OB/Gyn Pearls: A student guide

1. OB/Gyn Pearls: A student guide

2. 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

3. 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.

4. 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

5. 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

6. 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!

7. 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)

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

9. 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

10. 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 post-op note Short progress note, share Labor and Delivery: UNMC

11. 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

12. 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

13. 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: UNMC

14. 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

15. During the day: Check on antepartum pts throughout the day (F/U labs, US, etc.) Labor pts: checked q2-3hrs 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 Labor and Delivery: Methodist

16. 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

17. 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

18. 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

19. Benign Gyn Surg Monday, Tuesday, Thursday (wear scrubs) am hospital rounds, OR cases Wednesday (dress clothes) pre-op conference at 7am, 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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: G3 P1112 Ex: G3 P1012

27. Sample presentations OB 23 yo G1P0 PPD #1 from SVD at 39w1d. 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

28. Sample presentation OB (Methodist) 23 yo G2P0010 at 31w6d, 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

29. 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!

30. 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)

31. 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?

32. 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

33. Alphabet Soup GDMA1: gestational diabetes mellitus, diet controlled GDMA2: 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

34. 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

35. Words of Wisdom: Ultimately patient safety and care comes first Help me, Help You (Help us get our work done and we can help teach you more!) Become the Guru (Become the experts on new or outside of our scope to teach us) Know the basics of OBGYN Know what you don’t know and ask us to help teach that to you Master a few skills for our procedures (ultrasounds, suturing – express interest to learn) Pay it forward – help your students coming after you 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.