- Nonreassuring fetal heart tracing
Category 2-remote from delivery
Minimal/absent variability is most significant predictor of fetal acidemia
Category 3 any time is emergent deliver
- Failed IOL
Many different definitions: Most commonly 12-24hrs ruptured membranes on pitocin without active labor
- Arrest of dilation
Can only meet criteria once in active labor 6cm or greater
Do you know if her contractions are adequate? IUPC with MVUs>200-250
If the contractions are adequate, no change over 4hrs
If contractions are inadequate or no IUPC, no change over 6hrs
- Arrest of descent
Prime with epidural 3hrs
Prime without epidural-2hrs
Mutlip with epidural 2hrs
Multip without epidural 1hr
- Cord prolapse
-Breech, transverse, compound
What approach: Abdominal, laparoscopic, vaginal or combination
Taking or leaving the tubes and ovaries?
Tubes: What benefit do they provide? Risk?
Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off
If it’s laparoscopic–listen to the LSC podcast for more details on the approach
Let’s talk about important steps:
- The round ligament: What artery runs inside the round? Sampson’s.
- What structure conceals the blood flow to the ovary? The IP ligament (formerly the suspensory ligament of the ovary). The artery comes from the aorta, so if this is transected before it is fully sealed, it can hemorrhage while retracting back into the retroperitoneum. Badness!
- What are the four levels at which the ureter is injured during hysterectomy? 1- At the pelvic brim, 2- medial to the IP ligament, 3- as it passes under the uterine artery (water under the bridge) and 4- lateral to the vaginal cuff closure.
- Ligate and transect the uterine arteries–the uterus should blanch white.
- Colpotomy– disconnecting uterus from vagina
- Close vaginal cuff if total hyst
Review anatomy– you’ll be able to see well!
Pimped- Youtube Channel videos for laparoscopic anatomy
What case are you doing and why?
Review common indications, steps to procedure and potential risks/complications
Saying hi to the patient first
Being helpful setting up — yellowfins or stirrups for lithotomy
Scrubbing in — ask to grab your gown/gloves for the scrub, open carefully or get help if unsure
Abx: If entering uterus or vagina ie hyst
Prep: infection prevention with chloraprep or something
EtOH based, needs to evaporate before draping or risk fire!
Vaginal prep — betadine or chlorhexidine
Then everyone scrubs
Let resident/attending drape unless asked.
You may be asked to help with foley/manipulator
Uterine manipulators: Many sizes/shapes/types
Vagina is dirty– can’t go from vagina to abdomen
Entry: Typically in umbilicus or just above. Can use Palmer’s Point if needed.
Direct visualization with Hassan
Insufflate with CO2
Port placement: Typically middle ⅓ of distance between ASIS and umbilicus. Avoid obvious superficial vessels and inferior epigastric –watch from below
- Dx LSC– endometriosis, adhesions
- Tubal ligation or bilateral salpingectomy
Closing ports: Close fascia on ports >5mm due to increased risk of hernia
Post-op checks: Many LSC cases are same-day, meaning patients go home
-Nausea/vomiting, eating/drinking, voiding, passing flatus, ambulating
Hypertension in Pregnancy — One large spectrum
Mild range: 140/90
Severe range 160/110
CHTN → SIPE
gHTN → Pre-E
BP meds: Methyldopa, labetalol, hydralazine, nifedipine
- Neurologic symptoms
- Lab findings:
Hemolysis, Elevated Liver (enzymes), Low Platelets
Eclampsia — Seizures
Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation
In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective
Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout.
Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed.
Hysterotomy — lower uterine segment, lateral uterine vessels to avoid
Delivery baby — delay cord clamp, placenta
Likely lots of bleeding — same atony meds as vaginal delivery
Clean inside of uterus to remove all membranes etc.
Possibly exteriorize uterus to see better — depends on scaring
How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures.
Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis.
Clean up the abdomen–irrigation vs moist laps vs suction
Now to close:
Peritoneium — either way, close or not– no evidence either way
Muscle– don’t close, evidence that closing it can cause hematoma
Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric
Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection
Skin closure — stables, suture, absorbable stables
- Cardinal movements of labor: engagement, descent, flexion, internal rotation, extension, external rotation and expulsion
- Complete dilation, now station: Labor down vs push
- 2nd Stage of labor: Pushing
- Offer to help with maternal positioning—holding ankle/leg
- Delivery—downward traction on head, thumbs to nose, anterior shoulder, posterior shoulder, body. Skin to skin. Delayed cord clamping.
- 3rd stage placenta: Active management, Pitocin, gentle cord traction. 3 signs of placental detachment
- Bleeding: Atony, meds
- Lacerations: degree, repair
- Postpartum: Fundal tenderness, lochia, voiding, BMC.
- The OB One-Liner: “This is a _ yr old G_ P_ @_ wks GA here for ____.”
Ex: This is a 34yo G3P2002 @ 38wks3days GA here for contractions
- Triage: 4 essential questions to ask every pregnant woman in triage
Contractions, leaking fluid, vaginal bleeding, fetal movement
- What is labor? Cervical change and contractions
- Evaluate for ROM: Pooling, nitrazine (pH), ferning.
- Vaginal bleeding—when do we care? 2nd or 3rd trimester worry about placenta: abruption, previa, vasa previa
- DFM: NSTs, BPPs, Kick counts
High yield resources and tips for your Ob/Gyn clerkship.
Youtube Playlist: http://bit.ly/pimped-ob
- Obstetrics and Gynecology by Beckmann
- Pimped App – Clinical questions to expect in the OR and on the wards
- LactMed – medications safe in breastfeeding
- ASCCP: Cervical cancer screening
- CDC STI guidelines
- ACOG app/website
- OB Wheel or dating
Tips and Tricks:
- Be Proactive—talk to students who just finished the rotation about ways to be helpful and the day to day logistics.
- Expectations: Ask for them to be set at the beginning. Clarify as needed.
- Be Self-sufficient, but ask for help when appropriate
- Before leaving for the day, ask when you should come in to round, who to pre-round on and where to meet.
- Once or twice a week ask for feedback when everyone has a down moment.
Labor and Delivery:
- Gs & Ps aka Gravity and Parity.
- Primes, multips
- Gestational age Preterm vs term