OBSTETRICS & GYNECOLOGY

Note: You should be provided with a recent copy of the Resident Handbook (“Blue Book”), that is very useful.

ADMISSION NOTE

cc:	Pt is a __ yo f GP with EDC of ___ by (U/S, LMP), EGA __ here with c/o CTXs (location, duration, frequency, intensity). Pt with/without SROM (date, rate, time), mucous plug loss, blood, +/- dysuria, n/v/d/f/c, and fetal movement.
Meds:
Allergies:
PMH:	perinatal info, including hx DM, HTN, edema, nutrition, asthma
PSH:	abdominal, uterine, cervical
Gyn:	menarche, period (regularity, duration, intensity), present sexual activity, STDs, last Pap smear, previous pregnancies (date, gestation, complications, episiotomy?, weight of newborns), last period.
Family:	fetal anomalies, deaths, etc.
Social:	smoking, EtOH, drugs, work.
PN Labs:	H/H, glucose screen/GTT, Urine, U/S, rubella, Rh+/-, etc.
ROS:	HA, scotomas, diplopia, edema, epigastric pain, pruritus, dysuria, flank pain, fever…
PE:	Important things here are the vitals, abdominal exam (fundal height), cervical exam (dilation/effacement/station), extremity exam (edema, pedal pulses), and monitoring (FHT, decelerations)
Assessment:	__ yo f GP with IUP @ __ wk EGA by ___
Plan:	Admit, observe, manage expectant vaginal delivery. Activity: bedrest with bathroom privileges <Anesthesia consult if epidural requested> Diet: NPO, ice chips Continuous toco and FHM Labs: CBC, U/A, etc.

DELIVERY NOTE

Pt is a __ yo f GP @ __ wks. At (time) pt delivered a __lb __oz baby (sex) with Apgars _, _. Baby was (position) and delivered (method), nuchal cord x __ over __ degree episiotomy. Bulb suction was performed on the perineum. (? Meconium present) Placenta was delivered intact with three vessel cord. (? Episiotomy – median or medial lateral performed with repair in __ layers with __ suture.) EBL = ___ ml. Mother to recovery room in stable condition. Infant to __ nursery in __ condition. Anesthesia __ per __. Attending/Resident/MS.

POST-PARTUM PROGRESS NOTE

S:	PPD(POD)#__ s/p SVD (C/S 2^o to indication)/Gest. Age, date & time of delivery/Sex of baby, Apgars/Med. Problems/Antibiotics/Rh status (RhoGAM)/Rubella status/Breast or Bottle Feeding /Contraception/Follow-up Clinic. Document the following, e.g. Pt ambulating without difficulty and passing flatus. Eating and voiding without difficulty. Vaginal d/c (lochia, rubra). +/- breast engorgement. Pain control.
O:	Vitals, I/O, PE including abdomen (fundal height, firm/soft, bowel sounds), extremities, incision status. Labs, including pre and post-partum H/H.
A/P:	__ yo f Para___ PPD/POD#__ s/p SVD/cesarean with pertinent findings. Continue routine care. Ambulate, DC Foley, Hep-lock IV, start PO pain meds, etc. Discharge on Iron (if Hct <25 then start FeSO4 325 mg PO tid; >25 but <30, give bid; >30, give qD).

Info to get on a gynecologic history

² Age, G’s and P’s, LMP, contraceptive use?, last Pap smear and mammogram

² Menarche, cycle length, regularity, # days of menses, light vs. heavy flow, changes in flow

² Spotting or post-coital bleeding

² Pre-menstrual symptoms and medications

² History of STDs, vaginal discharge, abnormal pap smears, gynecologic surgeries

² If past menopause – use of hormone replacement therapy

² If with abnormal uterine bleeding - # pads used per day, passage of clots & size

G’s and P’s

G: gravida, or total number of pregnancies

P: para – “Tennessee Power And Light”

T – # full term births (> 37 wk)

P – # pre-term births (< 37 wk)

A – # spontaneous/therapeutic abortions

L – # living children

Naegle’s rule: EDC = LMP – 3 mo + 7 days

Pregnancy dating

Use the LMP if:

² 1^st trimester, and U/S and LMP differ < 7 d

² 2^nd trimester, and U/S and LMP differ < 14 d

² 3^rd trimester, and U/S and LMP differ < 21 d

FHT should be heard with Doppler @ 10-12 wk

FHT should be heard with stethoscope @ 18-20 wk

Fetal movement first occurs around 18-20 wk

From 15-36 wk, fundal height in cm = # wk gestation

Clinic visits (goal > 10 visits)

every 4 wk until 28 wk, then

every 2 wk until 36 wk, then

every week until 41 wk, then

twice weekly post dates.

Ante-natal labs

Initial Visit	CBC, type and screen, Rh, rubella, VRDL, GC/entamici, HbsAg, Pap, PPD, U/A, HIV, 50 g glucose tolerance test (GTT) if with risk factors.
15-18 wks	mat serum aFP, hCG, estriol, amniocentesis
18-20 wks	ultrasound for dates
24-28 wks	50 g GTT; 3 hr GTT if needed; if Rh(-), give RhoGAM @ 28 wk; repeat CBC if anemic
34-38 wks	CBC
36 wks	check cervix q week

Normal labor

Engagement à Flexion à Descent à

Internal rotation à Extension à External rotation

Causes of abnormal labor

1. Powers: ineffective uterine contractions, excess sedation, exhaustion, infection, severe polyhydramnios, neuromuscular disease

2. Passenger: abnormal fetal position, lie, or presentation (face, brow, compound), fetal macrosomia, hydrocephalus

3. Passage: cephalopelvic disproportion, uterine masses, unripe cervix, pelvic fractures, kyphosis, rickets, cervical pathology, overdistended bladder

Gestational Diabetes

Screening and diagnosis

Between 24-28 weeks, administer a 1-hour screening test. Glucose > 135 mg/dL should be evaluated further with a 3-hour oral glucose tolerance test (OGTT). Gestational diabetes is diagnosed when two out of four of the following values are elevated on the OGTT:

² Fasting < 105 mg/dL

² 1-hour < 190 mg/dL

² 2-hour < 165 mg/dL

² 3-hour < 145 mg/dL.

Additionally, two fasting glucose levels > 120 mg/dL in one week are diagnostic of gestational diabetes (no OGTT necessary).

White Classification for Diabetes in Pregnancy

A1	Abnormal Glucose Tolerance Test (GTT), controlled by diet
A2	Abnormal GTT, fasting glucose between 105-120 with 20-25 U NPH qd
GB	Fasting glucose > 120 despite diet and split-mix insulin
B	Age of onset > 20, or duration < 10 years
C	Age of onset between 10-20, or duration 10-20 years
D	Age of onset < 10, or duration > 20 years
F	Presence of diabetic nephropathy
H	Presence of ischemic cardiovascular disease
R	Presence of prolific retinopathy

Management during Pregnancy

A1	ADA diet (35 kcal/kg/day), check fasting blood sugars at routine prenatal visits.
A2	ADA diet and low-dose insulin (start with 20-25 U NPH before breakfast).
GB-R	ADA diet and split-mix insulin, prenatal visits every 2 weeks until 30 weeks, then every week. Baseline ophthalmology exam. Monitor urine protein/creatinine ratio. Ultrasound at 20-22 weeks, then every 4 weeks beginning at 28 weeks.

Post-partum Management

A1,2	ADA or regular diet, no insulin needed.
GB	Follow pattern dextrosticks for 24 hours, consider SSI. ADA diet when tolerating PO.
B-R	Decrease insulin to half pregnancy dose, or SSI. Dextrosticks q6h until taking PO, then pattern. Use NS instead of LR. Follow-up in one week.

Obstetrics Abbreviations
A/G/C	Ampicillin, entamicin, clindamycin	IUPC	Intrauterine pressure catheter
AFI	Amniotic fluid index	Lac	Laceration
AI	Amnio-infusion	LMP	Last menstrual period
AOL	Arrest of labor	LTCS	Low transverse cesarean section
BB	Bulging bag	rLTCS	Repeat LTCS
BMZ	Beta-methazone	Mec	Meconium
BPP	Biophysical profile	MFM	Maternal-fetal medicine
BRP	Bathroom privileges	MEU	Maternity evaluation unit (triage)
BPD	Biparietal diameter	MSAFP	Maternal serum alpha-fetoprotein
BTL	Bilateral tubal ligation	NHY	Not here yet
BV	Bacterial vaginosis	NRFHT	Non-reassuring fetal heart tracings
cCS	Classic C-section	NST	Non-stress test
CA	cardiac activity	OBAR	Obstetric automated record
CMN	Chris McNair Clinic	OBCC	OB Complications Clinic
COP	Concentrated oxytocin protocol	OCP	Oral contraceptive pills
CPD	Craniopelvic disproportion	OSH	Outside hospital
CST	Contraction stimulation test	OTD	Out the door
Ctx	Contractions	PIH	Pregnancy-induced HTN
DOD	Day of delivery	POD	Post-operative day
EASI	Extra-amniotic saline infusion	PPD	Post-partum day
EDC	Expected date of confinement	Pre-E	Pre-eclampsia
EHD	Eastern Health Dept.	PTC	Pre-term contractions
EOF	Elective outlet forceps	PTL (D)	Pre-term labor (delivery)
FH	Fundal height	PROM	Premature rupture of membranes
FHR	Fetal heart rate	PPROM	Preterm PROM
FM	Fetal movement	ROM	Rupture of membranes
FT	Fingertip dilation	RPOC	Routine post-op care
FLT	Floating station	SROM	Spontaneous ROM
FTE	First trimester exam	SSE	Sterile speculum exam
FTP	Failure to progress	SVD	Spontaneous vaginal delivery
GDM	Gestational diabetes mellitus	SVE	Sterile vaginal exam
GTT	Glucose tolerance test	STE	Second trimester exam
ICDB	Incomplete database	TAB	Therapeutic abortion
ILV	Indicated low vacuum	Terb	Terbutaline
IUFD	Intrauterine fetal demise	TTE	Third trimester exam
IUD	Intrauterine device	TTF	Transfer to floor
IUP	Intrauterine pregnancy	VBAC	Vaginal birth after C-section
		WHD	Western Health Dept.

Pearls about Gynecology Services (2 week rotations)

Gyn-Onc

1. You will be getting in VERY early (3am) to have notes written by 5 or 5:30am, Don’t complain

2. Expect to be in OR most of the day

3. Write Post-Op notes on patients you operated on

4. One student should attend sitdowns at 5pm in Fellows Conf. Room (2^nd flr OHB) each day, have copies of the surgery schedule for the next day. Get schedule from Gyn-Onc office (4-4986, OHB 540) by 4:45pm.

CGH Gyn

1. All students come in each morning for rounds (All students attend Fri. morning clinic)

2. One student designated for OR that day, will be off that afternoon (Mon.-Thur.)

3. Other students, not in OR, will have afternoon clinic with remainder of morning, after rounds, off.

REI

1. The attending likes students to know the different qualities of, and how to choose suture materials.