Obstetrics and Gynecology

Director: Sangeeta Jain MD Coordinator: Brandie Davis Overview: The Galveston Obstetrics and Gynecology clerkship consists of 1 week Labor and Delivery Days, 1 week of Labor and Delivery Nights, I week of Antepartum, 1 week of Post-partum 1 week of Gynecology, and 1 week of Out-patient clinic. However, the structure of the course is often changed in response to student feedback, so please refer to your syllabus for details! The obstetrics portion focuses on labor and delivery, antepartum, and postpartum aspects of patient care. The weeks that you spend in gynecology vary widely and can range from community clinics to gynecologic surgery. This clerkship is highly dependent on how much effort you put into it, as evaluations from residents and faculty make up a significant portion of your grade. The clerkship is generally VERY organized, which you will learn to appreciate as you go through other clerkships. Didactics: There are lectures one day per week, which are mandatory. You will be excused from all clinical duties on your didactic day. Apart from the lectures, you will have quizzes over certain topics in Ob-Gyn (refer to syllabus for schedule). The course textbook (Beckman) is an excellent study guide for these quizzes, but make sure you have the latest edition! Other helpful study resources are the online APGO quizzes, Blue Prints, First Aid and Case Files. You are allowed to wear casual clothes on didactic days. Small Groups: The small group sessions are where you will present your H&P and discuss your patient and treatment options. You will typically present a patient and learning issue in a Powerpoint presentation, but this varies with faculty. This is a good chance to impress a faculty member if you are looking for letters of recommendation. Otherwise, if is a good chance to improve your presentation skills. They are usually relaxed discussions, and the faculty usually keeps it short and sweet because of their busy schedule.

Hospital Tips: Obstetrics: During your postpartum and antepartum weeks, you are instructed to wear professional dress. During L&D, you will wear scrubs. There are scheduled C-sections as the beginning of each day and students should rotate going to the OR. Otherwise keep track of the patients on the L&D floor for progression. When scrubbing in for surgeries, the ob-gyns usually require the traditional scrubbing-in routine rather than the alcohol rub. Remember to keep your hands at or above the nipple line and not to touch your mask. There is now night call for L&D, which is not bad at all. It is usually pretty busy and goes by quickly if you stay involved. If it is slow, you have time to study for quizzes/shelf exam. The midwives are a lot of fun to work with, and will usually monitor your first delivery. Make friends with them, and your life will be much better! Antepartum and postpartum are constantly being changed due to student dissatisfaction, so please refer to the current syllabus. Gynecology: This portion of the course is spent in UHC, community clinics and in the OR. One student is required for each OR case; so split up the cases for the day with the students on your service. Send your preferences to Brandie early if you want a specific clinic or gynecologic surgery service.

Chapter 6

Obstetrics and Gynecology

De Concepto et generatione homminis, 1580.

Courtesy of the Blocker History of Medicine Collection, Moody Medical Library, UTMB, Galveston

Whats Inside:
Gynecology : Menstrual Bleeding Terms Hirsuitism Obstetrics: Prenatal Care OB History and Physical Labor and Delivery

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Gynecology Menstrual Bleeding Terms

Normal Menorrhagia Hypomenorrhea Polymenorrhea Oligomenorrhea Metrorrhagia Menometrorrhagia Frequency regular normal normal normal normal irregular irregular Amount/Duration <80ml/ 2-7d

/ /
normal normal normal

Cycle 21-35d normal

How to write Menstrual Index: age of menarche / frequency of menses (Q28d, Qmo., reg) / duration

Hirsuitism
Hirsuitism: male pattern terminal hairs on midline; may be physiologic Virilization: male pattern hair + muscle mass + clitorimegaly + temporal balding + deepening voice; pathologic Hypertrichosis: nonsexual hair DDx For Hirsuitism And Laboratory Confirmation Ovarian Tumor: testosterone; rapid onset Adrenal Tumor: dihydroepiandrosterone (DHEAS); rapid onset Congenital Adrenal Hyperplasia: 17OH progesterone; gradual onset Cushings syndrome: cortisol after dexamethasone suppression test Polycystic ovarian syndrome: LH/FSH >3, testosterone; gradual onset

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Obstetrics Prenatal Care

Naegeles Rule
1st day of LMP + 7 days 3 months = Due date

Trimesters
1ST: Conception-12 wks 2nd: 13-26 wks 3rd: 27-40 wks Prenatal Visits Q4 wks until 28 wks Q2 wks from 28-36 wks Q1 wk after 36 wks

Fundal Height By Weeks Of Gestation

12 Wks 16 Wks 20 Wks 20+Wks palpable @ symphysis pubis (SP) palpable midway between SP and umbilicus palpable at umbilicus fundal height in cm=gestational age in wks

Recommended Pregnancy Weight Gain

If mom is:
Underweight (<90% ideal body weight[IBW]) Average (90-135% IBW) Overweight (>135%IBW) 30-40lbs 25-30lbs 15-20lbs

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Prenatal Diagnostic Screening

10-12 wks 15-20 wks Chorionic villus sampling: genetic study Maternal serum AFP: AFP=neural tube/ventral wall defects or twins AFP=trisomy 21 Triple Marker Screen: Trisomy 21= AFP, estriol, -hCG Trisomy 18= AFP, estriol, -hCG Amniocentesis: genetic study Sonography: fetal anatomy screening (banana/lemon signspina bifida) 1-hr oral glucose tolerance test (OGTT): >140 mg/dl3-hr OGTT

>15 wks 18-20 wks 24-28 wks

Pregnancy Termination Terms

Abortion Preterm Term Post term <20 wks 20 to <37 wks 37 to <42 wks 42 +wks

Differential Diagnosis of First and Third Trimester Bleeding

Spontaneous abortion (all types) Ectopic pregnancy Gestational Trophoblastic Disease DDx for 1st Trimester Bleeding Painful Abruptio placenta Uterine rupture DDx for 3rd Trimester Bleeding Painless Placenta previa Vasa previa

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Hypertension in Pregnancy
Mild Preeclampsia: BP> 140/90 mmHg and < 160/110 mmHg Proteinuria=1-2+ dipstick or >300 mg/24hr BP> 160/110 mmHg or signs/symptoms or Proteinuria=3-4+ dipstick or >5 g/24hr Unexplained tonic-clonic seizures + mild/severe preeclampsia Pre-existing or diagnosed < 20 wks or Persisting > 6 wks postpartum Chronic HTN with BP/proteinuria in last half of pregnancy Isolated HTN w/o proteinuria in last half of pregnancy HTN + Hemolysis, Elevated LFTs, Low Platelets

Severe Preeclampsia:

Eclampsia: Uncomplicated chronic HTN: Chronic HTN with superimposed PIH: Gestational HTN: HELLP Syndrome:

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OB History & Physical

History:
CC: ROM/ UCs/ scheduled induction HPI: Age/Gravida/Para/Gestational age/LMP vs US/EDC/bloody
discharge(duration, consistency, #of pads)/ROM (time and color)/contractions (onset, frequency, duration)/fetal movement/Prenatal care/Pregnancy complications (UTI, ASCUS pap, STD)

PNL: CBC / Chem 7 / PT&PTT / UA / Blood Type / Rh (+/-) / HBsAg / HIV / RPR /
rubella immune / Glucola result / GBBS / GC / Chlamydia / pap smear

PMH: Diabetes/HTN/Lupus/etc. PSH: Meds: PNV, FeSO4 Allergies: NKDA OB/GYN Hx: Menarche / menses duration and length / OB hx (prior pregnancies
and complications) / h/o abnormal pap / h/o STDs

Social Hx: single, father of baby uninvolved, Denies T/E/D FH: Maternal grandfather with DM II

Physical Exam:
Vitals: Temperature, BP, P, RR, Oxygen Saturation General: Appearance Skin: Rashes/Bruising HEENT: PERRLA Chest: CTA bilaterally; +/ breast masses Cardiac: RRR, nl S1&S2, +/ M/R/G Abdomen: Soft, gravid, nontender, +BS, fundal height, Leopolds
maneuvers, fetal heart sounds, estimated fetal weight

Gyn: Genitalia (lesions, vesicles

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SVE: Cervix dilation, effacement, membranes (intact, ROM time), station,

presenting fetal part; Fluidsbloody show, +/- nitrazine, +/- ferning, meconium

FHT: Baseline rate, + accelerations/decelerations (early, variable, late), reactive Toco: frequency and regularity of UC U/S: fetal position (vertex, breech), AFI, placental location Extremities: edema Neurologic: DTRs

Assessment:
31 yo G2P1A0LC1 at 38 wks with uncomplicated IUP in active labor

Plan
1. Admit to L&DSROM without bloody show. Dilation 3 cm. Low risk pregnancy. 2. Obtain routine labs (T&S, RPR, CBC) 3. Expectant management; continue tocomonitor 4. FHT reassuring without signs of distress; continue to monitor 5. Anesthesia epidural at 5cm per pt request 6. NPO in case of emergent C section 7. Anticipate normal spontaneous vaginal delivery

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Labor and Delivery

Fetal Positions
A: Stations of the fetal head, B: Longitudinal and transverse lies, C: Types of breach presentations, D: Various positions of the fetal head in a vertex presentation, E: Types of cephalic presentation according to fetal head

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Three Stages Of Labor

1. First stage: (includes latent and active stages) a. Latent phase: from onset of contractions to 3-4 cm dilation b. Active phase: from 3-4 cm dilation to 10 cm dilation 2. Second stage: From 10 cm dilation to delivery of fetus 3. Third stage: From delivery of fetus to delivery of placenta

Bishop Scores
5 Components of Cervical Examination Dilation Effacement Station Cervix Position

0
Closed 0-30% -3 Posterior

1
1-2cm 40-50% -2 Middle

2
3-4cm 60-70% -1 Anterior

3
5+ 80+% +1/+2

Seven Cardinal Movements of Labor

1. 2. 3. 4. 5. 6. 7. Engagement-fetal head below pelvic inlet Descent-downward movement of fetus through birth canal (BC) Flexion-movement of fetal chin toward chest Internal rotation-fetal head rotates in BC from transverseAP Extension-movement of fetal chin away from thorax (head delivers) External rotation-fetal head rotates outside BC from APtransverse Expulsion-fetus completely emerges from BC

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Deceleration Patterns of Fetal Heart Rate

Early-start with uterine contractions Variable-variable shape Late-gradual FHR after contraction Indicate head compression Indicate umbilical cord compression Indicate uteroplacental insufficiency Benign Benign or ominous Ominous

Ob/Gyn Definition of Fever

Elevated body temperature: Temp >38.0C within 24 hours of delivery/surgery or as an isolated temperature reading taken @ least 24hrs post-op. Fever: Temp >38.0C on two temperature readings taken @ least 6 hrs apart & @ least 24 hrs post-op.

Causes of Postpartum Fever

Postpartum Day # 0 1-2 2-3 4-5 5-6 7-21 Cause Atelectasis UTI Endometritis Infection Septic pelvic thrombophlebitis Mastitis Mnemonic Wind Water Womb Wound Walking

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OB Skeleton Note (Progress Note)

Date Time JMS Note-Blue team

S:
Pre H&H Post H&H Blood Type RI/RS HIV status HBsAg status

F/C/N/V/D, ambulation, appetite, tolerating po, complaints, concerns, +/- flatus. VS-TmTcBPPUOP(urine output)-cc/hr, voiding without difficulty, BRP, foley PE-Gen- A&O x 4, NAD CV-RRR, nl S1 & S2 Pulm-CTA bilaterally Abd-S/NT/ND, BS x 4 Inc(if C-section)-clean, dry, intact (C/D/I), serosanguinous drainage, no erythema/induration Fundus-firm/soft at umbilicus Ext-no clubbing, cyanosis, or edema (C/C/E), 2+ pulses of all extremities

O:

A/P:28

yo G_P_ post operative day (POD)# or post partum day (PPD)# s/p 1 LTCS or RC/S or NSVD & BTL (if csection Indicate type(LT vs vertical incision)and why-FTP, FIOL) 1. Pt hemodynamically stable with post H&H of

2. Can D/C NSVD 24 hrs after delivery if baby ready & no probs 3. All problems in subjective/objective part of note must be addressed 4. C-sections generally stick around for 3 days. If LTCS then write for order to D/C staples on 3rd postop day; if vertical incision, then write that pt is being D/Cd with staple removal kit and is to F/U in Clinic (Pasadena, Pearland,etc.) on POD#7 for staple removal (the nurses will make the appt.) 5. Pt will/will not be breast feeding and desires as Contraception (OCP, Depo, condoms, BTL), & with follow up at clinic.

*make sure you ask all questions necessary to do above assessment/plan

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Helpful hints (from residents):

If post partum tox pt, please write BP range and accurate UOP Post H/H on PPD#1 isnt drawn until day #1 in a.m. so you wont find it in the computer Have all skeleton notes for OBA/OBB pts done by 0600 everyday (so come early enough to have this done) When removing staples, place steri strips vertically only, NOT transversely directly across incision (check w/ resident before removing vertical incision staples!) Put pre & post H&H on purple border sheet ASAP; the PE portion of this sheet will need to be filled out (by you) prior to D/C D/C paperwork: yellow border sheet, purple border sheet PE, birth certificate

Abbreviations:
ACD ........................... advanced cervical dilation AFI .............................. amniotic fluid index ASCUS ....................... atypical squamous cells of undetermined significance BRP ............................. bathroom privileges BSO/RSO/LSO........... Bilateral Salpingoophrectomy/ Right/Left BME ............................ bimanual exam BTL ............................. bilateral tubal ligation CPP ............................. chronic pelvic pain EDC ............................ expected date of confinement EMS ............................ endometrial stripe FIOL ........................... fetal intolerance of labor FHT ............................ fetal heart tracing FTP ............................. failure to progress GBBS .......................... group B hemolytic strep GC............................... gonococcus H/H............................. hemoglobin/hematocrit HSG ............................ hystosalpingogram IPI ............................... inpatient induction IUGR .......................... intrauterine growth restriction IUP.............................. intrauterine pregnancy LAVH......................... laparoscopic assisted vaginal exam LOF............................. leakage of fluid LTCS........................... low transverse cesarean section

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MFM........................... Maternal Fetal Medicine (high risk obstetrics specialty) NFEG ......................... normal female external genitalia NSVD ......................... normal spontaneous vaginal delivery OCA ........................... oral contraceptive agent OPI.............................. outpatient induction PIH ............................. pregnancy induced HTN preeclampsia & eclampsia PNL ............................ prenatal labs PTL ............................. preterm labor RI/RNI........................ Rubella immune/Rubella nonimmune RC/S............................ repeat cesarean section RVE ............................ rectovaginal exam ROM ........................... rupture of membranes S/AROM .................... spontaneous/artificial rupture of membranes SHG ............................ sonohystogram SSE .............................. sterile speculum exam SVE ............................. sterile vaginal exam T&S............................. type and screen TAH............................ total abdominal hysterectomy T/E/D .......................... tobacco/ETOH/drug use TOA............................ tubo ovarian abscess TSVD .......................... Term Spontaneous Vaginal Delivery TVH............................ total vaginal hysterectomy UC .............................. uterine contractions USG ............................ Ultrasonography VB ............................... vaginal bleeding WBD ........................... weeks by date WBD/U ...................... weeks by date consistent w/ ultrasound WBU ........................... weeks by ultrasound WWE .......................... well woman exam

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Obstetrics and Gynecology

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