HEAD FIRST

Tenth Edition

The OB/GYN

Clerk’s Companion

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Editorial Note

This Tenth Edition of Head First is based on the original created by Harsh Hundal of Meds 1995. The information provided herein is not the standard but a series of guidelines to be followed at your own discretion. The following basic guide contains outlines of admitting orders, chart notes, post-procedural orders, and medications. They may need to be modified based on the patient’s health status and the individual resident or physician’s preferences.

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Table of Contents

Abbreviations 4Admitting History & Physical

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Antenatal Section Chart Notes (Antenatal Rounds) 8Orders Previas/Abruption 10 PIH 10 PPROM 11 IUGR

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Delivery Room Chart Notes (Postpartum Rounds) 12Postpartum Delivery Note 13Postpartum C-section Note 14Orders - Admission Uncomplicated 15 Induction 15 Postpartum 16Postpartum Problems

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Gynecology Chart Notes (Gyne Rounds) 19Chart Notes (Operative Note) 20Day Surgery Orders 21Commonly Ordered Meds 22LHSC Phone List 25Hints & Tips 26Objectives 27

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Abbreviations

AAT activity as tolerated IPS integrated prenatal screen A/N antenatal IUPC intrauterine pressure catheter AUA average ultrasound age LFT liver function tests AVSS all vital signs stable LOF loss of fluid Ax assessment LMP last menstrual period BM bowel movement LSCS lower segment c-section BPP biophysical profile MCA middle cerebral artery doppler BR bed rest MSS maternal serum screen BRP bathroom privileges N normal BS breath or bowel sounds NKDA no known drug allergy C/S c-section NS normal saline CtX contraction NST non-stress test CVS chronic villous sampling NT nuchal translucency Cx cervix O/E on examination DAT diet as tolerated PIH pregnancy induced htn. DR delivery room POD# post-operative day

DV Ductus Venosus Doppler PPROM Preterm premature rupture of membranes

DVT deep vein thrombosis PROM premature rupture of membranes

Dx diagnosis PTL preterm labour d/c discharge PVR post-void residual EBL estimated blood loss PVB per-vagina bleed EDB expected date of birth Px physical EFM electronic fetal monitoring RL ringer’s lactate FHR fetal heart rate RTS real time scan FMC fetal movement count SFH symphysis-fundal height

FSE fetal scalp electrode SROM spontaneous rupture of membranes

FTP failure to progress SS surgical screen F/U follow up SVD spontaneous vag. del. GA gestational age U/S ultrasound GDM gestational diabetes mel. UA umbilical artery Doppler Hx history VSR vital signs routine IOL induction of labour WNL within normal limits

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Admitting History and Physical (Example)

ID: 29 y.o. G3T2P1A1L2 @ 37+5 GA presenting with (contractions, PIH etc) LMP: Aug 31/11 EDB: June 7/12 (by T1 u/s) GA: 38 wks RFA: SROM or PIH or threatened PTL, etc. HPP: abdo pain radiating to back onset 0930 today contractions now q5min lasting 30sec SROM @ 1300hrs, clear fluid, ongoing leak + Fetal Movement. No Per Vaginal Bleeding No GHTN. No GDM. No HSV. Uneventful pregnancy Antenatal tests: GBS +

A-ve, IPS -, Rb nonimmune, HIV-, HBV-, VDRL – G&C neg

Ultrasounds: list all ultrasounds and findings

Dec 11/11, 8 wks GA, SIUP Mar 1/12 20 wks, normal anat Apr/13 EFW<10ile, UA Doppler findings

OBHx: list yr/sex/GA/wgt/labour/Del mode& reason/Comps 2007, male, 40 GA, 8lb 12oz, SVD, PPH 2009, male, 38, 6lb 4oz, c/s for abnormal FHR, no comps

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Gyn Hx (only if pertinent. Otherwise this is optional!): Menarche @ 14 Regular menses Q21 days x 4days Chlamydia tx’d 3 years ago. No PID Paps UTD. Normal. (list if cervical treatments)

PMHx: healthy PSHx: laproscopic appendectomy 2009 Meds: Celexa PNV

ALL: Pen → rash

FHx: father DM2. Mother healthy SHX: no smoking, etoh or ivdu concerns O/E: (MAT Vitals) HR 99 BP 130/80 RR 18 Sa02 98%

Ra Tb 36.5 (FETAL VITALS) FHR 140, mod variability with accels no decels.

RESP: AE clear to bases bilat, adventitial sounds (crackles/wheezes) CVS: NS1S2 no EHS, syst ejection murmur at LSB

ABDO: soft non tender with intermit palp tightenings no rebound

Leopolds = longitudinal lie, vx presentation, back right

PELVIC: (to be done with MD in room only) Cx = 4cm dilated, 50% effaced, vx (note who done by)

7 Invest: Hb 120 WBC 12 PLT 189 Ultrasound confirmed vx presentation Note PIH labs if done IMP: Healthy term multiparous female with SROM x 6hrs, clear in active labour. GBS +. PLAN : (list issues and plan for each issue) 1. term pregnancy in active labour - admit - intermittent auscultation (vs CEFM) - epidural PRN 2. GBS + - Pen G SIGN Jane Doe cc3 Once finished page resident and review. (resident to cosign that reviewed)

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Chart Notes - A/N Rounds

Patient Age, GTPAL, Gestational Age Problem List: Twins gestation

PIH RH –ve

S/ General: OB: fetal activity? Bleeding? contr’ns?

Leakage? (always ask) Issue specific: blurred vision, headache, epigastric

pain (ex PIH) O/ MATERNAL VS: Temp - 37.1

HR -70 BP - 130-150/94-105 edema - pattern? How high? when it started? reflexes - increased, clonus? protein dip - trace to 1+

FETAL VS: HR 140

ISSUE DIRECTED EXAM: (PIH= edema, reflexes, clonus, epig/RUQ tender?) (abruption/chorio: tender uterus?)

Labs/ CBC - WBC/Hb/Plt LEs 24 hr. urine protein Ultrasounds NST - reactive?

9 A/Plan: status resolving, worsening? (ex. Is PIH

progressing?) Fetal concerns? What orders or investigations to consider? Sign Note, M3

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Orders – Previa/Abruption

DAT (NPO if active bleed) BR w/ BRP VSR (R/A if active bleed) CBC (repeat if active bleed) Coag. Screen (INR, PTT, Fibr.) G & X-match 2 units at all times Kleihauer test (sometimes for initial bleed) FMC BID, FHR TID NST daily x 2, then 2/wk External Monitor if active bleed BPP twice/wk US growth/placental location/ appearance If NPO: IV D5W/0.9 NaCl @ 125 cc/hr NICU Consult (if <35 weeks)

Orders – PIH

DAT Limited activity Toxic Protocol vitals, Daily Wgts. CBC, LE’s, lytes, Cr (PIH labs- daily initially then r/a) 24hr. urine protein (call resident w/ results) FMC bid FHR tid NST (freq depends on UA dopp & growth) US - growth/BPP/ UA Doppler initially then r/a NICU Consult (if <35 weeks)

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Orders – PPROM

DAT BR w/ BRP VSR (temps QID) CBC/diff q2d G & T Urine R & M, C & S Vag swab for C+S FMC bid (on admission) FHR tid NST daily BPP twice/wkly Limit use of antipyretic (ie. Tylenol) or you will mask chorioamnionitis!!! Consider Mercer Protocol ie <34 wks (copy in delivery room) NICU Consult (if <35 weeks)

Orders – IUGR

DAT BR w/ BRP VSR CBC, SS, LFT, Coag. Screen G & T Urine R & M if indicated FMC bid FHR tid NST 3x/week BPP, UA, MCA Doppler (freq depends on severity d/w resident) US growth q3-4wk NICU consult

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Chart Notes – Postpartum Rounds

Example:

24 y.o. G2P1 POD #2 LSCS for FTP

S/ pain? Diet (tol CF, DAT?), flatus? voiding? Ambulating?

PVB, lochia?

O/ VS: febrile?, stable?

Wound: dressed, clear, dry, draining, erythema?

Chest: clear, crackles, wheezes?

Abd.: soft, uterus firm? non-tender?

Vag: ↑/↓ flow, clots

Legs : calf swelling/warmth (DVT?)

Lab results:

Ax/ doing well or not, what to reconsider

P/ possible d/c POD #3/4

Sign Note, M3

C/S routine: d/c Foley POD #1

d/c Dressing POD #1

d/c Staples POD #3

(Pt should be passing gas by POD #2 if SVD or by POD #2-3 if C/S)

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Delivery Note – SVD Example: Del MODE: SVD vs. vacuum vs Forceps (if assist why?) Anesthesia: epidural vs nitrous vs none Attendants: staff/residents/ clerks Findings: live vs vigorous ♀/♂ infant. Apgars 8,9 Nuchal cord?�(yes or no) Placenta delivery (spontaneous vs manual

removal) Placenta intact? 3 vessel cord? COMPS: Shoulder dystocia? (yes or no, if yes list maneuvers)

episiotomy or tear? (degree?, Repaired w/ vicryl, Hemostatic?)

PPH? (yes or no) meds given? EBL: < 500cc Disposition: Mom & babe stable in room

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Delivery Note – C/S Example: Pre-op Dx - Abnormal FHR Procedure - 1. Primary LSTCS (lower segment transverse c/s) Post-op Dx - same Surgeon - (staff) Assist - (residents) Anesthetist - (staff) Anesthesia: epidural vs spinal Findings: normal uterus, ovaries & tubes Live or vigorous female infant Fetal weight Nuchal cords? Apgars placenta intact, uterus empty note if plac sent to path EBL - 1000 ml Counts - correct Comps - none Disposition - stable, babe with mom or nicu? Fundus firm?

Sign Note, M3

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Orders – Admission Uncomplicated Direct

to DR

Use standard order sheet

Orders – Induction

Use standard order sheet

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Orders – Discharge Note (as dictated)

Date of admission:Jan 5 2012

Date of discharge: Jan 9 2012

Admission Diagnosis: parturition

Other diagnoses contributing to length of stay:

1. Gestational hypertension

Other diagnoses not contributing to length of stay:

1. Anemia

Infections or complications:

None

Operative procedures:

Jan 5 2012, lower segment cesarean section, Dr. R. Gratton

Discharge meds:

Ibuprofen 400 mg po four times daily

Tylenol 650 mg po four times daily

Morphine 5 po 4 times daily

Ferrous gluconate 300mg PO twice daily

ALL: NKDA

Active issues:

Postoperative c/section recovery

17 Postpartum

Anemia

Resolving gestational hypertension

Hospital course:

Age, GTPAL, presented to OB triage @ weeks with…

Admitted, describe labour management

Serology protective?

Achieved what dilation

Consented for c/s for ? Indication

For further details refer to OR note

Post operatively did well?

Complications in hospital? Postpartum? How were

managed?

At time of discharge voiding well?, ambulating? Good supports at home?

Minimal vag bleeding, passing gas

Describe physical exam

Recent labs

Planned follow up

Discussed concerning signs & symptoms

Sign, Cc3

Carbon copy fam doc, yourself & OB

Gyne follow same template but omit delivery details

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Postpartum Problems

Anemia: if HB<100 and has had a BM ferrous gluconate 300 mg po tid

Bowels: consider fleet enema x 1 prn if no BM after

day 2 or Dulcolax 1 tab x 1 (1 now, 1 in 12 hours) po/ sup prn

ENSURE NOT CURRENTLY BLEEDING! VITALS! Fever: >38 in any of first 10 days except day 1�@38.5

? chorio –consider Amp/Gent/Flag (obtain vag & urine C&S first) CBC ? consider PE ? breast engorgement/abcess?/mastitis ? wound infection Remember the 5 W’s:

Wind - lungs (atelectasis) -first 24 hrs Water - bladder (UTI) - variable Wound - incision (cellulitis) - 2+ days Walking - legs (DVT/thrombophlebitis) -5-7 days Wonder Drugs -right away

Insomnia: consider ativan 1 mg SL qhs prn Leukocytosis: if >20 consider: CBC, C&S, urine R&M, C&S

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Chart Notes – Gyne Rounds (Example)

50 y.o. POD # 1 TAH + BSO for Menorrhagia Medical issues list, ie. 1. COPD

2. DM Type II 3. Wound infection

S/ Pain? Po fluids or DAT? Flatus, voiding? Foley in or out Ambulating? O/ VS: febrile?, Stable? HR, RR, BP,

Urine output, TFI/Balance CVS: N S1/S2, S3/S4, murmurs Resp: chest sounds, BS bilat., crackles/wheezes? Abd: BS, distension, tenderness Wound: clean? Dry? Intact? Draining? erythema? Vag: flow, clots, packing out? Legs: calf swelling/warmth (DVT?) Lab results:

Ax/ doing well or not, what to reconsider P/ ? Consult

? Discharge Sign Note, M3

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Chart Note – Operative Note

Example: Date & Time - September 3, 2013 08:00 Pre-op Dx - Menorrhagia Procedure - 1. TAH 2. BSO Post-op Dx - same Surgeon - (staff) Assist - (residents) Anesthesist - (staff) Anesthesia - GA Findings - bulky fibroid uterus, normal ovaries &

tubes EBL: 400ml Counts: correct Comps: none Drains: none Packs: (note if vag packing and foley in situ) Disposition: stable Sign Note, M3

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Orders – Day Surgery

Written on pink form: DAT AAT VSR IV RL @ 150 cc/hr, d/c WDW Morphine 2-10 mg SC q4h prn (0.1 mg/kg) Tylenol #3 / Plain 1-2 tabs po q4h prn Gravol 50 mg IV/PO q4h prn Ibuprofen 400 mg po q6h ATC Morphine 5-10 mg SC q4h prn Breakthrough Pain Gravol 50 mg IV/PO q4h prn Nausea d/c home when stable & able F/U with Dr _________ in 6wks

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Commonly Ordered Meds

Analgesia: Morphine 2-10 mg SC q4h prn Toradol 30 mg IV q6h prn (NOT TO PREGNANT PTNTS) Naprosyn 250 mg po tid prn (NOT TO PREGNANT PTNTS) Tylenol #3/pl 1-2 tabs po q4h prn Percocet 1-2 tabs po q4h prn (for codeine allergy) Ibuprofen 400 mg po q6h prn (NOT TO PREGNANT PTNTS) Tramacet 1-2tabs po q4h prn

Antiemetics: Gravol 50 mg IV/PO q6h prn

Maxeran 10 mg IV/PO q6h prn Stemetil 10 mg IV/PO q6h prn Ondansetron 4mg IV/PO q8h prn

Anticoagulant: Heparin 5000U SC bid

Fragmin 5000U SC OD Anti-Constipation: Colace 100 mg po bid

MOM 30 cc po bid prn Anti-Reflux: Diavol 15-30 cc po qid prn

Ranitidine 150 mg po bid prn 50 mg IV tid prn

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Commonly Ordered Meds Cont’d

Anti-Insomnia: Ativan 1 mg SL qhs prn

(Don’t use too liberally in elderly, can have bad

reactions)

Antibiotics:

(Chorioamnionitis therapy = amp, gent, flagyl)

Ampicillin 2g IV q6h

Gentamycin 120 mg IV q12h (gent. levels pre/post 3rd

dose)

Flagyl 500 mg IV/PO q12h

(Preop)

Ancef 1g IV q8h

(GBS)

Penicillin G 5 million units IV then 2.5 million units Q4h if no allergy

(may substitute with Ampicillin 2G IV then 1g IV q4h, but Pen G is

better)

If NON-ANAPHYLACTIC reaction to Penicillin, 2nd

line

is Ancef 2g IV then 1g IV q8h.

If ANAPHYLACTIC reaction to penicillin, and swab

proven sensitive to both erythromycin AND clindamycin

then 2nd

line is Clindamycin 900mg IV q8h OR

Erythromycin 500mg IV q6h

If sensitivities unknown, or resistant to EITHER

clinda/erythro, then 3rd

line is Vancomycin 1g IVq12h

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Commonly Ordered Meds Cont’d (Wound infection) Superficial cellulitis – Keflex 500mg PO QID Deep collection/fluctuant mass – add Flagyl 500mg PO TID Endometritis Keflex + Flagyl (UTI Tx Macrobid, Amoxil, Cipro) MacroBID 100mg PO BID Amoxil 500 mg po tid� Ciprofloxacin 500 mg PO bid or 400mg IV bid

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Phone List

Individual Pager #

Red Consultant 15600 Blue Consultant 15603 Red Resident on call 14465 Blue Resident on call 15009 Gyn Resident 15499 A/N Resident on call 10394 Anaes. Consultant 15572 Anaes. Resident 15573

Clerk Pager #

OB Red 14925 & 14927 (night) OB Blue 14920 & 15566 (night) Gyn Gray 19544 Gyn Purple 14912

Red Team Physicians Blue Team Physicians Consultants Pager # Ext. # Consultants Pager # Ext. #

Dr. Tracey Crumley 10803 66401 Dr. Saima Akhtar 15391 58002 Dr. Robert Di Cecco 10143 66152 Dr. Shannon Arntfield 18089 58289 Dr. Genevieve Eastabrook 18281 66091 Dr. Cynthia Chan 13979 58002 Dr. Robert Gratton 10116 64052 Dr. Barbra de Vrijer 16087 64052 Dr. Joanne Kirby 14629 58394 Dr. Laudelino Lopes 10424 61026 Dr. Yvonne Leong 15780 58223 Dr. Barry MacMillan 10196 66247 Dr. Jordan Schmidt 10762 66106 Dr. Michael Maruncic 15533 58193 Dr. Laura Sovran 15738 58223 Dr. Renato Natale 10407 66091 Dr. Angelos Vilos 17006 66104 Dr. Debbie Penava 10366 66401

Department Ext. #

Admitting 58116 Security 52281 Emergency 58141 Virology 64667 Hematology 56495 Pharmacy 52162 Blood Bank 58292 Microbiology 56495 Radiology 58297 Ultrasound 58296 OR 58226

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Hints & Tips General Hints: If you want to be involved, stick with the resident. This ensures you are aware of what is going on and around to help out.

No one gets along with everybody, but maintain a good attitude, and try to keep positive and you’ll be sure to enjoy the rotation.

If paged, answer as soon as possible – things happen quickly in the DR, and promptly answering pages ensures you won’t miss out on them.

Nights before call, make sure to get plenty of rest, you’ll need it.

Build a rapport with your labouring patients by checking in on their progress frequently. Being seen regularly helps keep you involved.

Introduce yourself to the nurses and make sure your pager number is written on the board so you will be called for deliveries.

Evaluation Tips: Wait until after the first week to give out your evaluations.

Prior to taking the admission hx & px from the patient - sit down alone with the patient’s chart and use the antenatal forms and referral notes to fill in as much of the hx first - you’ll save yourself a world of time.

Keep track of good hx & px admissions from DR or A/N you’ve done for later chart review evaluation.

Don’t sweat the exam, if you’ve been paying attention while in clinic and at teaching sessions, you’ll be fine.

Evaluations should be distributed to varying levels of residents (not all R2’s)

Technical Hints: Learn to do SFH and Leopold’s maneuvers early, you’ll be using them a great deal.

If cutting sutures, cut 1 cm above the knot unless requested otherwise, you can always cut shorter but not longer.

Practice tying knots and suturing on breaks. You will be given more opportunities if you can do these. Ask the OR nurses for extra sutures that you can take home for practice.

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Objectives

1. The clerkship will demonstrate basic knowledge and application of skills in women’s healthcare required to function effectively as an (undifferentiated) physician.

Obstetrics

2. Perform a focused history and physical examination in early pregnancy.

3. Establish and confirm gestational age.

4. Identify risk factors during an initial antenatal assessment.

5. Identify relevant health issues in pregnancy.

6. Counsel patients with respect to nutrition, activity and exercise, sexual activity, smoking and drug use in pregnancy.

7. Discuss the importance of routine prenatal laboratory investigations, prenatal diagnostic options (IPS, Quad screen, amniocentesis, CVS) and ultrasound assessment of fetal morphology.

8. Identify the optimal time in pregnancy to order the various prenatal diagnostic options and ultrasound.

9. Participate in ongoing antenatal care and investigations (GDM screening, Rh prophylaxis, GBS screening, term cervical assessment) to ensure maternal health and normal fetal growth.

10. Demonstrate knowledge and management of obstetrical complications seen in triage or on the antenatal ward (decreased fetal movement, preterm labour, premature rupture of fetal membranes, maternal hypertension, pre-eclampsia, antepartum bleeding).

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Obstetrics Continued

11. Describe normal and abnormal progress of lab or full nulliparous and multiparous women.

12. Participate in intrapartum management including assessment of labour, cervical dilation, fetal position.

13. State the criteria for ensuring antenatal fetal well-being (non-stress test, biophysical profile) and intrapartum fetal health (intermittent and continuous fetal heart rate monitoring).

14. Perform a vaginal delivery under supervision and actively manage the third state of labour.

15. Participate in or observe a caesarean section.

16. Identify a first, second and third degree obstetrical laceration.

17. Define and participate in the management of post-partum haemorrhage.

18. Support women in their effort to breast-feed.

19. Identify and manage post-partum complications (voiding difficulty, nerve injury, venous thromboembolism, perineal and bowel care, depression).

20. Describe normal healing at 6 weeks post-partum.

21. Provide counselling regarding risks and success rates of VBAC (vaginal birth after caesarean section).

22. List contraceptive options post-partum.

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Gynaecology

23. Perform a focused (including menstrual, contraceptive, sexual and gynaecologic) history in ambulatory patients presenting with gynaecologic problems.

24. Perform a complete physical exam with emphasis on the gynaecologic exam (abdominal exam, bimanual pelvic exam, speculum exam and Pap smear) in ambulatory patients presenting with gynaecologic problems.

25. Develop a differential diagnosis and management plan for common gynaecologic problems (dysmenorrhea, dysfunctional uterine bleeding, contraception, infertility, pelvic mass, menopausal symptoms, post-menopausal bleeding, pelvic relaxation and urinary incontinence).

26. Outline an approach to diagnoses and management of patients presenting to emergency or urgent care with acute gynaecologic problems (first trimester bleeding, pelvic infection, pelvic pain, wound infection and acute bleeding).

27. Participate on the gynaecologic surgical team providing perioperative care and assist in common gynaecologic surgeries (laparoscopy, vaginal and abdominal hysterectomy, repair of pelvic prolapse and urinary incontinence).

28. Diagnose, investigate and manage post-operative complication (VTE, PE, UTI, infection).

29. Describe the importance of screening of cervical cancer and current screening programs.

30. Discuss the results of an abnormal PAP smear and outline appropriate follow-up or investigation.

31. Identify the signs and symptoms of gynaecologic malignancies (vulvar, cervical, endometrial, ovarian).

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Gynaecology Continued

32. List the important investigations for gynaecologic malignancies (colposcopy, cervical or vulvar biopsy, endometrial biopsy, Ca125, pelvic exam).

33. Conduct patient-centered interviews that explore the patient’s feelings, idea, impact on function, and expectations.

34. Develop therapeutic relationships with patients characterized by compassion, empathy, respect and collaboration regarding management decisions.

35. Discuss access to abortion in Canada and how patients in London and Southwestern Ontario access services at LHSC.

36. Describe how new patients requesting abortion are assessed and how they are screened prior to booking a procedure date.

37. List the different methods of abortion and which are appropriate based on gestational age and patient selection.

38. Describe a first trimester D&C including the technique and potential complications.

39. List contraceptive options post abortion and follow up available to each patient.

40. Describe the psychosocial variables that place women at risk for unintended pregnancy and how they shape decision-making.

41. Recognize personal beliefs regarding abortion and, through values clarification, discover ways to suspend judgment and avoid bias in Options counseling.

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Notes: