EAST TENNESSEE STATE UNIVERSITY

James H. Quillen College of Medicine

Medical Student
Manual

For Obstetrics & Gynecology

MSIII Clerkship

2007 East Tennessee State University

James H. Quillen College of Medicine
Department of Obstetrics and Gynecology
Revision 6/2007
1

Contact Information
Martin Olsen, MD
Bldg 1, VA, 3rd Floor, Rm 315B
Ob-Gyn Chairman
Bruce Selman, MD
345 N. State of Franklin, ETSU
MS3 Ob-Gyn Clerkship Director
Stephanie Nave
Bldg 1, VA, 3rd Floor, Rm 311
MS3 Ob-Gyn Clerkship Coordinator
Academic Staff:
Arlene Bennett
Bldg 1, VA, 3rd Floor, Rm 315A
Administrative Assistant
Debbie Berry
Bldg 1, VA, 3rd Floor, Rm 315
Secretary
Patti Davidson
Bldg 1, VA, 3rd Floor, Rm 315C
Residency Coordinator
Norma Long
Bldg 1, VA, 3rd Floor, Rm 314
Grand Rounds Coordinator
Linda Lyons
Bldg 1, VA, 3rd Floor
Secretary
Beth Ann Henley, Office Manager 325 N. State of Franklin
ETSU Ob-Gyn Physicians and Assoc iates

439-8097
439-7232
439-6335
439-8097
439-8755
439-6262
439-8094
439-6722
439-7272

OB/GYN Faculty:
Martin Olsen, MD, Chairman, Residency Director, Pediatric and Adolescent Gyn
Norman Assad, MD, General GYN and Reproductive Endocrinology
Kevin Breuel, PhD, Research, East TN Reproductive Endo Lab
Jessica DeMay, MD, Maternal-Fetal Medicine
Janet Drake, MD, Gynecologic Oncology, Associate Program Director
Maurice Eggleston, MD, Maternal Fetal Medicine
Anne Gebka, MD, General OB/GYN
Sherri Holmes, MD, General OB/GYN
Frederick Jelovsek, MD, Urogynecology
Uchenna Nwosu, MD, Maternal Fetal Medicine
Gary Randall, Ph,D., Embryologist
Bruce Selman, MD, PhD, General OB/GYN, Clerkship Director

OB/GYN Resident Pager Numbers

Dr. Amy Carrillo, PGY-IV
917-4815
Dr. Howard Herrell, PGY-IV
917-4801
Dr. Olga Sarkodie, PGY-IV
917-4803
Dr. Camile Marsh, PGY-III
917-4818
Dr. Tony Reed, PGY-!III
917-4819
Dr. Sreedhar Tallapureddy, PGY III
917-4430
Dr. Brooke Foulk, PGY II
917-4816
Dr. Stephanie Gibson, PGY II
917-4817
Dr. Ross Spires, PGY II
917-4822
Dr. Charles Cesare, PGY I
917-4802
Dr. Jessica Keller, PGY I
917-4807
Dr. Rebecca McCowan, PGY I
917-4809

Other Numbers
L&D Triage
Same Day Surgery
Same Day Holding
Main OR
Main OR Holding
ER
Fast-track
Johnson City Specialty Hospital
Dr. Thomas Jernigan, 1st Choice Ob-Gyn

431-6436
431-2050
431-2000
431-1410
431-6592
431-6561
431-5888
926-1111
431-3812

Radiology Report Line 431-6139 (MD# 00950)

Contents
Introduction to the Department............................................................... 5
Obstetrics
Obstetrics History and Physical ................................................... 16
Intrapartum.................................................................................... 18
Delivery......................................................................................... 18
Postpartum .................................................................................... 19
Discharge....................................................................................... 21
Triage ............................................................................................ 23
Patient Calls .................................................................................. 25
OB Clinic ...................................................................................... 27
Sample Forms ............................................................................... 28
Obstetrical Pearls .......................................................................... 32
Gynecology
The Complete Gynecological History ......................................... 43
Notes for Gynecology/Gyn-Oncology......................................... 46
Gynecology Clinic ........................................................................ 48
Gynecologic Differentials ............................................................ 50
Gyn-Oncology
Gyn-Onc Sample H&P ................................................................. 52
Cancer Staging .............................................................................. 53
Sample Forms ............................................................................... 58
Common OB/Gyn Abbreviations ......................................................... 63
Recommended Resources ..................................................................... 66
Important Topics ................................................................................... 66
Notes...................................................................................................... 67

Introduction to the Department

Welcome to the Department of Obstetrics and Gynecology at the
James H. Quillen College of Medicine. We hope that your eight-week
rotation spent with us will be interesting, challenging, and stimulating
both academically and personally. Although only 6 to 7% of you will
choose Ob-Gyn as a career, all physicians must have certain
knowledge, skills and attitudes about womens health care. This
manual is intended to be a guidebook for your stay with us. Listed
below are the objectives of this clerkship:
1. To develop techniques in history taking which are specific to
the female patient, and provide information necessary for the
investigation of gynecological and obstetrical problems, while
establishing rapport with patient.
2. To learn the performance of the pelvic examination to provide
one with adequate assessment of the genital tract while
maintaining the patient in a state of relaxation, and cooperation.
3. To be able to prepare a case presentation for the obstetric or
gynecologic patient, focusing on material pertinent to this
specialty, and to present the case to a consultant in a concise and
coherent fashion.
4. To develop an understanding of a surgical discipline through
participation in operative procedures on patients with a
gynecological or obstetrics complaint.
5. To develop an understanding of and appreciation for
preoperative and postoperative evaluation and care.
6. To thoroughly understand pelvic anatomy and its
embryological development; menstrual, endocrine, and
histological changes, physiological changes in pregnancy so as to
apply these to diagnosis and management problems in obstetrics
and gynecology.

7. To be able to present a comprehensive diagnostic and

management plan for a patient with abnormal labor, abnormal
pap smear, acute onset of pelvic pain, abnormal uterine bleeding,
pelvic mass and the need for pregnancy prevention.
8. To demonstrate knowledge of obstetrics and gynecology above
the 50th percentile for students taking the National Board of
Medical Examiners exam at the end of the rotation.
NOTE: In addition to the experience and small-group weekly
lectures we offer, we do expect some self-teaching in the form of
reading. The recommended text for reading is Obstetrics and
Gynecology, 4th Edition, Beckmann et al. 2002.
It is not the intention of this rotation, nor is it possible, to provide
you with enough obstetrical experience to be comfortable in the
provision of obstetrical care. This is the responsibility of senior
electives and post-graduate level educational experiences.

Mechanics of the Clerkship

1. All third year students will participate in Low Risk Obstetric
Clinic, High Risk OB Clinic, Gynecology Clinic, Colposcopy
Clinic and Gynecologic Oncology Clinic.
2. The clerkship will be taught over a continuous eight week period
with specialty oriented lectures, weekly Grand Rounds, and
student M&M conferences with Dr. Selman. Attendance is
mandatory.
3. Students will spend rotational time at one or more facility.
4. Students assigned to obstetrics will follow patients during their
antenatal stay during labor and delivery and through postpartum/post-operative stay.
5. Students assigned to gynecology will see all surgical patients on
the day prior to surgery or upon admission, be present for surgery
and follow them during their entire hospitalization. Specific
assignment of admissions will be by the most senior resident on
the gynecology service at the time.
As students will be involved with the patients of clinical
faculty it is essential that the student confirm the degree of
involvement by directly contacting the individual physician.
6. Basic and introductory lectures will be given the first day. Call
begins at 5:00pm and ends at 8:00am. Students are excused on
Wednesdays from completion of morning notes to resumption of
regular duties next day. Exceptions are on-call students and GynOnc students. There will be no call the last week of rotation.
7. A copy of the lecture schedule is included in your orientation
packet. Unless otherwise noted, lectures are held in the VA
Building 1 3rd floor conference room on Monday through
Thursday at 4:00 to 5:00 pm. This will occasionally be extended
to 6:00 pm when there are two lectures. Attendance at lectures is
mandatory. You are expected to have read the pertinent materials
prior to lecture and to have reviewed the applicable objectives
7

and case scenarios on

apgo.org/objectives/index.cfm.

the

APGO

web

page:

Class Absence Policy

Students are required to be present for all lectures as well as
clinical and surgical experiences available to them. Absence from
examinations will be excused ONLY by submission of a doctors
excuse or permission of the Clerkship Director. Failure to take exams
at the scheduled time will result in 0 grade without prior clearance
from the clerkship director - such clearance being granted only in
extreme circumstances or documentation of medical illness. The
exam may be rescheduled at the discretion of the clerkship director.
Approved absence from on-call or delivery room time (the
student assigned to the labor and delivery is considered to be on call
during daytime hours) must be covered by one of your medical
students. Absence from clinical settings is to be cleared with the
clerkship director. Absence of sufficient time to interfere with the
overall program (as judged by the clerkship director) will require
remediation. The exact details of remediation will vary with the
specific circumstances, and will be worked out on an individual basis.
A student may miss 1/2 day a week while on the OB clerkship for
any ongoing original supervised research project, but time must
be made up prior to receiving final grade for clerkship.

Holidays
Students will follow the OB/Gyn and Gyn/Onc clinic schedules.

Professional Conduct
Student are expected to conduct themselves in a professional
manner at all times.
Appearance must be neat, clean, and professional. A clean white
coat and shirt, slacks, blouse, skirt, dress, etc. are acceptable. Scrubs
8

should not be worn in clinics and office settings and men are
expected to wear neckties during all clinics. Unless it is an
emergency, ALL staff should change into hospital provided scrubs
immediately prior to entering operating rooms. OSHA rules and
regulations are mandatory. Failure to comply may be reason for
dismissal. Scrubs should not be worn out of the operating or delivery
area unless appropriately covered by a clean white coat.
JCMC Identification: Nametags are required for proper dress
code for students doing clinical work at JCMC and clinic. Always
introduce yourself by name and status to staff members, nursing
personnel, patients and paramedical personnel.

Patient Responsibilities
When a patient is admitted to our service, you are required to
obtain a history and perform a physical examination. Your written
admission note must be reviewed with your attending/resident and
will be evaluated. You should include with this note a differential
diagnosis, and your plan of management. Your attending/resident will
determine to what extent you may write orders, progress notes, etc.
on the chart. It is important to request permission of the patient and
attending regarding your involvement in specific patient care. And
remember ALL patient information is to be kept confidential, and
failure to do so constitutes invasion of privacy and is
UNACCEPTABLE.
Please remember you are the medical schools ambassadors. What
you do- and the impression you create - will have a lasting effect on
the quality of medical education that will be available for those that
follow.

Patient Assignments
A list of patients admitted to ETSU Ob-Gyn will be available via
the hospital computer system. A daily list can be obtained from the
9

secretary at Labor and Delivery or the admission office. The

Spectra computer can be utilized for this purpose if an entry code is
obtained from JCMC Medical Staff Services.
A Pelvic exam is a critical portion of your learned skills, and you
are encouraged to examine your patients. These exams must be
done in the presence of an attending or resident. The bimanual
examination of a patient under anesthesia prior to gynecological
surgery is a unique and valuable learning experience. You are
encouraged to avail yourself of every possible opportunity to perform
such an exam. This will be done ONLY if the patient has signed a
consent form.
In addition to the responsibility for patient assignments in the
hospital, you will be assigned patients from the clinic. Your
evaluation of the patient and her problems are to be reviewed with
residents and faculty, and will be presented at rounds. You are
expected to know your assigned patients in depth, and be prepared to
discuss their management.
Also, please remember the information you obtain about a patient
belongs to the patient, and failure to respect this constitutes invasion
of privacy and is UNACCEPTABLE.

Assignments and Expectations

Obstetrics
In labor and delivery you will follow patients through their labor.
You will scrub in the deliveries of all clinic patients, and you may
scrub the deliveries of private patients depending on the attending
physician.
When you have a patient in labor, you will sit with the patient
throughout her labor, and may even get to assist with her delivery or
perform the delivery under the direct supervision of your attending.

10

Gynecology
On the GYN unit, patient care, operating room attendance, and
admissions are required activities. You will spend part of your day in
the operating room and part in the clinic.
A number of Obstetricians and Gynecologists are using the
Ambulatory Surgical Treatment Center (ASTC or Day Surgery)
located in the professional building adjacent to JCMC. You are
encouraged to attend the cases also.

Gynecologic Oncology
1. Round on patients before residents each morning (KNOW
PATIENTS WELL).
2. Be present at all surgeries, regardless of whether or not scrubbed.
3. Round on patients on weekends.
4. Round before lectures on Wednesday, then check in with Dr.
Drake and/or residents after lectures are over.

The Medical Record

Because medical records are both a medical and a legal document,
extreme care must be taken to:
1. Precisely state the facts. If you wish to record subjective features,
either directly quote the patient, or record them in a section
headed impressions. While you may disagree with physicians,
nurses, lab reports, etc., you must be extremely careful how you
phrase these disagreements.
2. Avoid the necessity for counter notes on the charts, or a potential
suit for libel or a defamation of character.
3. Always record your name and status (MS III) after each note.
4. Obtain a counter signature on all notes and orders. This is your
responsibility, not the nurses.

11

Grading
Students will be evaluated by the university faculty as well as by
the clinical attendings. Frequent discussions between the faculty
members and the clinical faculty will take place during your stay with
us, and as a result your progress during this time will be continually
under surveillance.
You will be evaluated weekly by the faculty during the rotation.
These evaluations will be a combination of narrative and numerical
assessment.
The following major areas of assessment have been agreed upon in
the clinical specialties:
Fund of Knowledge of both General Medicine and Ob-Gyn.
This is the basic store of factual knowledge that the student has at
his/her disposal, and should be a reflection of information gathered in
conferences, seminars, readings, and from data gathered directly
through patient care. The manner of measurement may include
written or oral examination in the clerkship setting. This will also be
assessed in the clinical setting by your attending.
Medical Skills. This reflects the ability to obtain a history, perform
a physical examination and record these in a logical, concise manner.
Included here is the ability to perform various motor skills relevant to
our specialty. This area may be evaluated by direct observation or
evaluation of the written comments of attendings.
Problem-solving and Clinical Judgment. This is the ability to
use the information and skills from 1 and 2 (above) to solve clinical
problems in a logical fashion. The differential diagnoses at the end of
your workups will be examined to aid in the evaluation of this
category. For example, a previously healthy patient admitted at 34
weeks gestation for painless vaginal bleeding, with a transverse lie is
more likely to be a placenta previa than Von Willebrands disease,
and this should be reflected in your approach to the patient.

12

Examinations
In-Course Exams
There will be one written and one oral exam. These two
examinations serve multiple purposes. Their prime purpose is to help
train you for your National Board Exam. Though none of the
questions are in any way derived from the exam, the material covered
is representative. The oral exam will be administered by Dr. Selman
in a small group setting. The written exam will cover both OB and
GYN and students will be broken into groups and will take exam at
different times during the rotation.

National Board of Medical Examiners

At the end of your rotation you will be given Part II (shelf exam),
Obstetrics and Gynecology, of the National Board of Medical
Examiners as your course exam.

Additional Evaluation
Evaluation of students will be sought from patients and hospital
personnel (other physicians and nursing personnel), as well as from
your peers. The intention here is to seek out those students who are
exemplary, and reward them for their achievements also, to identify
those who need additional help before it is too late.

Midrotation Evaluations
Each student will meet individually with Dr. Selman toward the
middle of the rotation for a preliminary subjective evaluation. This
will serve several purposes, but again mainly to identify those who
need additional help before it is too late.

Final Grade
Your final grade is calculated as follows:
13

15%
15%
35%
30%
5%
100%

Written Examination Score

Oral Examination Score
National Board Examination
Clinical Evaluations (all evaluations averaged)
Ob-Gyn Surgical Skills sheet

Grade Scale
A
92-100
B
80-91
C
79-70
D
69-60
F
59 or below
NOTE: The faculty reserves the right to assign a failing grade (D or
F), or to require the student to remediate a portion of the course as a
precondition to being assigned his/her earned grade (I submitted)
should performance be inadequate in ANY portion of the course.

Faculty and Course Evaluations

Your input is requested at several stages of your education. This
input is taken seriously, and is carefully evaluated. Constructive
criticism and suggestions from the student body go a long way
towards improving the educational experience of those who follow
you. We do value your input. On the other hand, we would ask that
you exercise an appropriate degree of maturity and judgment when it
comes to destructive and/or personal comments about individual
faculty. This is not to imply that adverse comments are out of place,
but rather that you might consider other ways to deal with a problem.
Directly approaching the faculty member, or course director, to deal
with a problem that you might be experiencing, before you reach the
end of the course, is often preferable. By the end of the course, it is
14

both too late for you to improve your experience with us, and for the
faculty member to deal with what may perhaps have been just a
misunderstanding.
It is extremely distressing to those of us who are particularly
interested in providing you with a quality experience when we
discover, after you have left our rotation, that a problem had existed
for which an easy correction was available but not applied because
the situation was not recognized.

Call Room
The Ob-Gyn student call room is located at the end of the long hall
of Labor and Delivery admissions. During orientation you will be
given a tour of the call rooms, the entrance code, and be assigned a
student locker.

Once again, we welcome you to Obstetrics and

Gynecology, and hope you will use all the educational
opportunities this rotation has to offer.
The following sections include recommended formats for the
documentation of the following:
Admission to Labor and Delivery
Daily notes for high risk OB patients
Intrapartum progress notes
Vaginal and Operative Delivery notes
Postpartum notes

15

Obstetrics
Obstetric Admission History and
Physical
Date __________ Time _________ Attending _________________
ID: Age, G___ P ___, LMP ______, @ ________ weeks gestation
(?consensus with EDC)
EDC ____ weeks by dates
EDC ____ weeks by ultrasound
C C : [e.g. contractions, leaking fluid, vaginal bleeding, fetal
movement, ruptured membranes, complications of pregnancy,
etc.]
Present pregnancy: Prenatal Care provided by whom? List any
complications of present pregnancy [Antenatal course
complicated by ]
PMH: Illnesses [e.g. HTN, DM, thyroid disease, asthma, heart
murmur, hepatitis, seizure, bleeding/anemia, injury]; Transfusions;
Anesthesia History.
PSH: Surgical history.
Current Medications: List all, including vitamins, herbs, etc.
Allergies: Define reaction type for each allergy.
Obstetrical History: Include dates, type of delivery, hours in labor,
birth weights, complications, etc.
Gynecologic History: Include age of menarche, length of menses
and frequency of cycle, lightness/heaviness of bleeding [e.g.,
13/3-5/reg/28-30], STDs, contraception, abnormal pap smears.
Family Hx: Include HTN, DM, birth defects, twin gestations,
pregnancy complications, breast cancer, ovarian cancer, etc.
Social Hx: Tobacco/EtOH/Illicit drugs. Include marital status,
number of children in home, support system, domestic violence
screening, etc.
Prenatal Labs/Studies: Heme: Hgb, Hct, ABO group, Rh, Antibody
status; ID: rubella, VDRL, GC, herpes, HIV, Hep B, Hep C;

16

Chemistry: U/A; Last Pap smear; AFP/Quad Screen; Ultrasound

results; Risk factors for Group B strep.
ROS: This section is frequently included in the review of present
pregnancy, and should include: headache, visual changes,
abdominal pain (RUQ), nausea, vomiting, fevers, discharge, etc.
PE: Vital Signs, FHTs/Toco, General, Skin, HEENT/Neck, Lungs,
Heart, Abdomen (Scars, CVA tenderness, Murphys sign,
tenderness, distention, fundal height, EFW (estimated fetal
weight), fetal lie (should be sketched).
Cervical Exam: Dilation, effacement, position, station, firmness
(and document time of check and by whom)
Extremities: Edema, reflexes/clonus, calf tenderness
Data Base: Biophysical profile, Labs: CBC, U/A with C&S, UDS if
needed, type & screen; Ultrasound [placenta, amniotic fluid, lie,
age/weight]; Sterile speculum exam [pooling, ferning, nitrazine];
Cultures; Amniocentesis; LS/PG
Assessment
Plan

High-Risk Patient, Daily Note. As high-risk obstetrical patients

are in the hospital often a long time prior to delivery, additional
information must be reviewed and noted in a daily note.
History: hospital day, reason for admission
Subjective: List ROS pertinent to admission.
Objective: including FHTs, contractions, etc. Vitals should include
BP range for 24 hours if pt is admitted with HTN.
Labs: cervical cultures?, Mg levels, etc. Record only new labs for
that day and list labs which are pending for that day.
Assessment: For example, 25 yo G2P1001 with IUP at 26 1/7 wks
with PPROM
Plan: tocolytics?, antibiotics?, activity level? steroids? BPP?

17

Intrapartum
Intrapartum Progress Note. This type of documentation is used
frequently while a woman is in labor. Notes are typically written
every two hours. It is best to take the initiative yourself and be
present when checks are to occur.
Subjective: Complaints, tolerance, etc.
Objective: Vital signs, Labs, FHTs and pattern, Contractions
[intensity, duration, frequency], uterine resting tone (soft, firm,
tense), Cervix [dilation, effacement, position, station]
Assessment: (relate to labor curve, fetal distress, maternal
compromise)
Plan: (Intervention or lack of and persons involved in decision
making)

Delivery
Delivery Note. The following is template often used following
delivery.
Patient is a ___ y/o female G___ P___ Ab___ EDC___ who
presents c/o ______. Patient [describe labor, admission findings,
initial cervical exam] was admitted in _______ [active labor, etc.].
Patient required _______ (if anything). Fetal heart tones were
_______ throughout labor. Patient monitored __________ [external,
internal, etc.]. Patient was completely dilated at [time]. Patient went
on to deliver at [time] in _______ presentation a [male or female]
infant. Apgars were ___ at one minute and ____ at five minutes.
Weight was ____ lb _____ oz. Infant required ___________
[routine, etc.] resuscitation and was taken to _______ [NBN, NICU,
kept at bedside]. Cord had __ vessels and appeared ________
[normal, etc.]. Placental delivered an ______ [time] by _______
[spontaneous, manual, etc.]. Vagina and cervix examined and were
________ [report findings]. A ____ degree episiotomy was
performed to aid in delivery and was repaired in the usual fashion
with ______ suture. Repeat pelvic and rectal examination were
______ [normal, etc.] EBL ___.

18

Operative Note for cesarean delivery. Students are encouraged

to write this type of note after a cesarean delivery.
Preop Dx: 1) ___ y/o female G___ P___ @ ___ wks
2) (Arrest of Dilation, NR-FHT, etc.)
Postop Dx: same
Procedure: (Primary, Repeat LTCD, Classical, etc.)
Attending:
Assistant:
Anesthesia: (Spinal, Epidural, General)
Operative Findings: (Weight and sex of infant, Apgars, normal
tubes and ovaries).
Specimens: (Placenta, cord blood, cord gases)
EBL:
Fluids, blood and urine output:
Drains: (none, Foley to gravity, etc.)
Complications:
Disposition: Patient sent to recovery in stable condition

Postpartum
When assessing a routine postpartum patient, the following areas
should be addressed:
General: Is the patient eating and tolerating her diet without
nausea or vomiting? Is she urinating, and if she has had a cesarean,
has she passed gas or had a bowel movement?
Pain: Does the patient have appropriate abdominal pain?
Contraction-like uterine pain may be merely after-pains, but a tender
fundus may be a sign of endometritis. Incision pain is common and
usually appropriate, but look for signs of infection.
Leg pain is common after birth due to the positioning of the
patient during labor, but calf tenderness can be a sign of thrombophlebitis or DVT. Encourage walking.

19

Episiotomy or Laceration pain may be reported, particularly with

3rd or 4th degree lacerations or medio-lateral episiotomies. This pain is
worse with sitting or walking. May use sitz baths and Tucks pads,
and consider a stool softener for 3rd and 4th degree tears.
Dysuria may be reported and UTI is common in women who have
been catheterized during the peripartum period. Dysuria may also be
secondary to urethral trauma associated with the babys head or
forceps delivery.
Lochia: Is the patients vaginal bleeding or lochia appropriate? You
may quantify bleeding by pad counts, though this is variable.
Usually, the nurses will have told the patient if her lochia is
inappropriate. The immediate postpartum period is characterized by
Lochia Rubra, a blood-tinged discharge that may include pieces of
tissue and decidua. Lochia Serosa is a serous discharge which may
last for two weeks. Lochia Alba is a thicker, yellowish discharge
which can last for a month postpartum.
Feeding: Does the patient plan to breastfeed or bottle-feed? If she
is breastfeeding, inquire about her success and any problems she may
be having, such as nipple cracking or problems feeding. Masse cream
may be appropriate for her nipples and a Breastfeeding Consult can
help with feeding issues. Warn patient about signs and symptoms of
mastitis and engorgement. If she plans to bottle-feed, advise the
patient that she can wear a tight bra and use ice packs while her milk
dries up. She should not express milk from her nipples.
Birth Control: Does the patient have plans for birth control?
Tubal Ligation is done at time of CS or within 24 hours of NSVD if
tubal papers are signed. IUDs and Diaphragms can be inserted and
fitted at the 6 week postpartum visit. OCPs and the Patch are started
on a Sunday, about two weeks postpartum. Minipills (Progestin-only)
can be started at any time and are recommended to women who plan
to breastfeed (and only while they are breastfeeding). Depoprovera
20

shots can be given prior to discharge and every two months

thereafter.

Postpartum Progress Note. Typical daily postpartum note:

Subjective:
Hospital Day # ___ Post Partum Day # ___
Maternal complaints, Diet, associated N/V, Pain Control, episiotomy
stitch pain, Ambulation, Flatus / BM / urination, Lochia, Breast or
bottle-feeding, Contraception plans, etc.
Objective: Vital signs, C/V, Lungs, Abdomen, BS, fundus [firmness,
relationship to umbilicus], distention, tenderness, Vaginal, noting if
lochia (pad counts) is present & if it is increasing or decreasing,
Extremities, Prenatal labs, also, note UOP and post-partum Hb &
Hct
Assessment: PPD #, Rubella status/Blood type with Rh
Plan: Rubella vaccine, Rhogam if appropriate, Contraception if
needed, Discharge planning.

The following is information regarding the discharge of OB patients.

Discharge
Patients who have had vaginal delivery may be discharged 24
hours afterwards; this typically means on the first or second
postpartum day. Patients who have had cesarean delivery typically
stay at least 48 hours, which usually means the second or third
postoperative day. Obviously day of discharge depends on the time of
day delivery occurred. Infants whose mother was GBS positive are
required to stay 48 hours and for convenience the mothers also
usually stay the 48 hours as well.
Discharge Medications: PNV may be continued until the patient
runs out merely as a nutritional supplement regardless of whether she
21

plans to breast or bottle-feed. If she plans to breastfeed, then PNV

should be continued as long as she breastfeeds.
Iron Supplement. The decision to offer iron supplementation is
variable among physicians. In general, if the postpartum hemoglobin
is above 11, no supplementation is required. If hemoglobin is,
10-11, then FeSO4 1 po daily;
8-10, then FeSO4 1 po BID;
less than 8, then FeSO4 1 po TID.
Also consider, adding Vitamin C to aid absorption for BID or TID
iron supplementation, and patients should be advised to take iron in
between meals. They may also take it with orange juice or other
Vitamin C enriched beverage.
Pain Control. Generally, patients will receive narcotic analgesia
as well as an NSAID. For example,
Percocet 5/325, 1-2 tabs po q4-6 hrs prn for pain
#10 for NSVD /#30 for CESAREAN (#18 for 3rd or 4th
degree lac)
Anaprox DS 1 po q12 hrs prn for cramping #30
May also use Tylenol #3, 1-2 tabs po q4-6 hrs prn #18 for
uncomplicated NSVDs. Lortab or Mepergan Fortis is an alternative
for Percocet.
Stool Softener. If the patient is going to receive BID or TID iron
supplementation, or narcotics for more than 3 days, or if the patient
had a 3rd or 4th degree laceration, then add,
Colace 100 mg po BID #30.
Birth Control. For breastfeeding patients,
Depoprovera 150mg IM x1 prior to d/c
Or the patient may use a progestin only pill, such as,
NorQD, 1 tab po qd #30.
For bottle-feeding mothers, any combination OCP they desire can
be used. The prescription should be started on the first Sunday two
weeks after delivery. IUDs or diaphragms can be addressed at six
week postpartum visit.
22

Rubella. If the patient is Rubella non-immune or Rubella

equivocal, then rubella vaccine should be given prior to d/c.
Rhogam. If the mother is Rh negative and the baby is Rh positive,
then the patient should receive Rhogam 1 vial IM.
Follow-up. Patients who have had uncomplicated NSVDs should
be followed-up in 6 weeks. Patients who have had a CESAREAN
should have a 2 week incision check and may require a visit sooner to
have staples removed if they were not removed prior to d/c. Patients
with other medical conditions may require sooner follow-up as well,
such as hypertensive patients who require a 1 week blood pressure
check.
Discharge Instructions. The following discharge instructions
should be given to patients and noted on their green discharge sheets:
- Call if you have vaginal bleeding more than one pad/hour;
- Call for foul-smelling vaginal discharge or discharge from incision
(if cesarean);
- Call for temperature of 101 degrees or greater;
- Call for feelings of depression, suicide, or homicide;
- Keep all appointments;
- Nothing in the vagina for six weeks (no tampons, no sex, no
douching);
- Do not drive while on paid medications;
- Do not drive until able to slam on brakes without difficulty.
The following outlines how patients are evaluated in L&D Triage.

Triage
For all triage patients, assess for FM, VB, LOF, contractions, and
other pertinent information based on complaints. Review prenatal
records and dating for pregnancy. All triage patients should have
EFM.

23

Labor: Labor is regular contractions with cervical change. If

patient is preterm, consider fetal fibronectin (fFN) prior to cervical
exam if patient is a candidate. If there is no question of ROM or
bleeding, serial SVEs can be used to evaluate for labor. If patient is
having preterm contractions, consider causes such as UTI,
dehydration, etc.
ROM: Do SSE, looking for pooling of fluid, fluid from cervix
with Valsalva maneuver, develop slide for ferning (arborization),
nitrazine. If tests are equivocal or negative but strong clinical
suspicion remains, can US for AFI. Vaginal d/c in pregnancy is
normal.
Decreased Fetal Movement: EFM, and look for Reactive NST. If
not reactive, get BPP.
Abdominal Pain: Assess for specific complaints. Dysuria? Round
ligament or inguinal ligament pain? Remember that pregnant women
can have the same causes for abdominal pain as nonpregant women,
including appendicitis, gallbladder disorders, gastroenteritis, GERD,
etc.
Round Ligament Pain: This pain often occurs at about 20-30 wks
and runs down the BLQ to the groin and into the vulva. It can be
reproduced by manually shifting the uterus from the left to the right.
Patients should be educated about the cause the pain and reassured.
Low Back Pain: Determine if the pain is related to contractions
versus musculoskeletal versus CVA tenderness.
Nausea and Vomiting: Does patient have normal N/V associated
with pregnancy? Consider hyperemesis gravidarum, viral
gastroenteritis, UTI/pyelonephritis. Is patient dehydrated?
Vaginal Bleeding: If patient complains of third trimester bleeding,
do not perform SVE without knowing location of placenta first. US
may be necessary. Vaginal bleeding can also be related to extropion
24

or eversion of the endocervix. This tissue is more friable and can

often bleed, particularly after intercourse.
Swelling: Low extremity swelling can be normal in pregnancy, but
edema has a weak association with preeclampsia, particularly
swelling in the face or rapid weight gain associated with water
retention. Evaluate blood pressure and may consider preeclampsia
workup in some cases.
Although medical students will not be taking direct patient calls, the
following information is provided as way of example as to how these
calls should be handled, ie what information is pertinent.

Patient Calls
Labor: For preterm patients with contractions, recommend
hydration and bed rest. If regular, short-interval pattern persists after
one hour, or if they have experienced a change in vaginal discharge
or vaginal bleeding, then the patient should be evaluated in triage.
For term multiparas patients with contractions q8-10 minutes for 1
hour, they should report to triage. Term nulliparas patients with
contractions q4-5 minutes for 2 hours should report to triage.
R O M : If history is plausible, patient should report to triage
regardless of gestational age.
Decreased Fetal Movement. Patients should be advised to do
kick counts. Patients should lie down and count fetal movements
for two hours or until 10 movements are appreciated, whichever is
first. If patient does not have 10 movements in two hours, they should
report to triage. At term, movements may be more subtle.
Headache: Headaches could be a sign of a hypertensive disorder,
and patients should be questioned for other related signs or
symptoms. Patients can take Tylenol, Regular or Extra Strength,
every four hours. Patients can also lie down and relax with a cold or
hot cloth on their heads. Patients whose headaches go unrelieved by
25

conservative measures or who have a history of hypertension, may

require closer evaluation.

Nausea/Vomiting: Patients should try to drink clear fluids in small

amounts, frequently. They may also try bland foods, like saltines or
applesauce. Phenergan suppositories may also be indicated. Patients
who are unable to keep down clear fluids are at risk for dehydration
and may require IV hydration.
For nausea/vomiting in the first four months or pregnancy
(morning sickness), recommend that patients eat small frequent
meals; eat bland food; eat saltines or dry toast before lifting head up
out bed in the morning; drink fluids separate from food; and avoid
fried and spicy foods and foods with strong odors.
Diarrhea: Recommend Immodium AD or Kaopectate to patients,
as well as the BRAT diet (Banana, rice, applesauce, toast). Persistent
or voluminous diarrhea or diarrhea associated with contractions may
warrant a triage evaluation.
Constipation: Recommend that patients increase fluid intake as
well as fiber intake. Patients can use Metamucil or MOM.
Cold symptoms: Sudafed or Actifed can be used for s i n u s
congestion. For a sore throat, patients may gargle with Chloraseptic
or Listerine or salt water (1 tsp in 8 oz of warm water). They may
also use Sucrets. For a cough, patients may use plain Robitussin (not
DM) and use throat lozenges. All patients with these viral symptoms
should drink plenty of fluids and they may use Tylenol Cold and Flu
medicine. If patients have a fever of 100 degrees or more or have
bacterial symptoms, they need to be seen in clinic or triage.
Seasonal Allergies: Seasonal allergies may be treated with
Benadryl or Chlortrimeton. Occasionally, Sudafed or Actifed may be
used, or Tylenol Sinus.
Heartburn: Advise patients to eat small frequent meals and avoid
eating at bedtime. They can try sleeping with their heads elevated and
26

OTC antacids such as Gaviscon, Tums, Maalox and Mylanta may be

used.
Hemorrhoids: If the patient is constipated, this needs to be
addressed. Otherwise, can recommend that patient take sitz baths or
soak in a tub and use Preparation H, Anusol, or Tucks pads.
Pain: Patients who call and complain of pain may be treated with
OTC pain medicines and non-narcotic prescription pain medications.
Pain severe enough to warrant narcotics should be evaluated in the
Emergency Department and the patient may be told that it is the
policy of our practice to not call in narcotics.

OB Clinic
The following is a guide for routine antenatal clinic care:
Before 28 wks gestation, patients are seen every 4 weeks.
Between 28-36 wks gestation, patients are seen every 2 weeks.
After 36 weeks, patients are seen weekly.
At each visit, check patients weight gain, urine, blood pressure.
Ask about VB, LOF, ctx, vag. discharge, dysuria, N/V, PNV use.
After 16-17 weeks, ask about FM. After 10-12 weeks gestation,
check FHT with Doppler. Between 20-36 weeks, measure fundal
height. Other questions are directed based upon patients past medical
history or complications of the pregnancy.
Initial Visit: Prenatal Labs: CBC, Type and Screen, Antibody
Screen, Rubella, RPR (VDRL), HbsAg, HCV, HIV, Pap,
GC/Chlamydia. If patients are unsure of their LMP, or if they have
a history of irregular menses, then offer a dating US.
16-18 Weeks: Quad Screen (AFP, Estriol, free B-HCG, Inhibin).
Offer Amniocentesis for AMA or family history of genetic disease.
16-20 Weeks: Ultrasound (Anatomy Scan).
26-28 Weeks: 1 hour glucose screen (50g). Rhogam injection if
mother Rh negative. Sign tubal papers if patient desires BTL.
35-36 Weeks: GBS culture.
27

28

29

30

31

OB pearls
The following are OB pearls. This information is fair game for
pimping by residents and attendings. Most of this information will
also be fair game for the end of rotation USMLE shelf exam.

Labor
Stages of Labor.
Stage
Event
Duration
First (Latent)
Dilation to 4 cm
6-11 h
First (Active)
4 cm -> 10 cm
4-6 h
Second
Delivery of baby
1-2 h
Third
Delivery of placenta
30 min
Should take about 1/2 the time for a multiparous woman.

Abnormal Labor Pattern.

First (Latent)
First (Active)
Second
No Dilation >/= 2 hr.

Nulliparous
> 20 hr
> 12 hr
> 50 min

32

Multiparous
> 14 hr
> 6 hr
> 20 min

Intrapartum Monitoring
Fetal Heart Rate (FHR) strips should be assessed for their
baseline, variability, accelerations, and decelerations. Monitoring
may be conducted externally or internally with a fetal scalp electrode
(FSE).
The Baseline is the mean FHR within 5 beats/min. Less than 100
beats/min is bradycardia; greater than 160 beats/min is tachycardia.
Variability is quantified with four terms: absent variability
defines an undetectable range of amplitude; minimal variability
defines a detectable amplitude range less than or equal to 5
beats/min; moderate variability defines a amplitude range between
6 and 25 beats/min; and marked variability defines amplitude range
greater than 25 beats/min.
Accelerations are reassuring. A reactive strip is defined be the
presence of at least two accelerations 15 beats/min which last 15
seconds within a 20 minute period. A prolonged acceleration lasts
between 2 and 10 minutes, and a baseline change is said to occur if
an acceleration lasts longer than 10 minutes. Before 32 weeks
gestation, accelerations are defined as 10 beats/min which last 10
seconds.
Decelerations are categorized as early, late, and variable (both
mild and severe). Early decelerations are caused by fetal head
compression and generally mirror the onset and duration of the
contraction. Late decelerations are caused by uteroplacental
insufficiency and are often stimulated by uterine contractions,
beginning at or after the peak of the contraction. Intervention for late
decelerations include decreasing uterine contractions, left, lateral
decubitus position, administering oxygen, hydrating, and preparing
for immediate delivery if not resolving.

33

Variable decelerations are characterized by a rapid downslope

and rapid recovery of the FHR. They are caused by compression of
the umbilical cord. Severe variables are variable decelerations
lasting at least 60 seconds or falling below 60 beats/min or falling 60
beats/min below baseline. Any deceleration may be defined as
repetitive or persistent if they are associated with more than 50% of
contractions. Shoulders associated with variables (accelerations
before and after the deceleration) are reassuring and are not
associated with hypoxia. Intervention for severe variables includes
changing maternal position, decreasing uterine contractions,
administering oxygen, elevating the presenting part, and amniotic
infusion.
A sinusoidal pattern is a smooth, sine waveform pattern often
associated with fetal anemia or fetal acidosis. This is an ominous
sign. A pseudosinusoidal pattern is a benign pattern and is less
regular in shape and amplitude than a true sinusoidal pattern.
Loss of variability, late decelerations, severe variable
decelerations, and a sinusoidal pattern are worrisome.
The Tocodynamometer (Toco) records the pressure waveform of
uterine contractions. This can be done with an external transducer
and, more accurately, with an Internal Uterine Pressure Catheter
(IUPC). Contractions are quantified by multiplying the peak of the
contraction in mmHg times the number of contractions in a 10 minute
period. This is referred to as a Montevideo Unit (MVU), and a
contraction pattern greater than 200 MVUs is considered adequate for
progression of labor.

34

Gestational Diabetes
White Classification of Diabetes Mellitus
Class
A1
A2
B
C
D
F
H
R
T

Description
DM diagnosed during pregnancy which is diet controlled.
DM diagnosed during pregnancy requiring insulin.
Insulin-requiring DM diagnosed before pregnancy, after the age of 20,
lasing less than 10 years.
Insulin-requiring, onset at age 10-19, with duration 10-19 years.
Onset before age 10 or duration longer than 20 years, or associated with
CHTN or background retinopathy.
DM with renal disease.
DM with CAD.
DM with proliferative retinopathy.
DM with renal transplant.

Women are screened for GDM at around 28 weeks, when human

placental lactogen has peaked (hPL). Screening is via a 50-g oral
glucose challenge. This challenge is failed with a glucose value
greater than 135. This then necessitates a 100-g 3 hour GTT. The
diagnosis of GDM is made if two or more of the four values after this
test are abnormal,
Fasting
95
1 hour
180
2 hour
155
3 hour
140
After the diagnosis of GDM, glucose screening is performed each
morning (fasting) and two hours postprandial. Fasting values should
be below 95 and two hour postprandial values should be below 120.
If more than half of these values are abnormal, then a change in
therapy is indicated.
Patients with GDM-A receive a 75-g two hour GTT at 6-8 wks
postpartum to monitor them for development of diabetes outside of
pregnancy.
35

Hypertensive Disorders of Pregnancy

Finding
CHTN
GHTN
Preeclampsia
Onset
<20 weeks
Usually 3rd Trim.
20 weeks
Degree of HTN
Mild or Severe
Mild
Mild or Severe
Proteinuria
Absent
Absent
Usually present
Serum Urate > 5.5
Rare
Absent
Usually present
Hemoconcentration
Absent
Absent
Severe disease
Thrombocytopenia
Absent
Absent
Severe disease
Hepatic Dysfunction
Absent
Absent
Severe disease
Adapted from Sibai, N Engl J Med 335:257.
Finding
Mild Preeclampsia
Severe Preeclampsia
BP (2 in 1 wk, 6 hrs apart)
140/90
160/110
Proteinuria (in 24 hrs)
300 mg
5g

Eclampsia is the presence of seizures in a preeclamptic which are

not attributable to another cause.
HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low
Platelets) can occur with or without hypertension. Criteria include
evidence of hemolysis (abnormal peripheral blood smear, increased
bilirubin, increased lactic dehydrogenase > 600 IU/L), elevated liver
enzymes (AST 72 IU/L), and thrombocytopenia (Platelet count <
100,000/mm3).
Labs to obtain to evaluate a pregnant patient with a hypertensive
disorder include CBC, CMP, Uric Acid, LDH, and 24 hour urine for
protein and creatine clearance. A chronic hypertensive patient should
receive a 24 hour urine analyses to determine a baseline early in
pregnancy.
In general, patients with HELLP syndrome are delivered
immediately, patients with severe preeclampsia are delivered at 34
weeks, and patients with mild preeclampsia are delivered at 37
weeks. Severe preeclamptics receive medications to keep blood
pressures in the mild range.
36

Risk factors for GHTN/Preeclampsia:

Nulliparity (risk ratio 3:1)
Age >40 or <20 (3:1)
African-American race (1.5:1)
Family or personal history of the disease (5:1)
Chronic hypertension (10:1)
Chronic renal disease (20:1)
Diabetes (2:1)
Multiple gestation (4:1)

IUGR
Commonly defined as growth at <10%tile, but significant morbidity
and mortality is noted when growth is <3%tile. One has to
distinguish between constitutionally small fetuses and those that are
truly growth restricted. Management includes modified bed rest,
growth US every 3 to 4 wks, fetal artery Doppler measurements (GA
< 35 wks), twice weekly antenatal testing, and steroids and early
delivery when indicated.
Note: The diagnosis of small for gestational age (SGA) can only be
made after the infant is born.

37

Rh Isoimmunization
Rh negative mothers may develop antigen to Rh if their fetus is
Rh positive. Since these antibodies are IgG, they can cross the
placenta and cause hemolytic disease of the fetus. To avoid this, Rh
negative mothers receive 300 mcg of RhoGAM (D Immunoglobulin)
at 28 weeks gestation, or if any situation where fetal and maternal
blood may be mixed, including abortion, amniocentesis, ectopic
pregnancy, or trauma. Mothers are also tested for Antibody D during
pregnancy. The D antibody is associated with Rh. If the mother is
antibody D positive, it shows some prior sensitization (in previous
pregnancies or possible in blood transfusions).
At birth, obtain cord blood of Rh negative mothers at delivery to
determine blood type of baby. If baby is Rh negative, RhoGAM
should not be necessary. If it is positive, RhoGAM is administered
again. High risk scenarios for isoimmunization include placenta
previa, abruptio placentae, cesarean section, and trauma. You may
perform a Kleihauer-Betke test to determine degree of blood transfer
and dose RhoGAM accordingly. If the mother at any time is positive
for the antibody, then it is necessary to know the babys Rh status. If
paternity is certain, then this can be done by checking the fathers
status. If paternity is unknown or if the father is Rh negative, then
maternal antibody titers are necessary (critical value is greater than
1:16) and perhaps serial amniocenteses for O D450 analyses and
stratification on the Liley Curve to direct treatment. Ultrasound
examination of MCA flows can also be correlated to degree of fetal
anemia.
Other non-ABO, non-Rh blood groups are associated with
hemolytic disease of the newborn, including Kell, Duffy, Kidd, and
MNS. Lewis antibodies are not associated with hemolytic disease.
Remember: Kell kills and Lewis lives (Lewis is IgM and therefore
does not cross the placenta).
38

Antepartum Monitoring
Antepartum fetal surveillance may be conducted by a Nonstress
Test (NST), fetal movement assessment or kick counts, Oxytocin
Challenge Test (OCT), and the Biophysical Profile (BPP).
An N S T is electronic fetal monitoring of FHR looking for
reactivity, as defined above. Kick counts are done by have the
patient lay on her side and counting fetal movements. At least ten
movements within two hours is reassuring. Vibroacoustic
stimulation to awaken the fetus or ingestion of food or caffeine can
often speed the success of these two tests.
An OCT is done by infusing oxytocin IV, titrated to cause three
contractions within ten minutes. A positive test is characterized by
the presence of at late decelerations following a contraction at least
half of the time.
A BPP is an ultrasound evaluation of the fetus which awards two
points each for fetal movement, fetal tone, fetal breathing, and an AFI
> 5 cm for a total of 8 points (10 points including a NST).
Antepartum fetal surveillance is indicated for the following:

More Obstetrics Pearls

Clinical Estimates for Gestational Age. Urine hCG positive as
early as 5 weeks. Fetal heart tones audible by Doppler at 11-12
weeks. Patient notes fetal movement at ~19 weeks for a primigravida
and ~17 weeks for a multigravida. At 20 weeks the fundus should be
at the level of the umbilicus.

39

Bishop Scores/Parts of Vaginal Exam.

Part of vaginal exam
0
1
2
Dilation
closed
1-2 cm
3-4 cm
Effacement
0-30%
40-50%
60-70%
Station
-3
-2
-1
Cervix position
Posterior Middle
Anterior
Cervix consistency
Firm
Medium
Soft
Add 1 for preeclampsia and vaginal delivery
Subtract 1 for nulliparity/post-term/ROM (early and late)
Scores 0-4: 45% 5-9: 10% 10-13 0%

3
5+
80+%
+1/+2

Induction of Labor
Indications
Preeclampsia/eclampsia
or +FHT
PROM
39 wks
Chorioamnionitis
39 wks
Post-term pregnancy
Fetal compromise
Intrauterine fetal death

Contraindications
Placenta previa

Fetal Maturity
36 wks since +serum Hcg

Classical uterine incision

U/S at 12-20 wks, g.a. >/=

Prolapsed umbilical cord

U/S at 6-11 wks, g.a. >/=

g.a.=gestational age

Preterm Terms.
Preterm labor: regular uterine contractions with progressive
cervical change or regular uterine contractions with a cervix that is at
least 2 cm dilated and 80% effaced at less than 37 weeks gestation
PROM: premature rupture of membranes, rupture of membranes
before the onset of labor
PPROM: preterm premature rupture of membranes, rupture of
membranes before 37 weeks gestation
Prolonged ROM: rupture of membranes for >24 hours before
delivery. Increases risk of chorioamnionitits and postpartum
endometritis
40

Classification of Perineal Lacerations and Episiotomies.

1st degree: extends only through the vaginal and perineal skin
2nd degree: extends deeply into soft tissues of perineum down to,
but not including, the external anal sphincter capsule. Involves the
bulbocavernosus and transverse perineal muscles
3rd degree: extends through the perineum and through the anal
sphincter
4th degree: extends through the perineum, anal sphincter, and the
rectal mucosa to expose the lumen of the rectum
Leopold Maneuvers.
1st maneuver
2nd maneuver
3rd maneuver
4th maneuver

Presentation by palpating fundus.

Fetal lie by palpating for back
Determining engagement
Determines fetal head flexion or extension
Apgar Scoring

Sign
A Activity (Muscle Tone)

0 Points
1 Point
2 Points
Activity (Limp) Arms and Legs
Active Movement
Flexed
P Heart Rate
Absent
Below 100 bpm
Above 100 bpm
G Grimace (Reflex Irritability) No Response Grimace (cries,
Sneeze, cough,
some movement) pulls away
A Appearance (Skin Color) Blue-gray,
Pink body, blue
Normal over
pale all over hands and feet
entire body
R Respiration
Absent
Slow, irregular
Good, crying
A score of 7-10 is considered normal, while 4-7 might require some
resuscitative measures, and a baby with Apgars of 3 and below requires
immediate resuscitation.

41

Postpartum Hemorrhage
Blood loss greater than 500 mL following a vaginal delivery or
1000 mL follow a cesarean delivery is defined as a postpartum
hemorrhage, though we are notoriously inaccurate in our estimate of
actual blood loss. Nevertheless, a postpartum hemorrhage can lead to
significant maternal morbidity and mortality. There is a long list of
risk factors for postpartum hemorrhage including prior history of
hemorrhage, history of bleeding disorders, prolonged labor, the use of
Oxytocin in labor, multiple gestations, etc. When it happens, the
following differential diagnosis may be of value:
Uterine atony
Vaginal/cervical lacerations (esp. for operative deliveries)
Retained products of conception
Uterine inversion
Bleeding disorder
DIC (or consumptive coagulopathy)
Steps that must be taken prior to calling the attending include,
thorough pelvic exam for lacerations, uterine massage, the
administration of the appropriate uterotonics, and, esp. make sure that
there is adequate vascular access (ie. two large bore IV sites) with
fluid running and that initial blood work has been ordered (CBC, type
and screen, and coags if necessary).
When conservative medical management fails to bring the
hemorrhage under control, consideration of operative interventions
will be necessary. These include D&C, uterine artery embolization,
and exploratory laparotomy.

42

Gynecology
The Complete Gynecological History
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Past Surgical History (PSH):
Current Medications (Meds):
Allergies (All):
Family History (FH):
Social History (SH):
Gynecological History:
Menstrual History. Record the age at menarche, the duration of
menstrual flow (normal is 3-7 days), the interval of their cycle,
and a qualification of the amount of flow, such as heavy, light,
or normal.
Last Menstrual Period (LMP). The date of the first day of
bleeding of the last period and normality or abnormality of her
menses. The following terms are used to describe the menses:
Dysmenorrhea: painful menstrual flow.
Hypomenorrhea: decreased menstrual flow.
Intermenstrual bleed: bleeding between regular intervals.
Menometrorrhagia: Frequent, irregular, and excessive menstrual
flow.
Menorrhagia: Excessive menstrual flow both in duration and
amount.
Metrorrhagia: irregular bleeding.
Amenorrhea: absence of menses.
Oligomenorrhea: Irregular bleeds, >45 day interval.
Polymenorrhea: Frequent regular menstrual flow, <18 day cycle.
Menstrual cycle: 28+/- 7 days, with duration 5+/-2 days.
43

Postmenopausal: Record date of cessation of menses and any

menopausal symptoms, including:
Hot flashes: most frequently occurring sx, sudden, episodic
skin flushing and perspiration. Last 3-4 minutes, once a day
up to 3 episodes per hour.
Lower urinary tract atrophy: atrophy of urethra and
periurethra, loss of pelvic tone, prolapse of urethrovesicular
junction. Sx of dysuria, urgency, frequency, suprapubic
discomfort, frequent stress and urge incontinence
Genital changes: shortening of vaginal canal, loss of vaginal
folds, epithelial thinning and friability, bacterial vaginoses
common. Leads to atrophic vaginitis, dyspareunia or vaginal
bleeding
Osteoporosis: associated with decreased bone mass, increased
susceptibility to fractures. Estrogen supplementation
decreases fracture risk by 50%
Dyspareunia. New or longstanding? Introital or with penetration?
Pelvic Pain. Duration, location, quality, associated symptoms,
what makes better or worse, etc.
Pelvic Infections. PID, STDs (Gonorrhea, Chlamydia, Syphilis,
Herpes, Hepatitis, HPV, HIV, etc.). Record date of infection and
if infection was/is being treated. Also history of other infections,
such as yeast, trichimonas, BV, etc.
Genital Neoplasm. Any tumors or growths on the external or
internal genitalia.
Endometriosis. History of diagnosis, treatment modalities.
Pap History. Last Pap smear, history of abnormal pap smears,
treatments to the cervix (LEEP, Cones, Cryo, etc.).
Mammogram History. Last mammogram, history of abnormal
scans, ultrasounds, biopsies, FNAs, etc.
Fertility. And history of difficulty with conception, assisted
reproduction, etc.
44

Sexual History. Is patient sexually active, what is sexual

orientation, how may life partners, how many current partners,
how many partners in last 12 months, age at first intercourse,
satisfaction with sex-life, orgasmic complaints, history of rape
or sexual abuse, or physical or emotional abuse, methods of
contraception and STD prevention.
Obstetrical History:
Gravidity (G). The total number of times a woman has been
pregnant, regardless of outcome.
Parity (P). Parity is recorded with four numbers, following TPAL
mnemonic.
T (term): Number of pregnancies reaching term (>37 wks),
regardless of number of fetuses.
P (preterm): Number of pregnancies delivered between 20 and
37 wks gestation, regardless of number of fetuses.
A (abortuses): The total number of pregnancies ended before
20 wks gestation, for whatever reason. There are six types of
spontaneous abortions (SAb) which is a naturally occurring
abortion or miscarriage, as opposed to a therapeutic or
elective abortion or an ectopic pregnancy, all of which are
counted as abortuses:
Spontaneous Abortions:
Threatened: Vaginal bleeding in the first half of pregnancy.
Inevitable: Rupture of membranes with cervical dilation in
the first half of pregnancy.
Incomplete: Expulsion of some but not all products of
conception.
Complete: Expulsion or removal of all the products of
conception.
Missed: Retention of dead products of conception for
several weeks.
45

Recurrent: Three of more consecutive spontaneous

abortions.
Ectopic Pregnancy: Ectopics occur outside of the uterus, and
might be in the tube, ovary, cervix, or abdomen.
Heterotopic Pregnancy: A pregnancy occurring ectopically
and another intrauterine at the same time.
Elective Abortion: Interruption of pregnancy prior to viability
without a maternal or fetal indication.
Therapeutic Abortion: Interruption of pregnancy prior to
viability for a maternal indication or after rape/incest.
L (living children): The total number of children delivered by
the patient who are currently living.
Delivery History. History of patients prior pregnancies, with
outcome of each (NSVD, C/S, D&C, etc.). Relate weeks of
gestation, gender, mode of delivery, weight of infant,
complications during pregnancy and delivery, etc.

Notes for Gynecology/Gyn-Oncology

Preoperative Note for a Gynecologic/Gyn-Onc Surgery. This
type of note should be written before each case is begun.
Preop Dx:
Planned Procedure:
Planned Anesthesia:
Major Medical Problems:
Medications:
Allergies:
Labs: Include any preop labs, as well as EKG/CXR if done
Consent: Document explanation of the risks and benefits of the
procedure and patients understanding and document that informed
consent is signed and on chart.

46

Brief Operative Note for a Gynecologic/Gyn-Onc Surgery.

Students are encouraged to write this type of note after each surgery.
Preop Dx: [Endometrial cancer]
Postop Dx: same
Procedure: [total abdominal hysterectomy, bilateral salpingoopherectomy, pelvic and para-aortic lymphadenectomy]
Attending: [Drake]
Assistant: (Resident, Student)
Anesthesia: General Endotracheal Anesthesia]
EBL: [100cc]
IVF: [2500 cc LR]
UOP: [150 cc]
Specimens: [uterus, tubes, ovaries, lymph nodes]
Drains: (none, Foley to gravity, etc.)
Complications: none
Disposition: Patient sent to recovery in stable condition

Postoperative Note for a Gynecologic/Gyn-Onc Surgery. This

type of note is typically written around six hours after surgery.
Subjective: Record any patient complaints and ROS pertinent to
immediate postoperative period, including adequacy of pain relief.
Objective:
Vitals: Record current temp/maximum temp, as well as other
vitals.
Urine Output: Urine output should be at least 30cc/hr
General Appearance/Orientation:
Heart and Lungs:
Abdomen:
Wound: Note excessive drainage or frank bleeding and
presence and functionality of drains.
Drain Output: Note volume and quality of drain output
(serosanguinous, etc.)
Labs: Any labs (e.g., H/H) drawn after surgery or that are
pending.

47

Assessment/Plan: [e.g., POD#0 s/p TAH/BSO/PPLND secondary

to endometrial cancer. Path pending. Pt stable with adequate pain
relief on PCA. UOP adequate. H/H pending. Continue routing
postoperative management.]

Daily Progress Note for a Gynecologic/Gyn-Onc Surgery

Patient. A note following this general format should be written daily
on all surgical patients.
Subjective: [Nausea, Vomiting, Flatus, Pain Control, Ambulation,
Voiding, Toleration of Diet, etc.]
Objective:
Vitals: Record current temp/maximum temp, as well as other
vitals, including in/outs for urine, drains, NGT tubes, etc.
General Appearance/Orientation:
Heart and Lungs:
Abdomen:
Wound/Incision: Note excessive drainage or frank bleeding and
presence and functionality of drains.
Labs: Any labs (e.g., H/H) which have come back since last
note, and if POD #1 include both the pre- and post-operative
H/H.
Assessment: [e.g., Age GP POD# ? s/p name of procedure for
what indication HD# ?. If applicable, Antibiotics/Line Day # ?. Also
list any additional diagnoses, such as anemia, nausea, fever, etc.]
Plan: [And planned treatments or procedures for the day related to
the diagnoses, such as remove Foley, ambulate, advance diet, iron
for anemia, IVF, antiemetics for nausea, HRT, D/C, labs, labs
pending, etc.]

Gynecology Clinic
New Patients. For any new patient or an old patient who has not
been seen in 3 years or more, the following template can be used:
48

HPI: Age GP with LMP date presents for indication for visit, referred
by who (if applicable). Expand in any pertinent issues regarding
onset, duration, frequency, etc.
OB/GYN Hx: Gs + Ps and described each pregnancy (e.g., G1 1998
SVD at term without complications 8#3oz, G2 2000 SAb at 8wks, no
D&C, G3 2001 C/S at 35 wks for preeclampsia 5#1oz, G4 2003
ectopic at 4 wks with left salpingostomy).
MI (menstrual index): Menarche/frequency/duration and when
changed (if applicable). Any contraceptives and duration of use
(e.g., total OCP for 5 years, none currently, BTL, etc.). Any infertility
drugs used with dates and durations.
H/o STDs, PID: list which, date(s), treatment(s)
Sexual activity: Age of first intercourse, number of lifetime partners
H/o sexual abuse or assault
Pap hx: last pap and result, h/o any abnormal pap smears and if so
what treatment was offered
MMG hx: last mammogram date and result, any abnormals and
what treatments
Dexa scan hx: Any scans with date and result
Gyn surg hx: Any gyn surgeries and for what indication (i.e., dx lap
for pelvic pain, TAH for fibroids, Burch for SUI, D&C for
menorrhagia, etc.).
Urinary or fecal incontinence
PMH, PSH, SH, Meds, Allergies, ROS
FH: Usual medical problems + Breast CA, Colon CA, Gyn Ca if
yes, note family member on maternal/paternal side, and age/decade
of diagnosis if known.
Vitals/Exam as indicated.
Assessment: Age G P with diagnoses
Plan: Include when to return for follow-up

Established Patients. For established patients for Gyn follow-up

or established annual/paps, the following template may be used (per
Dr. Gebka):

49

HPI: Age GP with LMP date presents for indication for visit. She was
last seen on date. Give pertinent information regarding whether the
patient is taking medicine as previously prescribed and outcomes,
changes to menstrual cycle since last visit, how long pt used
treatments and whether she is still using them, whether she saw
consultants and outcomes, etc.
Note and changes to PMH, PSH, FH since last visit if none, write
no changes. Allergies, Meds, ROS as usual.
Labs/Studies: Document date and results of each since last visit
(e.g., ultrasound results, pap results, Colpo, MMG, Dexa Scan,
EMB, etc.)
Vitals/Exam as indicated.
Assessment: Age G P with diagnoses
Plan: Include when to return for follow-up

Gynecologic Differential Diagnoses

Differential Diagnosis of Suspected PID
GYN: ectopic pregnancy, hemorrhagic ovarian cyst, torsion of an
ovary, endometriosis
GI: appendicitis, cholecystitis, gastroenteritis, IBS
Urinary: nephrolithiasis, UTI
Psych: somatization

Differential Diagnosis of Suspected TOA

GYN: endometriosis (endometrioma), ectopic pregnancy, ovarian
cyst/neoplasm, pelvic hematoma
GI: Appendicitis, periappendiceal abscess, IBS

Differential Diagnosis of Candidal Vulvovaginitis/Vulvitis

Infx: bacterial, trichomonal (d/c can cause a reddened, inflamed vulva)
Derm: Eczema, psoriasis (vulva only, not vaginal tissue), Intertrigo
(irritation in labial folds due to friction, moisture)
GYN: Vulvar vestibulitis, hypersensitivity or allergic vulvovaginitis,
smegma (physiologic desquamation of epithelium creating a white
d/c)

50

Gynecologic Causes of Chronic Pelvic Pain

Adnexal lesions, PID, Endometriosis, Mllerian anomalies, Ovulatory
pain, dysmenorrheal (Also consider Urologic, GI, and MS causes).

Differential Diagnosis of Primary Amenorrhea

Group I (breasts absent, uterus present): Gonadal failure, Turner
syndrome, 46X-Xdel, Mosaicism, pure gonadal dysgenesis, 17-hydroxylase def. with 46,XY karotype, inadequate GnRH release
secondary to hypothalamic failure, decreased synthesis, or NT defect,
pituitary failure, chromophobe adenoma, mumps encephalitis,
newborn kernicterus, prepubertal hypothyroidism
Group II (breasts present, uterus absent): Androgen insensitivity,
congenital absence of uterus
Group III (breasts and uterus absent): 17,20-Desmolase def.,
agonadism, 17--hydroxylase def. with 46,XY karotype
Group IV (breasts and uterus present): Hypothalamic, pituitary, ovary,
uterine.

Differential Diagnosis of Secondary Amenorrhea

With nrml ovarian function: Ashermans, Endometrial destruction
With decreased ovarian function, but high gonadotropins: premature
ovarian failure, surgical/radiation castration
With decreased ovarian function, low or normal gonadotropins:
psychogenic, nutritional, exercise-induced, pseudocyesis, CNS
lesions, thyroid, adrenal, or pancreatic endocrine disorders, drugs,
systemic infections, chronic diseases, neoplasm, feminizing ovarian
tumors
Increased ovarian androgen secretion: PCOS, masculinizing ovarian
tumors

Differential Diagnosis of DUB

Anatomic: Endometrial hyperplasia, cancer, polyps, leiomyomas, infx,
foreign bodies, cervical cancer
Abnrml pregnancy: Abortion, Ectopic, GTN
Coagulopathies: vWB, ITP
Drugs: Anticoagulants, narcotics, reserpine, MAOIs, phenothiazines,

anticholinergics, OCPs, HRT

Medical: Liver dz, thyroid dz, CRF, adrenal dz
Neoplasm: estrogen-producing tumors (Granulosa cell, Sertoli-Leydig)

51

Gynecologic-Oncology
Gyn-Onc Sample H&P
Date __________ Time _________
CC: swollen L leg
HPI: Ms. Jones is a 69 yo POD#7 from a TAH/BSO, PPLND for
Stage IC, grade 3 endometrial cancer. She presented to the office
today with a complaint of increased swelling of the LLE, pain, and
redness. Venous dopplers reveal a thrombus in the L common
femoral vein. She is being admitted for anti-coagulation. Denies
SOB or CP.
Meds: Vasotec 5 mg po daily, Percocet 5/325, 1 po q6 hours prn.
All: Sulfa (rash)
PMH: HTN, NIDDM
PSH: POD#7 s/p TAH/BSO, PPLND; Appendectomy (2/89);
Cholecystectomy (5/94).
Obstetrical History: G2P2002, with 2 NSVDs at term.
Gynecologic History: Spontaneous menopause at age 47, no
ERT, last mammogram 1/04, normal.
Family Hx: CAD in M; Prostate cancer in F; No hx of breast, colon
or gyn malignancies.
Social Hx: Denies tobacco/EtOH/Illicit drugs. Widowed, lives with
daughter in Erwin.
ROS: Skin: neg. HEENT: neg. CV: no CP, no orthopnea. Resp: no
SOB. GI: no N/V, no constipation, diarrhea, melena. GU: slight
vaginal d/c, no odor. Neuro: neg. Endocrine: neg. Constitutional:
fatigue. Hem/lymph: neg.
PE: VS: T-99.1 P-89 R-22 BP 107/74, Gen: well-appearing elderly
female in NAD. HEENT: NCAT, neck FROM, supple, sclerae
clear, pharynx clear. CV-RRR, no M/R/G. Resp: CTA-B.
Labs: Pending. LE Dopplers: thrombus in L common femoral vein.
Assessment:
Plan:

52

Cancer Staging
Cervical Cancer Staging (FIGO System)
Stage 0 Carcinoma in situ (CIS); CIN III. Also called pre-malignant
or precancerous.
Stage I Cancer in the cervix only
Ia Invasion of the cervical tissues can only be seen with a
microscope.
Ia1 Stromal invasion not more than 3.0 mm and extension
not more than 7.0 mm.
Ia2 Stromal invasion more than 3.0 mm but not more than
5.0 mm and extension not more than 7.0 mm.
Ib Lesions wider than 7 mm or deeper than 5 mm, or that can be
seen without a microscope.
Ib1 Lesions less than 4.0 cm.
Ib2 Lesions more than 4.0 cm,
Stage II Cancer extends beyond the cervix, but not as far as the
pelvic wall or the lower third of the vagina.
IIa Extends to upper part of the vagina, but not to the surrounding
tissues (parametria).
IIb Extends to the parametrial tissues (but not to the pelvic wall).
Stage III The cancer has extended to the lower third of the vagina or
to the pelvic wall.
IIIa The cancer has spread to the lower third of the vagina, but
nowhere else.
IIIb The cancer has spread to the pelvic wall or caused
hydronephrosis.
Stage IV Cancer has spread to the bladder, rectum, or outside the
pelvis.
IVa Spread to the rectum or bladder.
IVb Metastasis to distant organs such as the lungs or liver.
53

Endometrial Cancer Staging (FIGO System)

Stage I Cancer remains in the body of the uterus.
Ia Cancer is in the endometrium only.
Ib Cancer has invaded less than half of the thickness of the
myometrium.
Ic Cancer has extended to more than half of the thickness of the
myometrium.
Stage II The tumor has extended to the cervix.
IIa The cancer is only in the glands of the endocervix.
IIb The cancer has invaded deeper into the cervical stromal.
Stage III The tumor has spread beyond the uterus.
IIIa Invasion of the serosa and/or adnexa and/or positive pelvic
washings.
IIIb Spread to the vagina.
IIIc Spread to the pelvic and/or para-aortic lymph nodes.
Stage IV More distant spread of the cancer
IVa To the mucosa of the rectum or bladder.
IVb Distant metastases including intra-abdominal and/or inguinal
lymph nodes.
Ovarian Cancer Staging (FIGO System)
Stage I Tumor is only in the ovaries.
Ia Tumor is in one ovary, with the capsule intact and no tumor
visible on the surface, and no positive pelvic washings.
Ib Tumor is in both ovaries, but otherwise as above.
Ic Stage Ia or Ib, but tumor is either visible on the outside of the
ovary or the capsule has burst or there is ascites with
malignant cells or positive peritoneal washings.
Stage II Tumor has spread inside the pelvis, but not beyond.
IIa Tumor has spread to the tubes and/or the uterus.
54

IIb Tumor has spread to other parts of the pelvis, but no cancer
cells are found in ascites or peritoneal washings.
IIc Stage IIa or IIb, but tumor is either visible on the outside of
the ovary or the capsule has burst or there is ascites with
malignant cells or positive peritoneal washings.
Stage III Tumor is found on the surfaces of abdominal organs and/or
in nearby lymph nodes.
IIIa Microscopic seeding of abdominal peritoneal surfaces.
IIIb Abdominal implants smaller than 2 cm.
IIIc Abdominal implants larger than 2 cm and/or positive
retroperitoneal or inguinal nodes.
Stage IV Distant metastases; pleural effusion with positive cytology;
parenchymal liver metastasis.
Vaginal Cancer Staging (FIGO System)
Stage 0 Carcinoma in situ, VAIN 3, severe vaginal dysplasia. This
stage is not malignant.
Stage I Cancer is limited to the wall of the vagina.
Stage II Cancer has extended through the vaginal wall, into the
parametrium, but not as far as the wall of the pelvis.
Stage III Cancer has extended to the pelvic wall and/or to the local
lymph nodes.
Stage IV Cancer has invaded the bladder or rectum and/or spread
outside the pelvis.
IVa Tumor has spread to the inside of the bladder or rectum.
IVb Tumor has spread outside the pelvic area.
Vulvar Cancer Staging (FIGO System)
Stage 0 Carcinoma in situ, VIN 3, severe vulvar dysplasia. This stage
is not malignant.
Stage I Confined to vulva or perineum, tumor 2 cm or less.
Ia Less than 1 mm of stromal invasion.
Ib More than 1 mm of stromal invasion.
55

Stage II Cancer is confined to the vulva and/or perineum and larger

than 2 cm. Nodes are negative.
Stage III Cancer has spread to the lower urethra or vagina or anus
and/or local lymph nodes on one side only.
IVa Cancer has spread to the upper urethra or bladder or rectum or
local lymph nodes on both sides.
IVb Cancer has spread to the pelvic lymph nodes and/or sites more
distant.
Cervical Dysplasia
There are two different systems for classifying dysplasia, one
cytology based and one tissue based:
The Bethesda System or SIL (squamous intraepithelial lesion)
System is a cytological system which classifies individual cells from
a Pap smear or liquid based cytology and classifies cells according to
the degree of cell abnormality. These break down into:
ASCUS (atypical squamous cells of undetermined significance)
is used to identify cell abnormality which are not clearly
dysplastic. This can be due to a variety of factors, including
hormonal changes, yeast or other infections, medications, or other
sources of inflammation. Reflex testing for HPV to triage patients
according to the presence or absence of high risk viral subtypes.
ASC-H (atypical squamous cells, favor dysplasia) is a subtype
of ASCUS which identifies cells which are felt to be at higher risk
for being dysplastic. These are usually followed with coloposcopy
and biopsy.
AGUS or AGCUS (atypical glandular cells of undetermined
significance) is a finding of atypical glandular cells. These patients
should be evaluated for endometrial or endocervical cancer.
LSIL (low grade squamous intraepithelial lesion) usually
corresponds to CIN I or mild dysplasia. These patients should
undergo colposcopy.
56

HSIL (high grade squamous intraepithelial lesion) corresponds

usually to CIN II or CIN III and these patients should be referred
for colposcopy and biopsy.
The CIN System (cervical intraepithelial neoplasia) is a
histological system used for classifying dysplasia. There are
corresponding classifications for vaginal and vulvar dysplasia called
VAIN and VIN. This system of classification is based both on the
degree of dysplasia in the individual cells (like SIL) and how far
below the surface (epithelium) of the cervix the dysplasia goes. To
determine the level of CIN, a tissue biopsy is necessary.
CIN I This corresponds to dysplasia confined to the basal third
of the epithelium. About 11% will progress to CIN III. Only a very
small percentage of CIN I leads to cancer.
CIN II This corresponds to dysplasia confined to the basal twothirds of the epithelium. About 43% of CIN II will regress back to
normal, and 20% will progress to CIN III.
CIN III This corresponds to dysplasia encompassing more than
two-thirds of the epithelium. Full thickness lesions are often
referred to as carcinoma in situ (CIS).
Cancer By definition, when dysplasia invades the basement
membrane, which is the layer of cells under the epithelium, it has
become malignant.

57

58

59

60

61

62

Common OB/Gyn Abbreviations

Ab
AFE
AFI
AFP
AROM

Abortion
Amniotic Fluid Embolism
Amniotic Fluid Index
Alpha-feto protein
Artificial Rupture of
Membranes
ASCUS Atypical Squamous Cells of
Undetermined Significance
AUB
Abnormal Uterine Bleeding
BPD
BPP
BSO
BTL
Bx
CCM
C/D/I
CIN

DIC

Biparietal Diameter
Biophysical Profile
Bilateral SalpingoOopherectomy
Bilateral Tubal Ligation
Biopsy

CKC
CMT
CPD
CST
CS
CTA
CTX
CVA
CVS
Cx

Continue Current Management

Clean/Dry/Intact
Cervical Intraepithelial
Neoplasia
Cold Knife Cone
Cervical Motion Tenderness
Cephalopelvic Disproportion
Contraction Stress Test
Cesarean Section
Clear to Auscultation
Contraction
Costoverterbral Angle
Chorionic Villus Sampling
Culture

D&C
D&E
DES

Dilation and Curettage

Dilation and Evacuation
Diethylstilbestrol

DTR
DUB
Dx

Disseminated Intravascular
Coagulopathy
Deep Tendon Reflex
Dysfunctional Uterine Bleeding
Diagnosis

E2
EDC
EDD
EFM
EFW
EGA
ETOH

Estradiol
Estimated Date of Confinement
Estimated Date of Delivery
Electronic Fetal Monitoring
Estimated Fetal Weight
Estimated Gestational Age
Alcohol

FBS
Fasting Blood Sugar
FF@/U Fundus Firm At/Below
Umbilicus
fFN
Fetal Fibronectin
FH
Fundal Height
FHR
Fetal Heart Rate
FHT
Fetal Heart Tones
FL
Femur Length
FLM
Fetal Lung Maturity
FM
Fetal Movement
FOB
Father of Baby
FSE
Fetal Scalp Electrode
FSH
Follicle Stimulating Hormone
Ft
Fingertip
FTP
Failure to Progress
G
GBS
GDM
GIFT

63

Gravida
Group Beta Strep
Gestational Diabetes Mellitus
Gamete Intra-Fallopian
Transfer

GnRH
GTT

Gonadotropin Releasing
Hormone
Glucose Tolerance Test

hCG

Human Chorionic
Gonadotropin
HELLP Hemolysis, Elevated Liver
Enzymes, Low Platelets
HGSIL High Grade Squamous
Intraepithelial Lesion
HRT
Hormone Replacement
Therapy
HSG
Husterosalpingogram
HTN
Hypertension
IUD
IUGR
IUFD
IUI
IUP
IUPC

Intrauterine Device
Intrauterine Growth Restriction
Intrauterine Fetal Demise
Intrauterine Insemination
Intrauterine Pregnancy
Intrauterine Pressure Catheter

KB

Kleihauer-Betke

L&D
LAVH

Labor and Delivery

Laproscopic Assisted Vaginal
Hysterectomy
Low Birth Weight
Low Transverse Cesarean
Section
Loop Electrosurgical Excision
Procedure
Large for Gestational Age
Luteinizing Hormone
Last Menstrual Period
Lymph Node Dissection
Lysis of Adhesions
Leakage/Loss of Fluid

LBW
LCTS
LEEP
LGA
LH
LMP
LND
LOA
LOF

L/S
LTCS

Lecithin/Sphingomyelin Ratio
Low Transverse Cesarean
Section

M/F
MIFT

Maternal/Fetal
Micro-injection Fallopian
Transfer
Midline Episiotomy

MLE
NICU
NST
NSVD

Neonatal Intensive Care Unit

Nonstress Test
Normal Spontaneous Vaginal
Delivery

OCP
OCT
OOB

Oral Contraceptive Pills

Oxytocin Challenge Test
Out of Bed

P
PCOS
PE
PID
PIH

Para
Polycystic Ovary Syndrome
Pulmonary Embolism
Pelvic Inflammatory Disease
Pregnancy Induced
Hypertension
PNV
Prenatal Vitamins
POC
Products of Conception
POD
Postoperative Day
PP
Postpartum
PPD
Postpartum Day
PPP
Pitocin Per Protocol
PRBC Packed Red Blood Cells
PROM Premature Rupture of
Membranes
PPROM Preterm Premature Rupture of
Membranes
PPPROM Prolonged Preterm
Premature Rupture of
Membranes

64

PSTT
PTL

Placental Site Trophoblastic

Tumor
Preterm Labor

RI
R LTCS
ROM
RRR

Rubella Immune
Repeat LTCS
Rupture of Membranes
Regular Rate and Rhythm

SAb
SDE

Spontaneous Abortion
Suction, Dilatation, and
Evacuation
SGA
Small for Gestational Age
SROM Spontaneous Rupture of
Membranes
SSE
Sterile Speculum Exam
STD
Sexually Transmitted Disease
SUI
Stress Urinary Incontinence
SVE
Sterile Vaginal Exam
TAH
Total Abdominal Hysterectomy
TOA
Tubo-Ovarian Abscess
TORCH Toxoplasmosis, Other, Rubella,
Cytomegalovirus, Herpes
TUFT Trans-uterine Fallopian
Transfer
TVH
Total Vaginal Hysterectomy
TVT
Transvaginal Tape
UC
US

Uterine Contractions
Ultrasound

VBAC

Vaginal Birth after Cesarean

Section
VIN
Vulvar Intraepithelial Neoplasia
VSSAF Vital Signs Stable, Afebrile
VTX
Vertex

65

WNL

Within Normal Limits

ZIFT

Zygote Intra-fallopian Transfer

Recommended Resources
Beckman, Charles R.B. et al. Obstetrics and Gynecology, 4 th Edition.
Lippincott, Williams & Wilkins, 2002.
Beck, William W. NMS Obstetrics and Gynecology, 4 th Edition.
Williams & Wilkins, 1997.
Gabbe, Steven G. et al. Obstetrics: Normal and Problem
Pregnancies, 4th Edition. Churchill Livingston, 2002.
Sakala, Elmar P. High-Yield Obstetrics and Gynecology. Lippincott,
Williams & Wilkins, 2001.
Evans, Mark et al. Obstetrics and Gynecology: PreTest SelfAssessment and Review. 9th Edition. Appleton and Lange, 2000.

Important Topics
Normal physiology of pregnancy
Prenatal care
Normal and abnormal labor
First and third trimester bleeding
Ectopic pregnancy
Preterm labor and delivery
Postpartum hemorrhage and other postpartum complications
IUGR (intrauterine growth retardation)
Pelvic inflammatory disease and STDs
Common vaginal infections
Methods of contraception
Endometriosis
Amenorrhea
Premenstrual syndrome
Abnormal uterine/vaginal bleeding
Menopause, hormone replacement therapy
Primary dysmenorrhea
66

Additional Notes

67

68