Explore every episode of the podcast Procedure Ready: Ob/Gyn

Incidence: 

3.3% as of 2013 

Indications: 

• Prolonged second stage 
• Risk of fetal compromise 
• Shortening 2nd stage for maternal benefit (ex: cardiac conditions)

Consent: 

• Comparison is c-section typically 
• Failure rate of OVD is ~3-6% 
• Forceps has higher success rate over vacuum, but also higher risk 3rd/4th degree tear 
• Risks to both mom and baby

Prep: 

• Fetus appropriate station/position 
• Anesthesia
• Empty bladder
• Assess Pelvis/Passenger sizes/fit
• OR Ready
• Peds available 

Episiotomy – NO! 

Contraindications

• Fetal conditions, known or supspected: bone disorders (OI), bleeding disorders 
• Maternal infections: Hep C, HIV, etc 
• Concern for shoulder dystocia/cephalo-pelvic dysproportion 

Indications: 

• Post-dates (42+wks) 
• Late Term (41+ wks)
• Elective 39+wks 
• Diabetes
• Hypertension 
• Many more - check out ACOG Medically indicated delivery 

39week induction

ARRIVE Trial - Multicenter RCT showing benefit to 39wk IOL over expectant management to ~41wks 

Included 

• Primips 
• No medical indications for IOL prior to 40+5

Results 

• IOL group had LOWER c-section rate than expectant group 
• Neonatal composite outcome had a trend (not statistically significant) toward lower neonatal compilations in IOL group 

Conclusion

• IOL at 39wks is as safe as expectant management without increased risks
• Many pregnant people are now offered a 39wk IOL rather than waiting for spontaneous labor 

The IOL Process: 

Evaluate and Prep:

• Full H&P
• Ultrasound for position - Vertex
• VE for cervical exam: dilation/effacement/Station, also position and consistency 
• Calculate Bishops Score → help determine mode of IOL

Options for IOL: if biship score <8 for prime or <6 for multip, ripen first! 

• Mechanical cervical ripening (balloon)
• Chemical cervical ripening (misoprostol or cervidil) 
• Best yet--both! 

Contractions (pitocin) 

• Prime: Pitocin alone if Biship 8 or higher
• Mulitp: Pitocin alone if bishop 6 or higher&n

Causes (Four T’s):

1. Tone: Atony
   1. Pitocin
   2. Misoprostol: CI-allergy, SI-transient hyperthermia
   3. Methergine: CI-HTN, SE-HTN
   4. Hemabate: CI-asthma. SE-diarrhea
   5. Tamponade: bakri/utah balloons
2. Trauma: Lacerations
3. Tissue: Retained POC (placenta or membranes)
4. Thrombin: Coagulopathy  
5. Other: Involution

ACOG Practice bulletin: # 171

PTL or TPTL:  Preterm <37wks, cervical change

Evaluation:

SSE first: Collect GC/CT cultures, FFN (no gel, blood or semen), GBS, eval for rupture if needed

SVE:

Cervical change–can dilation or effacement changes

FFN: Fetal fibronectin

If tPTL:

• Magnesium for neuroprotection if <32wks, decrease CP rates
• Betamethasone for fetal lung development
• PCN
• Tocolysis for steroid window (48hrs) if <34wks, questionable if 34-36+6. Indocin if <32 wks, Nifidipine if 32+wks
• IV fluids
• NICU consult

PPROM: Preterm <37wks, Ruptured membranes

SSE: Confirm rupture with Pooling, nitrazine ferning. Collect GC/CT and GBS.

If PPROM: Delivery at 34wks or at diagnosis if chorio or 34+wks

• Latency antibiotics: Erythromycin/Azithromycin, Ampicillin x 2 days, PO Erythro/Amoxicillin x 5 days
• Magnesium for neuroprotection if <32wks, decrease CP rates
• Betamethasone for fetal lung development
• PCN
• NO Tocolysis
• NICU consult

1. Nonreassuring fetal heart tracing
   Category 2-remote from delivery
   Minimal/absent variability is most significant predictor of fetal acidemia
   Category 3 any time is emergent deliver
2. Failed IOL
   Many different definitions: Most commonly 12-24hrs ruptured membranes on pitocin without active labor
3. Arrest of dilation
   Can only meet criteria once in active labor 6cm or greater
   Do you know if her contractions are adequate? IUPC with MVUs>200-250
   If the contractions are adequate, no change over 4hrs
   If contractions are inadequate or no IUPC, no change over 6hrs
4. Arrest of descent
   Prime with epidural 3hrs
   Prime without epidural-2hrs
   Mutlip with epidural 2hrs
   Multip without epidural 1hr
5. Cord prolapse
   -Emergency!
6. Malpresentation
   -Breech, transverse, compound

Resources:

https://www.bedsider.org/methods

Table:

http://www.womenscommunityclinic.org/wp-content/uploads/Bedsider-Birth-Control-Effectiveness-Poster.jpg

Spanish:

http://s3.amazonaws.com/providers/images/images/000/000/032/center/Spanish_tiers_of_effectiveness.png?1464661802

What approach: Abdominal, laparoscopic, vaginal or combination
Taking or leaving the tubes and ovaries?
Tubes: What benefit do they provide? Risk?
Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off

If it’s laparoscopic–listen to the LSC podcast for more details on the approach

Let’s talk about important steps:

1. The round ligament: What artery runs inside the round? Sampson’s.
2. What structure conceals the blood flow to the ovary? The IP ligament (formerly the suspensory ligament of the ovary). The artery comes from the aorta, so if this is transected before it is fully sealed, it can hemorrhage while retracting back into the retroperitoneum. Badness!
3. What are the four levels at which the ureter is injured during hysterectomy? 1- At the pelvic brim, 2- medial to the IP ligament, 3- as it passes under the uterine artery (water under the bridge) and 4- lateral to the vaginal cuff closure.
4. Ligate and transect the uterine arteries–the uterus should blanch white.
5. Colpotomy– disconnecting uterus from vagina
6. Close vaginal cuff if total hyst

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,

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:

1. BPs
2. Neurologic symptoms
3. Lab findings:

HELLP
Hemolysis, Elevated Liver (enzymes), Low Platelets

Eclampsia — Seizures

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

• 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.

• 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

Definition: Failure to deliver fetal shoulders with normal downward traction 

Why we care: Baby hypoxia, brachial plexus injuries, maternal injuries

Risk factors: 

• DM, excessive weight gain in pregnancy, S>D, Large baby
• Hx of shoulder dystocia (~10-15% recurrence)
• Turtling while pushing 

Prevention 

• No real prevention as SD is very hard to predict 
• Offer cesarean delivery if EFW is >5000g and no DM, or >4500g and any type of DM

What do to: 

• Step back. If comfortable, can help minimize family interference. Calmly explain what is happening and what the docs are doing. 
• Offer to be the Timekeeper. Write down times and what is happening. Announce every 2 minutes. 

What you’ll see: 

• Prep: Hypothesize shoulder orientation for suprapubic pressure, place stool 
• Announce problem- call for help
• Maneuvers - McRobers, suprapubic
  • Posterior arm
  • Rotational: Wood’s screw, Rubin
  • Gaskins- all 4s
  • Episiotomy
  • Zavanelli 

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:

1. Gs & Ps aka Gravity and Parity.
2. Primes, multips
3. Gestational age Preterm vs term

Cancer Screening

• Cervical: Age 21-65 Cytology q3yrs, co-test q5 if normal.
• ASCCP guidelines (there is an app! Or PDF: http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-management-guidelines-august-2014-pdf )
• Breast: ACOG: 40-75 annual mammogram
• Colon: Colonoscopy, FOBT, FIT. Begin at age 50. If first degree relative with colon cancer begin screening at age 40 or 10yrs prior to youngest diagnosis, whichever is younger.
• Lung: 55-80 with 30pack-year hx, annual low-dose CT

Vaccinations

• HPV: 3 dose series age 12-26
• Influenza: annual
• Pneumovax: 1 dose and 1 booster any age if risk factors. After age 65 if no risk factors
• Shingles: 2 dose age 50+
• Hep B: initial vaccination in youth, vaccination for anyone non-immune
• MMR: if not immune
• Varicella: if not immune
• Tdap: Booster at 10yrs, new parents

Swab/Urine

• Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1
• Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin
• Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once.
• HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed.

Serum

• Syphilis: Painless chancre followed by latent, then secondary with palmar/plantar rash. If unsure stage, treat as if latent, PCN IM x3
• HIV: Universal screening. PREP if high risk. Referral to ID and counseling if positive.
• Hep B: Treatable, not curable. Routine serum screening.

No Routine Screening, diagnose if lesion

• HSV: Antivirals as needed for outbreaks, can prophylax if frequent outbreaks/immunosuppressed. Valacyclovir or acyclovir are most common.

Why: ASCCP guidelines (there is an app! Or PDF)

Cervical dysplasia — caused by HPV

CIN I–CIN3 is a progression

Risk factors: Smoking, other STIs including HIV, immunodeficiency

Histology: Increased Nuclear: cytoplasmic ratio when abnormal

Acetic Acid: exact mechanism unknown, the higher N:C ratio cells (aka abnormal cells) reflect more light and appear white.

Lugols: Iodine rich-reacts with glycogen in normal squamous cells so they appear dark.  Non-staining cells are abnormal.

HPV — changes

Colpo:

Increased vascularity, punctations, mosaicism, surface contour changes

LEEP:

Stain abnormality and know where abnormal biopsy was taken

Single pass is ideal–tag a side for orientation

+/- Top Hat depending on ECC result

CKC:

Higher up in cervical canal, but more complications

No electricity– okay if pregnant

Every visit:

• Doptones, fundal height, vitals
• Four question: Vaginal bleeding, contractions, leaking fluid, fetal movement

By Weeks:

• 20wks – get and review anatomy US
• 24wks – order glucola, cbc (check for anemia), discuss normal growing pains
• 28wks – Tdap and Rhogam if needed, discuss kick counts
• 32wks – Discuss BCM, sign tubal papers if needed, discuss TOLAC if needed
• 36wks – GBS screening, birth expectations, US for position
• 38-40wks – VE, “sweep membranes”

• Planned/Desired
• Options counseling if needed
• Exam/pelvic/pap
• Ultrasound for dating
• Screening options: QUAD, Sequential, NIPS, invasive testing
• Pregnancy guidelines
• Weight:
  • BMI under 18.5 should gain 28–40 pounds.
  • Normal-weight women (BMI, 18.5–24.9) should aim for 25–35
  • Overweight women (BMI, 25–29.9) should aim for 15–25
  • Obese women (BMI, 30 or more) should gain only 11–20
• Food: Avoid unpasteurized dairy, large fish (swordfish, shark, king mackerel, tilefish, bigeye tuna etc), uncooked meat/seafood, uncooked deli meat, EtOH
• Drugs: Nothing unless cleared by MD. Tylenol okay if needed, PNV, Colace, FeSO4. NO NSAIDs!
• Exercise: Nothing that could leave a bruise on your belly! Moderate exercise is great.

Hysteroscopy = looking inside the uterus with a scope

Steps:

1. Dilate the cervix
2. Distend the uterus with fluid
3. Look around, identify pathology, identify tubal ostia, remove pathology if using an operative scope or Myosure or another resectoscope.

Feared complication: Hyponatremia from excessive hypotonic fluid absorption.

Intrapartum

Differential diagnosis for Temp >38.0C

• Epidural fever (transient), DVT/PE (if prolonged IOL or limited mobility), UTI, Intraamniotic infection (with or without ROM), etc

Chorioamnionitis aka IAI aka Triple-I (intrapartum intraamniotic Infection)

• One temp >39.0C
• One temp 38.0C-39.0C AND one or more risk factors
• Two temps >38.0C 30+ mins apart

Tx: the standard is Ampicillin/Gentamycin until delivery. Tylenol prn temp>38C, IVF for maternal/fetal tachycardia, cooling blanket if needed to decrease temp.

If mild PCN allergy: Ancef/Gent

If severe PCN allergy: gent/clinda or gent/vanc

If vaginal delivery: No evidence that continued abx postpartum provide benefit.

If c-section: Add clindamycin to Amp/Gent.

Continue at least 1 dose postpartum. Clinical judgment on when to d/c. Some do 1 dose, some 24hrs afebrile, until clinical improvement, etc.

Postpartum

Wind – PNA, atelectasis, URI

Womb – Endomyometritis — Gent/Clinda x 24hrs afebrile

Wound – Superficial wound infection, cellulitis — eval for collection, probe wound/fascia if able

Water – UTI, Pyelo — get UA

Walking – DVT/PE

Weening – Engorgement or mastitis

Wonder drugs