Approach to the Patient
Since the inauguration of the physician assistant (PA) profession, primary care has played a key role in training PA students. Obstetrics and gynecology (OB/GYN) are practiced by many primary care and family medicine PAs; therefore, it is an important topic of interest in PA student education. The remarkable feature of OB/GYN is that it encompasses not only the outpatient setting but also the operating room (OR), inpatient setting, and labor and delivery setting. For this reason, it is important for PA students to be educated in every facet of these realms and understand this unique area of medicine. In obstetrics, you will treat pregnant women as well as their unborn children. In gynecology, you will be able to treat women from adolescence through menopause. OB/GYN gives you the capacity to build an effective rapport with your patients that will carry them through a life span. In this setting, you will encounter acute, subacute, and chronic conditions. You will need to be fluent as a geneticist, internist, and general practitioner. You will approach most gynecologic patients in a comprehensive manner, sometimes even functioning as their primary care provider and internist. You will manage chronic conditions such as hypertension and diabetes throughout pregnancy. An understanding of genetics is important in this setting because you need to illustrate to patients the reasoning and outcomes of prenatal testing.
What to Expect on Clinical Rotations
On the surgical service, you should expect to be up early preparing for cases and mentally preparing for your day in the OR. You should also read up on the cases the night before surgery to familiarize yourself with the anatomy. You may also have several postoperative patients whom you will round on before or directly after the surgical cases for the day. Common gynecologic surgeries include hysterectomy (total or partial), which may be performed through a variety of different surgical approaches depending on the situation, physician preference, and patient desire (open, laparoscopically, vaginally). Know the risks, benefits, indications, and complications of these procedures. Other surgeries include myomectomy, tubal ligation, and inserting a pelvic mesh to help support the bladder or uterus.
Arrive early to round on your patients before your intern or resident arrives. This allows you to have extra time to interview your patients without any other distractions. In many academic hospital settings, you will round with your resident and again with the attending physician. If you are rounding with a private practice physician, the same rules apply: Arrive early and round on patients so you may orally present each case to the physician. This will prove to your preceptor that you have spent the extra time with the patients and have thoroughly researched their conditions.
In an outpatient service, you will rotate in a clinical setting. This may range from private practice to an instructional setting, where several providers are associated with a teaching institution such as a university hospital. In both settings, you will provide care for patients with and without health insurance. You may even care for patients who are incarcerated. Clinic days may vary with obstetrics and gynecology. You will perform Papanicolaou (Pap) tests, pelvic examinations, rectal examinations, sexually transmitted infection (STI) screens, breast examinations, measurement of fundal heights, Leopold maneuvers, and complete cervical checks for dilation; interpret ultrasound images; provide extensive patient education; and communicate appropriate routine health maintenance on a daily basis. Procedures in the office may include intrauterine device (IUD) insertions, colposcopy, endometrial biopsies, and draining of Bartholin gland abscess. Two office procedures that you should familiarize yourself with in detail are Pap tests and insertions of IUDs.
According to the Centers for Disease Control and Prevention, almost 70% of women older than 18 years of age received a Pap test within the past 3 years. It is your duty to educate patients on the recommended frequency for screening. Many guidelines regarding the screening of women for cervical disorders have recently been updated, and you should familiarize yourself with them. It is important to note that many women seek care from an obstetrician or gynecologist unsure of how often they should receive such examinations. Even if women do not meet the criteria for a Pap test, almost all women should receive a complete pelvic examination on an annual basis, according to the American Congress of Obstetrics and Gynecology (ACOG). To perform a Pap test, you should have the woman lie in the lithotomy position with her feet placed gently in the stirrups. She should be wearing a gown and be covered from the waist down with a drape. You should depress the drape in the center so that from a seated position, you are able to visualize her face. You should explain all techniques to the patient before performing them. First, you should gently place the back of your gloved hand against the inside of her thigh and inform her that you will be inspecting the external genitalia. After this, you should depress the posterior vaginal introitus (again while verbalizing all of this to the patient in layman’s terms) and insert an appropriately sized speculum at a 45-degree angle into the vagina. The speculum should be warmed and lubricated with water only. As you advance the speculum, continue to rotate it to a full 90 degrees. For women who have posterior placement of the cervix, you may have to apply downward pressure so the cervix comes into view. Keep in mind that this may add discomfort to the patient, and explaining that a posterior cervix is an anatomic variant may ease some of her discomfort and allow her to understand that you are not trying to cause her any unnecessary discomfort. If you are still unable to view the cervix, you should have your preceptor come in behind you. When the cervix in in view, including the os and transformation zone, lock the speculum in place and take samples as necessary while inspecting the cervix and vaginal walls. As you complete the examination, remember to unlock the speculum and gently guide it out of the vagina in the same manner in which you inserted it.
Inserting an IUD can be one of the most difficult yet interesting procedures you will perform in OB/GYN practice. A few key points to learn when inserting an IUD will help you while on your rotation. First and most important, be sure that you receive consent from the patient to perform the procedure. Ensure that you and the preceptor have discussed all of the risks, side effects, and benefits of the procedure to the patient before placement. You will perform a speculum examination as described earlier. Confirm that the patient is not allergic to iodine or latex before performing the next step. If she is allergic to either iodine or latex, adhere to the institution’s protocol. Clean the cervix with povidone–iodine solution, and don sterile gloves. The next step is the placement of the tenaculum. It may improve the discomfort for this segment of the examination if you have the patient take a deep inhalation and then blow out swiftly and forcefully while you place the tenaculum at the same time. This instrument is used to grip a portion of the anterior cervix and allows you to manipulate the cervix and hold it in place while you insert the IUD. Make sure not to maneuver the cervix too forcefully or excessively because this may cause a vagal response in the patient (hypotension, syncope, nausea, and vomiting). Remember to explain all steps of the procedure to the patient as you perform them. Next, measure the fundal height of the uterus with an instrument called a uterine sound. You will be able to determine the length of the uterus by the mark of iodine left on the instrument. After this, use your measuring tool on the IUD kit to properly measure to the height of the fundus. Place the IUD according to the manufacturer’s directions. After you have ensured proper placement, remove the tenaculum and trim the strings of the IUD, leaving 1 to 2 inches. You can trim the strings again at a later date after some time has passed and you have established that the IUD is in the proper position. Ensure the patient’s comfort, and then remove the speculum.
Managing abnormal cervical cytology can be a difficult task for providers, and a diagnosis of dysplasia can also be a source of anxiety for patients. For this reason, it is essential that you understand the current guidelines and how to follow the recommended algorithms. Many women wonder how often they should obtain a Pap test. The evidence-based guidelines for the screening and management of abnormal Pap tests are formulated by the American Society for Colposcopy and Cervical Pathology (ASCCP). This body publishes guidelines based on evidence-based medicine. A few important changes to the guidelines include:
Co-testing for human papillomavirus (HPV) and cytology for atypical squamous cells of undetermined significance (ASC-US) every 3 years rather than every 5 years in patients with a history of an HPV-negative Pap test result
Patients with negative cytology without endocervical cells may be managed without annual testing.
If cervical cytology is unsatisfactory, then a repeat Pap test is needed even if the patient does not show the presence of HPV.
HPV-negative and ASC-US Pap test results are not sufficient means to discontinue screening in women older than 65 years of age.
In patients with ASC-US, immediate referral for colposcopy is no longer considered first-line management, and a repeat Pap test should be delayed for 1 year. If the subsequent test result is also negative, testing should resume at regular 3-year intervals.
Pap-only testing (cytology) without HPV is typically limited to women younger than 30 years of age. Women with dysplasia between the ages of 21 and 24 years are managed as conservatively as possible because colposcopy and other cervical procedures can damage the normal shape, length, and functionality of the cervix, thereby increasing the risk of preterm labor in future childbearing.
Labor and Delivery and Postpartum
On the labor and delivery service, you may be expected to work long hours. This can include night shifts, overnight call, or weekends. Babies don’t have a timeline or wait for the workday to start. If your preceptor permits it and the patient you’re following hasn’t delivered, remain until the fetus is delivered even if it means that you stay past your scheduled shift. This facilitates the opportunity to deliver your own patient. You should familiarize yourself with how to perform a cervical check for dilation and effacement. It is also essential to acquaint yourself with how to calculate a Bishop score so you will understand that if a patient has a score for induction of labor, it correlates to a successful vaginal delivery. During postpartum rounds, you will provide similar services as you did on your other inpatient gynecology patients. You should ask in all postpartum patients about pain, bleeding to include blood clots, and flatus. Build rapport with your patients; remember their names and the names of their infants.
Expectations for a Successful Rotation
In an article published by the Association of Professors in Gynecology and Obstetrics (APGO), a successful rotation is built on realistic (“do”) and unrealistic expectations (“do not”). We will divide these expectations based on the clinical setting.
|Surgery||Familiarize yourself with the surgical cases and procedures before getting started. |
Recall sterile field boundaries.
|Don’t scrub into a case if you are sick or have to leave during the surgery.|
|Inpatient||Get to know your patients on the service. Remember their names; if they are OB patients, know their infants’ names. |
Get to the service before your intern and round on your patients.
|Don’t expect others to see your patients. |
Don’t walk into a service and not introduce yourself even if you’ve seen the patient before.
|Outpatient||Review the last few progress notes to familiarize yourself with the patient in order to guide treatment. |
Review previous lectures and read about common pathology related to OB/GYN.
|Do not perform pelvic or breast examinations without a chaperone present. |
Don’t make appointments or engagements immediately after clinic because most times you will stay the duration of your scheduled shift.
|Labor and delivery and postpartum||Find a patient on the service and continue her care even if your shift is over. |
Make yourself accessible for any procedures and emergencies.
|Don’t assume that patients and other members of the health care team know you are a student. |
Don’t leave the floor even if the service is slow because situations can and do change swiftly.
Interprofessionalism on Obstetrics and Gynecology
In a surgical setting, you may encounter scrub techs; preoperative, postoperative, and surgical nurses; acute care nurse practitioners (NPs); PAs; and OB/GYN physicians, anesthesiologists, and certified nurse anesthetists (CNAs). To ensure the safety of patients, you will witness any of these members of the health care team performing “time outs.” This is a practiced universal protocol that will ensure the correct patient, the correct site of the operation, and the correct type of surgery to be performed. All health care team members are integral to the time-out to help decrease errors and iatrogenic injury to the patient. The University of Arizona Medical Center has implemented a Safety First Program to help decrease medical errors.
In an inpatient setting, you will encounter patient care assistants, floor nurses, PAs, and OB/GYN physicians. Care will be provided to patients with acute or chronic OB/GYN issues and postoperative and postpartum patients. It is important to be familiar with the patients on this service because you will likely encounter them for consecutive days or weeks. Assimilation of the health care team’s mannerisms in which they care for patients allows you to become an integral member of the team and help to provide a holistic approach to any given patient.
In an outpatient office setting, you will likely work with a variety of other clinicians. This may include medical assistants (MAs), nurses, NPs, PAs, certified nurse midwives (CNMs), and OB/GYN physicians. All of these health professionals work as a team to work toward one common goal. The main objective is to aid women in the maintenance of a healthy lifestyle from adolescence through menopause. The team is also responsible for patient care during pregnancy and in the postpartum period. To provide high-quality health care, an integrated medical team is necessary to enhance favorable patient outcomes. Many training programs embody this model of interprofessional education and collaborative practice to improve the understanding of roles that each specialty performs on the health care team. The New York University School of Medicine at Langone Medical Center requires OB/GYN fellows to design and integrate an interprofessional simulation into their undergraduate or postgraduate courses. The purpose of this mission is to improve students, residents, and staff members as specialists.
In the labor and delivery setting, you will collaborate with patient care assistants, obstetric and neonatal nurses, CNMs, NPs, PAs, and OB/GYN physicians along with pediatricians and neonatologists. If there are known medical conditions that affect the fetal cardiac, renal, or gastrointestinal tract, you may also consult with a pediatric cardiologist, nephrologist, or pediatric general surgeon. These specialists are usually available at the time of delivery of the baby. Each member of this team is integral in caring for the mother and child to ensure they both receive the most appropriate tailored care. When a child may be born with a fetal defect or mishap, it is imperative to consider the mental health status of the mother. In this instance, it is appropriate to involve mental health specialists, grievance counselors, and social workers. These specialists are able to provide a unique set of services for the mother.