High yield resources and tips for your Ob/Gyn clerkship.

Youtube Playlist: http://bit.ly/pimped-ob

Books:

• Netters
• Obstetrics and Gynecology by Beckmann

Apps:

• Pimped App – Clinical questions to expect in the OR and on the wards
• Uptodate
• Epocrates
• GoodRx
• LactMed – medications safe in breastfeeding
• ASCCP: Cervical cancer screening
• CDC STI guidelines
• ACOG app/website
• OB Wheel or dating

Tips and Tricks:

• Be Proactive—talk to students who just finished the rotation about ways to be helpful and the day to day logistics.
• Expectations: Ask for them to be set at the beginning. Clarify as needed.
• Be Self-sufficient, but ask for help when appropriate
• Before leaving for the day, ask when you should come in to round, who to pre-round on and where to meet.
• Once or twice a week ask for feedback when everyone has a down moment.

Labor and Delivery:

1. Gs & Ps aka Gravity and Parity.
2. Primes, multips
3. Gestational age Preterm vs term

• The OB One-Liner: “This is a _ yr old G_ P_ @_ wks GA here for ____.”
  Ex: This is a 34yo G3P2002 @ 38wks3days GA here for contractions
• Triage: 4 essential questions to ask every pregnant woman in triage
  Contractions, leaking fluid, vaginal bleeding, fetal movement
• What is labor? Cervical change and contractions
• Evaluate for ROM: Pooling, nitrazine (pH), ferning.
• Vaginal bleeding—when do we care? 2nd or 3rd trimester worry about placenta: abruption, previa, vasa previa
• DFM: NSTs, BPPs, Kick counts

• Cardinal movements of labor: engagement, descent, flexion, internal rotation, extension, external rotation and expulsion
• Complete dilation, now station: Labor down vs push
• 2nd Stage of labor: Pushing
• Offer to help with maternal positioning—holding ankle/leg
• Delivery—downward traction on head, thumbs to nose, anterior shoulder, posterior shoulder, body. Skin to skin. Delayed cord clamping.
• 3rd stage placenta: Active management, Pitocin, gentle cord traction. 3 signs of placental detachment
• Bleeding: Atony, meds
• Lacerations: degree, repair
• Postpartum: Fundal tenderness, lochia, voiding, BMC.

Why?

Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation

In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective

Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout.

Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed.

Hysterotomy — lower uterine segment, lateral uterine vessels to avoid

Delivery baby — delay cord clamp, placenta

Likely lots of bleeding — same atony meds as vaginal delivery

Clean inside of uterus to remove all membranes etc.

Possibly exteriorize uterus to see better — depends on scaring

How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures.

Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis.

Clean up the abdomen–irrigation vs moist laps vs suction

Now to close:

Peritoneium — either way, close or not– no evidence either way
Muscle– don’t close, evidence that closing it can cause hematoma
Fascia–Close!

Closing Fascia:

Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric

Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection

Skin closure — stables, suture, absorbable stables

Hypertension in Pregnancy — One large spectrum

Mild range: 140/90
Severe range 160/110

CHTN → SIPE
gHTN → Pre-E

BP meds: Methyldopa, labetalol, hydralazine, nifedipine

Severe features:

1. BPs
2. Neurologic symptoms
3. Lab findings:

HELLP
Hemolysis, Elevated Liver (enzymes), Low Platelets

Eclampsia — Seizures

Review anatomy– you’ll be able to see well!
Pimped- Youtube Channel videos for laparoscopic anatomy

What case are you doing and why?
Review common indications, steps to procedure and potential risks/complications

Saying hi to the patient first
Being helpful setting up — yellowfins or stirrups for lithotomy
Scrubbing in — ask to grab your gown/gloves for the scrub, open carefully or get help if unsure

Abx: If entering uterus or vagina ie hyst
Prep: infection prevention with chloraprep or something
EtOH based, needs to evaporate before draping or risk fire!
Vaginal prep — betadine or chlorhexidine
Then everyone scrubs

Let resident/attending drape unless asked.
You may be asked to help with foley/manipulator
Uterine manipulators: Many sizes/shapes/types
Vagina is dirty– can’t go from vagina to abdomen

Abdomen:
Entry: Typically in umbilicus or just above. Can use Palmer’s Point if needed.
Direct visualization with Hassan
Visiport
Veres needle
Insufflate with CO2

Port placement: Typically middle ⅓ of distance between ASIS and umbilicus. Avoid obvious superficial vessels and inferior epigastric –watch from below

Common procedures:

• Dx LSC– endometriosis, adhesions
• Tubal ligation or bilateral salpingectomy
• Cystectomy
• BSO
• Hysterectomy

Closing ports: Close fascia on ports >5mm due to increased risk of hernia

Post-op checks: Many LSC cases are same-day, meaning patients go home
-Nausea/vomiting, eating/drinking, voiding, passing flatus, ambulating
-UOP, BPs,

What approach: Abdominal, laparoscopic, vaginal or combination
Taking or leaving the tubes and ovaries?
Tubes: What benefit do they provide? Risk?
Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off

If it’s laparoscopic–listen to the LSC podcast for more details on the approach

Let’s talk about important steps:

1. The round ligament: What artery runs inside the round? Sampson’s.
2. What structure conceals the blood flow to the ovary? The IP ligament (formerly the suspensory ligament of the ovary). The artery comes from the aorta, so if this is transected before it is fully sealed, it can hemorrhage while retracting back into the retroperitoneum. Badness!
3. What are the four levels at which the ureter is injured during hysterectomy? 1- At the pelvic brim, 2- medial to the IP ligament, 3- as it passes under the uterine artery (water under the bridge) and 4- lateral to the vaginal cuff closure.
4. Ligate and transect the uterine arteries–the uterus should blanch white.
5. Colpotomy– disconnecting uterus from vagina
6. Close vaginal cuff if total hyst

Resources:

https://www.bedsider.org/methods

Table:

http://www.womenscommunityclinic.org/wp-content/uploads/Bedsider-Birth-Control-Effectiveness-Poster.jpg

Spanish:

http://s3.amazonaws.com/providers/images/images/000/000/032/center/Spanish_tiers_of_effectiveness.png?1464661802