OB/GYNClerkshipOrientationGuide

WelcometoyourOB/GYNClerkship!Wereexcitedtohaveyouhere.Wethinkthisisthe
verybestspecialtyofallandwewanttoshareourloveofthisfieldwithyouduringyourtime
withus.Thispacketincludessomeinformationwethinkyouwillfindhelpfulonyourrotation,
includingabriefoverviewofourexpectationsofyouduringthisrotation,samplenotes,and
highlightsofclinicalinformationwithwhichweexpectyoutobecomefamiliar.Wesuggest
thatyouusecreateapacketofindexcardsthatyoucancarrywithyouonyourrotationfor
quickreference.

OB/GYNisanoftenunpredictablefieldofmedicine.Somedayswillbecrazyandothersslow.
Useyourdowntimewiselyforstudying.Youareexpectedtodoindependentreading
regardingthetopicsthatyouencounter.Ifyouneeddirection,wecansuggestareaswhere
youshouldfocus.Weareheretohelpyoulearn,butmuchofyourlearningwillcomefrom
yourinteractionswiththepatientsandfromyourobservationoftheteamastheymanagethe
patients.

Ifthereisanythingthatyoufeelwouldbeausefuladditiontothiscompilation,pleaseletus
know.Wehopeyoufindthesenoteshelpful.

GoodLuckandEnjoy!

NotesonNotes:
AllnotesshouldbetitledwithyourPOSITION,TYPEofnote,andyourSERVICEforeasyidentification.
AllnotesmustbeDATEDandTIMED.
AllnotesshouldbeSIGNED
Youarenotpermittedtousetemplates.

Obstetrics
L&D
Triage
Patientswhopresentfortriageshouldfirstbeevaluatedbythemedicalstudent.Beonthelookoutfornewpatients.Oncethe
nurseisfinishedcheckinginpatient,youmaygoseethem,gettheirhistory,andperformphysicalexam(exceptforpelvic).
Afteryouhaveseenthepatient,presentthemtotheresident(usuallythejuniorresidentontheservice).SeeattachedOB
TriageH&Pnote.Itishelpfultolookthroughthepatientsmedicalrecordpriortoseeingthem.Theirprenatalrecordcanbe
foundundertheepisodestabunderchartreview.Bewarethatthemethodofdatingontheseformsisoftennotcorrect.
Radiologyultrasoundscanbefoundunderradiology,butMFMultrasoundsarescannedinunderthemediatab.
LaborPatients
Youshoulddividethelaborpatientsamongthemedicalstudentspresent.Onlyonestudentshouldseeeachpatient.Labor
patientsshouldhaveprogressnoteswrittenevery4hoursinlatentlaborandevery2hoursinactivelabor.Youare
responsibleforhavingnoteswrittenonyourpatientswewillnotremindyou.Onceyournoteiswritten,pleaseletyour
residentsknowandonewillreviewitwithyouiftimepermits.
Deliveries
Youmayonlyattendadeliveryifyouhavemetthepatientpriortothebeginningofpushing.Youwillneedtopullglovesfor
yourself(andsometimesagown)toplaceonthedeliverytable.Theseareusuallylocatedinsidethecabinetofthedelivery
table(orabovethescrubsinkatGottlieb).Surgicalcaps,boots,andmasksarelocatedindrawersnexttothenursesstation(or
intheroomnexttotheORatGottlieb).GETDRESSEDFAST.Wecantwaitforyoutogetyourgloveson,soifyourenotready,
youregoingtomissit.Afterward,youcanhelpbytakingtheinstrumentsbacktothedirtyutilityroom.Astudentshouldalso
scrubforeverycesareansection.Again,makesuretomeetthepatientfirst.Youshouldwritethedeliverynoteafterward.The
residentwillsignit.
AntepartumPatients
Progressnotesshouldbewrittenevery4hours,includingreviewingthestrip,andifhospitalizationisforamaternalmedical
indication,aphysicalexam.
MagnesiumSulfateNotes
Notesshouldbewrittenevery4hours.Patientsonmagnesiumneedspecialmonitoringformagnesiumtoxicity,respiratory
depression,pulmonaryedema,renalfailure,neurologicirritation,worseningbloodpressure,orsignsoffetaldistress.Note
shouldincludes/sxofpreeclampsia,vitals(includingO2sats),UOP,physicalexamincludingreflexes,andrecentlabs.

Postpartum
Postpartumpatientswouldhaveprogressnoteeveryday.PatientswhodeliverbetweenMidnightand6amarenotroundedon
untilthenextday.

Antepartum
Thesepatientsusuallyincludewomenwithpretermprematureruptureofmembranes,pretermlabor,placentaprevia,pre
eclampsia,ormedicalcomplicationsoforduringpregnancy.Theyofferanopportunitytolearnaboutmoreindepthdisease
processesrelatedtopregnancy.Pleasetrytoseeantepartumpatientsinadditiontopostpartumpatients.However,understand
thattheprolongedhospitalizationofthesewomencanbeverystressful,sobesensitivetotheirneedsandrequests.Progressnote
shouldincludequestionsaboutfetalmovement,LOF,vaginalbleeding,s/sxofpreeclampsia,sxofDVTorPE.Vitalsshould
includefetalhearttones,whicharemeasuredeveryshift.Objectiveportionofnoteshouldincludegeneral,cardiac,pulmonary,
abdomen,extremitiesandanynewlaborultrasoundresults.

TheSignout
Thisisanelectronicdocumentthatwekeepwithinformationregardingallofthepatientsontheservice.Itisavitalaspectinour
communicationwitheachother.Yourresidentsmayaskyoutoassistwithkeepingthesignoutupdated.Whenyouseeanew
patient,theyshouldbeaddedtothelist.Justfollowtheformoftheotherpatientsonthelist.Boldmeanscurrentlypregnant.

LaborandDeliveryPearls:
ANTENATALTESTINGKNOWTHESEDEFINITIONS!!!!!
Definitions of Fetal Heart Rate Patterns
Pattern

Definition

Baseline

The mean FHR rounded to increments of 5 bpm during a 10 min segment

Must be for a minimum of 2 min in any 10-min segment

Baseline variability

Fluctuations in the FHR of two cycles per min or greater

Quantitated as the amplitude of peak-to-trough in beats per min
o Absentamplitude range undetectable
o Minimalamplitude range detectable but 5 bpm
o Moderate (normal)amplitude range 625 bpm
o Markedamplitude range > 25 bpm

Acceleration

Increase in the FHR from the most recently calculated baseline

Duration defined as the time from initial change in FHR from the baseline to the return to the baseline
32 weeks and beyond: acme of 15 bpm above baseline, duration of 15 sec but < 2 min
Before 32 weeks: 10 beats per min or more above baseline, duration 10 sec but < 2 min
Prolonged acceleration: 2 min but < 10 min
If an acceleration lasts 10 min or longer, it is a baseline change

Bradycardia

Baseline FHR < 110 bpm

Early deceleration

Associated with a uterine contraction, gradual (onset to nadir 30 sec or more) decrease with return to baseline
Nadir of the deceleration occurs at the SAME TIME as the peak of the contraction

Late deceleration

Associated with a uterine contraction, gradual (onset to nadir 30 sec or more) decrease with return to baseline
Onset, nadir, and recovery occur AFTER THE BEGINNING, PEAK, AND END of the contraction, respectively

Tachycardia

Baseline FHR > 160 beats per min

Variable
deceleration

Abrupt (onset to nadir less than 30 sec) decrease in the FHR below the baseline
The decrease in FHR is 15 bpm, with a duration of 15 sec but < 2 min

Prolonged
deceleration

Visually apparent decrease in the FHR below the baseline

Deceleration is 15 beats per min or more, lasting 2 min or more but less than 10 min from onset to return to
baseline

NonstressTest(NST)
- Reactive:2ormoreaccelerationsoccurin20minutes
- Nonreactive:noaccelerationsnotedover40minutes

ContractionStressTest:
o PitocinorNipplestimulationapplieduntil3contractions
in10minutes
o Positive(nonreassuring):latedecelerationsfollowing50
percentormoreofthecontractions
o Negative(reassuring):nolateorsignificantvariable
decelerations
o Equivocalsuspiciouspattern:intermittentlateor
significantvariabledecelerations
o Equivocalhyperstimulatory:decelerationswith
contractionsmorefrequentthanq2minutesorlasting>
90seconds.
o Unsatisfactorytest:tracingisuninterruptableor
contractionsarefewerthanthreein10minutes.

BiophysicalProfile:
o 2ptsforeachofthefollowingin30minuteperiod:
NST
fetalbreathing(>1episodeofbreathinglasting>
30sec)
fetalmovement(>3discretebodyorlimb
movements)
fetaltone(>1episodeofextensionofextremity
withreturntoflexionoropeningorclosingofhand)
AFI(singleverticalpocket>2cm)
o Interpretation
810Reassuring
6Equivocaldeliverifmature,ifnot,administer
steroidsandrepeatin24hrs
4orlessdeliverunlessextremelypreterm
o ModifiedBPPNST+AFI

LABOR
PhasesofLabor
First:Onsetoflabortocompletedilatation
Second:Completedilatationtodelivery
Third:Deliveryofinfanttodeliveryofplacenta

NormalLaborProgress:
Nulligravida
Prolonged Latent
> 20 hrs
Protraction
Arrest

Dilation
Descent
Dilation
Descent
With epidural

< 1.2 cm/hr

< 1 cm/hr
> 2 hrs
> 2 hrs
> 3 hrs

Multiparous
> 14 hrs

Therapy
Rest, pitocin

< 1.5 cm/hr

< 2 cm/hr
> 2 hrs
> 1 hrs
> 2 hrs

AROM, pitocin
Pitocin
AROM, pitocin, c-section
Vacuum, forceps, c-section

Nulligravida
Avg.
Limit (95%)
4.9 hrs
50 min
2hr (3 with epidural )
9 hrs
18.5

Active phase
2nd Stage
Total

FetalLieaxisofthefetus.Longitudinal,Transverse,or
Oblique.
Presentationthefetalpartatthecervix.Cephalic,breech,
shoulder
Attitudeflexedorextended
Positionnamedforocciput,sacrum,ormentuminrelation
tomaternalpelvis

LeopoldsManeuver
1. FeeltopofuterusIdentificationofthefetalpoleinthe
fundus
2. HandsoneithersideofuterusLocationofbackandsmall
parts
3. Loweruterinesegmentbetweenthumbandfirstfinger
determinesengagement
4. Fingerspointedtowardpatientsfeettodetermineposition

CardinalMovementsofLabor
1. Engagementbiparietaldiameterhaspassedpelvicinlet,0
station.
2. Descentoftenbeginswithengagementinmultips
3. Flexionfromresistantforcesofpelvicwalls,pelvicfloor,
etc.,bringsshorterAPdiameterintopelvis
4. Internalrotationfetusfacesmaternalspine
5. Extensionheadextendsunderpubicbone
6. Externalrotation/restitution
7. Expulsiondeliveryofbody

DiagnosisofMembraneRupture
1. Pooling
2. +NitrazinewithpH>6.5(darkblue).
- AmnioticfluidpH=7.07.5(normalvaginalpH3.54.5)
- False+withblood,semen,orBV
3. FerningduetoNaCl,proteins,andcarbs
4. AFI

Multiparous
Avg.
Limit (95 %)
3.2 hrs
20 min
1 hr (2 with epidural)
6 hrs
13.5
PerinealLacerations:
1. fourchette,perinealskin,andvaginalmucosa
2. involvesfasciaandmusclesofperinealbody
3. involvesanalsphincter
4. involvesrectalmucosa

EtiologyofPostPartumHemorrhage
1. Atony
2. RetainedPlacenta
3. Lacerations
4. Uterineinversion

MedicalAgentsforPostpartumHemorrhage
Oxytocin
Methergine(ErgonovineandMethylergonovine)CIinHTN
Hemabate(CarboprostProstaglandinF2a)CIinasthma
Cytotec(Misoprostol)1000mcgrectally

Friedmancurve:

INDUCTION OF LABOR
Bishop Score- To determine if cervical ripening is needed. Calculate this for all Inductions
Dilation
Effacement
Station
Consistency
Position
0
Closed
0-30
-3
Firm
Posterior
1
1-2
40-50
-2
Medium
Mid
2
3-4
60-70
-1
Soft
Anterior
3
5
> 80
+1, +2
Modified Bishop Score: Add one point for preeclampsia, and each prior vaginal delivery, Deduct one point for postdates, nulliparity,
preterm or prolonged PROM
0-4: 45-50% failure
5-9: 10% failure
10-13: 0% failure
> 8: Probability of vaginal delivery similar to spontaneous labor
Cervical Ripening Agents

Cervidil- (Prostaglandin E2/dinoprostone) One 10 mg Insert q 12 hrs, max 3 doses (Also available as Prepidil gel)

Cytotec- (Prostaglandin E1/Misoprostol) 25 mcg (1/4 of 100 mcg pill) vaginally q 4 hrs

Transcervical Catheter

Extra-amniotic saline infusion (EASI)

Hygroscopic dilators

Oxytocin
Hyperstimulation
Uterine Tetany: Single ctx > 2
Tachysystole: more than 5 ctx in 10 minutes or 7 ctx in 15 minutes
Correction of Tachysystole or uterine tetany with resulting FHR tracings:
o Decrease or discontinue uterine stimulant
o IV fluids
o Maternal repositioning
o Maternal oxygen
o Consider Terbutaline if persists
Tocolytics
Medication
Magnesium Sulfate
Indomethicin
(Indocin)
Nifedipine (Procardia)
Terbutaline (Brethine)
Atosiban (Antocin)

Uterine Incisions: Classical, Low Vertical or Low Transverse

Mechanism of Action
Decreases calcium needed for
uterine contraction
Cyclooxygenase inhibitor
Calcium Channel Blocker
Betamimetic
Pitocin antagonist

Pre Term Labor

Steroids for Fetal Lung Maturity (FLM)
Betamethasone 12mg IM q 25 hrs x 2 doses
Dexamethasone 6 mg IM q 12 hrs x 4 doses
Tocolytic Medication to allow administration of steroids
Fetal Fibronectin (FFN)
Used between 24 and 32 weeks to determine
probability of PTL
High negative predictive value
Nothing per Vagina for prior 24 hrs
Blood and Semen interfere with results false +
Incisions
There are different types of skin and uterine incisions, and one
has nothing to do with the other. Only women with prior low
transverse uterine incisions can attempt VBAC. (Rupture rate
< 1%)

Skin Incisions: Midline Vertical vs Pfannenstiel

MedicalStudentLaborandDeliveryH&P
CC:LeakageofFluid,contractions,vaginalbleeding,abdominalpain,etc
HPI:27yoAAG6P2123@375byLMPconsistentwith1stTMUS(orbyUSalone)presentsfor______.Patientreports+/FM,no
LOF,VB,orcontractions.+/HA,visionchanges,RUQpain.Pregnancycomplicatedby_______.Prenatalcare@________.
LMP:_________
EDC:__________
OBHx:G6P2123
(Year;TermorPreterm,ifpretermwhy;VaginalorCesarean,typeofcesareanandwhy;maleoffemale;Weight;complications.If
SABorEAB,noteGAandifD&Cperformed)
1. 200141wNSVD(orFAVDorVAVDorVBAC),M,7lb6oz,nocomplications
2. 200336w1LTCS,PPROM,NRFHT,F,6lb2oz,chorioamnionitis
3. 20051TMSABwithD&C
4. 200539wVBAC,F,7lb12oz,preeclampsia
5. 20076wmedicalEAB
6. Current,GDMA1
GYNHx:h/oSTDs,abnormalpaps,etc
PMH:Asthma,cHTN,etc
PSH:D&C2005,1LTCS2003,appendectomy1985
Meds:PNV
Allergies:PCNrash(alwaysNOTEreaction)
FamilyHx:MotherDM,FatherHTN.+/birthdefects,mentalretardation,bleedingorclottingdisorders
SocialHx:+/tobacco,EtOH,drugs.Livingsituation.Occupation.Feelssafe?+/Depression
ROS:
Gen:+/Fever/chills
HEENT:visionchanges,sorethroat,rhinorrhea
CV:paplitations,chestpain
Pulm:SOB,prolongedcough
GI:abdominalpain,nausea,vomiting,diarrhea,constipation
GU:dysuria,hematuria,frequency,abnormalvaginaldischarge
MS:jointpain,swelling
Neuro:severeheadache,weakness
Heme:h/oanemiaorbloodclots
Psych:depressionoranxiety
PhysicalExam:
VS:BP125/80,HR72,RR18,O2Sat99%
FHT(babysvitals):Baseline,variability(absent,min,moderate,marked),accels?,decels(statetypeearly,late,variable)
Toco:q5minutes(or2in1hr,ornone)
Gen:A/O,NADorappearsuncomfortable,etc
CV:RRR,+SEM
Pum:CTAB
Abd:gravid,NT,FundalHeight=38cm.EFW=7lbs.Leopolds=cephalic
Ext:noedema,calvesnontender
Neuro:DTRs2+,noclonus(neededifanyconcernaboutpreeclampsia)
SSE:nobleedingorpooling,Cervixvisuallydilatedto23cm
SVE:3cm/50%/1

WetPrep:yeast,cluecells,ortrich.NitrazineandFerningnegative
UrineDip:negative
PNL:O+/Ab/HIV/HepB/RPRNR/RI/CF/GC/CT/Hgb13.2/PapNIL/1hr72/GBS
LevelIIUS:EFW3250g(40%),cephalic,3VC,posteriorplacenta,normalanatomy,BPP8/8,normaldopplers

A/P:27yoG6P2123@375byLMPc/w1TMUSinlabor,withSROM,PTL,etc
FWBreassuring.ClassIFHT
AdmittoL&D
NPO,IVF
Etc.

YourName,MS3

MS3LaborProgressNote
S:Patientcomfortableafterepidural
O:BP113/65,HR82,RR18,T97.8
FHT:150,moderatevariability,+accelerations,nodecelerations
Toco:q3minutes,MVUs120
SVE:4/50/1
Pitocin@6mU/minute
A/P:30yoG2P1001@384w,Labor
FWBreassuring.CategoryIFHT
ProtractedlaboraugmentationwithPitocin
GBS+,continuepitocin
Anticipatevaginaldelivery
YourName,MS3

MS3MagNote
S:+FM.DeniesHA,visionchanges,RUQpain.
O:VS:150/96,90,18,97.5,O298%onNC
I/O:4hr600/500mL.Urineprotein3+
FHT:150,moderatevariability,+accelerations,variabledecelerationsto120lasting20seconds
Toco:q3minutes,MVUs120
Gen:a/o,NAD
CV:RRR
Pulm:CTAB
Abd:gravid,NT,noepigastricorRUQtenderness
Ext:2+edema,calvesnontender,SCDsinplace.
Neuro:DTRs3+,noclonus
SVE:1/50/3
Labs:RecentHELLPlabsCBC,LDH,UricAcid,AST,ALT
A/P:19yoG1@370.IOLformildpreeclampsia
FWBreassuring.CategoryIItracing
IOLwithcervidil
Magnesiumforseizureprophylaxisnos/sxoftoxicity
UOPappropriate
BPstable.Hydralazine(orLabetolol)forBP>160/110
HELLPlabsnegative

YourName,MS3

PostDeliveryNote
PreopDx:32yoG3P2002@396,PPROM,InductionoflaborwithPitocin
Postop:same,delivered,livebornM/Finfant,2nddegreeperineallaceration
Procedure:NormalSpontaneousvaginaldelivery,repairofperineallaceration(orPrimaryorrepeatlowtranversecesareansection,
orclassicalcesarean)
Surgeon:Dr.Attending
Assistants:Dr.Resident,PGY3;You,MS3
Anesthesia:epiduralandlocal(orspinal,orgeneral)
Findings:livebornM/FinfantinLOA/ROA/OPposition,apgars8/9,3340g,placentadeliveredintact,3VC,nocervicalorvaginal
lacerations,2nddegreeperineallaceration(Ifcesarean,notenormalappearingtubesandovariesorexcessivescartissue,etc)
EBL:300mL
Specimins:placenta
Complications:none
Condition:StableInLDR

YourName,MS3

MS3PostPartumNote
S:26yoG3P3003PPD#1s/pNSVD(orPOD#2s/p1LTCS,VBAC,FAVD,etc).Paincontrolled.Toleratinggeneraldiet.Nonauseaor
emesis.+Flatus/BM.Voidingwithoutdifficulty.Ambulatingwithoutdizziness.DeniesCP,SOB,calfpain.Lochia=/</>menses.+/
Depression.Breast/BottleFeeding.Babyboy/girlinroom/nursery/NICU.Desirescircumsicionforinfant.
O:VS:120/89,90,18,97.5
I/O:24hr2350/2300mL.8hr1234/980mL(cesareanonly)
Gen:a/o,NAD

CV:RRR
Pulm:CTAB
Abd:soft,appropriatelytender,+BS,fundusfirmbelowumbilicus(incisionc/d/Iwithstaplesinplaceforcesarean)
Ext:calvesNT,noedema
Labs:Hgb12.310.2(Cesareansectiononly).Bloodtype:Aneg.Rubellanonimmune
A/P:26yoG3P3003PPD#1s/pNSVD(rLTCS,1LTCS,VBAC,VAVD,FAVD)
PaincontrolledwithMotrinandDarvocet(Norco,T#3,Toradol)
Advancediettogeneral(clears,fullliquid,etc)astolerated(cesareansections)
Urineoutputappropriate.Discontinuefoleycatheter(cesareansections)
EncourageambulationandIS(cesareansection)
SCDsforDVTprophylasix(cesareansection)
Colaceforconstipation.Simethiconeforgas
Ironforpostopanemia.MVIifbreastfeeding
RubellaNonimmuneMMRpriortodischarge
Rhnegative.Rhogampriortodischarge
Circforbabyboy
Dispo:floor.Hometomorrow
YourName,MS3

RoutinePostpartumCareOrdersVaginalDelivery
Generaldietimmediatelypostdelivery
DischargePPD#12
Colaceforconstipation
DischargeInstructions:nothingpervaginax6weeks(no
Motrin600mgq6hrsandDarvocetN10012q6hrs
intercourse,tampons,douching).f/u6weeks
prnpain

RoutinePostpartumCareOrderscesarean
SCDsforDVTprophylaxis
StaplesoutPOD#3forphannenstielincision,PD#7for
IS10timesperhourwhileawake
midline(generally,alwaysASKfirst)
DischargePOD#2or3
NPOxicefor6hrspostop,thenadvancetoclear.
DischargeInstructions:Cesareansection:nothingper
Bedrestx6hrsthenOOBTC
vaginax6weeks,showersonlyx2weeks,nodrivingx2
PCAifnoDoramorphinEpidural(Gottliebonly)orif
weeks,noheavyliftingx6weeks,f/u2weeksand6
underGeneralAnesthesia
weeks
Toradol30mgIVq6hrsx24hrs
POD#1:discontinuefoley,advancediettogeneralif+BS
andnon/v,removedressing,ambulateTID,d/cPCAand
advancetoPOmedsifapplicable,patientmayshower

CommonlyUsedPostpartumMeds:
Motrin600mgpoq6hoursPRNpain
Colace100mgpoBIDprnconstipation
DarvocetN100mg12tabq6hrsPRNpain(contains
SenokotS1tabBDprnconstipation(Gottlieb)
Simethicone80gm1tabpofourtimesdailyforgaspain
650tylenolPERTAB)
Toradol30mgIVq6hoursPRNpain(NSAIDdonotgive
Norco5/32512tabsq4hoursPRNpain(contains325
ifalsogivingMotrin)
mgtylenolpertab)

PostpartumVisit
Cesareansections2weeksand6weeks
Vaginaldeliveries6weeks
Documentusingregularsoapnote.Specialattentionto9Bs:Breast,Belly,Bottom,Bleeding,Bladder,Bowels,Birth
control,bluesandbaby.Papandbreastexamperformed.
2hrglucosetoleranceforallgestationaldiabetics

PRENATALCARE

1stPrenatalVisit:
Counselingondiet,exercise,weightgain,OTCmeds,
environmentalexposure,travel,frequencyorvisits,ED
precautions
RoutineLabs:CBC,TypeandScreen,GC/CTprobe,HepB,
RPR,RubellaTiter,UAandCulture,HgbElectrophoresisif
AA
Papsmearifnotdoneinpastyear
BreastExam
CysticFibrosisScreeningoptional
HIVoptoutscreeninghasbestresults
UltrasoundfordatingifuncertainLMP
1114wks:FirstTrimesterscreenoptional
1425wks(usually1522):Quadtest
1822wks:AnatomyUS
24wks:RhogamforRhNegativePatients
35wks:GBSculture

Visitsq4weeksuntil28weeks
Q2weeksfrom28to35weeks
Weeklyafter35weeksuntildelivery

PrenatalVisitProgressNote
S:+FM.NoLOF,VB,ctx.
O:BP115/60,Wt132lbs
Urinediptraceprotein
FH:32cm
FHT:145
Ext:noedema
A/P:25yoG2P1001@324byLMPc/w1TUS
PNL:O/Ab/HIV/HepB/RPRNR/RNI/CF/GC/CT
/Hgb13.2/PapNIL/1hr72
Rhnegatives/pRhogamat28weeks
ROB2weeks
YourName,MS3

DeterminationofGestationalAge:
1) FHTpresentbyfetoscope>20weeks,orbydoppler>30
weeks
2) 36weekssince+urinepregnancytestbyreputablelab
3) USCRL@612weeksc/wEGA>39weeks
4) US@1320weeksc/wGA>39weeks,consistentwith
historyandphysicalexam
FundalHeight
Measurementincentimetersfrompubicsymphysistotopof
fundus.After20weeks,shouldcorrelatewithgestationalage
inweeks+/2cm.

WELLWOMANEXAM
6Bs:Bleeding,Breast,Bowel,Bladder,BirthControl,Blues
SampleGYNhistory:
o Menses:LMP_____.Menarche@14,cycle28days,4daysflow,noseveredysmenorrheal.AgeofMenopauseif
applicableandifanyintermenstrualbleeding
o Paps:noabnormalpaps,lastpap2008NIL
o STDs:chlamydiaat16,treated
o SexualActivity:activewithmalepartnersonly,1currentpartner,monogomousx10years,4partnersinlifetime
o Contraception:Condoms,OCPs,IUD,BTL,etc.
RoutineHealthMaintanence:Mammogram,Colonoscopy,DexaScans,Lipid,Thyroid,DM,Immunizations,Calcium
supplementation,Seatbeltusage
GardisilVaccinefor
o Women926
o 3shotsat0,2,and6months
o Coverstypes6,11,16,18(prevents70%cervicalcancersand90%genitalwarts)

GYNECOLOGYRotations

ORExpectationsforallservices(theremaybesomeminorvariations)
Thereshouldbeamedicalstudentatallcaseswhenpossible.SubIsareresponsibleforassigningcases.IfnoSubI,decide
amongyourfellowrotationmateswhowillattendwhichcases.
YoushouldreadaboutthetypeofcaseyouwillbeperformingandreviewrelevantanatomypriortotheOR
Knowyourpatient.Befamiliarwiththepatienthistoryandknowwhytheyareundergoingtheprocedure
Benearpatientinpreopareaandpageresident(toORnumber)whenpatientisgoingback
HelpwheelpatienttoORandmovethemtoORtable.YoumayalsohelpbyplacingSCDsandhelpingtopositionpatient.
Writepatientname,procedure,allergies,HgbandBMIonwhiteboardinOR
Writeyournameandpositiononwhiteboard
Introduceyourselftoscrubnurseandcirculatingnurse.Pullglovesandgown(ifneeded)foryourself
Askthescrubnurseifyoucanplacethefoleycatheter.
Aftercase,retrievebedandhelpmovepatientbacktoPACU
WriteOperativeNoteandreviewwithresident
Foroutpatientcases,youcanhelpbygatheringthethreedocumentsthatweneedtocompletefromthechartH&Pfor,
H&PValidation,andConsent.Wewillfilloutthevalidationandtheconsent.PleasecompletetheH&Pform(thisisaBRIEF
H&P).Wewillreviewitwithyouandcosignit.

BenignGyn
PatientListunderSharedPatientListsBenignGYN
RoundingeveryweekdayexceptWednesdays.Yourresidentwilltellyouexactlywhattimeeachday,asitwillvarybasedon
numberofpatientsontheservice.Pleasepreroundandhavenotescompletedbythattime.
MondaysandThursdaysareprimarilyORdays.
TuesdaymorningisDr.SummerssproblemGYNclinicbeginningat8:30andusuallyuntil1or1:30.
Wednesdaystudentsdonotround.WednesdayafternoonisgenerallyProcedureclinic
Fridaysareprimarilyambulatorysurgerycases
InHouseandEDconsultsaretheresponsibilityoftheGYNService.Youmaybeaskedtoseethepatientaheadoftheresident.
ConsultnotesaredetailedH&PssimilartoOBTriagenotes.MakesuretogetadetailedGynhistory.SeeWWE.
KeyTopics:EctopicPregnancy,Hyperemesis,AbnormalUterineBleeding,Fibroids,Endometriosis

GynOnc
ThereisnoSharedPatientListforthisservice.
RoundingeveryweekdayexceptWednesdays.Yourresidentwilltellyouexactlywhattimeeachday,asitwillvarybasedon
numberofpatientsontheservice.Pleasepreroundandhavenotescompletedbythattime.
Dr.PotkulsClinic:Breiflyreviewcharttodeterminewhatpatienthasandwhattreatmenttheyhaveundergone.Introduce
yourselftopatientandaskiftheyarehavinganyproblems.BEBRIEF.Youshouldspendnomorethan5minutesonthis
process.PresentpatienttoDr.Potkul,thenseethepatientwithhim.Donotseenewpatients.Theresidentswillseethem
KeyTopics:anatomy,cancerstaging,tumormarkers,bowelobstruction,neutropenicfever,typesofhysterectomies.

UroGyn
Clinic:Trytoarrive1015minbeforethefirstpatient.Youwillnotseepatientsonyourowninclinic,sopickaresidentorfellowto
follow.Itcanbeverybusyinclinicandthefelloworresidentwillnotstopeachtimetoinviteyoutofollowthem,sopayattention
towhoneedstobeseenandaskifyoucancomein.
TheUrogynshavedevelopedaverydetailedsystemoforganizationfortheirclinic.Thisconsistsofawhiteboardmapof
theclinicwithmagnetsforthenurses,attendings,residents,students,andnumbersfortheorderofpatients.Theytakethisvery
seriously,sotrytolearnthesystemanditcanbehelpful.

ORDays:Youshouldknowwhichcasesyouwillbedoingatleastthedaypriorsothatyoucanlookovereachpatientshistory,know
indicationsforsurgeryandreviewpertinenttopics.EssentiallyalloftheUrogyncasesareperformedinthemainOR,evenifthe
patientwillbegoinghomethesameday.
Priortosurgery,eitheryouortheresidentneedtogettheantibioticsfromtheORPharmacypriortosurgery.The
PharmacywindowislocatedacrossfromOR18askyourresidentorfellowwhichantibioticthepatientwillneed(usually
cefoxitin).Youjustneedtoaskfortheantibioticandgivethemthepatient'sname.Additionally,itisyourresponsibilitytowriteup
thepatient'shistoryonthewhiteboardintheOR.Thisneedstohavepatient'sname,age,diagnosis,plannedprocedure,PMH,PSH,
Allergies,POPQ,andpreoplabs.Itisbesttodothiswhilethepatientisinpreop,sothatyoucandootherthingstohelpoutwhen
thepatientisintheroom.

TheUrogynsarealsoveryfocusedonkeepingthingsmovingintheOR,sotheydonotwanttoseeanyonejuststanding
around.Oncethepatientisintheroom,helpwithpositioning,takingthebedout,gettingSCDsonandwhateverelsemaybe
happening.Youwillscrubintocasesandbeabletoassist.Helpwithgettingthepatientoutattheendofthecasealso.

KeyTopics:Stress,Urge,MixedandOverflowincontinence;PelvicOrganProlapse

GenericOperativeNote
Service:GYN/UroGYN/GYNOnc
PreopDx:Menorrhagia,ovarinamass,uterineprolapse,etc
Postop:same,delivered,livebornM/Finfant,2nddegreeperineallaceration
Procedure:TotalabdominalHysterectomy,bilateralsalpingooophorectomy,Lysisofadhesions
Surgeon:Dr.Attending
Assistants:Dr.Resident,PGY3;You,MS3
Anesthesia:epiduralandlocal(orspinal,orgeneral)
Findings:livebornM/FinfantinLOA/ROA/OPposition,apgars8/9,3340g,placentadeliveredintact,3VC,no
cervicalorvaginallacerations,2nddegreeperineallaceration(Ifcesarean,notenormalappearingtubesand
ovariesorexcessivescartissue,etc)
EBL:300mL
Specimens:placenta
Complications:none
Condition:StableinLDR

YourName,MS3

MS3PostOperativeProgressNote
S:26yofemalePOD#1s/pTAH,BSO.Paincontrolled.Toleratingclearliquiddiet.Nonauseaoremesis.+
Flatus/BM.Voidingwithoutdifficulty(unlesscatheterinplace).Ambulatingwithoutdizziness.Deniesfever,
chills,CP,SOB,calfpain.+/vaginalbleeding
O:VS:120/89,90,18,97.5
I/O:24hr2350/2300mL.8hr1234/980mL(cesareanonly)
Gen:a/o,NAD
CV:RRR
Pulm:CTAB
Abd:soft,appropriatelytender,+BS,incisionc/d/Iwithstaples
Ext:calvesNT,noedema
Labs:(onlyincludemostrecentlabs)
Hgb12.310.2
A/P:26yoPOD#2s/pTAH,BSO
PaincontrolledwithMotrinandNorco(PCA,T#3,Toradol)
Advancediettogeneral(clears,fullliquid,etc)astolerated
Urineoutputappropriate.Discontinuefoleycatheter
PostopHgbappropriate(orIronorPRBCsasappropriateforacutebloodlossanemia)
EncourageambulationandIS
SCDsforDVTprophylasix(sometinesHeparinespeciallyonOnc)
Colaceforconstipation.Simethiconeforgas
Dontforgettomentionchronicmedicalconditionsandwhatwearedoingforthem
Dispo:floor.

YourName,MS3

Keytocommonlyusedabbreviations:
AGC=Atypicalglanularcells
AOL=augmentationoflabor
AROM=artificialruptureofmembranes
ASCUS=atypicalsquamouscellsofundeterminedsignificance
BMTZ=Betamethasone,giventopromotefetallungmaturity
BME=Bimanualexam
BPP=biophysicalprofile
BSO=bilateralsalpingooophorectomy
EAB=Electiveabortion(alsosometimescalledtherapeuticabortion,orTAB)
EDC=estimateddateofconfinement(duedate)
EFW=Estimatedfetalweight
EMB=EndometrialBiopsy
FHT=Fetalhearttracing
FFN=FetalFibronectin
FLM=FetalLungmaturity
FM=FetalMovement
FAVD=Forcepsassistedvaginaldelivery
FWB=Fetalwellbeing
FSE=fetalscalpelectrode
G3P1011:G=TimesPregnant.P=TPALTerm(>37w),Preterm(2037w),Abortions(<20w),Living

Note:Multiples=ONEpregnancy,ONEdelivery,MULTIPLEliving,ifapplicable
GDM=gestationaldiabetes.DocumenttypebyWhiteclassifications
IOL=inductionoflabor
IUPC=intrauterinePressurecatheter
LDR=labor,delivery,andrecoveryroom
LOA=lysisofadhesions
LOF=leakageoffluid
LTCS=lowtransversecesareansection
MVU=MontevideoUnits
NRFHT=NonreassuringFHT
NST=Nonstresstest
PROM=prematureruptureofmembranes(priortolabor)
PPROM=PRETERMprematureruptureofmembranes(<37wks)
PTL=Pretermlabor
PTD=Pretermdelivery
SAB=spontaneousabortion,before20weeks
SROM=Spontaneousruptureofmembranes
SCH:supracervicalhysterectomy
SSE=Sterilespeculumexam
SVE=Sterilevaginalexam(digitalexam)
TAH=totalabdominalhysterectomymeansuterusandcervix,doesNOTincludeovaries
TVH=totalvaginalhysterectomy
VAVD=vacuumassistedvaginaldelivery
VB=Vaginalbleeding
VBAC=vaginalbirthaftercesarean
VTE=venousthromboembolism
VTOL=vaginaltrialoflabor