Procedure Ready: Ob/Gyn (fka Pimped Ob/Gyn‪)‬ Med Ready

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:

Gs & Ps aka Gravity and Parity.
Primes, multips
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:

BPs
Neurologic symptoms
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,