Tag: oms

Hello hello!

I have to say, as my first rotation EVER as a third year, it was a bit daunting to have ob/gyn. If you aren’t a female, have never had a pregnant wife, OR you just haven’t ever needed to go to an ob/gyn before, it can be incredibly scary to go on this rotation. But also super exciting as you get to see patients!

I would say a fair amount of inner anxiety occurs before the first rotation in general. How will it go? What do I need? I have to talk to patients… WhAT? I might have to do a sensitive exam… oh no! I have to present and take a history! I have to chart! How do I even study during rotations?

So. much. anxiety.

BUT, that doesn’t matter what rotation you are in. Well, except the sensitive exam part lol. You are going to have anxieties before every rotation just because you haven’t experienced that before. And your first one is especially nerve-racking!

Not to mention the Ob/gyn specific nerves:

Babies?!? I can’t touch a baby! It’s so fragile!

Vaginas! But will the patient let me be part of the exam? Will they let me do it?

How do I even re-assure a pregnant lady when I’ve never been pregnant? I don’t even remember what I need to know for pregnancy!

Obviously I was thrilled to get out of books all day and start seeing patients. Well, the laughs on me because I was signed up for the hybrid model by my school (will probably do a post on it later) which caused more uncertainty. So I ended up only having half my rotation in clinic, and half doing didactics. I most definitely had extra assignments whereas my other classmates didn’t. But, it didn’t take away from the awesome experience I got while in clinic those 2 weeks.

What does ob/gyn entail?

Ob/gyn is a core rotation. Meaning everyone needs to do that rotation. Our school has 6, and they are pretty similar across the board. We need to do internal medicine, family medicine, pediatrics, ob/gyn, general surgery, and psych. We need to do two months in IM and surgery; one is usually the core part, and the other is usually a subspecialty within it. For example, one month will be general surgery, but the other month may be ENT or urology.

As a core rotation this also means you will have a shelf at the end of it. A shelf (or a COMAT in DO land) is the standardized test you take after your core rotation. The year I took it, my exams were self-proctored and were 125 questions. You got about 2 hours to do it… which didn’t feel like enough. You then find out in about 7-10 business days how you did. They do tend to “curve” a bit based on how everyone who took that specific COMAT/shelf did.

Ob/gyn is both inpatient and outpatient. So you will see patients in clinic and you will be in the OR and seeing patients in the hospital. It is a great mix; so if you want a bit of procedures and surgery but also get to see a lot in clinic, this is the specialty for you! A lot of physicians who go into ob/gyn are very passionate about women’s health. And although we have made great strides in this area of medicine, it still does need passionate providers and improvements in areas in the USA.

I happened to do my ob/gyn rotation at an ob/family medicine clinic. So unfortunately, I really didn’t get to see a lot of gynecology or gynecologic procedures. Which did hurt me a bit on my COMAT and my education. I’m hoping to get to see more on say my family medicine. But I did get to see a lot of preggo ladies and TONS of kids! Not to mention my preceptors were really awesome and allowed me to be hands on with almost everything.

What was my day like?

I touched on this a bit in another post, but basically because I was only in clinic for two weeks I wanted to be on call for the full two weeks to maximize my time. Although my providers didn’t want to risk my life while trying to drive to the hospital in the middle of the night, so they usually didn’t call me.

BUT, I would usually get there around 6:30-7 am or sooner. I would check in with any mothers on the labor & deliver floor (L&D as it is called), check in with the nurses, and see how patients were doing. The mothers who did give birth I would check up on them and baby. Good questions to ask:

Vaginal deliveries (mom):

• How are you feeling? (always good to develop rapport with the patient)
• Any pain? (they will usually refer to their cramping pain, but you do want to make sure nothing else is going on)
• How bad is your cramping?
• How much bleeding have you had? If you were to compare to your period, is it light, normal, or heavy?
• Are you breastfeeding? If so, how is that going? Any concerns?
• If they are, ask if there is any pain or redness. They shouldn’t have a mastitis, but any breastfeeding mother is at risk.
• Any other concerns/questions you have that I can relay to the doctor on call?

If you weren’t present for the delivery, it is always good to see what happened during it. Did mom need stitches? Did baby need vacuum or forceps? Did mom need to be taken to c-section? Is she GBS + ? (or group B strep). Did she have prolonged labor? Were antibiotics started? Did she use an epidural?

All of these are good for mom and baby to know.

Also, lochia= bleeding that happens after birth. It happens no matter if you have vaginal or c-section. Same with cramping.

For c-section:

• Ask the same as above except add:
• How is your incision? Any pain?
• Have you passed any gas or had a bowel movement yet?

As a medical student, always listen to heart and lungs of mother. If you are able to, look at mom’s incision if she is post c-section. If you are feeling savvy, do an abdominal exam; but you don’t really need to.

And ask mom/dad about baby:

• How’s feeding going?
• How often are you feeding? (they may have been given a chart by the nurses to write down times and amounts to keep track)
• Have they made a poop yet?
• Have they made a wet diaper yet?
• Any concerns?

You should ALWAYS do a newborn exam every time you see baby. Look for anything different or to see if anything has changed/improved. A lot of times mothers will have difficulty with latching/breastfeeding and are concerned baby hasn’t eaten enough. I really suggest asking your provider about this early on, so you can help re-assure mommas about this. And if any vacuum/forceps used, make sure to see if the swelling/hematoma has improved on baby!

After I would head to clinic. Thankfully, it was just a short walk outside to get between the two!

Depending on the day and provider, we would have clinic from 7/7:30a-4pm. Since I was on my ob rotation, I saw a lot of the ob patients. Which was great practice on how to measure fundal height, find fetal heart tones, and do GBS swabs. I unfortunately only got to try to examine how dilated a woman was once and that was while she had an epidural.

I don’t blame my providers for saying no to that in clinic though. It is uncomfortable. You have someone shoving a hand up your hoo-ha and bothering your very sensitive cervix to see how dilated you are. Not to mention, if they sweep your membranes (a method to try to induce mom naturally), the provider has to stick their finger through the cervix and try to separate the amniotic sac from the wall of the uterus. Which is also not pleasant and incredibly painful.

So long story short, I didn’t get to practice that much. And that’s okay.

After clinic, we would check in the hospital again and see who was ready to give birth and round on anyone new who came in!

Most days I was pulling about 12 hours. I had just enough energy after going home to eat, shower, and then pass out. Since my body had been sitting on my booty the past several years and just being mentally tired from studying, being physically tired was a whole new for me. But it meant I slept like a baby at night lol.

Patient Encounter:

So I discussed some of the things that you would ask while moms are post-birth above. But seeing mother’s in clinic will have a set of different questions.

Since baby grows up to 40 weeks, there is a lot of variation on what you can ask; however you will usually ask the same set of questions. I tended to stick to the same ones regardless of gestational age, and that is just so my learning baby doctor brain could understand it. But here is how things go:

1. New pregnant ladies get a large workup. Lots of blood work, urine, and full history and physical. Things that are usually checked are antibody titers, HIV/AIDS, STI’s, UTI’s, and chronic medical conditions. This is where you will get the baseline for the mom before pregnancy is far along, treat what you need to, know what you need to be on the lookout for, and manage early.
2. There is usually an ultrasound before 20 weeks just to verify gestational age. Ultrasound measurements are MOST accurate in the first trimester, or between weeks 1-12. However baby usually won’t start showing up until around 5 weeks. After that, the ultrasound measurement for gestation will not be as accurate. If I remember correctly, its +/- 2 weeks in second trimester, and +/- 3 weeks in third trimester. So they want that early one to verify gestational age as mom’s last menstrual period is not always accurate.
3. The anatomy scan will be at around 20 weeks. This is usually where you find out the sex and if there are any concerning findings with baby’s anatomy. Things looked at are amniotic fluid index in all four quadrants of the amniotic sac, limbs, head, all that fun stuff. Heart beat of baby is usually heard, and verifying how many vessels are in the umbilical cord are assessed. Kidney size is another big thing looked at here.
4. You will have them see a doctor once every four weeks up until week 28 gestation. Remember, first trimester is where organs are formed. Second is where organs enlarge/improve injunction. From 28-36 weeks they are evaluated every 2 weeks. After 36 weeks you see them weekly until birth of baby.
5. Gestational diabetes is evaluated weeks 24-28 (whenever their appointment falls in that timeframe) unless there is an issue earlier. Such as previous history of gestational diabetes, obesity, or other concerns.
6. GBS swab is done weeks 35-37. If mom is +, it’s no big deal for her. But it can give baby meningitis. So we treat mom.
7. UTI’s even if asymptomatic are treated as they can cause kidney infections in mom. So always do a urine screen. Usually multiple bacteria or >100,000 colonies per (I forgot the measurement, the lab result will tell you) you need to treat.

That’s a pretty good baseline to start with. When you are deep in your studies for this rotation, you’ll look into more details. I’ve switched on to my next rotation of study, and the ob details are a little hazy.

Questions to ask pregnant ladies in office:

• How are you feeling?
• Confirm pregnancy gestation and how many previous births they’ve had (or gravid and para) and how far along they are. This is usually charted for you, but it is always good to check and practice asking as a medical student.
• Any new complaints/concerns?
• Any vaginal bleeding, itching, or new discharge? (rule out abortion or vaginal infection)
• Any urinary symptoms such as urgency, frequency, bloody urine, or low abdominal pain? (rule out UTI)
• Any large gush of fluid noted? (rupture of membranes). Most moms first time moms will not be able to distinguish if they just peed or if their sac ruptured. If it ruptured, you can explain that their underwear would be soaked through repeatedly even after changing it. A multiple time mother will usually know, but always good to check.
• Feeling baby move? * This one is super important. If mom is worried about decreased movement, we need to get her hooked up to a non-stress test or fetal monitoring to make sure baby is okay and not in distress. But mom won’t be able to feel baby move until probably 16-25 weeks, usually closer to 25 weeks.

The other big thing to discuss is postpartum contraception and screening for postpartum depression. In general, especially if breast feeding, you want them to stick to a progesterone only contraceptive. This includes:

• mini-pill
• injection (such as implantable Nexplanon in arm or Depo-Provera shot)
• IUD (copper or progesterone only)

At the office I was at, since mom’s needed 6 weeks of pelvic rest post delivery, contraception was initiated then. You can give mom’s combined contraception (estrogen and progesterone), but there is a window that you should wait to give it. Giving it sooner increases the chances of DVT. However, if you leave mom with no possible contraception for able to give combined therapy, you risk her getting pregnant. And any pregnancy that occurs within 6 months after delivery has a much higher chance of miscarriage; so providers for the most part recommend waiting to get pregnant.

In general, the office I was at opted for the progesterone only option for a bit and then much later discussing switching to combined, especially if not breastfeeding baby.

Delivery!

Oh my, this was by far my favorite part! Even though you are gowned up, expect to get dirty. So don’t wear your own scrubs; try to change into the hospital scrubs before your shift. I definitely got peed on, pooped on, and lots of amniotic fluid and blood all over me despite the barrier. It happens. A lot of things occur with the body when you push out a baby in a hole the size of a large donut. I guess it depends on the person.

And then the mom has to deliver a dinner plate sized placenta. So, a lot of stuff is going to happen. Don’t make mom feel embarrassed. She already has her bits exposed to the world to deliver the baby, and you are basically constantly shoving your fingers in there to help prevent her tear, or help get baby out. Don’t make it more embarrassing for her.

Also if you are squeamish about it I just have to say: get over it.

But basically, your provider may push down on the perineum/posterior vaginal wall during birth to help stretch out the area and try to minimize tears. If labor progresses slowly, usually tears occur less. If it is super quick, the body/skin hasn’t had time to adjust and stretch so more tears occur.

Head massages to the baby help stimulate them. So when they are mostly “stuck” when trying to push past mom’s pubic bone area, this can help them. I say “stuck” in quotes because if baby was actually stuck that’s a medical emergency. But going through the pelvic bone area is the hardest part of labor and usually takes the longest.

Also, it is not uncommon for mom to push and baby to come forward more, but then almost get sucked back in. This is also normal! It is basically baby isn’t far enough along, and since they still have the ability to go back in they will.

Once baby is about ready to pop (or their head is practically poking out), make sure you have your hands at the 12 and 6 o’clock positions. Place them on the baby’s head to help guide them and stick ONE finger through to check for nuchal cord. Otherwise, once there, loop under their SHOULDERS. Do not grab their neck. Much harder said than done, and I definitely had a hard time with that one. Babies are hella slippery, and if you don’t have a good grasp they can fly out.

No one wants that.

Once out, whether you are in charge of this part or not, help suction out their mouths to help make them do a big ol cry. They gotta start using those lungs, and the best way to open up their alveoli is to do that giant scream! Crying babies = good healthy babies. Quiet babies = not good.

If able to (no issues with birth/baby/mom), place on momma so there can be skin to skin. Baby will need to be on lower belly though, because cord is still attached to the placenta, which is still inside mom….

While baby is being dried off vigorously to help cry and pick up by nurses/staff (maybe that’s you!), your job is to feel the cord. If still a pulse that is strong, don’t cut yet. Let baby get that extra bit of blood from the placenta.

When pulse has weaned, the provider (you usually don’t get this pleasure) will clamp the cord and use hemostats to clamp the other side. They will usually have dad cut the cord in-between the two areas.

Then you are in the clear to help deliver the placenta. In general, you want cord blood first. If using the needle, pull the cord down and place the bevel of the needle up. Find the VEIN. You know, the giant, spirally thing. Pull blood from this. Unless you need an ABG (issue with baby), you should go for the vein. If an ABG is needed, you’ll need to find one of the tiny arteries… Maybe you should let the provider do that one. It’s easier to miss.

The other common way is actually to unclamp the end of the cord and allow blood flow to just fill up the tubes itself. I’ve seen both ways. They are both messy. And honestly, if you don’t clamp down where you’ve poked the cord it’ll squirt blood everywhere. IT’S SUPER HIGH PRESSURE. I SPRAYED THE ENTIRE ROOM… Learn from my mistakes people.

After that you deliver placenta! Use traction (gentle, don’t tug and rip off the placenta and cause hemorrhage here). Some moms will deliver this easy. Some will need fundal massage. If it’s past 30 minutes, you’ve got yourself a retained placenta. As a student, you need to step away. Because at this point the provider needs to stick their arm up there and manually detach the placenta.

Check the cord for all three vessels, and look at the placenta to make sure there aren’t any abnormalities. If there was an issue with labor or the placenta, it will be sent off to pathology. If not and it’s healthy, it will be discarded later.

And yea, that’s pretty much it! If there are any tears, they will need to be fixed. But as a third year medical student you’ll be luck to deliver placenta or a baby. So watch the repair, but don’t be surprised if you don’t get to help much.

Gynecology:

Again, I unfortunately didn’t get to see much of this. In general, you still need to check for any change in health history (diabetes or recent antibiotics = increased risk for yeast infections), sexual history, vaginal symptoms, urinary symptoms, pregnancy history, and any other concerns they have. Oh, and breast concerns/symptoms such as pain, redness, lumps, or discharge. It is a focused exam, so you don’t need to do a head to toe exam.

The guidelines for Pap smears based on age change frequently. Look up the current guidelines before your rotations, but here is one from the American College of Obstetrics and Gynecology:

ACOG:

• Screening should no longer be done on women before the age of 21.
• Ages 21-29 should have pap testing once every 3 years. No need for HPV testing (although if pap comes back normal there are different flow charts to help you evaluate the cause).
• Ages 30-65 should have pap and HIV co-testing every 5 years. Pap testing alone can be done every 3 years, but is not preferred.
• After 65 it is not recommended to be regularly tested. Again, if there is a history of abnormal Pap smears or someone comes in with new signs/symptoms, the approach to testing and treatment changes.

Exam:

There are two parts. Speculum and bimanual. Speculum is what feels like a car jack spreading open the vagina walls. The goal is to visualize the cervix. Is it friable? Is there bleeding coming out of the os? Is there discharge in the vault? All things you need to see.

If getting a Pap smear, the sweep of the Endo and ectocervix will be performed during the speculum exam.

The bimanual exam will be goo on the finger and two fingers inserted into the vaginal vault, while the other hand is on top the abdomen. Basically, you are compressing each ovary from inside and outside (if you can feel it; larger ladies you won’t be able to feel) and trying to feel the top of the fundus. The goal is to feel for any masses or extreme tenderness –> go looking for something else like cancer. It will be uncomfortable for the woman, but it shouldn’t be extremely painful.

I hope that ya’ll end up seeing more gyn on your rotation than I did. I really only saw one LEEP procedure and one lichen sclerosis case. Other than that, my gyn was very limited.

Study materials:

I had a hard time figuring out how to study for my first COMAT exam and adjust to being in clinic for the first time. So take this with a grain of salt. I have been an average medical student and honestly, I’m okay with being in the middle of the road. If that isn’t your cup of tea or you don’t want to accept the reality that you are average in medical school, maybe don’t take my study advice.

I used the Dorian Anki deck. It is hefty for sure, but a lot of students just use that to study. I was able to get through some of this, but not enough. I attribute that to not being on top of my studies/strict with myself.

U world or Truelearn (or both!) questions. Truelearn has OMM integrated into it. As a DO student, you will see OMM on your shelf. Learn by questions this year.

Case studies: definitely helpful. I wish I would have used more of it. Again, I just didn’t have time to use it much.

Blueprints: A great background tool, but honestly I didn’t have time to read it. I could usually find what I needed through up to date, the ACOG website, or through my preceptors or a book they had. If I had more time to look up my cases, I think this would have been helpful for me.

Caveat: In the years prior, if you used COMQUEST which gave you a simulated score on practice exams and/or just using the Dorian Deck was enough to pass your COMATS. However, the year I took it we were self-proctoring it. Which meant they made the exams harder and more like a mini-step or a mini-COMLEX exam. They apparently did so to cut down on “cheating”. However in making it harder, they actually increased the amount of students around the country who cheated. Some students felt COMQUEST was still close to their actual scores, some didn’t.

And yea… I think that’s about it. I hope this was helpful and an insightful post on what to expect for an ob/gyn rotation! Cheers.