OBGyn Pearls A student guide Objectives General knowledge

OB/Gyn Pearls: A student guide

Objectives • General knowledge • What you can expect from the residents • What we expect from you • How to shine on each service • Transitions between services • Miscellaneous pearls and helpful hints • Alphabet soup

OBGYN • We love our specialty – we love if you want to incorporate OBGYN into your future practice but also understand if it’s not. That’s OK! – But… You can learn something from each rotation for your future practice.

General Pearls • Know why we’re doing what we’re doing – Meet the patient, learn her history, read about the disease process before surgery • In the OR – Get involved – learn how to position the patient, help move the patient, help clean up the patient, etc. – Be the first in the OR to help with setup and the last to gown • Take ownership of your patients – Watch for lab results, vitals, new information

General Pearls • Emails are sent out over the weekend prior and give updates for what cases are going on and for staff coverage – Use them to help look up patients and prepare for the week ahead – Check your system list on the day prior to the rotation to see if there are patients who need rounded on in the morning (GYN or GYN ONC) – Check out with the students from the previous week on Friday for GYN and GYN ONC

General Pearls • Please round on patients and have notes done at least 15 minutes prior to rounds – Send them to most senior level resident – This way we have time to look at them and give you suggestions for presenting – If you find something concerning, please notify the residents and don’t bring it up at rounds for the first time. Allow us to help you formulate a plan for the concern. • We want you to look good!

MD Interaction Room • Reserved for those on L&D • Students on other services should refrain from using this room (please use the student room UT 4243)

Labor and Delivery: UNMC • What to expect: – Rounds at 7 am (8 am on weekends) – Scheduled cesarean sections or IOL’s, labors – Postpartum tubal ligations – Outpatient triages (>20 weeks with OB complaints) – Circumcisions – Emergent situations • In general, the more available and involved a student is, the more you get to do

Labor and Delivery: UNMC • What we expect from you: – Round on the postpartum patients • Divide the patients with your classmates • Bring up any questions or concerns PRIOR to rounds – Present your patients at rounds • Speak up if you saw the patient • Practice before you present – Divide the laboring patients • Meet her with one of the residents or on own, learn her history, discuss plan with resident • Fill out a blue card afterwards (no abbreviations), have the second year resident approve card and help edit if you have questions

Labor and Delivery: UNMC • What we expect from you: – C-section patients • Meet the patient • Be ready to help • Be ready to tie suture, staple, and sew • Fill out a blue card • See the patient 4 hrs after surgery and write a postop note – Short progress note, share

Labor and Delivery: UNMC • Mag Notes – All patients on mag get notes at least three times per day: 0600, 1400, 2200 – Students should write the 1400 and 2200 notes • Short progress note, share – See example on gray card

Labor and Delivery: UNMC • If you feel like you are stuck in the interaction room: – Watch the monitors • You can figure out when someone is pushing, a new patient arrives, or a patient is having decels – Follow the intern on the floor – You can always ask one of us "Can I come with you? " • If you feel like you don't know what it going on with your patient, read through progress notes in the chart or ask a resident

Labor and Delivery: UNMC • Don’t: – Walk into a room when a patient you haven’t met is delivering – Write your notes late – Do an invasive exam on a patient without the resident present

Labor and Delivery: Methodist • Morning rounds at 8 am. – unless otherwise told by resident – SOAP notes on antepartum patients –done before rounds and sent to perinate resident – Round with MFM resident and staff • After rounds, get the list of laboring patients from the charge nurse – Coordinate with the OB resident (usually one student OR resident per delivery, unless MFM pt) – Meet the patients and nurses – Stay involved and visible (aka nurses station)

Labor and Delivery: Methodist • During the day: – Check on antepartum pts throughout the day (F/U labs, US, etc. ) – Labor pts: checked q 2 -3 hrs by nurses, keep up to date on how the pts are progressing • Be on the lookout for sections scheduled in the afternoon or that get added on – Assist resident with any new admissions

Gyn Onc • What to expect – OR cases for suspected or known cancer • Uterine, cervical, ovarian, vulvar, etc • Many patients will be receiving chemotherapy and/or radiation – Clinic

Gyn Onc • Daily: rounds in am and pm – Time, determined daily based on schedule – Throughout the day, read the nursing notes and notes from consulting services on your patient (VS, I/O tab) • Monday: Surgery with Remmenga (wear scrubs) • Tuesday: Surgery with Rodabaugh (wear scrubs) • Wed, Thurs, Fri: clinic (dress clothes) – See the return patients, check out with resident, then check out with attending – Go with the resident to see the new patients

Benign Gyn Surg • What to expect – OR cases for benign disease • Hysterectomies, ablations, D&C’s, etc – Inpatient consults throughout the day – ER consults throughout the day – Gyn Chief Clinic (Wed afternoons) – Clinic Add-ons

Benign Gyn Surg • Monday, Tuesday, Thursday (wear scrubs) – am hospital rounds, OR cases • Wednesday (dress clothes) – pre-op conference at 7 am, am rounds, am Chief clinic, pm Education • Friday (wear scrubs) – am rounds – Students present a 10 -15 min article topic, please bring grade sheet with you

OR Etiquette • Discuss amongst your fellow students who will scrub for each case • Ask scrub if you can drop your gloves and gown • Write your names on the white board in the OR • Scrub as long as the most senior person scrubs • Don’t grab anything from the mayo stand • Be prepared to retract, cut suture, and sew • If you want to suture, please let us know

General Knowledge: Scrubbing • Traditional Scrub (Five Minutes) – Wet hands/forearms – Clean nails using enclosed nail pick. – Scrub nails, fingers, hands, wrists, arms. – Important aspect is total contact time with soap – Rinse so that dirty water doesn't drip down to your fingers • Avagard is an acceptable alternative – Be sure Avagard dries before gloving – Directions on the bottle

Staff Clinics • What to expect – Variety of patients with OB or GYN concerns – Ask attending about how/when they want notes written – Get focused history and check fundal height and get heart tones on ROBs – Take focused history with NOB and GYN patients, wait on the exam until the physician gets there

What to Expect From Your Residents • Teaching – We will pass on the basics of OB/GYN with a focus on likely shelf questions – We will try to do informal teaching sessions through your rotation. If you’re interested in a specific topic, please let us know so we can cover it. • Maximize your educational opportunities – We will get you involved with high-yield cases • No busywork – Things we ask you to do are important for patient care • Address your concerns – If you are having concerns/questions, please let us know

How to be a successful student • Phrases for students: – What can I do to help? • Ask questions as they come up – It is easier to learn and remember a concept when you can associate it with a patient – Remember there is a proper time and place for questions if your resident is busy • Treat the rotation as a job interview – Put out your best effort and you will be rewarded with a better experience and a greater increase in knowledge

How to be a successful student • Communicate with your residents – Text, email for any non-immediate concerns – Page only if necessary • Don’t ask to go to sleep or be sent home – We realize the days are long – There’s always something you can learn

G’s & P’s • G: gravida (number of pregnancies) • P: para (number of deliveries) • A: abortus (number of abortions/ectopics) • G_TPAL – Gravida, term, preterm, abortus, living children • Ex: G 3 P 1112 • Ex: G 3 P 1012

Sample presentations • OB – 23 yo G 1 P 0 PPD #1 from SVD at 39 w 1 d. Pregnancy complicated by history of IUGR. She is doing well. Minimal lochia, breastfeeding, pain well controlled. • Only pertinent vitals, if normal, say WNL • Exam findings: Fundal height • A/P: repeat the above opening sentences. Comment on Rh and rubella status, method of feeding for infant, and method of birth control

Sample presentation • OB (Methodist) – 23 yo G 2 P 0010 at 31 w 6 d, admitted on 5/1 for PTL. Pregnancy complicated by history of cervical insufficiency with delivery at 18 weeks. Denies CTX/LOF/VB. Reports +FM. • PPROM: Denies abdominal pain, fevers/chills. • Preeclampsia: Denies HA/vision changes/SOB/CP/RUQ pain

Sample presentation • OB (Methodist) – Only pertinent vitals • If chorio, report afebrile • If preeclampsia, comment on what BPs are – FHT, toco – Physical exam: • Again, only pertinent findings – Make sure you know what abbreviations stand for. Don’t use them if you can’t tell us what they are!

Sample presentation • GYN ONC and GYN – 23 yo female, POD #1 TAH/BSO for Grade 1 endometrial cancer. Pain well controlled on PCA, tolerating po intake, foley in place, has not ambulated yet. • Vital signs WNL (do not say “stable”) • Full exam, look at incision(s) • Comment on I’s and O’s • Labs (pertinents only)

Sample presentations • GYN ONC and GYN – Repeat your initial statement for assessment of the patient – Plan: Postoperative goals, then list accordingly to other health issues they may have • If ONC patient, is their pathology back yet? Are there plans for chemo/radiation?

Alphabet Soup • CTX: contractions • LOF: loss of fluid • VB: vaginal bleeding • TAH: total abdominal hysterectomy • TVH: total vaginal hysterectomy • BSO: bilateral salpingoophrectomy • LAVH: laparoscopic assisted vaginal hysterectomy • LVH: laparoscopic vaginal hysterectomy • PTL: preterm labor • SROM: spontaneous rupture of membranes • PROM: premature rupture of membranes • PPROM: prolonged premature rupture of membranes

Alphabet Soup • GDMA 1: gestational diabetes mellitus, diet controlled • GDMA 2: gestational diabetes mellitus, controlled with meds • ROB: return ob visit • NOB: new ob visit • s/p: status post • h/o: history of • IOL: induction of labor • PNV: prenatal vitamin • TVT: transvaginal tape

Alphabet Soup • SVD: spontaneous rupture of membranes (sometimes NSVD: normal spontaneous vaginal delivery) • PLTCS: primary low transverse c-section • RLTCS: repeat low transverse c-cestion • PPTL: post partum tubal ligation • BTL: bilateral tubal ligation • LVAVD: low vacuum assisted vaginal delivery • OVAVD: outlet vacuum assisted vaginal delivery • LFAVD: low forceps assisted vaginal delivery • OFVAD: outlet forceps assited vaginal delivery

Words of Wisdom: 1. Ultimately patient safety and care comes first 2. Help me, Help You (Help us get our work done and we can help teach you more!) 3. Become the Guru (Become the experts on new or outside of our scope to teach us) 4. Know the basics of OBGYN 5. Know what you don’t know and ask us to help teach that to you 6. Master a few skills for our procedures (ultrasounds, suturing – express interest to learn) 7. Pay it forward – help your students coming after you 8. Be this person – be the kind of person you want to work with Remember… No matter how many hours you have to work, how many notes you have to write, how tired you are – there is someone who applied for medical school to be in your position who didn’t get in who is equally as smart and qualified. We are the lucky ones. Our job to care for other human beings in their most vulnerable state is an absolute privilege.