos. Rubella reactive. Delivered by Joseph Montes, M.D. and Mary Falls, MSIII.

NOTE: Certain residents/attendings prefer different formats. Refer to your OB/GYN orientation packet for different formats.

Post Partum Note

I.D.: [Age] [Race] Female G- P - - - - estimated gestational age-
This is a regular SOAP note, but you need to pay special attention to:
Level of uterine fundus (in relation to umbilicus)
Is the uterus firm (i.e., contracted down)?
Lochia (this is the postpartum bleeding) - quality and quant.
Episiotomy - intact? edematous?
LE edema/tenderness (for DVT's)- review Homan's sign.
Rubella status, Blood type (Does the mother need Rhogam?)
f/u care and discharge instructions (ask your resident)
Ask about contraceptio, breast/bottle feeding.


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