Welcome to OB/GYN

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Welcome to OB/GYN

• Lloyd Holm, DO
• Clerkship Director
• Generalist Faculty
• Sonja Kinney, MD
• Assistant Clerkship Director
• Generalist Faculty

• Jill Ramsdell
• Student Education Coordinator
• M3s, M4s

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Orientation Agenda

• Morning
• Clerkship Overview and Expectations
• Tour of Conference Rooms and Clinics
• Pictures
• Pelvic Model
• UNMC OB students LD system orientation
• Afternoon
• UNMC OB students-Page residents
• Methodist OB students site orientation

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Methodist Site Orientation

• Please go to the Medical Staff Office on the
  first floor of MH and ask for Kristi.
  Orientation at MH will begin promptly at 200PM,
  therefore, please try to be at the staff office
  by 155PM.

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Overview Clerkship Blocks

• Obstetrics Block (2 weeks)
• Gynecology Block (2 weeks)
• Gynecologic Oncology- 1 week
• Benign Gynecology 1 week
• Outpatient Clinics Block (2 weeks)

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University Assigned Students

• Obstetrics- 2 weeks University
• Gynecology block- 2 weeks University
• Outpatient Clinics block- University

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OB Methodist Students

• Obstetrics block done at Methodist
• on team with residents and MFMs
• Gynecology block and Outpatient Clinics blocks
  done at University Hospital

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Sample Schedule

• Student A
• Weeks 1-2 Weeks 3-4 Weeks 5-6
• Obstetrics Gynecology Clinics
• (Kinney Amoura)
• Call expected approx 3 weeknights and one
  weekend night during Weeks 1-2 (OB)
• Weeks 5-6 schedule found on Kinney Amoura
  clinic advisor handout

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Sample Advisor Schedule
Sample only, please see actual advisor schedule
in your packet
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Who will teach, supervise, and evaluate you?

• Obstetrics 2 weeks
• UNMC- 1 faculty/week and service team
• Methodist- MFM faculty, one resident
• Gynecology 2 weeks
• Benign- resident team and faculty in cases
• Oncology- Dr. Remmenga and team
• Outpatient Clinics 2 weeks
• One faculty per week

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Who are the Chief Residents?
Joshua Sampson, DO Allison Sampson, DO
Maria Gondra, MD
OB ONC
GYN
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Who are the Methodist Residents?
Matthew Bruner, MD Sara Gross, MD
Gynecology Obstetrics
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Wednesday Teaching Mornings

• No matter which clinical block or hospital
  currently assigned to, every student should
  attend
• 0800AM Grand Rounds University
• 0900-1200noon Lectures
• v schedule in notebook

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Other scheduled teaching conferences

• Students on OB rotation at Methodist
• Tuesday 0700AM meet with Dr. Bassett
• Students on Outpatient Clinics and Benign Gyn
• Teaching rounds
• Monday 0700AM GYN - Chapter
• Tuesday 0700 AM GYN Preop Conf DOC 4608
• Wednesday 0700AM Questions
• Thursday 0700AM GYN Student presentations
• Thursday (once/month) 12-1 Dysplasia conf.
• Friday 0700AM Diagnostics Obstetrics and
  Gynecology (DOG) in DOC 4608 (OB classroom).

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Other scheduled conferences

• UNMC Obstetrics-
• - Friday 12 noon FHT Tracing Rounds

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Chairmans Luncheon

• Dr. Carl Smith will host a luncheon towards the
  end of the 6-week clerkship.
• Lunch will be provided (Mexican, Chinese, Greek,
  Italian, etc)
• All students on this rotation are expected to
  attend.

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Communication

• You will be responsible for reading your email.
• Jill and Dr. Holm will communicate all
  information by email or at the Wednesday morning
  student lectures.

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Text Books

• Required textbook
• Beckman, Obstetrics and Gynecology
• 5th Edition
• Reading assignments listed for each lecture.
• Other suggested text
• Hacker, Essentials of Obstetrics and Gynecology
• 5th Edition

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Web Site

• The departments education website is found under
  Ob/Gyn department www.unmc.edu/obgyn
• Lecture materials located here
• - Student Education
• - Lecture schedule
• - Click for Power Point presentations
• You may access resident education information
  from this address as well.

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What do I do with down-time?

• Read, read, read try to focus on mechanisms
  of disease
• Review practice questions from books Jill has in
  her office
• (Appleton Lang Review, Wylen Pretest, On-Call)
• Preview lectures for week
• (Print out web site Power Point lecture, review
  recommended reading)
• Directed studying web-site links
• Blackboard practice questions

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Policies Attendance

• Excused ABSENCES
• If you are ill, you must contact
• Jill Ramsdell _at_ 9-8133 (no emails)
• Your current assigned service faculty or chief
  resident.
• If you miss more than 1 day in the 6-week
  clerkship, you must make up this time. All make
  up time should be arranged with Jill Ramsdell.

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Clerkship Grading Structure

• 50 Evaluations based on faculty and resident
  evaluations (department grading meeting)
• - Clinic advisors, Gyn chief, OB chief and
  faculty
• 50 Testing - Shelf Exam NBME 2 hour and 10 min
  exam, last Friday of the clerkship _at_ 9 AM
• (nursing staff comments do not count towards
  final grade points)

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PASS, HIGH PASS, HONORS

• Our department complies with the College of
  Medicines recommended grade distribution of
• 20 Honors
• 20 High Pass
• 60 Pass

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Criteria for Passing Rotation

• Minimum requirements for passing this clerkship
  include
• Receiving 10th scaled score on the NBME shelf
  exam
• AND
• Receiving satisfactory resident faculty
  evaluations

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Policies Marginal or Fail Grades

• MARGINAL Grade
• lt 10th scaled score on the NBME shelf exam
• Student may opt to re-take the shelf exam
• - if they pass second exam then his/her grade
  sheet will have an addendum noting the improved
  exam performance, but the grade remains MARGINAL
• - if they fail the second exam then his/her
  grade will be changed to a FAIL and the entire
  rotation must be repeated.
• FAIL Grade
• A student may also receive a FAIL grade if
  significant professionalism issues have occurred
  on the rotation.

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Grade Appeals

• All students have the right to appeal a clerkship
  grade and/or comments for the Deans letter.
• Initial requests must be made by email to Jill _at_
  jramsdell_at_unmc.edu
• Requests must be made within 30 days of grades
  being emailed to students
• OB/Gyn department has committee to evaluate these
  requests

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OB/Gyn Clerkship Expectations

• Expectations for each Block
• -Website listing of areas to focus on for each
  Clinical Block

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Obstetrics Knowledge and Skills Expectations

• By the end of the Obstetrics block students will
  be expected to competently1)  Obtain, present,
  and document a relevant history on patients being
  evaluated or admitted examinations will be done
  with supervising resident/ faculty2)  Interpret
  and document fetal heart rate monitoring
  strips3)  Assess and document labor course in
  patients, postpartum assessments4)  Write
  appropriate post-delivery orders (vaginal and
  C/S)5)  Understand the normal hospital course
  for the patient after a normal vaginal delivery
  or operative C/S delivery

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Clerkship Expectations

• www.apgo.org/members/medical-students.cfm

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Professionalism Expectations

• Attendance, on-time to activities
• Take your professional role seriously
• Demonstrating respect for patients, staff, and
  supervising residents and faculty

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Professionalism Problems Examples

• Being late/not writing notes on assigned patients
• Talking to patient about experimental therapies
• Talking about patient information on elevator
• Laughing and talking during lectures
• Inappropriate discussions in front of patients
  during pelvic exams, labor and delivery, etc.

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Professionalism Problems Other examples

• Not following patients after surgery
• Informal conduct calling attending faculty or
  resident physicians by first names
• Residents and/or faculty will give appropriate
  feedback and notify Clerkship director of this
  interaction if problems arise

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Feedback

• Mid Clerkship meeting
• Dr. Holm will meet with each student.
• Mandatory.
• Informal 10 min. meeting to give you feedback and
  receive feedback from you regarding the first
  half of the clerkship.
• See schedule in your binder.
• Please let Jill know right away if you have any
  conflicts during your scheduled time.
• End of rotation comments
• You will receive written comments in your Wittson
  Hall mailbox.

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COM Professionalism Forms

• Will be filled out on each student and sent to
  Sue Pope along with your grade at the end of the
  clerkship.
• NOTE This is separate from your actual letter
  grade received at the end of the clerkship.

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Evaluations for you to fill out

• Department Evaluation
• COM on-line Evaluation

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OB/Gyn Clerkship Helpful Tips

• How to not only survive. . .
• but enjoy your time with us!

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Obstetrics Block

• 2 weeks on In-patient team service
• Students follow labor patients and post-partum
  patients, usually not antepartums
• Pelvic exams usually limited to labor cervix
  checks when patients have epidural
• Be familiar with ACOG antepartum record form used
  for all patients
• Outline for note formats included in packet
• Students usually give one prepared presentation
  to group on assigned topic

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OB Block Notes

• Schedule On-call 3-4 nights (1 weekend night)
  next day students go home after morning rounds
  completed
• Appropriate attire SCRUBS
• Introduce yourself to patients, nurses
• Try to be available for checks, labor
  assessments, and pushing phase
• Make sure your gloves and an extra gown are
  pulled for you
• Try not to get upset with interns who are
  learning how to do deliveries

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Obstetrics Block Skills Determining EGA

• Last Menstrual Period
• - Sure date, unsure date
• Pelvic exam-
• - concordant with EGA
• Ultrasound-
• - best in 1st trimester (good within one week)

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Obstetrics Block SkillsDetermining Gs and Ps

• Gravida __ Para ___ ___ ___ ___
• - Gravity- total number of pregnancies
• - Para-
• Total term deliveries (gt 37 weeks EGA)
• Total preterm deliveries (20- 37 weeks EGA)
• Total deliveries/ abortions under 20 weeks
• Total living children

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Gravida/ Para Examples

• G6 P4024
• 4 term deliveries, 2 abortions, 4 living
• G3 P1112
• 1 term, 1 preterm, 1 abortions, 2 living
• G4 P0030
• Currently pregnant, 3 previous abortions
• G1 P0102
• 1 preterm delivery of TWINS

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REMEMBER

• A woman currently pregnant with her first
  pregnancy is NOT a Primip!

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Intrapartum Triage

• Maternal vital signs
• Auscultate maternal heart and lungs
• Fetal heart rate
• Fetal lie and presentation
• Uterine contractions
• Cervical exam
• dilatation
• effacement
• station

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Vaginal ExaminationAlways under supervision,
usually limited to patients with epidurals
dilatation effacement
fetal station
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Normal Presentation Leopolds maneuver

• Longitudinal lie
• Cephalic presentation vertex
• Fetal head in attitude of flexion

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Intrapartum TriagePRESENT THE PATIENT

• 19-year-old Caucasian Gravida 1 Para 0 at 39
  4/7 weeks presents to LD reporting painful
  contractions every 5 minutes for the past 3 hours
  and blood-tinged mucus from the vagina. Her baby
  is active and she denies any loss of fluid. Her
  pregnancy has been uncomplicated except she is
  Group B strep positive. She desires an epidural
  for labor.
• Maternal VS are stable,she is afebrile. Fetal
  heart tones are in the 120s and reactive.

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Intrapartum TriagePRESENT THE PATIENT

• Contractions are showing on the monitor every 7
  minutes . Her cervix is 4-5 centimeters dilated,
  100 effaced, with the fetal vertex at -1 station
  and a bulging bag of water.
• Assessment is 19 yo at term in labor who is GBS
  and requests an epid. Fetal and maternal
  assessment is reassuring.
• My plan would be to admit her to LD, continue
  routine monitoring, get routine labs, start an
  IV, start penicillin for Group B strep
  prophylaxis, and notify Anesthesia for placement
  of an epidural.

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Admission to LD
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How do I follow a labor patient?

• Subjective
• pain management
• Objective
• Maternal vital signs
• fetal heart rate
• uterine contractions
• vaginal examination
• medications given

• Assessment
• Plan
• medications
• procedures
• monitoring

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Stages of Labor
cervix is not dilated, not effaced NOT IN LABOR
1st stage of labor- regular contractions, cervix
dilates
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Stages of Labor
1st stage continues cervix is 8 cms dilated,
100 effaced ACTIVE LABOR
fully dilated, fully effaced, fetus in birth
canal SECOND STAGE LABOR
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Stages of Labor
CROWNING
BIRTH OF THE HEAD
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Postpartum Orders
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How do I make postpartum rounds?

• SUBJECTIVE
• breast or bottle feeding?
• uterine cramping
• perineal pain
• bleeding (lochia)
• ambulation
• urination / defecation
• emotions
• contraceptive plans

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Postpartum Rounds

• OBJECTIVE
• vital signs
• heart lungs
• abdomen- incision
• uterine fundus
• perineum (supervised)
• Homans sign

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Preparing for Morning Rounds

• Talk with residents about abnormal assessments
  before morning report to faculty
• - for example, wound drainage
• Keep the charts out at nursing station while
  visiting with patients
• Try to organize in SOAP format

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SOAP notes

• Subjective- what patient tells you
• Objective- vital signs, physical exam,
• laboratory and imaging testing
• Assessment- Summarize the patients current
  status and problems
• Plan- what your next steps will be
• (Assessment and Plan should be separate)

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Postpartum Discharge Instructions and Orders

• Routine analgesics
• Stool softener
• FeSO4 PRN
• Contraception
• Visiting nurse referral
• RTC in 6 weeks after C/S or vaginal delivery or
  as needed

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Gynecology Block Benign and GYN-Onc

• 2 weeks of in-patient team services
• Gynecology notes and post-op course outlined in
  your orientation packet
• GYN team covers ER and in-patient consultations
  as well as OR cases
• GYN-Onc team does OR cases and also will go to
  Dr. Remmengas clinic

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Gynecology Block

• Appropriate attire wear scrubs when scheduled
  to be in OR, no scrubs when going to GYN-Onc
  clinics
• Students expected to prepare one presentation for
  both Benign and Onc weeks

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Preparing for an OR case

• - Read background history on that patient,
  review ultrasounds, pathology, etc.
• - Read about that particular surgery
• - Introduce yourself in pre-op before surgery
• - Assist with moving/positioning of the patient
• - Introduce yourself to OR staff, offer to get
  your own gloves
• - Visit the patient after the case, read the op
  note dictation, and review the pathology findings

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Gynecology Knowledge and Skills Expectations

• By the end of the Gynecology block students will
  be expected to competently1)  Write a complete
  operative note and postoperative orders2) 
  Discuss the normal hospital course after a
  routine Gyn surgical procedure3)  Discuss the
  appropriate work-up and differential for
  postoperative low urine output, fever, and wound
  problems4)  Discuss the relevant history,
  examination, and laboratory or radiology work-up
  involved in ER assessments of 1) pelvic pain and
  2) abnormal vaginal bleeding5)  Briefly describe
  the differences between types of hysterectomies
  (supracervical, simple, radical, vaginal,
  laparoscopic)

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Outpatient Clinics Block

• 2 weeks of outpatient clinic exposure students
  assigned to 1 faculty/ week
• Students attend morning Gyn teaching rounds on
  all mornings except Tuesday
• Look at faculty schedule the day before to get a
  sense of topics to prepare, for example-
  postmenopausal bleeding
• Variable hands-on opportunities for exams
• Review Gynecology clinic progress note in
  orientation packet
• Scrubs never appropriate

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What if I feel uncomfortable with pelvic exams?

• - You are not alone- many physicians do not feel
  comfortable with pelvic exams
• - Today is the practice pelvic exam session
• - We expect you to become more familiar with the
  mechanics of the exam and how to appropriately
  talk to your patient during the exam- all exams
  should be supervised
• - It takes a lot of practice to do them well.

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Outpatient ClinicsKnowledge and Skills
Expectations

• By the end of this clinical block, students will
  be expected to competently1)  Conduct a normal
  annual GYN examination obtain and present
  history, under supervision do an appropriate
  physical exam, and counsel patient appropriately
  on screening recommended by age group2)  Conduct
  a new and return obstetric patient clinic visit
  (exam with supervision of faculty or
  resident)3)  Discuss appropriate triage of
  abnormal Pap smears4)  Discuss indications for
  vulvar biopsy and endometrial biopsy5) 
  Appropriately counsel patients on choices of
  contraception/ sterilization6)  Discuss issues
  related to risks and benefits of hormone
  replacement therapy

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Student of the Week

• One student each week will be chosen as Student
  of the Week
• Weeks 2-6
• Announced at Grand Rounds
• Nominations by house staff and faculty
• UNMC and Methodist students

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Additional Educational Resources

• uWISE APGO educational/testing module. (See
  info sheet in orientation notebook)
• The following CD-ROM educational materials are
  available for check-out
• - Advanced Colposcopy (abnormal pap smear
  work-up and management)
• - Blackboard questions
• Review books (to be checked out from Jill)
• Appleton Lange - Review
• Wylen Pretest
• On Call

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How can I make the most of my outpatient
experience?

• Be flexible and keep an open mind. . .
• your schedule is an outline - be available if
  opportunities to learn come up

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The END

• QUESTIONS???