Orientation Powerpoint!

GYN Intern Skills Checklist

https://docs.google.com/document/d/1OboABnGYfDabWoN9BY7hX2zmXhxYp7v5mHdDDaDdvGM/edit?usp=sharing

OB Intern Skills Checklist

1st half of the year checklist

https://docs.google.com/document/d/1-JKVxl99CI9t1i6hgM7EZoB_6AQ4wvMPyR9Bhc51YLc/edit?usp=sharing

2nd half of the year checklist

https://docs.google.com/document/d/1_bHzoZv10gM5MucqmV76LI9-Qgk7iCpIz8lhT8MhK0Q/edit?usp=sharing

INPATIENT / DISCHARGE INFORMATION

Meriter L&D

Schedule (Monday - Friday)

• 6:00 am/pm: Sign-out and postpartum rounding - progress notes (remember to co-sign to attending if it is an MFM patient!) and discharge orders & scripts (if going home) need to be signed before 7:00am

• 7:05 am: Sign-out with UW ASOG & MFM (Sim Lab 5E)

• 7:30 am: Teaching

• 8:00 am/pm: Board rounds with nursing (L&D Nursing Station)

• Exception: 

  • Thursday: M&M, Grand Rounds, and Didactics from 7:00 am - 11:30 am

Schedule (Weekend)

• 6:00 am/pm: Sign-out and postpartum rounding

• 8:00 am/pm: Board rounds with nursing (4N Nursing Station)

Discharge

Timing by delivery type:

• Vaginal delivery - PPD #2

• Cesarean section - POD #3-4

• If patient has HTN - PP/OD #3-4 (aka needs to be inpatient for at least 72 hours) with BP check in 2-3 days after discharge versus PP/OD #2-3 if set up with Telehealth.

Medications to prescribe:

• Tylenol - OTC or print (insurance may cover it this way) - 100 tabs, 650 mg every 6 hours PRN

• Ibuprofen - OTC or print (insurance may cover it this way) - 100 tabs, 600 mg every 6 hours PRN

• Oral dilaudid - FOR C-SECTIONS - 5-20 tabs, 2-4 mg every 4 hours PRN

  • Base how many you give off of how many they have been using in past 24-48 hours!

• Miralax - OTC or print - 1 bottle (340 g or so), 17 g daily PRN

  • FYI data is not great on colace as a stool softener! Opt for Miralax!

• Oral iron (ferrous sulfate) if needed - OTC or print - 30-60 tabs, 325 mg daily or twice daily

  • Make sure you prescribe a stool softener with this due to iron-associated constipation!

Other discharge pearls:

• For MFM patients: You must order a follow-up appointment via the specific order "Amb Referral to Perinatology" and specify when in the comments. You cannot just put in a "Follow-up with..." order as this does not get into MFM clinic's system.

• Telehealth: A program that gives women equipment to check BP daily at home, including an iPad for daily submission of BPs, and involves checking in daily with Telehealth RNs to titrate BP meds. Equipment return at 6 weeks postpartum. The goal is to reduce postpartum admission.

Board Rounds

Presentation guidelines for antepartum and labor patients with postpartum hemorrhage risk assessment

UW Gyn Onc

Schedule (Monday - Friday)

• 6:00 am/pm: Sign-out and rounding - progress notes to be finished and co-signed to attending before 7:00am

• 7:00 am: Rounding with attending

• 7:45 am: Gyn Onc clinic starts, may be later depending on day/schedule

• Exception: 

  • Wednesday morning: 7:30 am teaching by PGY3, to Gyn Onc clinic at 8:30 am

  • Thursday: M&M, Grand Rounds, and Didactics from 7:00 am - 11:30 am

Schedule (Weekend)

• 6:00 am: Sign-out and rounding

• 7:30-9:00 am: Rounding with attending (timing per on-call attending's preference)

Floor/inpatient

• Do not give senna/sennakot to patients after a bowel resection (we do not want to stimulate the bowel around a new anastamosis)

• No toradol for patients >65 years old (unless approved by attending/fellow)

• No ibuprofen for patients with CKD or history of gastric ulcers, otherwise okay to give even if >65 years old (but consider scheduling PRN and consider decreasing dose to 400 mg every 6 hours if > 65 years old)

Discharge

Medications to prescribe:

• Tylenol - OTC or print (insurance may cover it this way) - 50-100 tabs, 650 mg every 6 hours PRN

• Ibuprofen - OTC or print (insurance may cover it this way) - 50-100 tabs, 600 mg every 6 hours PRN

• Oral oxycodone - 10-40 tabs, 5-10 mg every 4 hours PRN

  • Base how many you give off of how many they have been using in past 24-48 hours!

  • Give fewer after laparoscopy (10-15 tabs) and more after laparotomy (15-40 tabs)

• Miralax - OTC or print - 1 bottle (340 g or so), 17 g daily PRN

• Colace/docusate - OTC or print - 40 tabs, 100 mg daily or twice daily PRN

• Oral iron (ferrous sulfate) if needed - OTC or print - 30-60 tabs, 325 mg daily or twice daily

  • Make sure you prescribe a stool softener with this due to iron-associated constipation!

St. Mary's L&D

Schedule (Monday - Friday)

• 6:00 am: Sign-out (postpartum rounding completed by night team!)

• 7:30 am, 10:00 pm: Board rounds with attendings and nurses (L&D Nursing Station)

• Exception: 

  • Tuesday: 6:45 am teaching with Dr. Stafeil (in his office)

  • Thursday: M&M, Grand Rounds, and Didactics from 7:00 am - 11:30 am

Schedule (Weekend)

• 6:00 am: Sign-out (postpartum rounding completed by night team!)

• 7:30 am, 10:00 pm: Board rounds with attendings and nursing (L&D Nursing Station)

LABOR MANAGEMENT

Triage 

Complete the following checklist with supplemental readings to become proficient in triage. Instructions / checklist can be found here.

Labor management

Are they an OB/GYN patient (UW or Private)? 

• If yes --- It’s your time to shine!

• If no (Fam Med or Midwife) --- Not your patient to admit!

Are they super uncomfortable or have a Category II tracing?

• If yes --- Quick survey of chart and CHECK THE CERVIX/scan for position! Then fill in the H+P as best you can.

• If no --- No rush! Take a thorough H+P and then scan for position + check their cervix!

Is the baby cephalic?

• If yes --- Continue on

• If no --- Time to assess for c-section

Are they in labor or here for a scheduled induction of labor?

• If yes --- Put in your Labor Admission order set (Don’t forget a CBC + Type & Screen!)

• If no --- Consider a two hour recheck to assess for cervical change

If induction / augmentation of labor, are they a TOLAC?

• If yes --- NO prostaglandins! Consider cook and/or pitocin only and make sure they have a TOLAC consent form signed and discuss benefits of epidural during TOLAC. Prostaglandins increase risk of uterine rupture.

• If no --- You have some prostaglandin options if needed!

If induction, what is their Bishop Score?

• < 6 --- Go for some cervical ripening

• > or equal to 6--- You can skip cervical ripening! AROM or pitocin typically.

What do I use for cervical ripening for inductions?

• If closed and category I tracing --- Consider oral misoprostol

• If closed and category II tracing/IUGR --- Consider cervidil and/or attempt balloon placement. Avoid oral misoprostol (you can't "take it away" thus it is harder to control if they start contracting too much)

• If at least a little dilated but <3 cm --- Consider balloon placement +/ misoprostol or pitocin depending on provider preference

What is their GBS status?

• Positive --- start IV antibiotics (penicillin first line, clindamycin, or vancomycin) after cervical ripening or on admission if Bishop Score > 6. Typically, you want 3-4 hours of IV antibiotics prior to AROM especially for a G2+ (in case of fast labor).

• Negative --- No worries!

• Don’t know --- Collect a swab and start IV antibiotic prophylaxis if 1. < 37 weeks or have had rupture of membranes > 18 hours or have a history of neonatal GBS sepsis or 2. > 37 weeks and have a history of GBS infection in previous pregnancy

Is Artificial Rupture of Membranes (AROM) an option for induction?

• If the fetal head is well applied to the cervix and GBS negative --- Alert your attending and go for it!

• If the fetal head is ballotable / GBS positive --- Try other techniques first. 

Is their BMI >40?

• If yes --- Give anesthesia a heads up for evaluation on admission

• If no --- Can wait until epidural request to call anesthesia

Did they have Spontaneous Rupture of Membranes (SROM) confirmed with pooling/nitrazine/fern/ROM test?

• If yes and uncomfy --- Consider expectant management + check GBS status ASAP

• If yes and not uncomfy --- Consider augmentation with pitocin if ruptured for > 4-6 hours without contracting + check GBS status ASAP

• If no --- Consider AROM as option for induction

Acute hypertension management

Did they have BP >140/>90 before 20 weeks?

• Yes -- They have chronic hypertension!

• No --- Okay, keep going

If no chronic HTN, have they had more than one mild range BP after 20 weeks greater than 4 hours apart?

• Yes --- Check if they are > 37 weeks. If so, move to delivery!

• No --- Keep in triage for BP monitoring

  • If they are > 37 weeks, keep patient’s for monitoring for 4 hours from first elevated BP. If they meet criteria, move to delivery.

  • If they are < 37 weeks, monitor for a couple of hours and see if they meet criteria. Recommend a BP check in clinic or triage the following business day.

Are they symptomatic (severe headache that doesn’t go away with tylenol, visual changes or spots in their vision, shortness of breath, RUQ pain, worsening edema)?

• Yes --- These symptoms are concerning for preeclampsia with severe features

• No -- Cool, move on

What about labs?

• If mild range BP --- Always get preeclampsia labs! These include checking for platelets (CBC), Liver Enzymes (ALT, AST), Creatinine, and Urine Protein/Creatinine ratio (>0.30 is the number to remember)

• If labs are normal --- Not preeclampsia unless patient is symptomatic....we're getting into the weeds here

• If labs are abnormal --- Preeclampsia!! Continue down this list…

<37 weeks, new mild range BP, and > 0.30 on Urine P/C but all other labs are normal?

• Get a 24-hour urine protein! This can be done at home or on antepartum depending on how their BP trends.

• Is their 24-Hour urine protein >300? PREECLAMPSIA!

How do we characterize high blood pressure in pregnancy?

• Gestational hypertension --- Mild range BP, urine P:C < 0.30

• Preeclampsia without severe features --- Mild range BP, urine P:C > 0.30

• Preeclampsia with severe features --- Severe range BP alone or mild range BP with any of the following:

  • Thrombocytopenia (platelets < 100k)

  • Liver enzymes twice the upper limit of normal

  • Renal insufficiency (creatinine > 1.1 mg/dl)

  • Pulmonary edema

  • New headache and/or visual disturbances

When do I deliver my patient?

• 37 weeks for patients with gestational HTN, chronic hypertension, or preeclampsia without severe features

• 34 weeks for preeclampsia with severe features, HELLP

What if there are severe features/BP sustained >160/>110?

• Call your senior!

• Order labs! 

• Plan to start magnesium for seizure prophylaxis

PROCEDURE BASICS / STEPS

Cesarean section

1. Place orders if not already done using the "Cesarean Birth Pre-Procedure" orderset. Give preoperative antibiotics [cefazolin/cefoxitin 2g (if weight <120kg) or 3g (if weight >120kg) + azithromycin 500 mg if laboring/ruptured].

2. Help position patient in OR - left lateral tilt to help decompress the IVC while patient is supine during surgery. Place foley. Go scrub while the nurses are prepping the abdomen.

3. Once scrubbed in, test the abdomen with Ferris Smith tissue forceps to ensure adequate coverage from spinal / epidural anesthesia.

4. Draw anticipated pfannenstiel incision with pen -- 2 fingerbreadths above pubic bone and 8 cm on either side (can use width of hand as roughly 8 cm).

5. #10 blade scalpel for incision. Make sure you extend excision through skin all the way across your pen mark!

6. Use scalpel through subcutaneous fat (Campers and Scarpas).

7. Knick the fascia at midline with the scalpel.

8. Extend the fascia bilaterally with Mayo scissors, holding the fascia up with Ferris Smith tissue forceps. Your assistant will complete this on the side closest to you.

9. Grasp superior fascia with Kocher clamps. Push underlying muscle down. Repeat on the inferior portion of the fascia.

10. Split the rectus muscle at the middle using your fingers.

11. Sweep to enter the peritoneum with your fingers. Sometimes you need to do this with pick-ups and Metzenbaum scissors.

12. Stretch the muscle and peritoneum open wide. Place the Alexis-O retractor (or bladder blade with Richardson depending on the attending).

13. Depending on the attending, you may make a bladder flap, which helps create more distance between the bladder and uterus. To do this, pick up the uterine serosa with Russian tissue forceps and incise the peritoneum with Metzenbaum scissors. Extend this incision to the left and the right. Gentle sweep the filmy fibers down.

14. Make your hysterotomy with a (clean) #10 blade scalpel. This should be a "smile" shape or "V" shape. The water may break during this, or you may get down to exactly above the amniotic sac. If the amniotic sac is intact, rupture with an Allis clamp.

15. Extend the hysterotomy with your fingers -- pull superiorly and inferiorly.

16. Reach down and elevate the baby's head from the pelvis and deliver the baby!

17. Cut a cord segment for blood gases (we don't always take blood for gases but we always cut a segment just in case). Fill a little tube with cord blood. 

18. Remove the placenta with gentle traction. Use a moist, clean laparotomy sponge to feel/wipe the inside of the uterus superior and inferior to the hysterotomy to ensure to placental tissue is left inside.

19. Close the hysterotomy in 2 layers with 0 Vicryl. The first layer is a running locked stitch. The second layer is an imbricating stitch, which will be horizontal or vertical depending on the attending.

20. Clean the paracolic gutters with a moist laparotomy sponge. During this, make sure you visualize the ovaries and fallopian tubes (you will need to document if they are normal or abnormal in your op note).

21. Close the fascia with a running stitch of 0 Vicryl or 0 PDS depending on the attending. Suggest PDS if it is an obese patient or a repeat section.

22. Irrigate the subcutaneous tissue with warm water. Bovie any small vessels. If the subcutanoeus tissue is >2cm, place a subcutaneous stitch with 0 Vicryl -- this will help prevent seroma and hematoma formation.

23. Close the skin with 4-0 Monocryl or 4-0 Vicryl.

24. Place an island dressing over the incision.

25. Frog leg the patient's legs and perform a fundal check -- you will likely expel a lot more blood than you think! Wash off blood / abdominal prep with a moist laparotomy sponge.

26. Place postoperative orders using the "Cesarean Birth Post-Procedure" orderset.

    1. Scheduled tylenol and toradol. Toradol will transition to ibuprofen after 24 hours.

    2. PRN oral dilaudid -- recommend 2-4 mg every 4 hours to start.

    3. PRN stool softeners and antiemetics.

    4. Remove foley on POD #1.

Risks:

External cephalic version (ECV)

1. Perform ultrasound for position. Perhaps they aren't breech!

2. Place orders using the "OB External Cephalic Version Procedure Focus" orderset. Place IV, order CBC and T&S. No antibiotics indicated.

3. Give terbutaline IV 25 mg 1-2 minutes before the procedure (longer if you're giving it IM).

4. Lots of gel on the abdomen (although a few attendings do it without gel).

5. You'll often do three tries, usually some counterclockwise and some clockwise. Scan for fetal heart rate between each attempt.

6. Monitor fetal heart rate for 1 hour after procedure, regardless of outcome, and then discharge.

Risks:

Dilation and curettage (D&C)

1. Preoperative orders are likely already entered. If not, place orders using the "Gyn Surgery Pre-Procedure" orderset. Confirm the patient has doxycycline 200 mg orally ordered for 1 hour prior to procedure. The patient will likely void prior to the procedure, however, if the procedure is under ultrasound-guidance, the patient should have a full bladder to aid with visualization. No foley is needed.

2. Position patient in yellow fin stirrups.

3. Perform a bimanual exam to evaluate uterine position (anteverted or retroverted) and size (6-week size, 8-week size, 10-week size, etc).

4. Inject 1-2 mL of local anesthetic into anterior lip of cervix. Grasp cervix with a tenaculum.

5. Inject 8-9 mL of local anesthetic into cervicovaginal junction at 4 and 8 o'clock.

   1. Position is key -- you want to numb the nerves that lie at 4 and 8 o'clock and want to avoid the cervical branches of the uterine artery that lie at 3 and 9 o'clock.

6. Gently dilate the cervix to goal dilation with either Pratt or Hegar dilators (attending-specific).

   1. Pratt dilators (the longer, more slender ones) measure in "French" (like a foley) and only come in even numbers. Dilation to the gestational age x3 -- e.g. if the fetus is 6w2d, dilate to 18 French. Sometimes we round up depending on gestational age -- e.g. if the fetus is 6w6d, dilate to 22 French (7 weeks x 3 = 21 French, but round up to 22 French).

   2. Hegar dilators (the shorter, fatter ones) measure in "mm" and come in all numbers. Dilate to the weeks gestation -- e.g. if the fetus is 6w2d, dilate to 6mm. Sometimes we round up depending on gestational age -- e.g. if the fetus is 6w6d, dilate to 7 mm.

7. Pass the suction curette through the cervical os and into the uterus (remember if it is anteverted or retroverted as this helps guide the passage of the scope). Use the suction curette size that correlates with gestational age -- e.g. use a 6 mm suction curette for 6w2d, use an 11 mm suction curette for 10w6d.

8. Suction everything out. When the uterus is empty, it should feel "gritty" all the way around.

9. Remove the tenaculum. If the tenaculum sites are bleeding, apply pressure with gauze / sponge stick or apply silver nitrate.

10. Remove the speculum.

11. Rinse the vagina with water.

12. Enter postoperative orders using "Oxytocin/Same Day Surgery Discharge" orderset.

    1. Prescribe tylenol and ibuprofen.

    2. Do not give narcotics.

Risks:

Hysteroscopy

1. Preoperative orders are likely already entered. If not, place orders using the "Gyn Surgery Pre-Procedure" orderset. No antibiotics indicated. The patient will likely void prior to the procedure, however, if the procedure is under ultrasound-guidance, the patient should have a full bladder to aid with visualization. No foley is needed.

2. Position patient in yellow fin stirrups.

3. Perform a bimanual exam to evaluate uterine position (anteverted or retroverted) and size (6-week size, 8-week size, 10-week size, etc).

4. Inject 1-2 mL of local anesthetic into anterior lip of cervix. Grasp cervix with a tenaculum.

5. Inject 8-9 mL of local anesthetic into cervicovaginal junction at 4 and 8 o'clock.

   1. Position is key -- you want to numb the nerves that lie at 4 and 8 o'clock and want to avoid the cervical branches of the uterine artery that lie at 3 and 9 o'clock.

6. Gently dilate the cervix to goal dilation with either Pratt or Hegar dilators (attending-specific).

   1. Pratt dilators (the longer, more slender ones) measure in "French" (like a foley) and only come in even numbers. Dilate to the weeks gestation x3 -- e.g. if the fetus is 6w2d, dilate to 18 French. Sometimes you go up one dilator e.g. if the fetus is 6w6d, dilate to 22 French (e.g. 7 weeks x 3 = 21 French, but increase to even number of 22 French).

   2. Hegar dilators (the shorter, fatter ones) measure in "mm" and come in all numbers. Dilate to the weeks gestation -- e.g. if the fetus is 6w2d, dilate to 6 mm. Sometimes you go up one dilator e.g. if the fetus is 6w6d, dilate to 7 mm.

7. Pass the hysteroscope through the cervix (remember if it is anteverted or retroverted as this helps guide the passage of the scope). The hysteroscopy is usually 6.25 mm, depending on the manufacturer.

8. Visualize the bilateral tubal ostia to ensure you're in the correct cavity. Take pictures.

9. To remove a polyp or fibroid, if present, insert the Myosure device through the operative part of the hysteroscope (sounds complicated but we'll show you). Chomp away! Take a final picture after the pathology is removed.

10. Remove all devices. Remove the tenaculum. 

11. If the tenaculum sites are bleeding, apply pressure with gauze / sponge stick or apply silver nitrate.

12. Remove the speculum.

13. Rinse the vagina with water.

14. Enter postoperative orders using "Outpatient/Same Day Surgery Discharge" orderset.

    1. Prescribe tylenol and ibuprofen.

    2. Do not give narcotics.

Risks: