Introduction
From the beginning of the physician assistant (PA) profession, primary care has been a key focus in training PA students. The special health care needs of women are an essential part of primary care. PA students will provide care for obstetric or gynecologic patients on a variety of clinical rotations, including obstetrics and gynecology (OB/GYN), family medicine, internal medicine, emergency medicine, and pediatrics. Most PA students, however, also have a dedicated clinical placement in OB/GYN. Obstetrics is unique in that the provider treats two patients (mother and child) at the same time. Gynecology encompasses the spectrum of a woman’s life from menarche through menopause and beyond. Practicing OB/GYN offers the opportunity to build a lifelong rapport with patients. Women’s health providers encounter acute, subacute, and chronic conditions each day. The approach to a gynecologic patient is comprehensive. Many times, an annual wellness visit is the only time the woman visits a clinician. For this reason, it is the provider’s responsibility to provide wellness education and recommend appropriate screening tests. Women’s health practitioners have an especially strong understanding of how to treat chronic conditions in the setting of pregnancy.
The approach to the patient is based on the multiple roles women’s health providers have in a woman’s life: to provide preventive care; to help a woman make decision about fertility and childbearing; to care for her before, during, and after a pregnancy; to guide her through menopause; and to treat acute and chronic medical conditions. The specific approach to each patient will be guided by her needs at the moment of care. Young women who have never had a pelvic examination have different needs than a woman who is pregnant with her third child. A college student who is seeking contraception requires a different approach from a woman newly diagnosed with ovarian cancer. Watch your preceptors and learn how they adapt their approach to each patient’s needs.
What do physician assistants in women’s health typically do on a daily basis?
The scope of practice varies widely for PAs in the field of women’s health. PAs in OB/GYN work in surgery, in labor and delivery units, on inpatient floors, and in clinics. Many women’s health PAs work in several of these settings each week. In the surgical setting, PAs assist with gynecologic surgeries and cesarean sections and assist with or perform vaginal deliveries. A small number of states allow PAs who have obtained additional experience and qualifications to perform vaginal deliveries autonomously. OB/GYN PAs also provide care to hospitalized patients. Some of these patients have undergone surgery, and others are hospitalized for childbirth or for cancer treatment. PAs working in the hospital round on patients, provide and request consultations, perform procedures, place orders, and provide patient education. They also can be the link between the inpatient floor team and the attending doctor, who is often working in the operating room (OR). In the clinic setting, PAs practice full spectrum OB/GYN. They provide preventive, prenatal, and postpartum care. They also care for patients with acute and chronic health problems, such as endometriosis, sexually transmitted infections, cervical cancer, infertility, uterine fibroids, and polycystic ovarian syndrome. PAs are able to read and interpret ultrasounds; perform Papanicolaou (Pap) smears and culture collection; counsel patients regarding appropriate contraceptive practices; and perform intrauterine device (IUD) insertions, endometrial biopsies, and colposcopies.
What will I be expected to do on this rotation?
Your role as a PA student will differ based on the environment in which you are working on any given day. Common environments include the surgery service, the inpatient service, the outpatient clinics, and the labor and delivery suite.
Surgery service
When you are assigned to a surgical service, you need to be proactive to get the most out of the experience. The day before you go to the OR, find out which cases you will scrub into. Review the relevant surgical anatomy and pathophysiology for these cases the night before. Working in the OR typically means an early start to your day. Arrive early. Once you are done with OR duties, you may be responsible for the postoperative care of patients on whom you will round today and in the days to come. One of the most common gynecologic surgeries is a 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, or vaginally). Know the risks, benefits, indications, and complications of this procedure. Other common procedures include myomectomy, tubal ligation, and gynecologic cancer resections. Occasionally, students are offered the opportunity to perform a pelvic exam on a patient who is anesthetized. Be aware that you (or the surgeon) must have obtained informed consent for a pelvic examination by a student before the patient was sedated. Several states have now established laws banning the practice of allowing students to perform pelvic examinations on anesthetized patients without consent, making the practice not only unethical, but also illegal.
Inpatient service
When caring for hospitalized patients, you should arrive before the rest of the medical team to interview the patients and to discuss the patient with the overnight nursing team. In many academic medical centers, you will round with your resident and round again with the attending physician. You will present each of your patients to the team. Be ready to answer specific questions about the patient’s course during their hospitalization. Be ready to discuss possible plans for the patient, including medication changes, recommended procedures, further testing, or discharge from the hospital.
Outpatient clinic
PA students are placed in both academic and private-practice women’s health clinics. Clinic days offer the opportunity to see a variety of obstetric and gynecologic presentations. Be ready to perform pelvic examinations, Pap tests, rectal and breast examinations, and sexually transmitted infection (STI) screenings. Make sure you always have permission from your preceptor to conduct these examinations and that you always perform them with a chaperone present. Become practiced in measuring fundal height and Leopold maneuvers. In addition, you may be asked to complete cervical checks for dilation/effacement; interpret ultrasound images; or provide patient education and routine health maintenance. You may observe placement of IUDs, colposcopies, endometrial biopsies, marsupialization of Bartholin’s cysts, or drainage of Bartholin’s gland abscesses. It is very important to have a strong understanding of the management of abnormal Pap smears and cervical dysplasia because many patients you see will have these abnormalities and will look to you for quality patient education. Familiarize yourself with all of the guidelines for managing cervical dysplasia, for cervical and breast cancer screening, and for screening and management of STIs.
Labor and delivery and postpartum care
The labor and delivery ward is busy all day and night. Therefore you may be required to work nights, weekends, or holidays on this rotation. If your preceptors permit, you may be allowed to “catch” a baby with their assistance. Your preceptors may also ask you to stay after your shift has ended to deliver a baby if your patient is close to delivery. Familiarize yourself with how to perform a cervical check for dilation and effacement, and learn how to calculate a Bishop score ( Fig. 22.1 ). Be aware that many low-risk deliveries are handled by certified nurse midwives (CNMs). These colleagues are very well trained and have an enormous amount of knowledge and experience to share with you. If you are offered the opportunity to work with them, take it. PAs in OB/GYN often assist the obstetrician in performing surgical deliveries. Try to attend as many of these deliveries as possible.
Postpartum rounds are similar to other inpatient OB/GYN rounds. Ask all postpartum patients about pain, bleeding, and flatus (especially in the instance of a cesarean delivery). It is also helpful to inquire about blood clots emerging from the vagina, including the size and number of clots produced. Mothers who are lactating may require assistance or have questions about milk production. Refer them to a lactation consultant if the hospital has one available. If you suspect any of the following complications: deep vein thrombosis, endometritis, or postpartum hemorrhage, find your preceptor immediately! Remembering the names of your patients and their infants will go a long way toward helping you develop rapport with the families.
Which other types of health professionals will I work with on this rotation?
The other health professions you will encounter in women’s health depend on the environment in which you are practicing. In a surgical setting, you are likely to encounter scrub techs; preoperative, postoperative, and surgical nurses; acute care nurse practitioners (NPs); PAs; and OB/GYN physicians, anesthesiologists, and certified nurse anesthetists (CNAs). Each has their own role to play in the intraoperative care of the patients and each is critical for safe care.
In the inpatient and labor and delivery settings, you will encounter patient care assistants, floor nurses, CNMs, PAs, and OB/GYN physicians. Inpatient teams provide medical, surgical and oncologic care to patients with obstetric or gynecologic needs. Surgeons can teach you much about surgical technique and pelvic anatomy. Anesthesiologists have insights regarding intraoperative physiology and the importance of proper intraoperative positioning of the patient. Surgical technicians and OR nurses can help walk you through the anticipated surgical procedure and advise you on your instrument choice. When the fetus has anatomic abnormalities, you will also consult with a pediatric subspecialist for guidance, both before and after the delivery. Neonatologists will usually be present in the delivery room when a serious fetal abnormality is suspected. Watch them perform the immediate postpartum examination. In cases of a complicated pregnancy or pregnancy loss, it can be useful to consult metal health specialists, grievance counselors, chaplains, and social workers to support the family. In less complicated cases, observe an experienced nurse providing postpartum patient education; you will be amazed at her knowledge base! When working on an inpatient floor, get to know the preferences of the attending physician to allow you to fit well into the team. Watch how the team interacts with patients to improve your interviewing and patient education skills. Aim to provide holistic care to each woman on your service.
In the outpatient office setting, you will likely work with medical assistants (MAs), nurses, NPs, PAs, CNMs, and OB/GYN physicians. All of these health professionals work as a team to work toward one common goal: the health and safety of their patients. Their main objective is to aid women in the maintenance of a healthy lifestyle from adolescence through menopause. In addition, this team is responsible for patient care during pregnancy and in the postpartum period. Observe these providers for tips and tricks on performing difficult physical examinations, breaking good and bad news to patients, and motivating patients toward healthier behaviors.
What clinical information do the physician assistants and physicians on this rotation always want to know about their patients?
When caring for female patients, your preceptors will always want you to collect some essential information about their gynecologic and obstetric history. Although this list will help guide you, it needs to be customized to your patient’s age and stage of life. Clearly, you should not ask a 20-year-old woman whether she has gone through menopause! Ask the patient about the dates of her last menstrual period, the length of her menstrual cycle, and the duration of her menses each month. If she is postmenopausal, collect the date of her last period and ask her if she has had any postmenopausal vaginal bleeding. Document the number of pregnancies, deliveries, abortions, and miscarriages the patient has had. Inquire if the deliveries she has had were vaginal or surgical and ask about pregnancy complications.
Find out if she is sexually active, and if so, whether she has sex with men, women, or both. What types of contraception does she use and how regularly does she use them? Is she trying to get pregnant? Ask about any history of sexually transmitted infections (STIs) and when she was last screened for STIs and human immunodeficiency virus (HIV). Inquire about personal or family history of breast, ovarian, or cervical cancer and assess whether the patient feels safe at home in her current relationships. Assess gynecologic surgery history, whether the patient has ever had an ectopic pregnancy and whether she has received treatment for an abnormal Pap smear. Review the general surgery chapter for questions that might be useful to ask an OB/GYN surgical patient postoperatively.
Special settings, issues and populations in women’s health
Labor and delivery
The labor and delivery setting is unique in medicine. This is a setting where emotions run high. Arm yourself with knowledge about the labor and delivery process so that you can remain calm even in difficult circumstances. Educate yourself about the physiology of labor, cervical dilation and effacement, fetal stations, and the cardinal movements so that you may advise the patient and her family member(s). Help your patient understand the stages of labor, pain management options, fetal monitoring, and what to expect in the delivery room. Keep the patient informed of all events that are occurring and provide her with education for any procedures so she can make appropriate informed decisions. Keep in mind that the most appropriate person to inform the patient of complications is your preceptor. Labor and delivery is an important place to practice situational awareness. If you are uncomfortable or notice a possible error that is not life-threatening, then gently speak to your preceptor out of the sight and hearing of the patient.
Sexual health
Sexual health is a critical aspect of women’s health care. Safe sexual practices should be discussed at every visit, regardless of the patient’s marital status. It is not safe to assume that because a woman is married that she is in a monogamous relationship or that she is not at risk for the transmission of STIs or sexual violence. It is also essential to discuss unsafe sexual practices with all patients, including the risks of having multiple partners, unprotected intercourse, and oral sex. Any women can be in a violent relationship, regardless of education, sexual orientation, marital status, or wealth. To facilitate the interview regarding these sensitive issues, it may help to open the session with a statement such as, “I try not to make any assumptions, so I ask all of my patients these questions.” “How many partners do you have?” “Do you have sex with men, women, or both?” “Do you have vaginal, anal, oral intercourse or all of these?” “How do you protect yourself against sexually transmitted infections?” “Do you feel safe at home?” Conducting this interview in a private setting and establishing a nonjudgmental atmosphere will help you obtain detailed and accurate information from your patient. Remember to take into consideration your patient’s perceptions about sexual behavior. You should accept that discussing sexual behavior may be uncomfortable for you and your patient. How you respond during the interview will affect how much information she is willing to divulge. Your duty is to listen to her, educate her, and provide a welcoming environment where she can feel free to discuss any issues honestly and forthrightly.
Diverse populations in women’s health care
All OB/GYN providers encounter diversity in practice. You will care for lesbian, bisexual, and transsexual patients; women with physical and mental disabilities; and patients with different cultural expectations about sex, childbearing, gender relationships, and contraception. It is essential to maintain a nonjudgmental attitude when engaging with all patients to encourage them to provide the most accurate information of their health and social situation. For example, lesbians are often wary of misunderstanding and judgment from OB/GYN providers. According to several research studies, lesbians and transgender patients often face barriers to care. , , These included providers who assumed they were heterosexual; a sense of false perception that they were not affected by STIs or HIV; and a lack of access to health care or health insurance, especially if the spouse or partner was of the same sex. Studies have demonstrated that a lack of appropriate social support from family or peers may increase the risk for mental health disorders such as depression, suicide, and substance abuse. ,
You will also encounter transgender people in women’s health clinics. Being kind and professional with these patients is essential because they have often endured judgment and discrimination. Always use the patient’s preferred name and respect the patient’s gender identity. Using the appropriate pronouns to address the patient will go a long way in the development of rapport. Educate yourself about the particular endocrine issues this patient faces and know the appropriate screening guidelines for this patients. Just because the patient has transitioned from female to male does not mean the patient no longer needs cervical cancer screening, for example.
Women with physical and cognitive disabilities have special needs in the women’s health setting. Some providers do not acknowledge that women with disabilities are sexually mature and engage in sexual activity; thus they may be disinclined to discuss sexual health. It may be challenging to get women with mobility limitations onto the examination table and in position to undergo gynecologic examination. Work closely with patients and their caregivers to solve these issues. Usually, women with mobility limitations know how best to accommodate their disability. Women with intellectual disabilities may have difficulty providing a clear medical history or understanding the need for gynecologic examination or procedures. Partner with the patients’ caregivers to devise strategies for decreasing the trauma and stress associated with these visits for the patient. Consider consulting the child life professional at a local medical center or pediatrics practice. These professionals are experts in preparing people who do not understand medical procedures for what will be coming and can help you develop effective care strategies.
Patients with non-North American cultural backgrounds may have different beliefs about how much of their history or their body is appropriate to reveal to a medical provider. Some cultures attach shame to medical conditions, such as breast masses, sexual dysfunction, urinary incontinence, and vaginal discharge. Women from some cultures may be reluctant to engage in a visit about OB/GYN issues with a male provider. Be respectful of the patient’s wishes and make accommodations. If your region has many people from the same culture, take time to learn about that culture to be the most effective PA you can be. Cultural differences play a major role in the use and choice of birth control methods. Table 22.1 outlines various religious beliefs regarding contraception and sexuality according to the Family Planning Association.
