So, I survived my first rotation, and turns out I enjoyed it a lot more than I thought I would.
I chose to do OB/GYN (and 3 other rotations) at a community hospital for a few reasons; fewer learners, more exposure to the bread & butter of each specialty, more one-on-one time with preceptors, and less chance of (my directionally-challenged self) getting lost every other day.
I remember mostly being lost during our 4-week OB/GYN block last year and no matter how many times I’ve been taught, I still couldn’t wrap my head around the menstrual cycle.
My first week was on the gynecology service in the operating room (OR). In that week, I had contaminated myself at least four times, almost toppled over a cart, and ran a patient (who was unconscious still, thank God) into the wall several times while taking them back to the PACU. As embarrassing as it all was, everyone was nice about it and I had to remind myself that this was my first week in clerkship.
Gynecology
~ Surgery, ER consults, Post-operative Rounds ~
Surgery
Laparotomy myomectomy (mainly to remove subserosal fibroids) · Laparoscopic salpingectomy (surgical management of ectopic pregnancy) · Total hysterectomy · Polypectomy · Dilatation and curettage · Endometrial ablation
I got to scrub in at least 75% of the time, depending on how many surgeons and assistants were on the case. Believe it or not, initially, the most stressful part of this for me was scrubbing in lol, half the time I was waiting to be scolded by one of the scrub nurses for contaminating myself. I got to hold the retractor, cut sutures, suction, manipulate the uterus during laparoscopic surgeries, and dilate the cervix - all under supervision. I also got lots of practice with bimanual pelvic exams (made sure to introduce myself to the patient beforehand!) and putting in foley catheters. I volunteered to write the surgical procedure note for most surgeries. When I wasn’t scrubbed in, sometimes I would keep myself awake by learning the names of the instruments the scrub nurse was handing over.
ER Consults
Pelvic inflammatory disease · Spontaneous abortion/Miscarriage · Abnormal Uterine Bleeding/Ovulatory dysfunction
I, unfortunately didn’t get to see a lot of gyne consults from the ER, except the ones highlighted above. Usually how it worked was once the patient was seen by the ER physician, we would be consulted if it was gyne-related. I took a history and would do a speculum examination with the resident, who reviewed the case with the staff OB/GYN on-call.
Post-operative Rounds
I didn’t get to round on any of the patients on the gynecology in-patient ward because we usually had seminars at the same time.
Obstetrics
~ Triage, Labor & Delivery, Post-partum Rounds ~
Triage
Labor assessment · Suspected rupture of membranes · Pregnancy-induced hypertension · Renal colic · UTI · Induction of labor · Reduced fetal movement · Antepartum hemorrhage · Hyperemesis gravidarum
I spent most of my time here and took a history from patients presenting with any of the above chief complaints. The big takeaway from my time in triage was making sure to ask the 4 cardinal questions to every pregnant mom: 1) reduced/absent fetal movement, 2) Vaginal bleeding 3) Loss of fluid/SROM 4) Contractions. After taking a history, sometimes I would practice doing Leopold’s maneuver to check for the baby’s presentation. I would ultimately review all cases with the staff OB/GYN and after a while, I became comfortable proposing a management plan.
Labour & Delivery
Artificial rupture of membranes · Spontaneous vaginal deliveries · Operative vaginal deliveries · Placental deliveries · Vaginal tear repairs · Emergency C-Sections (cord prolapse, Cephalo-pelvic disproportion) · Elective C-sections (gestational diabetes, dichorionic diamniotic twins)
L&D was a whirlwind, to say the least; I was sprayed with amniotic fluid, got blood on my favorite running shoes (don’t ask why I thought it was a good idea to wear them to deliveries), and meconium on my gloves. I think I got to perform at least 8 vaginal deliveries, clamped their cords, obtained cord samples for cord pH, delivered placentas, and did some vaginal tear repairs (all under supervision). I also got to learn just how much L&D nurses do by shadowing a nurse for a 12-hr shift. On one day, I scrubbed into six C-sections, some elective, some emergencies. I mostly got to retract the bladder, cut sutures, and closed the skin (so cool!). By the end of the rotation, I could correctly estimate cervical dilation and effacement (small wins!).
Post-Partum Rounds
After each over-night shift, I got to round on patients in the post-partum ward who had delivered their babies via C-sections within the last 48hrs. I asked questions about their pain control, how much bleeding they had, whether they had urinated and passed gas, their activity level, and their diet, and also screened for DVT/PE. I inspected their incision site for infection and checked to make sure their fundus was firm at the umbilicus. Most of the patients I saw were generally well. Sometimes, I got to follow a patient from triage to L&D and post-partum which was a pretty neat continuum of care.
Clinics
OB/GYN clinic ~ Early Pregnancy Assessment Clinic ~ Biophysical Profile Clinic
OB/GYN clinic
Abnormal uterine bleeding (due to fibroids) · Post-menopausal bleeding · Uterine prolapse · Urinary incontinence · IUD insertion · Speculum exams · Pap smears · Endometrial biopsy · Routine antenatal clinics · Leopold’s Maneuver · Dopotone
I had four clinic full-days and was paired with one preceptor for the entire time. She took the time to teach and ensured I had many opportunities to learn and improve. I got to work with her in the early pregnancy assessment clinic, the OR, and on L&D.
I usually saw at least four of my own assigned patients in a day, these were either new referrals from family doctor offices or pregnant moms who were there for their routine antenatal visits. I also got to follow up with some patients I had seen earlier in the rotation. I took extensive histories, reviewed the referral note and lab results, and incorporated these into a consultation note. After a quick review with my preceptor, we would then go in together and I would perform the speculum exam, which was at first tricky but by my last clinic day, I was able to find the cervix on my first attempt. I also got to do three pap smears and two endometrial biopsies. For antenatal visits, if it was their first visit, I would take a full health history and populate their antenatal record. For routine follow-up visits, I performed Leopold’s maneuver and used the Dopotone to find the baby’s heartbeat.
Early pregnancy assessment clinic (EPAC)
Most women presented with missed, spontaneous, or threatened abortions or were managed as outpatients for an ectopic pregnancy. After taking a quick history (pain, cramping, bleeding), we did an abdominal or transvaginal ultrasound to search for gestational sac or fetal heart rate. Given the highly sensitive nature of the cases, we had to be cognizant of how the patients were coping emotionally and my preceptor was quite mindful of this and was good at checking in with each patient.
Biophysical Profile Clinic (BPP)
I spent around 4 days in BPP. A lot of the patients were followed here for abnormal placental marker bloodwork, gestational diabetes, small for gestational age babies, or pregnancy-induced hypertension. This was more of a shadowing experience and was less hands-on but one of my preceptors on the last day allowed me to hold the ultrasounds probe and find the fetal head and heartbeat.
Overall, I thoroughly enjoyed the variety and how hands-on this rotation was. My favorite part would have to be delivering babies. Also, I finally understand the menstrual cycle, for the most part.
~GoldRimMD