UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL

OB/GYN CLERKSHIP STUDENT HANDBOOK

Academic Year 2005-2006

Table of Contents THE CORE CURRICULUM Explanation of clerkship goals Clerkship Contacts Clinical Opportunities Outside your Main Site Expectations Competencies OB/GYN Faculty Clerkship Grading Shadow Project Womens Health Care Team Whos Who in Womens Health Care OSCE Oral Case Presentation Form Overview of OSCE Stations Page 3 3 4 4 5 7 11 13 14 16 17

CLINICAL SKILLS SUPPLEMENT Abbreviations Used in OB/GYN Charting Write-ups (samples) Periodic screenings Indications for ultrasonography in pregnancy Drug classification schedule for pregnancy and lactation Fetal Monitoring Criteria Comparisons Multicultural Issues in Women's Health Normal Lab Value variations in pregnancy Suggested Documentation of findings from breast & pelvic exams Guidelines for Professional Behavior Vaginal Wet Prep Identification 21 24 29 30 31 32 35 39 41 43 44

REVIEW OF CLERKSHIP GOALS This rotation should offer you a chance to profoundly widen your knowledge and understanding of womens health issues, and continue the third year task of incorporating your theoretical knowledge into clinical care. OB/GYN is an exciting specialty; it requires varied skills interviewing and counseling; watchful waiting and crisis intervention; complex medical and surgical treatment; inpatient and outpatient care. You will be working with a diverse team of providers sub-specialists, pediatricians, midwives, nurses, social workers, lactation consultants, STD and family planning counselors, nutritionists, case managers, interpretersand observing their work will help you understand the intricacies of comprehensive, multi-disciplinary care. Our goals for this clerkship are that you: 1. 2. 3. 4. Gain an understanding of this specialty to aid you in career planning Increase your ability to perform complete pelvic exams, and recognize the significance of abnormal findings Deepen your understanding of common issues in womens health care, enabling you to appropriately manage, triage and refer, regardless of your future practice choice Gain at least the level of medical knowledge related to womens health care that you will need to pass your licensing exams

Required text: Obstetrics and Gynecology by Charles R.B. Beckman et al, 5th edition, Lippincott, Williams and Wilkins: Philadelphia, 2006. Our curriculum is based on a national curriculum developed by the Association of Professors of Gynecology and Obstetrics (APGO). The objectives of this curriculum are delineated for you in the Beckman text. Please refer to these objectives, as they will guide you in your learning. Attendance Policy: Because the clinical years are designed specifically to expand your professional growth and responsibilities for patient care, your attendance at all your assigned clerkship activities is mandatory. This includes core curriculum sessions based at Memorial, learning sessions with standardized patients, OSCE and written exams, and all clinic and call sessions scheduled at your clinical site. If, for any reason, you will miss any portion of your clerkship responsibilities, make this clear to clerkship administration and/or preceptors and team leaders. Unexcused absence will result in additional assignments, completion of professionalism incident form, or reduction of grade, possibly including not passing clerkship, at the discretion of the clerkship director. Clerkship Administration: Edward (Ted) Peskin, MD, Clerkship Director Phone: 508-334-6255 E-mail: peskine@ummhc.org Pager: 3415 Kate ODell, CNM, Assistant Clerkship Director
Phone: E-mail: Pager: 508-334-538

Dawn Tasillo, MD, Associate Clerkship Director Phone: 508-334-6255 E-mail: tasillod@ummhc.org Pager: 1964 Ty Fraga, Education Coordinator Phone: 508-334-8459 fragad@ummhc.org E-mail: Pager: 8007
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odellk@ummhc.org
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Clinical Opportunities Outside Your Main Site: SCRUBBING: If you are a non-Memorial student and have not done surgery yet, you may join the Memorial students on the maternity floor on the afternoon of orientation day for a participatory session on Gowning, gloving and scrubbing. Its a great way to prepare yourself to participate in Gyn surgery and C-Sections. Most of the other sites have their own introductory session on scrubbing, but it is usually not as detailed. PLANNED PARENTHOOD: If you are interested in observing for a half-day or more at an area family planning or abortion clinic, please contact Ty Fraga to schedule observation time. Please allow 10 days to schedule your observation time. Observations may be done at the Planned Parenthood clinics in Worcester, Boston or Springfield. Many students have reported that this was a particularly de-mystifying and important experience for them. OUTPATIENT GYN: If you feel you are getting insufficient outpatient Gyn experience at your site, contact Ty Fraga. We can sometimes arrange supplemental office hours with UMass faculty. PELVIC EXAM EXPERIENCE: If you are nearing the end of the clerkship and feel you lack sufficient experience to perform a competent female pelvic exam, OR you have had no opportunity to have your pelvic exam competency card signed by a preceptor, notify Ty Fraga; she will make arrangements to supplement your pelvic exam experience. CAREER OPTIONS: If you are interested in evaluating your career interests, the GlaxoSmithKline Pharmaceutical Company has developed the Pathway Evaluation Program, which has a CD, workbook and web site. The CD and workbook are available in the UMMS library or in Ty Fragas office.

EXPECTATIONS: During this rotation, we expect that you will: 1. 2. 3. 4. 5. 6. 7. 8. 9. Pass each identified assessment area with at least an expected performance. Participate actively in the on-call schedule arranged at your clinical site. Notify staff team leader, preceptor, and clerkship or site coordinator if you are ill or have a crisis that prevents you from fulfilling your assignment. Attend all scheduled core-curriculum. Avoid doing invasive exams on any patient unless you are assigned to do this by your preceptor / team leader. (For example: dont just walk in and do a vaginal exam on a laboring woman.) Be cheerful and attentive, even if you are physically tired. When you participate in surgery, understand why each patient is being operated on presenting symptoms and signs, goals of surgery before you begin your scrub. Spend time with nurses, aids, social services, dietitians, and consultants to understand the team approach to care. Get a real flavor of child birth: spend time at the bedside of laboring women to get a realistic idea of the process of labor; ask women what they experiences before they were admitted; ask them how they view the experiences they had from the perspective of being postpartum; ask family members and friends about their experiences. Make sure you are clear about what the expectations are for your participation at your individual clinical site; be prompt in your attendance. Be appreciative of patients who allow you hands on participation in their care; many of the questions we ask and the procedures we do are invasive.

10. 11.

COMPETENCIES: At the conclusion of your clinical session, we expect you to be able to perform the following: 1. Patient interaction: Communicate with a variety of patients in a variety of settings; listen to their stories; demonstrate empathy; explain your intent; facilitate self-health care and patient-directed health planning, including high risk behavior change; facilitate appropriate referral. History taking: Obtain a thorough womens health history, including age-specific history of menses, obstetrical events, gynecological health, sexuality, and a review of significant social and family history. Modify the information you seek for a problem-specific history. Appropriately document and communicate findings. Physical diagnosis: Perform a complete physical assessment in pregnant and non-pregnant women, including a complete, gentle evaluation of the thyroid, breast, abdomen, pelvis and rectum. Begin recognizing deviations from normal. Appropriately document and communicate findings. We do not expect you to be proficient at vaginal exams in laboring women, but you should be able to identify why, when, and how these exams are and are not done. Vaginal delivery: In an emergency situation, provide informed assistance at a birth in any location, calmly combining your experience and knowledge to recognize issues related to maternal and fetal wellbeing, and working with the equipment and facilities available to you to minimize risks to the mother and newborn. Screening and obtaining specimens: Obtain adequate Pap smears, cultures for STD testing, and samples for vaginal microscopy. Perform wet preps, KOH, and fern evaluations and interpret results. Obstetrical examination: Perform Leopolds maneuvers, auscultate the fetal heart tone with a doppler, and obtain an accurate fundal height. Fetal heart tracings: Recognize reassuring findings on a fetal monitor strip normal baseline, variability, contraction patterns and timing; and identify 3 basic periodic changes early, late, and variable decelerations, explaining their significance. Surgery: Participate in OB/GYN surgery, strictly adhering to sterile technique, and recognizing basic anatomy and principles for prevention of iatrogenic sequelae.

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Helpful hints contributed by our OB/GYN residents: Keep up with your reading. Read ahead. Review pertinent chapters that related to your core programs or patients youve seen. Ask preceptors and residents to review articles and questions with you in down time. Prior to taking OB, reading a clinical guideline like OB Pearls can be very helpful. This would take you about 2 hours, cover to cover. Practice oral presentations with fellow students or with the residents. Know your patients well. Never, ever make things up. Say what you dont know. Take responsibility for what you didnt get done. Carefully note the time and date on all lab work so that you are sure you are considering results in order.
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Introduce yourself to everyone patients, nurses, families, other team members. Explain your role when time permits. Defer difficult questions to a more senior team member. Be your own advocate. Take initiative to learn what you need or want to know. Ask to be involved in procedures. In down times, look for learning experiences do Medline searches, watch ultrasounds, practice suturing, review questions, talk to patients and families about symptoms, impressions and experiences they had leading up to their hospitalization or visit. If you dont know, ASK. If you arent getting feedback, ASK. If youve read up on a topic and havent grasped it to your satisfaction, ASK.

UMASS MEMORIAL OB/GYN FACULTY

This section is designed to help you plan independent research, obtain career and residency advice, and choose 4th year electives. It is easy to contact listed faculty by email: last name/first initial@ummhc.org Educational background information and photos of physician faculty can also be viewed on-line at http://lynxweb/intranet/find/index.cfm, the UMMHC physician finder, choose Obstetrics and Gynecology. Michael Aronson, MD Womens Health Services Director SPECIALTY: Urogynecology / Reconstructive Pelvic Surgery EDUCATION: Tufts; Tufts (med); Brown University/Women & Infants (res), Mayo Clinic, MN (fellow) OTHER STAFF EXPERIENCE: Tufts - New England Medical Center PROFESSIONAL ORGANIZATIONS: ACOG, ACS, Society of Gyn Surgeons, American Urogynecology Society RESEARCH AREAS: MR imaging of female pelvic floor anatomy, intraoperative anatomic relations, outcomes of vaginal vault prolapse surgery, monoamniotic twins, lower urinary tract injury, neurologic effect of sacrospinous colpopexy, intraoperative cystoscopy. Patricia Aronson, MD SPECIALTY: OB/GYN Generalist EDUCATION: Brown University, Eastern Virginia (med), Women & Infants (res) OTHER STAFF EXPERIENCE: Women & Infants, Tufts New England Medical Center, Faulkner Hospital PROFESSIONAL ORGANIZATIONS: ACOG RESEARCH AREAS: Womens Health Initiative, Induction of labor, cervical ripening Harrison Ball, MD Gyn Oncology Division Chief SPECIALTY: Gyn Oncology EDUCATION: St. Josephs U., Tufts (med), U of Pennsylvania (res), U of Pennsylvania (fellow) OTHER STAFF EXPERIENCE: Madigan Army Medical Center, Magee Womens/U of Pittsburgh, New England Medical Center / Tufts PROFESSIONAL ORGANIZATIONS: ACOG, SGO, ACOS, ASCO, NEAGO, ARS RESEARCH AREAS: Clinical trials in endometrial and ovarian cancer Robert E. Berry Jr., MD OB/GYN Residency Program Director SPECIALTY: OB/GYN Generalist EDUCATION: Williams, University of Virginia and Tufts (med), Tufts (res) OTHER STAFF EXPERIENCE: St. Margarets, New England Medical Center, Faulkner Hospital PROFESSIONAL ORGANIZATIONS: ACOG, APGO, NEOGS, Boston OB Society RESEARCH AREAS: Antibiotic prophylaxis in TAH/BSO, medical education, best practices Annette Chen, MD Assistant Residency Program Director SPECIALTY: Gyn Oncology EDUCATION: Johns Hopkins, Harvard (med), Brigham & Womens (res), Mass General (fellow) PROFESSIONAL ORGANIZATIONS: Gyn Onc Group, Mass Med Society RESEARCH AREAS: Ovarian cancer cytoreductive surgery, management of cervical dysplasia in pregnancy, proteonomics in ovarian cancer screening, clinical trials

Brian Clark, MD Reproductive Endocrinology & Infertility Division Chief SPECIALTY: Reproductive Endocrinology and Infertility EDUCATION: Colby College, University of Vermont (med), University of Vermont (res), University of Vermont (fellow) PROFESSIONAL ORGANIZATIONS: ACOG, AAGL, AMA, AOA, ASRM, ASEI, Boston Fertility Society, American College of Surgeons RESEARCH AREAS: Hormone Replacement, BMI and Methotrexate Failure in the Treatment of Ectopic Pregnancy, IVF Oocyte Aspiration Ellen Delpapa, MD Medical Director of Labor and Delivery SPECIALTY: Maternal Fetal Medicine EDUCATION: College of St. Elizabeth, University of Medicine & Dentistry of New Jersey (med), St. Francis Hospital & Medical Center University of Connecticut Medical School (res), University Health Center of Pittsburgh Magee-Womens Hospital (fellow) PROFESSIONAL ORGANIZATIONS: ACOG, Society of MFM, New England Perinatal Society, APGO, Christian Medical Society, MA Medical Society RESEARCH AREAS: Macrosomia, placental function ,pre-term labor, pre-eclampsia Matthew Esposito, MD SPECIALTY: Maternal Fetal Medicine EDUCATION: Williams, University of Rochester (med), University of Maryland (res), Brown (fellow) PROFESSIONAL ORGANIZATIONS: ACOG, Society of MFM RESEARCH AREAS: Maternal diabetes, VBAC, Perinatal thrombophilia, uterine rupture, antiphospholipid antibody syndrome Karen Green, MD Maternal Fetal Medicine Division Chief SPECIALTY: Maternal Fetal Medicine EDUCATION: University of Rochester, University of North Carolina (Med), University of Pittsburgh (res), UCSD (fellow) PROFESSIONAL ORGANIZATIONS: Society of MFM, American Institute of ultrasound in Medicine, NE Perinatal Society, Worcester and MA Med Societies RESEARCH AREAS: Ultrasound, use of fetal fibronectin, drug abuse and HIV in pregnancy Mary Herlihy, MD Director of Community Womens Care SPECIALTY: OB/GYN Generalist EDUCATION: Harvard, UMass (med), UMass (res) OTHER STAFF EXPERIENCE: Brigham & Womens RESEARCH INTERESTS: VBAC and uterine rupture, management of ASCUS pap smears Bruce Meyer, MD OB/GYN Department Chair SPECIALTY: Maternal Fetal Medicine EDUCATION: Duke University, U of Texas/Austin, U of Tennessee; U of Texas Health Sciences Center San Antonio (med); U of Texas Health Science Houston (res); U of Texas Health Science Houston (fellow) PROFESSIONAL ORGANIZATIONS: ACOG, APGO, CREOG, Society for Maternal-Fetal Medicine, American College of Physician Executives, American Hospital Association Section on Maternal-Child Health RESEARCH AREAS: Epidural effects on labor and vaginal delivery, cord blood gas and clinical outcomes, psychosocial stressors and pregnancy outcomes, VBAC, triplet gestation outcomes, financial impact of clinical care, skin closure and wound healing in obstetrics, LEEP and incompetent cervix

Tiffany Moore Simas, MD SPECIALTY: OB/GYN Generalist EDUCATION: Clark University, UMass (med), UMass (res), Harvard University (MPH) PROFESSIONAL ORGANIZATIONS: ACOG, APGO, CREOG, MMA RESEARCH AREAS: Extended Perineorrhaphy, Obstetric Intervention and Outcomes in Pregnancy Following LEEP, Cervical dysplasia and colposcopy, contraceptive choice and management, teenage pregnancy, domestic violence, postpartum depression, menopause, menstrual issues, VBAC, laparoscopic and minimally invasive surgery Abraham N. Morse, MD Fellowship Director, Urogynecology SPECIALTY: Urogynecology and gynecologic surgery EDUCATION: Swathmore; Harvard/MIT (med/health science technology); John Hopkins (res), Mayo Clinic / AZ (fellow) OTHER STAFF EXPERIENCE: Mayo Clinic/MN, UCSF PROFESSIONAL ORGANIZATIONS: ACOG, American Urogynecology Society, Tissue Engineering Soc. RESEARCH AREAS: Surgical adhesion formation and prevention, computers in medical education, biomechanics of pelvic support and pelvic connective tissue; tissue engineering in OB/GYN; animal models of vaginal surgery Katharine ODell, CNM MSN, OB/GYN Associate Clerkship Director SPECIALTY: nurse-midwifery EDUCATION: Mayo Clinic, Rochester (RN), Frontier Nursing Service, KY, (CNM), Case Western Reserve (MSN) RESEARCH AREAS: pre and post op education outcomes, Depo Provera and bone density, pelvic floor dysfunction, medical education Debra Papa, MD SPECIALTY: OB/GYN Generalist EDUCATION: Sienna College; Georgetown University (med); Long Island Jewish Medical Center (res) OTHER STAFF EXPERIENCE: Indian Health Service (Navajos/Arizona) PROFESSIONAL ORGANIZATIONS: ACOG, APGO, Association of Colposcopy and Cervical Pathology RESEARCH INTERESTS: Colposcopy

Edward Peskin, MD OB/GYN Clerkship Director Generalist Division Chief SPECIALTY: OB/GYN Generalist EDUCATION: U of Wisconsin (Madison) and Rutgers; Washington U/St Louis (med); Barnes Hospital and Washington U (res) with 3rd year internship in Social Medicine at Montefiore Med Center and Albert Einstein College of Medicine; Medical Administration Management Fellowship OTHER STAFF EXPERIENCE: OB/GYN Chief at St. Vincents Hospital Worcester, MA PROFESSIONAL ORGANIZATIONS: ACOG, APGO, AMA, Mass Medical Society, Worcester Medical Society RESEARCH AREAS: Prostaglandin use in menstrual induction, improving physician-patient communication, teaching difficult topics in womens health, new developments in contraception, emergency contraception, ethics of abortion, abnormal uterine bleeding, the correct C-section rate, techniques to reduce prematurity, medical education

Finda Quinama, MD SPECIALTY: OB/GYN Generalist EDUCATION: Albert Einstein COM (med); UMass (res) OTHER STAFF EXPERIENCE: Sandia Health System, Albuquerque, NM Jami Star, MD - Director, Ultrasound and Prenatal Diagnosis SPECIALTY: Maternal Fetal Medicine EDUCATION: Brown University; SUNY Stony Brook (med); St. Lukes/Roosevelt Hospital (res); Women & Infants Hospital, Brown University (fellowship) OTHER STAFF EXPERIENCE: Women & Infants Hospital, Brown University PROFESSIONAL ORGANIZATIONS: ACOG, APGO, Society of MFM, International Society for the Study of Hypertension in Pregnancy; National Perinatal Association, American Diabetes Association RESEARCH AREAS: Hypertension, diabetes in pregnancy, platelet activation, HIV, substance abuse in pregnancy Dawn Tasillo, MD Associate Clerkship Director SPECIALTY: OB/GYN Generalist EDUCATION: Northwestern University; SUNY Brooklyn College of Medicine (med); University of Massachusetts (res) PROFESSIONAL ORGANIZATIONS: ACOG, AMA, Mass Medical Society, APGO RESEARCH AREAS: Cervical ripening Stephen Young, MD Urogynecology Division Chief SPECIALTY: Urogynecology and reconstructive pelvic surgery EDUCATION: Columbia; George Washington U (med); Mount Sinai/NYC and Women & Infants/ Brown U (res); Mount Sinai (fellow) PROFESSIONAL ORGANIZATIONS: ACOG, American Urogynecology Society, Society of Gyn Surgeons RESEARCH AREAS: Surgical treatment of female urinary incontinence and pelvic floor prolapse, subjective and objective outcomes of reconstructive pelvic surgery, including the suburethral Mersilene Mesh slings and vaginal paravaginal repair, safety and efficacy outcomes of combinations of minimally invasive vaginal procedures in the therapy of massive pelvic organ prolapse and genuine stress incontinence in acoital women (LeFort Colpocleises, Extended Perineorrhaphy and Tension free vaginal tape combined operations), clinical registry of ongoing care of patients treated for prolapse with pessaries.

Susan Zweizig, MD Director, Reproductive Physiology SPECIALTY: Gyn Oncology EDUCATION: UC Berkeley; Harvard (med); LA County/USC Medical Center (res/fellow) PAST STAFF EXPERIENCE: LA County USC Medical Center PROFESSIONAL ORGANIZATIONS: Society of Gyn Oncologists, ACOG, American Society for Colposcopy and Cervical Pathology, Gyn Oncology Group Surgery Committee RESEARCH AREAS: Perioperative care, AGUS pap smears, HPV typing, adnexal torsion, ovarian and endometrial cancer, surgical prophylaxis for prevention of ovarian cancer

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OB/GYN CLERKSHIP GRADING (EFFECTIVE 7/1/03) For grading purposes, an end-of-clerkship summative evaluation of each student will include the following components: Clinical Evaluation: Oral Exam and OSCE NBME Written Exam Team Presentation Shadow Project 45% 35% 10% 5% 5%

Students are required to pass EACH of the first three areas to complete the OB/GYN clerkship. A failure in any of these areas will result in an "incomplete" final grade until remediation is complete. An overall grade of Below Expected Performance requires remediation. The Clerkship Director in consultation with the department faculty determines specific requirements. An incomplete grade in this rotation will prevent graduation. Final grades are calculated as follows: Final Grade Points Outstanding Above Expected Performance Expected Performance Below Expected Performance
A. Clinical Evaluations

85-100 75-84 55-74 <55

Clinical evaluations will be completed by the preceptors, attending physicians, supervising nurse-midwives or nurse-practitioners, and/or house staff in OB/GYN or Family Practice who have worked with you at your clerkship site. Final grade points will be assigned based on these evaluations. A Below Expected evaluation in this area will require remediation. Evaluation Point Total Grade 39 - 45 (3.5-4.0) Outstanding 31 - 38 (2.8-3.4) Above Expected 20 - 30 (1.8-2.7) Expected <20 (<1.8) Below Expected

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B. OSCE and ORAL EXAM A 7 station OSCE will be conducted in the last week of the clerkship. You may earn up to 4 points at each station. Detailed information about OSCE content is available in this packet. RATING OSCE Points Outstanding Above Expected Expected Below Expected 25-28 22-24 18-22 < 18

A below expected grade requires that the OSCE be repeated. This can be done once; a second below expected requires that the clerkship be repeated.
C. NBME Exam

The OB/GYN NBME Written Subject Exam is a proctored, multiple-choice test, which is nationally normed and extensively pre-tested. It is designed to test your knowledge of OB/GYN at a very detailed level. If you pass this test, it is a very good predictor that you will pass the OB/GYN questions on your Step 2 exam. You are allowed 2 hours and 10 minutes to complete the exam. It is usually administered on the final day of the clerkship. SCORE Grade Points > or equal 79 71-78 64-70 56-63 < 56 Retake required Any student who does not score at least 56 points (3rd percentile nationally) on the written exam may retake it a maximum of 2 times during a subsequent end-of-clerkship exam period. IT IS THE STUDENTS RESPONSIBILITY TO SCHEDULE THE RE-EXAMINATION with our education coordinator. If the test is failed 3 times, the clerkship must be repeated.
D. Review of Final Grade

10 (Outstanding) 8 (Above Expected) 6 (Expected) 4 (Below Expected)

We encourage, but do not require, preceptors to review their written evaluations with students to provide feedback for continued clinical growth. Students may review their grading packet when evaluations, OSCE grades, and NBME results are tabulated. This process takes 4-6 weeks after the end of the clerkship. Call our education coordinator to set up an appointment to review your packet.
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Shadow Project: Womens Health Care: A Team Approach

Spend 4-8 hours working with or shadowing a non-physician provider of direct care to women. Examples of appropriate personnel include counselors who specialize in topics like problem-pregnancy, contraception, HIV prevention and/or treatment, STD prevention/ treatment/ follow-up social workers or case managers childbirth educators labor room or postpartum nurses nurse-midwives, physicians assistants, nurse-practitioners or direct-entry midwives doulas lactation consultants physical therapists specializing in women's health nurse-specialists in areas like osteoporosis management and prevention genetic counselors complementary health therapists who specialize in care for women--acupuncture, herbalists, naturopaths, perinatal massage therapist, practitioners who teach hypnobirth. You may never again have the time and opportunity to gain this depth of insight into the role of other providers. Make the most of your day. You can earn up to 5 points toward your final grade when you turn in the completed results at your oral exam station during your OSCE. Points are awarded for completing the project and content of response. Your BRIEF write up should include: Name of provider Type of care How long you worked with this provider Cover the following content areas: CONTACTS AND AVAILABILITY For example: How did you learn about/ contact this provider? Would patients have difficulty learning about and accessing this type of care? Were other physicians you worked with aware of this providers services? Did you see referrals being made? PROVIDERS PERSPECTIVE For example: What did the provider feel was their role in patient care? How did they think a physician could best help to incorporate their expertise? What patients did they feel would benefit the most from their special service? YOUR PERSPECTIVE For example: How did you see this role augmenting or detracting from overall care provided? How did the role of this provider differ from what you see as a physician's role? What did you learn from the experience? How would you improve a similar interaction for patients you might encounter in the future?

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Whos Who in Womens Health Care

We hope that you come away from your rotation with a clearer understanding of how the team approach to womens health care works. These are examples of team members, and weve tried to limit the list to providers you may not encounter on other rotations: Anesthesia: Either physicians or nurse-anesthetists may practice at your site, providing general and regional anesthesia for OB and GYN cases. They may be assigned to OB only, or they may be covering the entire facility, making accessing them a little harried at times. Usually OB anesthesia only becomes involved with women at the time of labor. However, if high risk factors are present (like a history of anesthesia problems, back abnormalities, blood dyscrasias, or unusual physical characteristics a short, thick neck or a receding jaw) patients are frequently scheduled for a prenatal consult with anesthesia. Advanced Practice Nurses (APNs): Registered nurses who have advanced education, usually through graduate school programs, in areas such as anesthesia (CRNA), psych (CS), midwifery (CNM), Pediatrics (PNP), Family Medicine (NP) and Womens Health (NP). These nurses expand the traditional role of the nurse, such as direct care, administration of medications, health education, and patient advocacy to encompass more of the tasks that had fallen under the scope of medical practice in the last 100 years, such as physical diagnosis, provision of prescriptions, and minor surgery. APNs are required to have both state licensure and national certification to practice. They work with written agreements with collaborating physicians and consult with physicians regarding health care outside their scope of practice. In theory, this team approach allows physicians more time to care for patients whose complex health problems require greater depth of medical and/or surgical knowledge. Case Managers: May be social workers, nurses or non-professionals, depending on the needs of the agency and the patients for whom they work. At UMMHC Memorial campus, for example, in-house case managers are registered nurses who facilitate discharge planning; organizing access to referrals, treatments, equipment and in-home or rehabilitation care. Doulas: Are people who specialize in labor support. Couples often hire doulas privately to help them prepare for labor through prenatal classes; assist them during labor with comfort measures and support; and provide some degree of care and support for the new family. There are doula-training programs, but no certification or licensure is required. More information on doula training is available at www.dona.com. Genetic Counselors: Are health professionals with academic and clinical preparation enabling them to help patients and their families understand complex issues related to occurrence or the risk of occurrence of genetic conditions and birth defects. Their role goes beyond providing information; they also help families cope with the emotional, psychological, medical, social and economic consequences of genetic diagnoses. There are several avenues of preparation as a genetic counselor, and a national certification process is available. Lactation Consultants: May be either lay or professional people who have gained extra knowledge about breast-feeding management and support. There are undergraduate degree programs in lactation services. Certification is available through an international organization. There is even a mechanism through which physicians may become certified lactation consultants. Midwives: Midwife means with woman and a midwife is traditionally a person who attends to the needs of a laboring woman and assists her at birth. There are several avenues open to people who want to be midwives; regulations can vary from state to state. Certified Nurse Midwives (CNMs) are APNs (see above). In Massachusetts they are required to be licensed and nationally certified. They may work in clinics, hospitals, birth centers, or homes as long as they have a written agreement with a collaborating physician to outline the
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scope of practice and provide consultation in cases of emergency. In the US today the traditional role of CNMs has expanded to include primary care and womens health care throughout the life span. You will find CNMs doing a variety of health care provision, from endometrial biopsy and pregnancy termination to surgical first assisting and ultrasonography. Other types of midwives are not licensed in Massachusetts (they are neither legal, nor illegal). This includes all direct-entry midwives who either learn their skills through a school or through apprenticeship. They attend deliveries in peoples homes. There is a national certifying agency for lay and direct-entry midwives. People who pass those requirements are called Certified Professional Midwives. Any other midwife may be highly skilled, but the consumer has no guarantee of care. Social Workers: Offer essential skills needed especially when maternity care is provided to patients with socio-economic stressors. A social worker provides access to local agencies and resources either through patient requests for assistance or through needs assessments. Social workers may have either undergraduate or graduate degrees. Massachusetts requires licensure for social workers through a test of related knowledge. A Licensed Independent Social Worker (LISW) has a Masters Degree in social work and has passed a rigorous licensure requirement. A LISW can work in private practice providing psychosocial counseling and can bill as an independent provider. Other social workers act as agency employees.

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OB/GYN Clerkship Oral Case Presentation Form

(NOTE: Please track at least 3 OB cases. At least two should include a minimum of one frequently encountered condition from the following list: Pregnancy Induced Hypertension (also called Gestational Hypertension) and the related conditions of preeclampsia, eclampsia, and/or HELLP syndrome; diabetes in pregnancy, preterm labor or premature rupture of membranes, third trimester bleeding, infection in the ante or postpartum period, multiple gestation, IUGR, failure to progress, non-reassuring fetal heart tracing). One case may be a normal, vaginal delivery. You will be asked to present two of these cases and submit this form at the time of your OSCE. The examiner will determine which two cases will be presented.
Student Name:_________________________Clinical Site:______________________________Block:_______ Pt Initials 1. Dates Seen Inpt or Outpt Evaluation Process Procedures Performed Complications Final Diagnosis

2.

3.

To whom did you give your evaluation forms: 1._________________________________________ 2._________________________________________ 3._________________________________________

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Overview of the OSCE Stations

The OB/GYN end-of-clerkship OSCE is comprised of 7 thirty-minute stations. The subject matter is designed to allow you to demonstrate clinical knowledge you have gained in this clerkship. Much of womens health care involves interviewing, patient education, and communicating with the health care team. A significant portion of your grade in the OSCE will relate to your ability to demonstrate these skills. We see this both as a testing and as a learning experience for you; at many of the stations you will receive structured, immediate feedback. Here is a general description of the stations to help you prepare: Station 1: Case Presentations You will present to a faculty member 2 of the 3 obstetrical cases you have entered on your case form. The cases should detail antepartal or intrapartal patients with whom you have worked. We want to be sure you understand basic management strategies for common findings. At least 2 of the 3 cases that you prepare for presentation must include a primary diagnosis from the following list or must be pre-approved: Pregnancy induced hypertension (also called gestational hypertension) or its related conditions (preeclampsia, eclampsia, HEELP syndrome) Diabetes in pregnancy Preterm labor and /or premature rupture of membranes Third trimester bleeding Antepartum or intrapartum infection Multiple gestations Intrauterine growth retardation Failure to progress Non-reassuring fetal heart tracing The case presentations should be concise and thorough, and include in this order: Presenting complaint and history of recent symptoms Past pertinent medical, surgical, social, sexual, menstrual, gyn and OB history Review of symptoms Pertinent physical findings Related initial labs Differential diagnosis Initial management plan Patients course through her hospitalization if applicable You will be graded both on your ability to present in a cohesive and concise style and on your ability to answer faculty questions related to your patients diagnosis and potentially other diagnoses as well. You can use notes, but dont READ your presentation. The full course of the hospital stay should NOT be presented. Rather, you should present the patient as if you have just completed her history and physical exam. Try to explain your reasoning behind your assessment and plan. Station 2: Macy Communication Station This is an interview and counseling station designed to provide you with an opportunity to apply the skills presented in the communication sessions of the core curriculum. You will interview and counsel a patient, and then get feedback and discuss the case with the standardized patient (SP). Your patient may be facing a problem pregnancy or involved in sexual behavior that puts her at risk for future health problems. Please note
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that, as in true clinical practice, any of the patients you encounter at any of the stations may be currently involved, or have been involved in the past, in a same sex relationship. Your tasks in this station will be to: Obtain a targeted history If you identify high risk behaviors: Identify gaps in the patients knowledge about her risk Determine what change the patient is willing to make Help the patient formulate a plan that includes these changes and any testing you feel would be appropriate today and at subsequent visits Plan with the patient for appropriate follow-up If your patient verbalizes that she is confronting an unplanned and/or unwanted pregnancy: Ascertain whether she is severely depressed or suicidal and triage appropriately For non-emergent patients: Identify her support systems Review her pregnancy options with her Answer any questions she may have about medical and surgical abortion Plan with the patient for appropriate follow-up. Your grade will be determined on your ability to interview the patient, following a logical plan toward appropriate follow-up, and documentation of the interview. Station 3: Preconception Counseling This patient will be seeking information to prepare for a future pregnancy. Preconception counseling is becoming an essential element in womens health care. Identifying risks and providing preventive education will allow you to have a profound impact on the outcomes. At this visit, you will obtain a history, answer patient questions, document, and advise a patient about follow-up. We suggest that in addition to the short section in your text, you review the ACOG Technical Bulletin No. 205, May 1995 Preconceptual Care included in the lecture section of this handbook. Station 4: Pelvic Pain Your patient will present with a common acute pelvic pain problem. You will be graded on your ability to assess and triage this patient. A summary of your specific tasks includes: Interview the patient Write a differential diagnosis list and a diagnostic plan Review the initial diagnostic results that you are given Modify your differential diagnosis Develop a management plan

Station 5: Postpartum Care Your patient will be seeing you for a 6-week postpartum visit. Your tasks include: Obtain a directed history, including the mothers, familys, and babys health status and adjustment to the birth. Make sure you are specific in covering a directed review of the mothers systems, targeting especially those you feel are important for a postpartum interview. Answer any questions the patient may have.
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This patient will request that you make an anatomical drawing to help her understand some part of the information you explain to her. Your explanations should use vocabulary appropriate for an Englishspeaking HS graduate. If the patient raises any concerns that you feel may justify follow-up, discuss with her what her follow-up options are.

Station 6: General GYN and Womens Health At this computer station you will complete questions on a separate answer sheet that correlate with Power Point slides of common physical findings. Review of Beckman, Chapters 27 & 28 and the core curriculum on STDs and vaginitis, combined with clinical experiences you may have encountered, should provide you with adequate preparation for this station. Station 7: Perimenopausal Issues At this writing station you will complete several tasks designed to review your knowledge of risks and benefits of hormones for menopausal women; general recommendations for health screening for peri and postmenopausal women; general follow-up of common abnormal findings on cytology and pathology specimens in this age group.

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CLINICAL SKILLS SUPPLEMENT

20

ABBREVIATIONS COMMONLY USED IN OB/GYN

Please note: You do not need to memorize these abbreviations; this is to help you get by and continue learning. (If you dont understand what a phrase means when it is spelled out, thats a different story. Look it up or ask.) 3/50/-1 3 cm dilated / 50% effaced / -1 station 12 x 30-32 x 7 x mod This is a menstrual history: menarche age 12, menses every 30-32 days lasting 7 days of moderate bleeding AB abortion MAB missed abortion SAB spontaneous abortion TAB therapeutic abortion EAB elective abortion ACIS adenocarcinoma in situ ACOG American College of Obstetricians and Gynecologists AFP Alpha Fetoprotein MSAFP maternal serum alpha-fetoprotein AGUS atypical glandular cells of unknown significance AMA advanced maternal age AFI amniotic fluid index ANSVD anticipate normal spontaneous vaginal delivery APGO Association of Professors of Gynecology & Obstetrics AROM artificial rupture of membranes ASCUS atypical squamous cells of unknown significance BBOW bulging bag of water BBT basal body temperature BCC benign cellular change BMD bone mineral density BPD biparietal diameter BPP biophysical profile BSO bilateral salpingo-oophorectomy BTBV beat-to-beat variability BTL bilateral tubal ligation CCCT clomiphene citrate challenge test CIN cervical intraepithelial neoplasia CKC cold knife cone CPD cephalopelvic disproportion CRL crown rump length CST contraction stress test CT chlamydia trachomatous CVS chorionic villi sampling D&C dilatation & curettage D&E dilatation & evacuation DES diethylstilbestrol DIC disseminating intravascular coagulopathy DI/DI dichorionic / diamniotic twins D/W discussed with EDC / EDD estimated date of confinement / estimated date of delivery EFM electronic fetal monitoring EFW estimated fetal weight EGA estimated gestational age
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EMB ERT FAVD FHR / FHT FL FLM FM FOB FSE FSH FTP GBS / GBBS GC GDM GFM GIFT GnRH G_P_ GTD HCG

HELLP HGSIL HPL HPV HRT HSG HSV I&D ICSI IUD IUFD IUGR IUI IUP IUPC IVF LEEP / LOOP LGA LGSIL LH LMP / LNMP LOA / LOT / LOP LTC LTCS / LVCS MFM MLE MVU NRRPR NST

endometrial biopsy estrogen replacement therapy forceps assisted vaginal delivery fetal heart rate / fetal heart tracing or tone femur length fetal lung maturity fetal movement father of baby fetal scalp electrode follicle stimulating hormone failure to progress group B beta streptococcus gonorrhea gestational diabetes mellitus good fetal movement gamete intra-fallopian tube transfer gonadotropin releasing hormone gravida, para (TPAL term, preterm, abortions, living children) gestational trophoblastic disease human chorionic gonadotropin BHCG beta human chorionic gonadotropin (usually serum) UHCG urinary human chorionic gonadotropin hemolysis, elevated liver enzymes, low platelets high-grade squamous intraepithelial lesion human placental lactogen human papilloma virus hormone replacement therapy hysterosalpingogram herpes simplex virus incision & drainage intracytoplasmic sperm injection intrauterine device intrauterine fetal death intrauterine growth retardation intrauterine insemination intrauterine pregnancy intrauterine pregnancy catheter in vitro fertilization loop electrical excision procedure large for gestational age low grade squamous intraepithelial lesion luteinizing hormone last menstrual period / last normal menstrual period left occiput anterior / left occiput transverse / left occiput posterior long, thick, closed low transverse C- section / low vertical C-section maternal fetal medicine midline episiotomy Montevideo units non-reactive RPR non-stress test
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NSVD NTD OCP OT PCO / PCOD PCT PID PIH POC POD / PPD PPH PPROM PROM PTL PUBS PUPPPS ROA / ROT / ROP ROM SA SBE SGA SROM SSE STD / STI SVE TAH TOA TOL TRIPLE TEST TVH UDE US VAVD VB VBAC VAIN VIN

normal spontaneous vaginal delivery neural tube defect oral contraceptive pills occiput transverse polycystic ovarian disease post-coital testing pelvic inflammatory disease pregnancy induced hypertension products of conception post-operative day / postpartum day postpartum hemorrhage preterm premature rupture of membranes premature rupture of membranes preterm labor percutaneous umbilical blood sampling pruritic urticarial papules and plaques of pregnancy right occiput anterior / right occiput transverse / right occiput posterior rupture of membranes semen analysis self breast exam small for gestational age spontaneous rupture of membranes sterile speculum exam sexually transmitted disease / sexually transmitted infection sterile vaginal exam total abdominal hysterectomy tubo-ovarian abscess trial of labor MSAFP / HCG / Estriol total vaginal hysterectomy uro-dynamic exam ultrasound vacuum assisted vaginal delivery vaginal bleeding vaginal birth after C-section vaginal intraepithelial neoplasia vulvar intraepithelial neoplasia

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Examples of write-ups (Brought to you by past and present OB/GYN residents at Memorial special thanks to Gabrielle Reine, MD, Renee Lockey, MD and Tiffany Moore Simas, MD) revised 6/15/02 Labor and delivery sample admit note Cc: briefly mothers comments on contractions, ROM. FM, bleeding HPI:____y/o G__P__@___wks w/ EDC ______ by LMP______or___U/S presents to L&D w/ (expand on chief complaints). Pt has been followed in pregnancy by ___________w/regular PN care or inconsistent attendance at appointments or no prenatal care. First PN visit @____wks. On last office exam pt was noted to have ________(describe exam if available) Prenatal chart is (is not) available. Issues for this pregnancy include: i.e.: late registrant Size not equal to dates HTN / GDM / Infections / PTL / bleeding (Describe management) Rh neg (RhoGAM given_______) Review abnormalities in PN labs (u/s, amnio, AFP, Glucola, CVS, HepB, anemia, etc) Anticipated plan for pain management in labor is_______________. OB/GYN history: Date of prior pregnancies and outcomes (complications, wt, labor progress) Menstrual history onset, regularity, duration, complications Pap history and follow-up STD history Breast problems Contraception history especially before pregnancy Past Medical history; illnesses, asthma, steroids, HTN, DM, renal Past Surgical history: any w/general anesthesia, including dental, complications, etc Meds: PNV, Fe, allergies Allergies: NKDA or specific reactions Family History: HTN / DM in pregnancy, bleeding disorders, congenital anomalies Social History: Support systems (who lives at home? Who will help with the baby?) Same FOB as other children Occupation / school plans Hazardous exposures Tobacco, ETOH, Drugs Safety domestic violence Sexual history: STDs, risks, partner change, recent pain or discomfort ROS: HA, scotoma, vision change, edema, abdominal pain, pruritus/rashes/sores, dysuria, vomiting, bowel change, fever. PE: General i.e.: uncomfortable, writhing, relaxed, breathing through contractions VS: temp, BP, pulse, resp, urine dip (ketones, protein) HEENT Neck Chest Abdominal: Fundal height, Leopolds, EFW, tenderness, scars, contractions (regularity, strength, length) FHT: baseline, variability, accels, decells (length, depth, orientation to contractions) Extrem: edema Neuro: DTRs / clonus External genitalia: note lesions, especially herpetic Sterile speculum exam prn: bleeding, fern, pooling Sterile vaginal exam: (if NO PREVIA)dilatation, effacement, station, presenting part, membrane status
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Labor admission note: continued Labs: review PN glucose, blood type, pap, UA, RPR/VDRL, RH, PPD, Rubella, CBC, HepB, HIV A/P:____yoG___P___@____wks in (prodromal, latent, active, expulsive) labor. Comment on mothers status (tolerating contrax well/uncomfortable/anxious/tense but stable). Comment on babys status (FHT reassuring or non-reassuring). D/W DR._____. Admit to L&D for anticipated NSVD. Monitoring per low risk/high risk protocol. Address plan for any problems or anticipated needs. (ie: desires epidural, IVF started for hydration in anticipation SROM, PTA, PCN indicated with temp > 38 or p 18 hrs Rh neg check infant blood type after delivery) Labor admission routine ordersAt Memorial Hospital these orders are pre-printed; make sure you know the content and rationale. Admit toL & D Dx: IUP @_____wks w/ GDM, preeclampsia, in labor w/r/o membranes PTA Condition: Stable Vitals: per L & D routine Allergies Activities Nursing: per routines with EFM, catheterize PRN, I/Os Diet: NPO except sips and chips IV Fluids: _____________;for epidural, administer 1 L LR @ 125 cc/hr prior Meds Labs Intrapartum Note S: O: Note what pt says is happening; or why you were called in to see patient General appearance of patient VS, including temp Membranes: clear fluid? How long ruptured at this point Abd exam: contrax, tenderness, relaxation between contrax, Toco/IUPC readings FHT/FSE: baseline, variability, accels, decels (depth, length, alignment to contrax) SVE: dil/eff/station per Dr________(or sterile spec exam) Meds: Pitocin ? analgesia _____yo G____P____@____wks in ____stage of labor Comment on pt condition (coping well or with difficulty) Comment on FHT pattern (reassuring, non-) D/W Dr.____ Impression (acceptable progress; slowed progress following epidural; arrest of dilatation/descent) Describe interventions planned (IUPC, FSE, AROM, pain meds, antibiotics ABX) Expectant management, monitoring of progress, support Signature MSIII/cosigned

A:

P:

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Vaginal Delivery Note Following a _____minute second stage, a viable male/female _____(wt in lbs or grams) was delivered (over intact perineum or over midline episiotomy with epidural or local anesthesia of 5 cc @% Xylocaine) from the _____position (LOA,etc). Delivery route was: Normal spontaneous vaginal delivery (NSVD) Vacuum or forceps assisted fro (indication maternal exhaustion, fetal bradycardia) Applied at______(station, position and time) # pulls with # contrax # of pop-offs Total application time include releases of pressure between contrax Nuchal cord, loose or tight, ____(reduced on perineum,/abd or clamped and cut prior to delivery of shoulders) Infant mouth and nares suctioned with bulb or DeLee (when/where: on perineum, prior to delivery of shoulders, on maternal abd) Cord doubly clamped and cut. Apgars____at 1 min and ___at 5 min. Cord pH____(if done). Routine cord blood drawn and sent. Cord blood donation collected. NICU present (give indication) Placenta delivery spontaneous/expressed/controlled cord traction/extracted manually intact, 3-vessel cord (describe variations Batteldore, velamentous insert, 2 cord vessels, trailing or incomplete membranes, knots in cord) Inspection of the perineum indicated ___________degree episiotomy or lacerations (perineal, vaginal, periurethral, sulcus) repaired with_____suture in the standard fashion. (Be specific about suturing techniques with 4th degree laceration) Inspection after repair (including rectal if needed) demonstrates good support, hemostasis. Mother tolerated procedure well; no complications. Delivery performed by_______and_______with___________attending. For C-section Note Use op format; specify indications, low transverse c-section (LTCS) for (FTP/CPD/fetal bradycardia/failed vacuum)and include infant stats under findings. Be sure to document BTL if one was done. Postpartum Notes PPD/POD #! S: comment on pt complaints, level of pain control with what meds, voiding, flatus, BM, diet status and toleration, amt of bleeding pt reports, infant feeding status and problems, activity level up walking, dizzy, episodes of fainting O: T amx________BP P I/O Lungs Heart Abd: soft/nontender/distended/FF (fundus firm) 2 cm above umb Incision if applicable: dressing dry, drainage, erythema, ecchymosis, induration/intact or separated (CDI = clean, dry, intact) Perineum intact/healing. Mod rubra without odor. Ext: no calf tenderness Labs: HCT (PPD#1)_____Rh neg mom. Baby Rh pos review prenatal to see rubella status, BC plan A/P:____yo G___P___PPD# 1 s/p NSVD, stable Check HCT. Address intervention related to specific problems/co and discharge plan. Routine PP care F/U on BC plan
RhoGAM IM prior to discharge prn Signature 26

Routines for 1st PPD

Check HCT Review PP Birth Control Plan and document Review Male Circumcision plan Review Blood type and RhoGAM order

Routines for POD # 1 same, but add Change dressing Sample PP routine orders: At Memorial Hospital these orders are now pre-typed; make sure you understand the content and rationale. D/C Foley D/C PCA Percocet 1-2 tabs PO q 3-4 h prn Regular diet Decrease IVF to 80 cc/hr HLIV for PO >500cc (Heparin lock) OOB to chair (tid) Ambulate as tol Heating pad prn PP Discharge (PPD#2/POD#4) Discharge to home. With infant. F/U visit 4-6 weeks D/C staples Motrin 600 mg if vag del Percocet if C-Section PPBC Instrux: call for fever, pain, increased bleeding, inability to care for self or baby, breast-feeding problems Operative Notes Brief op note: Preop dx Postop dx Procedure Anesthesia Surgeon Assistants IVF EBL U/O Drains Specimens Complications Findings

27

Postop check S: Pt statement re: pain, nausea, etc O: Temp, BP, P, I/O, POx, Lungs CTA, Heart, Abd, Dressing, Ext, Foley A/P: ___yo woman___hrs postop from____doing well except for____. Adequate U/O and pain control. Will give____for____.

Post-op Gyn Orders: Check with the surgeon; generally the orders are similar to the post-C-section orders except replace regular diet with: Clear diet ADAT for flatus

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Summary of Cancer Screening Recommendations for Low-Risk Patients From: http://www.findarticles.com/cf_dls/m3225/6_63/71579247/p11/article.jhtml?term=periodic+screening+ guidelines Medical organization Screening recommendations Breast Cancer: MAMMOGRAPHY Every 1 to 2 years, ages 50 to 69; counsel women ages 40 to 49 about potential risks and benefits of mammography and clinical breast exam. Every 1 to 2 years starting at age 40, yearly after age 50 Annually after age 40 Every 1 to 2 years in women ages 40 to 49; annually beginning at age 50 Every 1 to 2 years, ages 50 to 59 Data currently available do not warrant a universal recommendation for mammography for women in their 40s; each woman should decide for herself whether to undergo mammography. Every 1 to 2 years, ages 50 to 69 Cervical cancer: Pap tests Pap test at least every 3 years to women who have ever had sexual intercourse and who have a cervix Annual Pap test and pelvic examination beginning at age 18 or when sexually active; after 3 or more tests with normal results, Pap test may be performed less frequently on physician's advice Pap test annually starting at age 18 or when sexually active; after 2 to 3 normal (negative) tests, continue at discretion of physician. Pap test every 3 years until age 70; in women of any age who have never had a Pap test, screening with at least 2 negative smears 1 year apart Annual Pap test and pelvic examination starting at age 18 (or when sexually active); after 3 or more normal annual Pap tests, the Pap test may be performed less frequently at the physician's discretion. Pap test annually beginning at age 18 or following initiation of sexual activity; after 2 normal Pap results, perform Pap tests every 3 years to age 69. Pap test at least every 3 years in women who have ever had sexual intercourse and who have a cervix; discontinue regular testing after age 65 if Pap test results have been consistently normal.

AAFP ACOG ACS AMA CTFPHC NIH

USPSTF AAFP ACOG

ACS AGS AMA

CTFPHC

USPSTF

ABBREVIATIONS FOR MEDICAL ORGANIZATIONS: AAFP = American Academy of Family Physicians ACOG = American College of Obstetricians and Gynecologists ACP-ASIM = American College of Physicians-American Society of Internal Medicine ACS = American Cancer Society AGA = American Gastroenterological Association AGS = American Geriatrics Society AMA = American Medical Association AUA = American Urological Association CTFPHC = Canadian Task Force on Preventive Health Care NIH = National Institutes of Health USPSTF = U.S. Preventive Services Task Force.

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Indications for Ultrasonography During Pregnancy

Estimation of gestational age for patients with uncertain dates or verification of dates for patients who are to undergo scheduled elective repeat cesarean deliver, indicated induction of labor or other elective termination of pregnancy. Evaluation of fetal growth Vaginal bleeding of undetermined etiology in pregnancy Determination of fetal presentation Suspected multiple gestation Adjunct to amniocentesis Significant uterine size/clinical dates discrepancy Fetal mass Suspected hydatiform mole Adjunct to cervical cerclage placement Suspected ectopic pregnancy Adjunct to special procedures Suspected fetal death Suspected uterine abnormality Intrauterine contraceptive device localization Biophysical evaluation for fetal well-being Observation of intrapartum events Suspected polyhydramnios or oligohydramnios Suspected abruptio placenta Adjunct to external version from breech to vertex presentation Estimation of fetal weight and presentation in premature rupture of membranes, premature labor Abnormal serum alpha-fetoprotein value Follow-up observation of identified fetal anomaly Follow-up evaluation of placental location for identified placenta previa History of previous congenital anomaly Serial evaluation of fetal growth in multiple gestations Evaluation of fetal condition in late registrants for prenatal care

Adapted from US Department of Health and Human Services. Diagnostic ultrasound in pregnancy. Bethesda, MD: National Institutes of Health, 1984; NIH publication no. 84-667.

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Drugs in Pregnancy and Lactation

Risk Factors (A, B, C, D, and X) have been assigned to all drugs based on the level of risk the drug poses to the fetus. Risk factors are designed to help the reader quickly classify a drug for use in pregnancy. They do not refer to breast-feeding risk. Because they tend to oversimplify a complex topic, they should always be used in conjunction with the Fetal Risk Summary. The definitions for the Factors are those used by the Food and Drug Administration (Federal Register 1980; 44:37434-67). Many older drugs have not been given a letter rating by their manufacturers and the Risk Factor assignments were made by the authors. If the manufacturer rated its product in its professional literature, the Risk Factor with be shown with a subscript M (e.g. CM). If the manufacturer and the authors differed in their assignment of a Risk Factor, our Risk Factor is marked with an asterisk and the manufacturers rating is shown at the end of the Fetal Risk Summary. Other Risk Factors marked with an asterisk (e.g. sulfonamides, morphine) are drugs that present different risks to the fetus, depending on when or for how long they are used. In these cases a second Risk Factor will be found with a short explanation at the end of the Fetal Risk Summary. We hope this will increase the usefulness of these ratings. The definitions used for the Risk Factors are presented below: Category A: Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of risk in later trimesters), and the possibility of fetal harm appears remote. Category B: Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence in later trimesters). Category C: Either studies in animals have revealed an adverse effect on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus. Category D: There is positive evidence of human fetal risk, but the benefits from the use in pregnant women may be acceptable despite the risk (e.g. if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). Category X: Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may be pregnant.
Drugs in Pregnancy & Lactation: A Reference Guide to Fetal & Neonatal Risk, 5th edition, G. Briggs, R. Freeman, S. Yaffe, 1998; William & Wilkins.

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FETAL HEART TRACING INTERPRETATION

Criteria ACOG definitions (May,05) (Adapted from NIH 1997 Statement) Normal: 110-160 BL is the approximate mean FHR to nearest 5; over 10 minutes; excluding periodic changes, marked by variability, or segments varying by >25 BPM; must be 2 minutes of uninterrupted BL / 10 minutes to be determined Fluctuations in baseline of 2 or > cycles per minute of irregular amplitude and frequency. No differential between short and long term. Document amplitude change as: Absent Minimal = 0-5 Moderate = 6-25 Marked = > 25 Visually apparent abrupt increase of > 15 BPM lasting between 15 seconds and 2 minutes; 2 to 10 minutes = prolonged accelerations; >10 minutes = change in baseline; At < 32 wks gestation an acceleration is >10 BPM for > 10 seconds ACOG definitions (1995) (May still be in use at some sites) Normal: 120-160 at term. ACOG Interpretation ACOG Management Suggestions Non-reassuring if outside normal range. (1995)

Baseline

Variability

Variations in successive beats in the FHR

Bradycardia is the initial response to hypoxia; Tachycardia may follow if hypoxia is prolonged or severe. Other causes can include brady or tachycardia as a result of fetal heart defects; tachycardia as a result of maternal fever. (1995) Flattening of BL may follow periodic changes indicating neurological depression. Other related factors are fetal sleep, medications. Absence of variability without periodic change is unlikely to be hypoxia. (1995)

Flattened BL is nonreassuring. (1995) In most cases, normal variability provides reassurance about fetal status(2005)

Accelerations

Increase over BL of > 15 BPM for > 15 seconds

Common with fetal movement

Presence is reassuring (2005) If not present in association with decreased or absent variability, attempt to elicit accelerations by either vibroacoustic stimulation or scalp stimulation. If accelerations result, acidosis is unlikely and labor can continue. (2005)
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Periodic Changes (Decelerations)

Should be quantified by depth and duration; recurrent is defined as with > 50% of contractions in 20 minutes

Commonly found changes in BL

Late Decelerations

Gradual decrease to nadir over > 30 seconds, with return to BL; nadir is after peak of contraction

Variable Decelerations

Abrupt (nadir in < 30 seconds) BL change of > 15 seconds for < 2 minutes, with return to BL. Vary in timing with contractions 2-10 minutes = prolonged decel > 10 minutes = change in BL

1. Determine etiology of pattern 2. Attempt to correct pattern 3. If unsuccessful, consider scalp stimulation or scalp pH measurement 4. Determine if operative intervention is warranted and how urgently(2005) Late decels: UDecreased fetal R/O excess shaped, gradual oxygenation contractions, onset and return, exceeding that maternal shallow (10-30 usually seen in hypotension, BPM) reaching labor; persistence of maternal hypoxia; nadir after peak of finding is more IMPROVE contraction. significant than oxygenation and Prolonged decels depth of decel. perfusion by > 60-90 seconds Prolonged decels maternal O2 by are more concerning mask; maternal lateral recumbent position; D/C Pitocin; give IV hydration ? tocolysis ? c-section (1995) Abrupt onset of Most common R/O cord prolapse slowed FHR with decels in labor; or rapid descent of return to BL; with persistent, fetal head. Give or without accels progressively maternal O2 by mask; maternal proceeding & deepening, following associated prolonged variables lateral recumbent position; D/C with umbilical cord are non-reassuring Pitocin; increase compression; vary volume with IV in depth, duration hydration; consider and shape. amnioinfusion Decreases to < 70 tocolysis BPM lasting > 60 ? c-section (2005) seconds or with slow return to BL are concerning. Prolonged decels are > 60 90 seconds

Decels are sometimes in response to fetal intermittent hypoxia

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Early Decelerations

Gradual decrease over > 30 seconds with nadir at peak of contraction Regular, smooth pattern of change in baseline

Sinusoidal

Shallow, symmetrical, Ushaped reaching nadir at peak of contraction Regular oscillations of the BL resembling a sine wave lasting > 10 minutes with 3-5 cycles/minute of 5 15 BPM change in BL. Without shortterm variability

Benign indication of No action needed fetal head (1995) compression

Rare, nonreassuring. Associated with chronic fetal anemia, severe hypoxia. Transient after some medications. Often confused with small, frequent, low amplitude accels which are benign

Non-reassuring (1995)

FHT Evaluation Conclusions: ACOG Intrapartum Fetal Heart Rate Monitoring, Practice Bulletin #62, May 2005 The false-positive rate of EFM for predicting adverse outcomes is high, has not been associated with a decrease in cerebral palsy rates, and is associated with an increased rate of operative interventions. With persistent variable decelerations, amnioinfusion reduces the need for emergent Cesarean delivery and should be considered. The labor of parturients with high risk conditions should be monitored continuously Reinterpretation of the FHR tracing, especially knowing the neonatal outcome, is not reliable The use of fetal pulse oximetry in clinical practice cannot be supported at this time. NIH (Electronic FHR Monitoring: Research Guidelines for Interpretation; NICHHD research planning workshop, 1997, Am J of Obstetrics and Gynecology, 12/97, 1385-1389.) Purpose of the consensus statement: Standardized and unambiguous definitions of FHR tracings to allow for research to establish recommendations for interpretations and subsequent evidence-based management. Current criteria are for human visual interpretation; future will be for computerized interpretations. If it is not possible to validly interpret tracings or predict outcomes with our current level of knowledge because of the lack of standardized research. The individual components of the FHR pattern do not occur alone and evolve over time; therefore a full description should include BL rate, variability, accels, periodic changes, and trends over time. Interpretation must be made in context of gestational age and maternal condition. General consensus has been reached: reassuring FHR includes normal BL, moderate variability, accelerations, and no decelerations. This tracing confers an extremely accurate prediction of a normally oxygenated fetus. At the other extreme, recurrent late or severe variable decelerations, bradycardia, and absent variability are predictive of current or impending fetal asphyxia. All other FHR patterns are controversial at this point.

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Multicultural Traditions as they Impact Womens Health Care

Although each individual patient will have her own beliefs and values, this general information is meant to help you understand how your patients religious and cultural traditions may impact her health care decisions. The information is NOT exhaustive but is representative and provided by community members and staff. Jehovahs Witnesses: for the most part accept routine hospital and medical procedures. Women would make individual choices on matters like pain medications, biopsies, tissue donation, end-of-life issues (including burial method), labor management, and baby feeding methods. There are no special requirements for disposition of the placenta. There are no sacraments or rituals that need to be observed. The only religious holiday observed is the Last Supper, during which a minister or church elder would visit the hospitalized woman. On the other hand, some medical treatments are prohibited as against Gods law. These would include elective abortion and any infertility treatment that required masturbation or surrogacy (which would be seen as a form of adultery). There is a strict prohibition against the transfusion of any blood product. Autologous blood transfusions are prohibited. The decision to use serum injections containing minute blood derivatives is left up to the individual Christian conscience (this would include RhoGAM). For cases like postpartum hemorrhage, non-blood expanders, plasma volume expanders, and IV solutions are acceptable. Birth control methods are a matter of individual conscience as long as they do not act after conception. Active or passive euthanasia is not acceptable. Judaism: The Jewish religion is practiced very differently by individual adherents. These interpretations were offered by an Orthodox rabbi. Jews live by the commandments of Jewish law but they are not expected to die by them. For example, there are several religious occasions that require a time of fasting (no food or drink). These fasts DO apply to pregnant and nursing women, but if fasting would be a health risk, preservation of life takes precedence over religious practice. The fasts generally are NOT applied to women in labor and for 3 days postpartum, or 30 days for nursing mothers. Non-urgent care (elective surgery, office visits) should not be performed on the Sabbath or on major Jewish Festival days. A rabbi should always be consulted if there is a question about interpretation of how the law affects a particular health care situation. Jewish Law mandates that the sick seek care from a physician, but some Hasidic rabbis may ascribe to some spiritual healing, and may be requested by the patient to provide a second opinion. Male circumcision should be performed by a ritual circumcisor on the 8th day of life. It can be delayed for medical contraindication. Some liberal Jews would have this procedure done by a pediatrician. In cases of OB emergency, the mothers life takes precedence over that of the fetus until the birth of the infants head. At that point life is considered to be separate and each case must be viewed individually. Although the physician should not shorten life, if the patient will not be able to respond to treatment, no heroic measures need be taken. If there is a death, the human remains should be kept intact if possible. (Autopsy is generally discouraged, but if it is required for some reason, all body parts must be returned for burial together. Needle aspiration biopsies are recommended when possible.) Newborns are still considered fetuses for the first 30 days of life. Any fetus must be buried, but there would not be a ritual mourning period as there would be for an adult or older child. Cremation is not in keeping with Jewish Law. Because blood is considered a sacred body part, a family might ask that any blood soaked clothing be returned for burial with the body. The placenta does not need to ritually disposed of. Organ donation is permissible. Abortion is only permissible if continuation of the pregnancy presents grave physical or psychological danger to the mother. In general, complicated cases should be reviewed by the rabbi. Premarital testing, for example for Tay-Sachs, is allowed. If positive, the suggested solution would be not to marry. Infertility treatments are generally allowed, although semen analysis is not encouraged and sperm donation is not allowed. Artificial insemination is not allowed, unless the sperm is that of the husband. There is no prohibition of egg donations, but inheritance laws would be difficult to interpret, so it is not encouraged. Sterilization is prohibited (wasting of the potential for life). Acceptability of other birth control options varies, but generally Orthodox men can not have vasectomies, practice coitus interruptus, or use condoms. Examples of other applicable Jewish Law include: 1) Tsnuit law of modesty and dignity of the human body (Orthodox women wear clothing that
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covers their elbows and knees, and usually wear a hat, scarf or wig to cover their hair because it is considered a private part of the body. The husband would not want to be present if his wife were immodestly exposed. Hospital attire, draping and procedures should be modified to allow for these customs. 2) Niddah laws that define times when the husband and wife must be physically separate. These laws hold true in labor, but when they start varies by interpretation (first regular contractions, rupture of membranes, bloody show, full dilatation, or when the mother cannot walk unassisted are all used as markers). Ask the couple what their plan is. Once commenced, the husband can support his wife by his presence, but other supporters would have to offer physical aids like massage and assistance. 3) Kashrut laws for eating and drinking (keeping Kosher) include ritual hand ashing before eating. The dietary department should be able to help with special requests. Islam: Generally, any therapeutic regimen is allowed. For example, although all intoxicants are normally prohibited, they would be allowed if necessary for treatment. A woman who is Islamic will want to pray the prescribed 5 times a day (before sunrise, just after noon, late afternoon, at sunset, and 2 hours after sunset). She will need to perform ritual ablutions before prating. She will practice ritual genital washing after voiding. Prayer is usually done kneeling on a prayer rug, but for patients who cannot adopt this position, sitting is allowed. Although fasting is one of the 5 pillars of Islam, the following are considered exempt: pregnant and nursing women, the physically aged, and the infirm. Women who are menstruating are not expected to pray or fast. Birth practices include ritual words that are whispered into the ear of the newborn, either by the parent or by a relative. Circumcision is expected, but not ritualistic. Modesty is expected at all times women should cover their hair and be covered to the ankles and elbows. The husband will usually leave the room for exams. All exams must be done by a person of the same sex, if at all possible. In case of death, ritual washing of a Muslim of the same sex is required, followed by burial (not cremation). Autopsy is only done if imperative, and then all tissues must be buried. A fetus is considered a separate living being 140 days (18 weeks) after conception and should have a separate burial. Transplants of organs are allowed if need is immediate and lifesaving, but no donation is appropriate to a donor bank. Genetic testing is permissible, but abnormal results are never justification for pregnancy termination. Fertility treatment is allowed between a husband and a wife. There are no specific restrictions related to masturbation that would effect infertility testing. Artificial insemination is only allowed between spouses. Abortion is not generally permitted. The life of the mother and the fetus are seen to be equally valuable and sacred. Sterilization is permissible only if future pregnancy would put the mothers life in danger. Other birth control methods may be used as long as they do not break the law that what is harmful to the body is prohibited. A note on female circumcision: Although practiced in some Muslim countries, female circumcision is considered a cultural rather than a religious tradition. It is most commonly practiced in parts of Africa and is mentioned in Egyptian texts dating back to 3,000 BCE. Female circumcision techniques vary between geographic locations and can involve a range of amputations, from removal of the clitoral hood only to infibulation, which s the removal of the clitoris and the labia minora, with surgical approximation of the labia majora to obliterate the introitus. A small posterior opening is left for urination and menses. Depending on the extent of the approximation, the majora may need to be surgically released to allow for intercourse or childbirth. Cultures that practice female circumcision hold that it promotes fidelity, decrease transmission of HIV, increases facial beauty, and/or decreases ,masturbation, homosexuality, and neuroses. Side effects include hemorrhage, infection, shock, death, painful scarring, chronic infections including UTIs, sexual dysfunction, obstructed labor, and depression. Vietnamese & Southeast Asian: The family takes precedence over the desires of the individual in Vietnamese culture. Families traditionally have lived in multi-generational households. Elders are cared for by the family and would choose to die at home whenever possible. The eldest son is in charge of organizing the commemorations involved in ancestor worship. Having a son is important in the Vietnamese culture. First and second generation Vietnamese teens have additional stress as they attempt to incorporate new cultural noms into the framework of their families traditional teachings. Touching in public is not the norm, with the exception that female relatives / friends hold hands and elders can touch the heads of small children. Traditionally, in Vietnam there has been an importance placed on signs that portend good luck or bad luck healthy children and dogs are signs of good luck; pregnant women, people in mourning, sick or dying people, physically unusual
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people and certain animals (cats, crows, snakes, etc) are bad luck, and are to be avoided especially during celebration periods. Pregnant women or ill people would be expected to avoid celebratory gatherings. If a pregnant woman attended a funeral, her baby might catch the sorrow and cry all the time. Incense is used as a method of pacifying evil spirits, for example during times of illness. Traditionally, postpartum women are advised to limit fluid and avoid bathing or showering for up to one month. Excess contact with water is thought to bring on fever. Sponge baths are allowed. Vietnamese women drink ginger tea to clean the system and decrease cramping and clotting. Traditionally Vietnamese women were encouraged to drink urine, especially the urine of toddlers, for the first month postpartum to aid vitality. Certain foods were to be avoided postpartum, especially raw fruits and vegetables. Male circumcision is not a tradition. Traditions in Southeast Asia vary widely. Many relate strongly to the astrology depicted in the Chinese zodiac; newborns may be given their own astrological drawing of the future. Women may defer to readings as a way to aid decision making. In Laos and Cambodia, pregnant women are not considered with the sick as bad luck. Korean women drink quantities of pungent garlic soup postpartum and often bring crock-pots to the hospital to make this medicinal brew. Cambodians traditionally have a one month period of seclusion which girls participate in when they reach puberty assuming a vegetarian diet, a girl will stay in a darkened room and be visited only by her mother. Burial rites vary: Vietnamese tend toward burial, Cambodians to cremation. Catholicism: While the Catholic Church does issue directives to the faithful, it recognizes that each person is her own moral agent and must make her own conscientious choices. Catholic women from different cultures may exercise their religion very differently. In general, the Catholic Church holds respect for life as a priority and has used this tenet to condemn abortion, sterilization, euthanasia and infertility treatments that involve risk to viable embryos. Human sexuality is seen as an expression of the whole person and the integrity of unitive and procreative elements within a marriage relationship are stressed. Contraceptives are not generally accepted in official Church teaching. Our Catholic hospital chaplain said, Abortion is a lightning rodA priest would be at a loss for being able to support a choice for abortion prior to the actuality, but there might be an important role for a pastoral referral during the time of recovery and healing. If OB crisis indicates possible imminent death of a fetus or a newborn, ascertain how the mother feels about baptism. ANYONE attending the delivery is able to validly baptize the infant by pouring water over the babys head while saying, I baptize you in the name of the Father, and of the Sone, and of the Holy Spirit. Amen. The Pastoral Care Office has the necessary information to document this event. In the case of a stillborn, contact a priest ahead of time if the mother desires. The Catholic Church sees sacraments like baptism as important for the living, but a blessing may be bestowed upon a stillborn. Exceptions to this general rule can be made for the sake of the emotional well being of the parent(s). Latin Americans: There are many Latin American populations in the US and patients represent a wide variety of cultural, religious and individual beliefs. Most Latin American cultures put a strong value on family involvement (and families can included a large network of blood relatives, in-laws and close non-blood relationships) and stoic self-sacrifice. This particularly effects women: self-medication is common, patients may indefinitely defer attending to their own health care needs, decisions may be deferred to allow for family input, domestic abuse may be tolerated by the patient and accepted by her family. Also, while cultural norms often dictate that a man protects his female partner from any outside threat, this doesnt apply to condom use and STD prevention. In some cultures male promiscuity is seen as a normal sign of machismo. Some Latinas are taught that sex is a duty that they dont have to participate in during pregnancy. The mother tends to attentive and indulgent; discipline is left to the father. In labor, some Latin cultures expect women to be very emotionally expressive, in others stoicism is the norm. In expressive cultures, it is common to have many female relatives present at a birth, with lots of hands-on comforting and massage. He laboring womans mother may be especially expressive, with much weeping and hand-wringing. In some South American countries, particularly Brazil, C-section on request is the norm and the rate of cesarean births in some areas exceeds 60%. Indications can include convenience, desire to avoid pain, and a desire to protect the pelvic floor. A Brazilian woman may find it difficult to understand the US C-section policies. It is very common for Brazilian women to breast-feed their babies. Male circumcision is not the norm among Brazilians, but is on the rise for babies born
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in the US whose parents want them to be more American. In Worcester, many of our staff and patients are Puerto Ricans. Puerto Rican newborns are often immediately adorned with gold charms used to ward off the evil eye and prevent bad luck. There are several dietary challenges to consider when providing care to pregnant Puerto Rican women carbohydrates and fats make up a substantial portion of the average diet, green and orange vegetables are rarely a staple, and the popular beverage, Malta, does not contain alcohol according to the label.
Thanks to Tuyet Nguyen, Abby Martinez, Maggie Primeau RN, Father Tom Landry, Ileana DaSilva and Ty Fraga.

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Normal Laboratory Values in Pregnancy

Hematology: Anemia is difficult to diagnose and lab findings must be judged by pregnancy specific standards. Erythrocyte sedimentation rate (ESR) increases markedly and is of little diagnostic value in pregnancy. Ferritin (serum) decreases markedly, by 30% in the 2nd trimester, then remains stable at this decreased level. Folate (plasma) varies widely within any individual over a 24 hour period but typically decreases 50% toward term. Hematocrit decreases 5% by 36 weeks without iron supplementation, 3% due to the increase in plasma volume. Hemoglobin decreases 10% below non-pregnant levels without iron supplementation, 2% with supplementation. Serum iron decreases approximately 35% toward term, actual amount varies markedly between patients, even those who take iron supplementation. Serum transferrin increases by 100% or more during the 2nd trimester. Total iron binding capacity normally increases by 25-100%. White cell count increases markedly due to increased neutrophils. No change in eosinophils and lymphocytes. [Pre-pregnant norm 5640/microliter (SD 1001) to 10,240/microliter (SD3390) at 36 weeks; rates elevated even further during labor and the puerperium to 15,000-30,000 and continue elevated to 6 weeks postpartum] Chemistry: Albumin/globulin ratio decreases due to decreased plasma albumin and a lesser decrease in globulin. Alkaline Phosphatase normally doubles. Blood urea nitrogen (BUN) reduced; (8.17 SD1.5mg/100ml in pregnancy; 13 SD 3 mg/100ml non-pregnant). Creatinine decreases markedly in the 1st trimester, stabilizes during the 2nd, and increases slightly toward term, but remains below non-pregnant norms. (Non-pregnant norm 0.89mg/dl; 12weeks gestation 0.68 mg/dl; 38 weeks gestation 0.73 mg/dl) Calcium decreases slightly Glucose FBS decreases in the 1st trimester and then stabilizes. Postprandial levels take longer to peak (55 minutes after consumption vs. 30 minutes in non-pregnant women) remain elevated longer, resulting in delayed return to fasting levels (Normals at UMMHC: 1 hr after 50 gm Glucola < 135; normal fasting <95, after 100 gm GTT, 1hr < 180, 2 hr < 155, and 3 hr < 140) Lipids (triglycerides, cholesterol, phospholipids) all increase progressively to term and are of little diagnostic value. Magnesium decreases 10-20% during the 1st half of pregnancy with a possible small increase toward term. Potassium decreases about 0.5 mEq/liter in early pregnancy and then stabilizes. Sodium decreases during early pregnancy by about 3 mEq/liter and then is stable. Thyroid stimulating hormone (TSH) unchanged in pregnancy. Monitor q trimester in patients on thyroidreplacement because increased estrogen levels can cause increased levels of thyroid binding proteins. T3 total increase; free fraction is unchanged. T4 increases. Uric acid decreases markedly during the 1st trimester, stabilizes and then increases slightly toward term (Nonpregnant average 3.9mg/dl; 12 weeks gestation 2.9mg/dl) Clotting Factors: Platelets decrease slightly but remain in normal range. Fibrinogen increases to 400-500 mg/dl at term. Factors VII, VIII, IX, and X increase.
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Factors XI and XIII decrease by 30% or more by term. Fibrin and fibrinogen degradation products increase progressively throughout pregnancy. Bleeding and clotting times do not change. Urinary Values: Culture colony counts as low as 25,000 single pathogenic organisms are considered treatable as asymptomatic bacteria in pregnancy. Urinary Output 24 hour volume is unchanged Glucose excreted in increasing, random amounts and is not diagnostic of blood glucose abnormalities. Protein 24 hour excretion is unchanged; normal <300mg.24hrs Ultrasound Findings Amniotic fluid index > 8 is normal; <5 is critical Biophysical Profile results of < 6 of 8 are abnormal (fetal breathing is not always witnessed during the time allocated). Sources: Special thanks to Ellen Delpapa, MD, Maternal Fetal Medicine Compendium of Selected Publications, 2001, ACOG. Current OB/GYN Diagnosis and Treatment, DeCherney & Pernoil, 1994. Maternal Physiology, Lind, 1985. A CREOG Monograph.

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Suggested Documentation of Findings: Breast & Pelvic Exams

The physical exam of the breasts and pelvis provides a two-pronged opportunity: 1. The physician gathers invaluable information about the patient, not only anatomical and structural data, but also indications for how the patient relates to her own body. 2. The physician uses the time to teach the patient information she should know about herself and her body. Accurate, descriptive, comprehensive, legible documentation of physical exam findings is extremely important for communication with the health care team. Documentation serves several purposes: 1. It aids in identifying changes that may be harbingers of disease. 2. Treatment outcomes may be evaluated. 3. Thoroughness and quality of care demonstrated through appropriate charting may prove invaluable in legal defense at a later date. BREAST EXAM 1. Symmetry (symmetrical, asymmetrical, L>R) 2. General appearance discoloration (ecchymosis, erythema, peau dorange skin changes), dimpling, increased venous prominence, papules, pustules, and supernumerary nipples. 3. Masses or nodules (no masses or describe findings of masses: location (reference by clock face and centimeters from nipple), size (in centimeters), shape (round, discoid, irregular, stellate), consistency (soft, firm, hard), demarcation (well circumscribed, poorly circumscribed), mobility (mobile or fixed), tenderness. 4. Regional lymph nodes (negative nodes or describe) 5. Nipple structure (especially in OB patients, or if nipples are asymmetrical everted, flat, inverted, etc) 6. Discharge (present or absent) Color (bloody, clear, yellow), multi-ductal vs. uni-ductal, bilateral vs. unilateral. PELVIC EXAM 1. External genitalia: Hair pattern (normal escutcheon/female hair pattern/male hair pattern with increased growth on abdomen and thighs), pediculosis, skin changes (erythema, excoriation, ecchymosis, loss of pigment, ulcers, vesicles, pustules, warty growths, nevi, pigmented lesions, atrophic thinning, abnormal clitoral length > 1.5 cm), status of hymen (intact, interrupted, imperforate), introitus, urethral meatus (suburethral diverticulum, eversion), perianal inspection (hemorrhoids, lesions), cysts of Skenes or Bartholins glands (size and tenderness), cystocele, rectocele or cervical prolapse (Stage 1 cervix to vaginal canal, Stage 2 cervix to introitus, Stage 3 cervix through introitus). 2. Vagina: Walls (normal rugae, decreased rugae), lesions, cysts (clear, flocculent, tender, erythema, erosions), discharge (color, odor, consistency) 3. Cervix: Normal is pink, shiny with no lesions. Nullip os is round, multip os is fish mouth, slit. Describe any other findings: lacerations, ectropion, lesions 4. Uterus: Position other than normal (anteverted and anteflexed), size if not near 7cm x 5 cm x 2.5 cm in nullips and 1.5 cm larger in each dimension for multips, shape, consistency, mobility, tenderness and nodularity. Describe enlargements either by cm or by comparison with weeks of normal gestational size; on average a 12 week gestation uterus is globular and 8 cm in diameter.

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5. Adnexa: Average size is 4 cm x 2.5 cm x 1.5 cm (large almond or walnut in women of menstrual age) Comment on size greater than or less than normal, immobility, unusual firmness or tenderness. Not palpable is the normal in pre-pubertal and post-menopausal women. 6. Rectum: Note decreased sphincter tone, masses in the rectovaginal septum, thickening or beadiness along the uterosacral ligaments, hemorrhoids, fissures, skin tags, occult blood test results.

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GUIDELINES FOR PROFESSIONAL BEHAVIOR

The Faculty and Student Body of the University of Massachusetts Medical School regard the following as guidelines for professional behavior. These areas are derived from the school's Technical Standards (see Student Handbook). Students are expected to show professional behavior with or in front of patients, members of the health care team, and others in the professional environment (school, hospital, clinic, office) including members of the faculty and administration, other students, standardized patients, and staff. Faculty members and administrators are expected to abide by similar standards.

PROFESSIONAL ATTRIBUTES Displaying honesty and integrity

Never misrepresents or falsifies information and/or actions (ie cheating) Does not engage in other unethical behavior

Showing respect for patient's dignity and rights

Makes appropriate attempts to establish rapport with patients or families. Shows sensitivity to the patients' or families' feelings, needs, or wishes. Demonstrates appropriate empathy. Shows respect for patient autonomy. Maintains confidentiality of patient information

Maintaining a professional demeanor

Maintains professional demeanor even when stressed; not verbally hostile, abusive, dismissive or inappropriately angry. Never expresses anger physically. Accepts professionally accepted boundaries for patient relationships Never uses his or her professional position to engage in romantic or sexual relationships with patients or members of their families; never misuses professional position for personal gain. Conforms to policies governing behavior such as sexual harassment, consensual amorous relationships, hazing, use of alcohol, and any other existing policy of the medical school. Is not arrogant or insolent. Appearance, dress, professional behavior follow generally accepted professional norms

Recognizing limits & when to seek help

Appears aware of own inadequacies; correctly estimates own abilities or knowledge with supervision Recognizes own limits, and when to seek help

RELATIONSHIP TO OTHERS Responding to supervision

Accepts and incorporates criticism in a non-resistant and non-defensive manner Accepts responsibility for failure or errors.

Demonstrating dependability and appropriate initiative

Completes tasks in a timely fashion (papers, reports, examinations, appointments, patient notes, patient care tasks) Does not need reminders about academic responsibilities, responsibilities to patients or to other health care professionals in order to complete them. Appropriately available for professional responsibilities (ie required activities, available on clinical service, responds to pager) Takes on appropriate responsibilities willingly (not resistant or defensive) Takes on appropriate patient care activities (does not "turf" patients or responsibilities)

Interacting with other members of the team

Communicates with other members of the health care team in a timely manner Shows sensitivity to the needs, feelings, wishes of health care team members Relates and cooperates well with members of the health care team

Approved by the Education Policy Committee 11/01

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