Ch6_ObGyn

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.

Obstetrics and Gynecology 51

Chapter 6

Obstetrics and

Gynecology

De Concepto et generatione homminis, 1580.

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

What’s Inside:

Gynecology :

Menstrual Bleeding Terms

Hirsuitism

Obstetrics:

Prenatal Care

OB History and Physical

Labor and Delivery


Frequency Amount/Duration Cycle regular <80ml/ 2-7d 21-35d

Gynecology

Menstrual Bleeding Terms

Normal

Menorrhagia normal ↑ / ↑ normal

Hypomenorrhea normal ↓ / ↓ ↓ Polymenorrhea normal normal ↓ Oligomenorrhea normal normal ↑ Metrorrhagia irregular normal ↓

Menometrorrhagia irregular ↑ / ↑ ↓

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

Cushing’s syndrome: ↑ cortisol after dexamethasone suppression test

Polycystic ovarian syndrome: LH/FSH >3, ↑ testosterone; gradual onset


Obstetrics

Prenatal Care

Naegele’s Rule

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

Trimesters

Prenatal Visits

1ST: Conception-12 wks Q4 wks until 28 wks

2nd: 13-26 wks Q2 wks from 28-36 wks

3rd: 27-40 wks Q1 wk after 36 wks

Fundal Height By Weeks Of Gestation

12 Wks palpable @ symphysis pubis (SP)

16 Wks palpable midway between SP and umbilicus

20 Wks palpable at umbilicus

20+Wks fundal height in cm=gestational age in wks

Recommended Pregnancy Weight Gain

If mom is:

Underweight (<90% ideal body weight[IBW]) 30-40lbs

Average (90-135% IBW) 25-30lbs

Overweight (>135%IBW) 15-20lbs


Prenatal Diagnostic Screening

10-12 wks Chorionic villus sampling: genetic study

15-20 wks Maternal serum AFP: ↑ AFP=neural tube/ventral wall defects or twins

↓ AFP=trisomy 21

Triple Marker Screen:

Trisomy 21=↓ AFP, ↓ estriol, ↑ β-hCG Trisomy 18=↓ AFP, ↓ estriol, ↓ β-hCG

>15 wks Amniocentesis: genetic study

18-20 wks Sonography: fetal anatomy screening (banana/lemon sign→spina bifida)

24-28 wks 1-hr oral glucose tolerance test (OGTT):

>140 mg/dl→3-hr OGTT

Pregnancy Termination Terms

Abortion <20 wks

Preterm 20 to <37 wks

Term 37 to <42 wks

Post term 42 +wks

Differential Diagnosis of First and Third Trimester Bleeding

DDx for 1st

Trimester Bleeding DDx for 3rd

Trimester Bleeding

Spontaneous abortion (all types)

Painful Painless

Ectopic pregnancy Abruptio placenta Placenta previa

Gestational

Trophoblastic Disease

Uterine rupture Vasa previa


Hypertension in Pregnancy

Mild Preeclampsia: BP> 140/90 mmHg and < 160/110 mmHg Proteinuria=1-2+ dipstick or

>300 mg/24hr

Severe Preeclampsia: BP> 160/110 mmHg or signs/symptoms or Proteinuria=3-4+ dipstick or

>5 g/24hr

Eclampsia: Unexplained tonic-clonic seizures +

mild/severe preeclampsia

Uncomplicated chronic HTN: Pre-existing or diagnosed < 20 wks or

Persisting > 6 wks postpartum

Chronic HTN with

superimposed PIH:

Chronic HTN with ↑ BP/proteinuria in last

half of pregnancy

Gestational HTN: Isolated HTN w/o proteinuria in last half of pregnancy

HELLP Syndrome: HTN + Hemolysis, Elevated LFTs, Low Platelets


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, Leopold’s

maneuvers, fetal heart sounds, estimated fetal weight

Gyn: Genitalia (lesions, vesicles


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

presenting fetal part; Fluids→bloody 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&D—SROM 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


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


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

0 1 2 3

Dilation Closed 1-2cm 3-4cm 5+

Effacement 0-30% 40-50% 60-70% 80+%

Station -3 -2 -1 +1/+2

Cervix Position Posterior Middle Anterior

Seven Cardinal Movements of Labor

1. Engagement-fetal head below pelvic inlet

2. Descent-downward movement of fetus through birth canal (BC)

3. Flexion-movement of fetal chin toward chest

4. Internal rotation-fetal head rotates in BC from transverse→AP

5. Extension-movement of fetal chin away from thorax (head delivers)

6. External rotation-fetal head rotates outside BC from AP→transverse

7. Expulsion-fetus completely emerges from BC


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 >38.0°C within 24 hours of delivery/surgery or as an isolated temperature reading taken @ least

24hrs post-op.

Fever: Temp >38.0°C on two temperature readings taken @ least 6 hrs apart & @ least 24 hrs post-op.

Causes of Postpartum Fever

Postpartum Day #

Cause Mnemonic

0 Atelectasis Wind

1-2 UTI Water

2-3 Endometritis Womb

4-5 Infection Wound

5-6 Septic pelvic thrombophlebitis Walking

7-21 Mastitis


OB Skeleton Note (Progress Note)

Date Time JMS Note-Blue team

S: F/C/N/V/D, ambulation, appetite, tolerating po,

complaints,

concerns, +/- flatus.

Pre H&H O: VS-Tm- Tc- BP- P-

Post H&H UOP(urine output)-cc/hr, voiding without difficulty,

BRP, foley

Blood Type PE-Gen- A&O x 4, NAD

RI/RS CV-RRR, nl S1 & S2

HIV status Pulm-CTA bilaterally

HBsAg status 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

A/P:28 yo G_P_ post operative day (POD)# or post

partum day

(PPD)# s/p 1º LTCS or RC/S or NSVD & BTL (if c-

section

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 post- op day; if vertical incision, then write that pt is being D/C’d 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


Helpful hints (from residents):

If post partum tox pt, please write BP range and accurate UOP

Post H/H on PPD#1 isn’t drawn until day #1 in a.m. so you won’t find it in the computer

Have all skeleton notes for OBA/OBB pt’s 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 β‐ 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


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

Ch6_ObGyn

Documents

Transcript of Ch6_ObGyn