Procedure Ready: Ob/Gyn

• Operative Vaginal Deliveries

  Incidence:  3.3% as of 2013  Indications:  Prolonged second stage  Risk of fetal compromise  Shortening 2nd stage for maternal benefit (ex: cardiac conditions) Consent:  Comparison is c-section typically  Failure rate of OVD is ~3-6%  Forceps has higher success rate over vacuum, but also higher risk 3rd/4th degree tear  Risks to both mom and baby Prep:  Fetus appropriate station/position  Anesthesia Empty bladder Assess Pelvis/Passenger sizes/fit OR Ready Peds available  Episiotomy – NO!  Contraindications Fetal conditions, known or supspected: bone disorders (OI), bleeding disorders  Maternal infections: Hep C, HIV, etc  Concern for shoulder dystocia/cephalo-pelvic dysproportion 

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  13:36
• Induction of Labor

  Indications:  Post-dates (42+wks)  Late Term (41+ wks) Elective 39+wks  Diabetes Hypertension  Many more - check out ACOG Medically indicated delivery  39week induction ARRIVE Trial - Multicenter RCT showing benefit to 39wk IOL over expectant management to ~41wks  Included  Primips  No medical indications for IOL prior to 40+5   Results  IOL group had LOWER c-section rate than expectant group  Neonatal composite outcome had a trend (not statistically significant) toward lower neonatal compilations in IOL group  Conclusion IOL at 39wks is as safe as expectant management without increased risks Many pregnant people are now offered a 39wk IOL rather than waiting for spontaneous labor  The IOL Process:    Evaluate and Prep: Full H&P Ultrasound for position - Vertex VE for cervical exam: dilation/effacement/Station, also position and consistency  Calculate Bishops Score → help determine mode of IOL Options for IOL: if biship score <8 for prime or <6 for multip, ripen first!  Mechanical cervical ripening (balloon) Chemical cervical ripening (misoprostol or cervidil)  Best yet--both!    Contractions (pitocin)  Prime: Pitocin alone if Biship 8 or higher Mulitp: Pitocin alone if bishop 6 or higher    Augmentation: AROM    Failed IOL Failure to reach active labor after 18+hrs ruptured on pitocin (definition varies 12-24hrs ruptured on pitocin)  If reaches active labor (6+cm), no longer failed IOL, now arrest of dil...

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  17:53
• Shoulder dystocia

  Definition: Failure to deliver fetal shoulders with normal downward traction  Why we care: Baby hypoxia, brachial plexus injuries, maternal injuries Risk factors:  DM, excessive weight gain in pregnancy, S>D, Large baby Hx of shoulder dystocia (~10-15% recurrence) Turtling while pushing  Prevention  No real prevention as SD is very hard to predict  Offer cesarean delivery if EFW is >5000g and no DM, or >4500g and any type of DM What do to:  Step back. If comfortable, can help minimize family interference. Calmly explain what is happening and what the docs are doing.  Offer to be the Timekeeper. Write down times and what is happening. Announce every 2 minutes.  What you’ll see:  Prep: Hypothesize shoulder orientation for suprapubic pressure, place stool  Announce problem- call for help Maneuvers - McRobers, suprapubic Posterior arm Rotational: Wood’s screw, Rubin Gaskins- all 4s Episiotomy Zavanelli 

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  16:53
• Cancer Screening and Vaccinations (HCM)

  Cancer Screening Cervical: Age 21-65 Cytology q3yrs, co-test q5 if normal. ASCCP guidelines (there is an app! Or PDF: http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-management-guidelines-august-2014-pdf ) Breast: ACOG: 40-75 annual mammogram Colon: Colonoscopy, FOBT, FIT. Begin at age 50. If first degree relative with colon cancer begin screening at age 40 or 10yrs prior to youngest diagnosis, whichever is younger. Lung: 55-80 with 30pack-year hx, annual low-dose CT Vaccinations HPV: 3 dose series age 12-26 Influenza: annual Pneumovax: 1 dose and 1 booster any age if risk factors. After age 65 if no risk factors Shingles: 2 dose age 50+ Hep B: initial vaccination in youth, vaccination for anyone non-immune MMR: if not immune Varicella: if not immune Tdap: Booster at 10yrs, new parents

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  12:03
• STIs

  Swab/Urine Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1 Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once. HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed. Serum Syphilis: Painless chancre followed by latent, then secondary with palmar/plantar rash. If unsure stage, treat as if latent, PCN IM x3 HIV: Universal screening. PREP if high risk. Referral to ID and counseling if positive. Hep B: Treatable, not curable. Routine serum screening. No Routine Screening, diagnose if lesion HSV: Antivirals as needed for outbreaks, can prophylax if frequent outbreaks/immunosuppressed. Valacyclovir or acyclovir are most common.

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  19:14

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