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1st Trimester Bleeding OB-GYN 101 Facts Card ©2003 Brookside Press

st abortion), or it may be voluntary


Any bleeding during the 1 TM is ("induced" or "elective" abortion). The chance of a 2nd SAB is about 1
abnormal. The cause may be trivial or Miscarriage is the layman's term for in 6. Following 2 SABs, the odds of
serious, but it is always abnormal. spontaneous abortion. another is still about 1 in 6. After 3
SABs, the risk of having a 4th is only
At least one-third of all pregnant slightly greater than 1 in 6.
Abortions are further categorized by
women experience some degree of degree of completion.
bleeding. Half will ultimately abort, and Many obstetricians recommend
half will continue normally. • Threatened (cramping/bleeding) bedrest for Threatened AB, but
• Inevitable (will occur) without scientific evidence rest
Evaluate for: • Incomplete (some tissue left behind) changes the outcome. Some women
• Complete (everything is passed) feel better if they are at rest.
• Inevitable abortion • Septic (complicated by infection)
• Incomplete abortion Inevitable AB may be treated with
• Ectopic pregnancy These are largely unpredictable and simple observation, awaiting the
• Gestational trophoblastic disease unpreventable. 2/3 caused by SAB, or with evacuation of the
• Cervical/vaginal trauma, infection, chromosome abnormalities. 30% uterus. Either is reasonable.
and polyps caused by placental malformations.
The remaining miscarriages are
Evaluation may include a history, Incomplete AB usually requires
caused by miscellaneous factors but
physical exam, ultrasound, quantitative D&C.
are not usually associated with:
HCG, and progesterone.
• Minor trauma Complete AB requires no treatment.
Abortion is the loss of a pregnancy • Intercourse
during the first 20 weeks of pregnancy, • Medication Rhogam is given to Rh- women
This may be involuntary (spontaneous • Too much activity within 72 hours.
2nd Stage of Labor OB-GYN 101 Facts Card ©2003 Brookside Press
seconds. Most women can get three or
On reaching complete cervical four pushes into a single contraction.
dilatation, the woman has entered the She will usually push more effectively if
second stage of labor. The second her knees are pulled back towards her
stage lasts until the delivery of the shoulders.
baby. During the second stage, try to
measure the fetal heart rate every 5
minutes. Some women find they are not
comfortable in the semi-reclining
position and they may push while tilted
During the second stage of labor, the toward one side or the other.
woman will feel the uncontrollable urge
to bear down. This Valsalva has the
effect of increasing the expulsive Some women prefer to deliver on their
forces and speeding the delivery side, with one knee drawn up and the
process. other leg straightened (the Sims
position).
For most women, the most effective
way to push is in the semi-recumbent Some women prefer to deliver in the
position. With the onset of a sitting or squatting position.
contraction, she takes several, rapid,
deep breaths. Then she holds her Duration of the second stage is
breath and tightens her stomach typically an hour or two for a woman
muscles, as though she were trying to having her first baby. For a woman
move her bowels. She pushes for 10 having a subsequent baby, the second
seconds, relaxes, takes another stage is usually shorter, less than an
breath, and pushes for another 10 hour.
3rd Trimester Bleeding OB-GYN 101 Facts Card ©2003 Brookside Press
coagulation disorder which often
Bloody show occurs. Women with complete Placenta previa
As the cervix thins and begins to dilate placental abruptions are generally If any part of the placenta covers the
in preparation for labor, some bloody desperately ill with severe abdominal internal os, this is a placenta previa.
mucous may appear. This is normal pain, shock, hemorrhage, a rigid and
during the days leading up to labor. unrelaxing uterus. A complete placenta previa covers
Prior to full term, it may signal the the entire cervix, making it
imminent onset of preterm labor. impossible for the fetus to pass
Symptoms of partial placental
abruptions range from insignificant to through the birth canal without
Cervicitis and cervical trauma very dramatic. causing maternal hemorrhage.
During pregnancy, the cervix is softer,
more fragile, and more vulnerable to A marginal placenta previa covers
Clinically, an abruption presents after
the effects of trauma and microbes. only the edge of the placenta. In this
20 weeks gestation with abdominal
cramping, uterine tenderness, condition
Placental abruption contractions, and usually some vaginal
All placentas normally detach from the bleeding. Occasionally, the blood is These patients present after 20
uterus shortly after delivery of the trapped inside the uterus. ("concealed weeks with painless vaginal
baby. If any portion detaches prior to abruptions.") bleeding, usually mild. Later
birth, this is a placental abruption. It episodes of bleeding can be very
occurs in about 1% of all pregnancies. substantial. Because a pelvic exam
Mild abruptions may resolve with
bedrest, but moderate to severe may provoke further bleeding it is
A complete abruption is disastrous. abruptions generally result in rapid important to avoid a vaginal or rectal
Untreated, the fetus will die within 15- labor and delivery. If fetal distress is examination in pregnant women
20 minutes. The mother will die soon present, rapid C/S may be needed. during the second half of their
afterward, from either blood loss or the pregnancy unless you are certain
there is no placenta previa.
Abnormal Presentation OB-GYN 101 Facts Card ©2003 Brookside Press

At 16 weeks: however, abnormal presentations


Vaginal delivery may be possible,
• 50%transverse lie may require special handling and
but with risk of injury to the arm.
• 25%breech sometimes cesarean section.
• 25%cephalic Try to gently push the hand or arm
At 36 weeks: A fetus in transverse lie, unless back inside, but such attempts are
• 96%cephalic very small and non-viable, cannot usually not successful and pose
• 4%breech deliver and usually require a C/S some risk of injury to the fetus. Try
• <1%Transverse lie • A transverse lie is a danger pinching the hand, hoping the fetus
sign: Some problemwith the withdrawthe hand. If the hand will
Many factors influence fetal
internal architecture of the not withdraw, cesarean section is
presentation: uterus or the placenta. frequently contemplated.
• Shape of the pelvis • Placenta Previa
• Location of the placenta • Risk of prolapsed umbilical cord. ROA=Right Occiput Anterior
• Shape of the uterine cavity and ROP=Right Occiput Posterior
the kicking activity of the fetus. A compound presentation means ROT=Right Occipput Transverse
that both the head, plus some LOA=Left Occiput Anterior
During most of pregnancy, it other fetal part, are coming down LOP=Left Occiput Posterior
doesn't matter very much what the the birth canal together (or feet and LOT-Left Occiput Transverse
fetal presentation is. At full term, hands, for example).
Abnormal Presentation OB-GYN 101 Facts Card ©2003 Brookside Press
• Cephalic = head first.
Transverse Lie Compound Presentation
• Breech = fetal butt first.
Can’t deliver vaginally. Will rupture Hand + head. Increases volume
• Transverse lie = sideways
the uterus unless C/S done. passing through birth canal.
• Compound = hand + fetal head. Exceptions:
• Shoulder = variation of Trans. Lie
Risk of injury to the arm/shoulder
• Very small, non-viable fetus
Presentation different from position. • External version
• Second twin May resolve if fetus can withdraw
Breech
hand. If fetus and arm relatively
• Frank breech = buttocks Predisposing factors: small, vaginal delivery may be
• Footling breech = one or both possible, but risk of injury.
feet. AKA incomplete breech. • Grand multiparity >5 babies
• Complete breech = tuck position. • Placenta previa
If large, obstructed labor will occur
• Bony abnormalities of the pelvis
Increased risk of: and a cesarean will be needed.
• Pelvic kidney
• Mechanical injury (fractures, • Other pelvic mass
Shoulder presentation
nerve damage, and soft tissue
Common in early pregnancy, when it Shoulder presentation means that
injuries)
is of no consequence. the fetal shoulder is trying to come
• Asphyxia due to umbilical cord out first. This is a more advanced
prolapse and obstruction, and • 16 weeks = 50% TL form of transverse lie and is
fetal head entrapment. • 28 weeks <10% TL undeliverable vaginally.
Many breeches delivered by C/S. Scan to r/o predisposing factor and
All? Maybe. check cervix for dilatation.
Adnexal Mass OB-GYN 101 Facts Card ©2003 Brookside Press
that may influence management Ultrasound findings that decrease
Sometimes, a small incision is made in choices. the concern for malignancy
the perineum to widen the vaginal
• Have the patient use an enema to • Thin-walled cyst
opening, reduce the risk of laceration,
cleanse the lower bowel of stool • Simple cyst
and speed the delivery.
and then re-examine the patient to • No loculations
see if the mass has disappeared. • Recent onset
Evaluation of the patient with an • Pelvic ultrasound scan to identify • Shrinking in size
adnexal mass the sonographic characteristics of • Stable in size
The primary goal of this evaluation is to the mass.
distinguish those patients with an • Rapidly changing appearance
• Serum CA-125 level to see if the
innocent, self-resolving mass from peritoneal surface is being irritated.
those who will need intervention to Ultrasound findings that increase the
• CT scan (with contrast) of the concern for malignancy
achieve the best results. abdomen and pelvis to evaluate out • Thick-walled cyst
the possibility that the mass from of • Solid tumor
Evaluation techniques that may prove a non-gynecologic source, such as
useful include: • Mixed cystic and solid mass
a pelvic kidney, diverticular
• Internal papillary excrescences
abscess, or colon carcinoma.
• Re-examine the patient after the • Large amount of free fluid in the
next menstrual flow to see if the • Culdocentesis or paracentesis of
pelvis or abdomen
mass has disappeared. ascitic fluid for microscopic
• Gradually enlarging
evaluation.
• Exam under anesthesia if the
normal exam is equivocal or • Laparoscopy to look directly at the
difficult. pelvic mass, with possible
laparoscopic removal
• Pregnancy test to rule out ectopic
pregnancy or intrauterine pregnancy • Laparotomy to explore the mass
and remove it.
Adolescent Breast Problems OB-GYN 101 Facts Card ©2003 Brookside Press
shape and contour. By age 18 breast asymmetric breasts is generally
Several breast growth patterns can be development is usually complete. delayed until after age 18.
troubling to the adolescent and her
family. Among these are:
Premature thelarche is breast
• Unusually early breast development development prior to the age of 8 (and
• Unusually delayed breast in the absence of pubic hair
development development). These children are
• Unusually large breasts (Mammary evaluated to rule out estrogen-
hypertrophy) producing ovarian tumors, ingestion of
• Unusually small breasts estrogen-containing compounds, and
• Asymmetrical breast growth the rare, true precocious puberty.
• Breast lumps
Delayed thelarche reflects absence of
Initial breast development occurs on any breast development by age 13.
average at age 9, with the appearance
of a breast bud. The normal range for
Asymmetrical breast growth during
breast bud appearance is from age 8- adolescence is the rule rather than the
13. It is not rare for one bud to appear
exception. Reassurance is given that
up to 6 months prior to the second bud
the asymmetry usually evens out by
appearing.
the time of full maturation. Even at
maturity, breasts are rarely 100%
Breast growth is then progressive, with symmetrical, so minor degrees of
enlargement of the breast tissue, asymmetry are expected. Because the
areala and papillae, and change in breasts are continuing to grow and
change, surgical intervention for
Arrest of Labor OB-GYN 101 Facts Card ©2003 Brookside Press
• Nipple stimulation
During active labor (> 4 cm), the cervix
Target: Contractions Q 2-3 minutes x
should dilate at a rate of:
60 seconds. If contractions >Q2
• 1.2 cm/hour (for first babies) minutes, slow down the oxytocin.
• 1.5 cm/hour (for subsequent
babies). If no Δ in 2 hrs, despite adequate
contractions, consider C/S.
Slower than this is arrest of labor:
• Slower than expected
• Complete arrest (no Δ in 2 hrs.)
2 causes:
• Inadequate contractions, or
• Mechanical impediment.
Mechanical impediments include:
• Absolute fetal disproportion,
• Relative fetal disproportion,
• Fetal malposition
• Asynclitism
Inadequate contractions are treated
with uterine stimulation:
• Oxytocin by infusion pump
Sexual Assault OB-GYN 101 Facts Card ©2003 Brookside Associates, Ltc.
• Doxycycline 100 mg PO BID x 7
Sexual assault is any sexual act Place 4-5 drops of the patient's blood
days
performed by one person on another (taken from the needle or drawn from
During Pregnancy:
person without that person's consent. one of the red-top tubes) on a piece of
• Ceftriaxone or Spectinomycin,
filter paper and let it air-dry. Place the
• Evaluate for serious injuries plus
filter paper in an envelope, label it and
(fractures, hemorrhage, etc.) which seal it. • Erythromycin 250 mg PO QID x 7
might require immediate treatment. days
• Obtain a brief history
The risk of gonorrhea from a sexual Postexposure hepatitis B vaccination
• Gather all materials and notify legal assault is approximately 6 to 12% (without HBIG) should adequately
and administrative authorities. (CDC), and the risk of acquiring protect against HBV.
• Examine the patient, obtaining chlamydia probably a little higher. The
various specimens. risk of acquiring syphilis is estimated at Emergency Contraception
• Offer treatment for STDs, about 3%. The risk of developing AIDS
pregnancy. from a sexual assault is quite low.
• Arrange for follow-up care. Children may not have an
appreciation of exactly what
Blood and Urine Tests Standard prophylaxis: happened to them, or may be unable
to express themselves. Some
• VDRL or RPR - repeat in 1 month • Ceftriaxone 125 mg IM, plus
examiners have the child use dolls to
• Hepatitis B - repeat in 1 month • Azithromycin 1 g PO once (or
demonstrate what happened. During
• HIV - repeat in 1 month and 6 Doxycycline 100 mg PO BID x 7
sexual assault of a prepubertal child,
months days), plus
serious internal injuries may occur,
• Pregnancy test - repeat weekly until • Metronidazole 2 g PO once including laceration of the vaginal
next menstrual flow Alternative prophylaxis: wall and tearing of the uterus from
• Spectinomycin 2 gm IM, plus its' supports at the top of the vagina.
1 extra red-top tube for the Investigator
Rectal injury may occur.
Bartholin Cyst OB-GYN 101 Facts Card ©2003 Brookside Press
more aggressive surgical treatment
The Bartholin glands are located on Should the Bartholin gland become is sometimes used.
each side of the vaginal opening at the infected, it will form an abscess. In this
level of the posterior fourchette. case, the labia majora becomes
Normally, they are neither visible nor excruciatingly painful, red and swollen. Insertion of a "Word Catheter" helps
palpable. These glands produce small Some of these will drain spontaneously keep the drainage tract open long
amounts of secretions that are not and this process may be hastened by enough for the cut skin edges to re-
clinically significant. Their physiologic warm moist dressings or sitz baths. epithelialize to the inside of the cyst.
purpose is not known. Only when they Others will require drainage.
become diseased do they become Marsupialization involes suturing the
clinically apparent. I&D gives immediate relief. skin edge to the cyst wall. This
• Give local anesthetic of 1% creates a new opening to allow
Lidocaine over the incision site (thin secretions to escape.
If a duct becomes obstructed (from
area of skin medial to the cyst).
trauma, swelling, infection, etc.), the
• Steady the cyst or abscess with one Complete excision of the Bartholin
normal outflow of gland secretions is
hand while directing a scalpel into gland is an option when other,
blocked. The secretions will then
the center of the abscess. simpler procedures have been
gradually build up beneath the skin
surface, forming a Bartholin cyst. • Culture purulent drainage for unsuccessful. Excision should result
gonorrhea. in permanent cure, but it technically
• Antibiotic therapy is optional but challenging as the tissue planes may
Bartholin cysts are painless swellings usually used, particularly if the
in the labia majora. They are not be scarred from old infection,
patient is febrile, the abscess large, bleeding may be surprisingly brisk,
dangerous, have no malignant or the skin is red or tender.
potential, and may be ignored. and healing more painful and
Alternatively, they can be drained. In a significant minority of patients protracted than you might think.
treated with simple I&D, the abscess or
cyst will re-occur. For this reason,
Bleeding OB-GYN 101 Facts Card ©2003 Brookside Press
will find bleeding from the uterus
Normal Bleeding coming out through the cervical os. Hormonal Problems
• Occurs monthly (Q 26 to 35 days).
Excluding pregnancy, there are really Thyroid disease can be ruled out
• Lasts a short of time (3 to 7 days).
only three reasons for abnormal clinically or through laboratory
• Does not involve passage of clots. testing (TSH)
• Often is preceded by PMS uterine bleeding:

Abnormal Uterine Bleeding • Mechanical Problems Adrenal hyperplasia can be ruled out
includes: • Hormonal Problems clinically or through laboratory
• Malignancy testing (DHEAS, 17
• Too frequent periods (>Q 26 days). hydroxyprogesterone, ACTH
• Heavy periods (with passage of Mechanical Problems stimulation test)
large clots). Such problems as uterine fibroids or
• Any bleeding at the wrong time, polyps are examples of mechanical
problems inside the uterus. Prolactin-secreting pituitary
including spotting or pink-tinged adenoma can be ruled out clinically
vaginal discharge or through laboratory testing (serum
• Any bleeding lasting > 7 days. Endometrial polyps can be identified prolactin)
• Extremely light periods or no with a fluid-enhanced ultrasound
periods at all (sonohysterography), a simple office
procedure. They can also be identified Hormone-secreting ovarian
Any woman complaining of abnormal during hysteroscopy. neoplasms can be ruled out clinically
vaginal bleeding should be examined. or through laboratory testing
Occasionally, you will find a laceration (ultrasound, estradiol, testosterone)
An endometrial biopsy can be useful in
of the vagina, a bleeding lesion, or ruling out malignancy or premalignant
bleeding from the surface of the cervix changes among women over age 40 Abnormal bleeding from hormonal
due to cervicitis. More commonly, you causes are often treated with OCPs.
Breast Development OB-GYN 101 Facts Card ©2003 Brookside Press
also the area in which about half of
At puberty, the female breast develops, The breast is not round, but has a "tail" all breast cancers will develop.
under the influence of estrogen, of breast tissue extending up into the
progesterone, growth hormone, axilla (or armpit).
prolactin, insulin and probably thyroid
hormone, parathyroid hormone and This is clinically significant because
cortisol. This complex process typically abnormalities can arise there just as
begins between ages 8 to 14 and they can in other areas of the breast.
spans about 4 years. During breast examinations, this area
should be palpated.
The breast contains mostly fat tissue,
connective tissue, and glands that Breasts are never identical, comparing
following pregnancy, will produce milk. right to left. One is invariably a little
The milk is collected in the ducts and larger, slightly different in shape, and
transported to 15-25 openings through location on the chest wall. The nipples
the nipple. are likewise never identical but show
minor differences in size, location and
During the menstrual cycle, the breast orientation.
is smallest on days 4-7, and then
begins to enlarge, under the influence The breast is divided into quadrants to
of estrogen and later progesterone and better describe and compare clinical
prolactin. findings.

Maximum breast size occurs just prior The upper outer quadrant is the area of
to the onset of menses. greatest mass of breast tissue. It is
Breast Exam OB-GYN 101 Facts Card ©2003 Brookside Press
a dimpling of the skin while she flexes
A breast examination consists of these muscles. Check the supraclavicular area for
inspection and palpation. The breasts palpable masses.
may be examined while the patient is
sitting or reclining. Breast tissue is normally somewhat
nodular or "lumpy," particularly in the Stripping the ducts toward the nipple
upper outer quadrant. You are looking will cause any secretions to be
While generally symmetrical, most for a dominant mass. Some have expressed. This should be done
breasts are slightly asymmetrical in suggested that you are looking for "a firmly, but not so hard as to cause
respect to size, shape, orientation, and marble in a bag of rice." discomfort or pinching. You will
position on the chest wall. Inspect for: almost always be able to bring a
drop or two of breast secretions to
• Visible masses (change in contour) Palpate the breast using the proximal the surface. This is normal and the
• Skin dimpling and middle phalanges of the fingers. secretions will be clear, milky, or
• Nipple retraction Move your hand in a circular motion have a slight greenish tinge.
• Redness while pressing into the breast
substance. Making these small circles
Have her raise her arms while you will help you identify mass occupying Bloody discharge is always
continue to watch the breasts. lesions. Cover the entire breast in a considered a danger sign.
systematic fashion, including the tail of
• An underlying malignancy can fix Large amounts (many drops) of
the breast that extends up into the
the skin in place. secretions are not considered
axilla.
• Raising the arms will accentuate normal and usually require further
these changes. investigation.
Check the axilla for masses or
Have her flex the pectoralis major palpable lymph nodes.
muscles or raise her arms over her
head. Suspicious areas will appear as
Breast Screening OB-GYN 101 Facts Card ©2003 Brookside Press
a threat, but they are subjected to the U.S., however, as an adjunctive
If there were no such thing as breast biopsy and excision. method to evaluate abnormalities
cancer, there would be little need to palpated by the examiner or
screen individuals for breast disease. identified on mammograms.
Breast cancer is the issue that drives Mammography: The goal is to detect
all breast screening programs. early cancers before they spread, and
is felt to be about 80% effective. Thermography is a means of looking
at the breast with an infrared (heat-
The primary strategy involves a three- sensitive) imaging device. It relies on
armed effort: Periodic (annual) If there is a clinical abnormality,
mammograms can be used to gain the principle that cancers have
professional breast examination, increased metabolic activity,
monthly self-breast examination, and additional information about the
abnormality (a "diagnostic" generating more heat, that can be
mammography at appropriate intervals. detected with a thermographic
mammogram). Many physicians
recommend "screening:" process. While this has some
Breast Examination: Annually, breasts mammograms be performed every theoretical advantages over other
should be evaluated. Professional other year between ages 40 and 50, imaging techniques, in practice,
exams are felt to detect about 80% of and annually thereafter. thermography has not been
breast abnormalities. demonstrated to be effective in early
detection of significant lesions, and
Breast ultrasound is used in some
Self Breast Examination: Monthly, a so is not generally used as a primary
areas to screen for breast cancer. It
woman should examine her own screening technique.
has the advantage that it is relatively
breasts. Critics of self breast exams inexpensive, quick, painless, and uses
believe they may cause more problems no radiation. It is particularly good at
than they solve. By the time a breast detecting cystic masses. In skilled
cancer is large to feel, it is not likely to hands, it does a fair job of detecting
be "early." Most self-discovered breast malignancies.It is commonly used in
lumps are benign and do not represent
Breech OB-GYN 101 Facts Card ©2003 Brookside Press
Breech presentation: • Flexion of the fetal head
Try not to let the head "pop" out of
• Buttocks first • EFM OK
the birth canal. A slower, controlled
• One leg first • Progress in labor delivery is less traumatic.
• Both legs first.
Spontaneous breech: Mother pushes
Frank breech: buttocks are presenting the baby out with the normal bearing
and legs are along the fetal chest. The down
fetal feet are next to the fetal face.
Safest position for breech delivery. Assisted breech: Spontaneous to the
umbilicus, then sweep legs out, arms
out, and suprapubic pressure to deliver
Footling breech risks: the head.
• Umbilical cord prolapse
• Delivery of the feet through an Breech Extraction: Reaching up into
incompletely dilated cervix, leading the birth canal to find the legs and
to arm or head entrapment. bring them down.

For fetus, C/S safer In general, but It is important to:


vaginal delivery OK if operator is • Keep you hands low on the baby's
experienced and risk factos hips
acceptable: • Keep the baby at or below the
horizontal plane.
• Size of the fetus
• Keep suprapubic pressure applied
• Size of the maternal pelvis Previous
by assistant
vaginal births Previous vaginal
breeches
• Presentation
Carpal Tunnel Syndrome OB-GYN 101 Facts Card ©2003 Brookside Press
of the carpal tunnel with steroids may
Approximately 30% of pregnant women also be done (after 24 weeks of
will develop numbness in one or both pregnancy).
hands following the distribution of the
median nerve. (index finger, middle
finger, medial surface of ring finger, Rarely, surgery may be necessary to
with sparing of the lateral surface of free up the median nerve, although this
the ring finger and the little finger). is almost never required during
pregnancy.
This is due to swelling and
compression of the median nerve as it
passes through the "carpal tunnel" in
the wrist.

The dominant hand is more frequently


effected. It is usually worse in the
morning and improved in the evening.
After delivery, the condition goes away
gradually.

No treatment is necessary for this


condition, so long as the motor portion
of the nerve is still functioning
normally. When treatment is
necessary, splinting the wrist in a
"cockup splint" will be helpful. Injection
Cancer of the Cervix OB-GYN 101 Facts Card ©2003 Brookside Press
patient will notice back or flank pain
Relatively uncommon malignanc, provoked by ureteral obstruction and II-Cancer extends beyond the cervix,
representing ~ 2% of all new cancers. hydronephrosis. but not to the pelvic sidewall, and not
(breast 30%, lung 13%, colon 11%). to the lower third of the vagina-60%
Less common than uterine (6%).
ovarian (4%), bladder (3%) cancers. The diagnosis confirmed by biopsy, but
suspected if friable, visible, exophytic III-Cancer extends to the pelvic
lesion seen on cervix. Endophytic sidewalls and/or to the lower third of
Pap smear screening has had a lesions invade deeply into cervical the vagina.-45%
dramatic impact on the incidence of stroma, creating an enlarged, firm,
cervical cancer. Initially throught to barrel-shaped cervix. Initial metastases IV-Cancer extends beyond the true
promote early diagnosis of cervical are to the parametrial tissues and pelvis, or extends into the bladder or
cancer, Pap screening has been most lymph nodes. Later, aggressive local bowel mucosa-18%
helpful in detecting the pre-malignant spread into the upper vagina, rectum
changes that, when treated, are and bladder, and hematogenous Treatment can consist of surgery,
effective in preventing the actual spread to liver, lungs, and bone. radiation therapy, and sometimes
development of cervical cancer. Most
adjuvant therapy. The best option for
cases of invasive cervical cancer occur
Stage-Extent-5 Yr. Survival Rates treatment depends on the stage of
among women who have not been
the cancer. Surgery seems to work
screened with Pap smears or who
0-Carcinoma in situ, limited to the best on Stages I and IIA (no obvious
have not had a Pap smear in years.
epithelium, without invasion->99% parametrial involvement).
Radiotherapy seems to work better
The most common symptom of cervical for more advanced stages.
cancer is abnormal vaginal bleeding, I-Cancer limited to the cervix -70%- Complications of either approach
either spontaneous or provoked by 99% include bladder and bowel fistula
intercourse or vigorous physical formation, and loss of vaginal length.
activity. In advanced cases, some
Chancroid OB-GYN 101 Facts Card ©2003 Brookside Press
polymorphonucleocytes ("school of fish
This sexually-transmitted illness begins " appearance).
as a tender, reddened papule filled
with pus. It then breaks down,
ulcerates and reveals a grayish, Recommended Regimens (CDC 2002)
necrotic base with jagged, irregular
margins. Azithromycin 1 g orally in a single
dose,
There is no significant induration OR
around the base, unlike primary Ceftriaxone 250 mg intramuscularly
syphilis. In untreated cases, the (IM) in a single dose,
lesions may spread and substantial OR
tissue damage may result. Tender, Ciprofloxacin 500 mg orally twice a day
enlarged inguinal lymph nodes are for 3 days,
found in 50% of patients. OR
Erythromycin base 500 mg orally three
times a day for 7 days.
Hemophilus ducreyi, the causative
organism, is difficult to culture, so the
diagnosis is made on the basis of After starting therapy, recheck the
history, physical exam and exclusion of patient in about a week to be sure they
other ulcerative diseases of the vulva. are improving. If not, the initial
A gram-stain from the base of a clean diagnosis may not be correct.
ulcer or aspirate from a bubo may
reveal a gram-negative coccobacillus Complete resolution may take longer
clustered in groups around than 2 weeks, particularly if the lesion
is large.
Chorioamnionitis OB-GYN 101 Facts Card ©2003 Brookside Press

Chorioamnionitis is an infection of the • The fetus may suffer not just from Maternal temp Rx’d with PO or PR
placenta and fetal membranes. infection, but also from elevated acetaminophen, 1 gm Q 4 hours.
core temperature of the mother.
Organisms responsible for this • Increased core temperatures lead to Plans are made for prompt delivery.
infection include Strep, coliforms, and an increased metabolic rate of the Vaginal delivery is usually possible.
anaerobes. Polymicrobial infection is fetal enzyme systems, which in turn
common. need more oxygen than normal. At
timesthis leads to progressively
In its' earliest stage, there may be no hypoxia and acidotis.
symptoms or clinical signs. As it Chorioamnionitis during labor is treated
advances, clinical evidence of infection very aggressively, with broad-spectrum
may appear, including: antibiotics such as:
• Maternal temp > 100.4. • Ampicillin 2 gm IV Q 6 hours, plus
• ↑WBC gentamicin 1.5 mg/kg (loading
dose) and 1.0 mg/kg Q 8 hours
• Fetal tachycardia
• Foul-smelling amniotic fluid
• Ampicillin/sulbactam 3 gm IV Q 4-6
hours
• Uterine tenderness
• Mezlocillin 4 g IV Q 4-6 hours
Chorioamnionitis may be a problem for • Piperacillin 3-4 g IV Q 4 hours
both the mother and the fetus:
• Ticarcillin/clavulanic acid 3.1 gm IV
• Serious maternal infections. Q 6 hours
Condyloma (Warts) OB-GYN 101 Facts Card ©2003 Brookside Press
warts may be a nuisance and so are associated with another skin change
Condyloma acuminata, (venereal usually treated. Subclinical warts are known as "dysplasia." About 1/3 of
warts) are caused by a virus known as usually not treated since they are not a all adult, sexually-active women
"Human Papilloma Virus" (HPV). nuisance (most people with subclinical have been infected with HPV, but
warts are unaware of their presence). probably less than 10% will ever
Clinical warts appear as tiny, develop dysplasia.
cauliflower-like, raised lesions around Treatment consists of removal of the
the opening of the vagina or inside the wart. This can be accomplished in any 90% of mild cervical will never
vagina. These lesions appear flesh- number of ways, some more painful develop a more advanced problem.
colored or white, are not tender and than others:
have a firm to hard consistency.
Most women with moderate to
• Trichloracetic Acid
severe dysplasia of the cervix, if left
Subclinical warts, are invisible to the • Cryosurgery
untreated, will ultimately develop
naked eye, are flat and colorless. They • Podophyllum resin cancer of the cervix. If treated, most
usually do not cause symptoms, • Imiquimod of these abnormalities will revert to
although they may cause similar • Surgical removal normal, making this form of cervical
symptoms to the raised warts. These cancer largely preventable.
subclinical warts can be visualized if Untreated, many warts will gradually
the skin is first soaked for 2-3 minutes resolve and disappear spontaneously.
with vinegar (3-4% acetic acid) and In any patient with venereal warts
then viewed under magnification (4- Patients with HPV are contagious to (condyloma), you should look for
10X) using a green or blue (red-free) others, but there is no effective way to possible dysplasia of the cervix
light source. prevent its spread.

Warts are not dangerous and have While warts are not considered
virtually no malignant potential. Clinical dangerous, HPV infection is
Condyloma Lata OB-GYN 101 Facts Card ©2003 Brookside Press
• Condyloma accuminata are bulky
The word "condyloma" comes from the During pregnancy, it is important that
while, condyloma lata are flat.
Greek word meaning "knob." Any sufficient antibiotic gets across the
knob-like or warty growth on the Surface scrapings of condyloma lata placenta and to the fetus.
genitals is known as a condyloma. under darkfield microscopy will show
Venereal warts caused by human spirochetes. Serologic test for syphilis Within 24 hours of treatment, you
papilloma virus are known as (VDRL, RPR) will be positive. may observe the Jarisch-Herxheimer
"condyloma accuminata" (venereal reaction in patients. This reaction
warts). Optimal treatment is: consists of fever, muscle aches and
headache and may be improved by
The skin lesions caused by Molitor • Benzathine penicillin G 2.4 million concurrent treatment with antipyretic
hominus are known as "condyloma units IM in a single dose medication.
subcutaneum" (molluscum But for those allergic to penicillin, you
contagiosum). The skin lesions may substitute: Both the patient and her sexual
associated with secondary syphilis are partner(s) need treatment.
called "condyloma lata." They have in • Doxycycline 100 mg orally twice a
common with veneral warts the fact day for 2 weeks, or Long term followup is needed to
that they are both raised lesions on the • Tetracycline 500 mg orally four make sure that the syphilis is
vulva (or penis), but there ends the times a day for 2 weeks. completely gone from the patient
similarity. • Ceftriaxone 1 gram daily either IM and her sexual partner(s). The
or IV for 8--10 days (possibly means to do that is complicated and
• Condyloma accuminata are
effective). current CDC recommendations are
cauliflower-like, while condyloma
• Azithromycin 2 grams PO once best followed.
lata are smooth.
(possibly effective).
• Condyloma accuminata are dry,
while condyloma lata are moist.
Delivery OB-GYN 101 Facts Card ©2003 Brookside Press
• Expulsion (shoulders and torso of
Delivery is the second stage of labor, After the fetal head delivers, allow
the baby are delivered.)
beginning with complete dilatation and time for the fetal shoulders to rotate
ending when the baby is completely As the fetal head descends below 0 and descend through the birth canal.
out of the mother. station, the mother will perceive a This allows the birth canal to
sensation of pressure in the rectal squeeze amniotic fluid out of the
As the fetal head passes through the area, similar to the sensation of an fetal chest.
birth canal, it normally demonstrates, in imminent bowel movement. At this time
sequence, the "cardinal movements of she will feel the urge to bear down, After 15-30 seconds, have the
labor." These include: holding her breath and performing a woman bear down again, delivering
Valsalva, to try to expel the baby. This the shoulders and torso of the baby.
• Engagement (fetal head reaches 0 is called "pushing." The maternal
station.) pushing efforts assist in speeding the Leave the umbilical cord alone until
• Descent (fetal head descends past delivery. the baby is dried, breathing well and
0 station.)
starts to pink up. During this time,
• Flexion (head is flexed with the For women having their first baby, the keep the baby level with the placenta
chin to its' chest.) second stage will typically take an hour still inside the mother.
• Internal Rotation (head rotates or two.
from occiput transverse to occiput
anterior.) Once the baby is breathing, put two
The fetal head emerges through the clamps on the umbilical cord, about
• Extension (head extends with vaginal opening, usually facing toward an inch (3 cm) from the baby's
crowning, passing through the the woman's rectum. Support the abdomen. Cut between the clamps.
vulva.) perineum to reduce the risk of perineal
• External Rotation (head returns to laceration from uncontrolled, rapid
its' occiput transverse orientation) While the cord remains intact,
delivery. elevation of the fetus above the level
Diagnosis of Pregnancy OB-GYN 101 ©2003
• Softening of the cervix situation, a confirmatory HCG is
Pregnancy may be suspected in
(Goodell's sign) not necessary.
any sexually active woman, of
childbearing age, whose • Softening of the uterus (Ladin's
menstrual period is delayed, sign and Hegar's sign)
particularly if combined with • Darkening of the nipples
symptoms of early pregnancy, • Unexplained pelvic or
such as: abdominal mass

• Nausea (1st trimester) Pregnancy should be confirmed


• Breast and nipple tenderness with a reliable pregnancy test.
(1st trimester) Urine or serum pregnancy tests
can be used. Both are reliable and
• Marked fatigue (1st and 3rd
detect human chorionic
trimesters)
gonadotropin (HCG). Pregnancy is
• Urinary frequency (1st and 3rd
considered present if 30-35 mIU
trimesters)
of HCG are present in the urine or
• The patient thinks she's serum.
pregnant
Early signs of pregnancy may Ultrasound may be used to
include: confirm a pregnancy, if the
gestational age is old enough for
• Blue discoloration of the cervix visualization of a recognizable
and vagina (Chadwick's sign) fetus and fetal heartbeat. In that
Painful Urination OB-GYN 101 Facts Card ©2003 Brookside Press
intense that urination becomes
Painful urination is one of the classical Non-gonorrheal Urethritis complete misery. A Foley catheter
symptoms of bladder infection, along These patients complain of symptoms until the symptoms resolve is
with frequency, urgency and suggesting cystitis (frequency, burning, merciful.
sometimes hematuria. Such an and urgency), but the urine culture is
infection can be confirmed by a negative and they do not improve on
positive urine culture (>100,000 conventional antibiotic therapy. Yeast, Trichomonas
colonies/ml), or strongly supported by Pain on the vulva when urine passes
a positive "dipstick" (for bacteria or over it can also be a symptom of
A purulent discharge from the urethra yeast and less-commonly
leukocyte esterase) and a clinically may or may not be present, but the
tender bladder (normally the bladder is trichomonads. These infections
urethra is tender to touch. should be apparent on inspection of
not the least bit tender).
the vulva/vagina and may be
Cultures from the urethra may be confirmed by microscopic
Gonorrheal Urethritis positive for chlamydia, Mycoplasma or examination of vaginal discharge.
Urinary frequency and burning in a Ureaplasma, but will be negative for
patient with a history of exposure to gonorrhea.
gonorrhea suggests gonorrheal Painful urination may also be a
urethritis. symptom of other gynecologic
Herpes disease, not specifically related to
Painful urination in which the vulva the bladder. Endometriosis, for
The urethra is normally not tender. burns when the urine drips across it example, may initially present as
Should the urethra be tender, can the primary symptom of herpes. In painful urination with a tender
particularly if combined with a purulent this case, inspecting the vulva will bladder which does not respond to
discharge, urethritis should be reveal multiple, small (1-2 mm), tender typical antibiotic therapy and all urine
suspected. ulcers filled with grayish material and cultures will be negative.
perhaps some blisters that have not
yet ruptured. Sometimes, the pain is so
Early Labor Management OB-GYN 101 Facts Card ©2003 Brookside Press
eclampsia. Elevation of temperature
If the patient is in early labor, with a >100.4 may indicate the development Prior to active labor, the fetal heart
normal pregnancy, and intact of infection. rate for low risk patients is usually
membranes, she may feel like evaluated every hour or two.
ambulating and this is very acceptable.
Avoid oral intake other than small sips
of clear liquids or ice chips. If labor is Once in active labor, evaluate the
Not all women in early labor feel like lengthy or dehydration becomes an fetal heart rate every 30 minutes.
walking and she need not be forced issue, IV fluids are administered. Look at the EFM, or measure the
out of bed. Some patients, particularly FHR following a contraction. Fetal
those with ruptured membranes and jeopardy is likely if the auscultated
those with certain risk factors are Periodic pelvic exams are performed FHR is <100 BPM, even if it later
probably better off staying in bed, even using sterile gloves and a water- rises back to the normal range of
during early labor. soluble lubricant. The frequency of 120-160. Persistent fetal tachycardia
such exams is determined by individual (>160 BPM) is also of concern.
circumstances, but for a normal patient
While in bed, it is preferable, in women in active labor, an exam every 2-4
without continuous electronic fetal hours is common. If the patient feels For women with significantly
monitoring, to have them lie on one rectal pressure, an exam is increased risks, it is better to
side or the other, but to avoid being on appropriate. evaluate the fetal heart rate every 15
their back. Such lateral positioning minutes during the active phase of
maximizes uterine blood flow and labor.
provides a greater margin of safety for Some women experience difficulty
the baby. emptying their bladder during labor. If
the patient cannot void spontaneously, Women in the second stage of labor
insert a catheter. (completely dilated but not yet
Recheck the maternal vital signs every delivered) usually have their fetal
4 hours. Elevation of blood pressure heart rate evaluated every 5 minutes
may indicate the onset of pre- until delivery.
Ectopic Pregnancy OB-GYN 101 Facts Card ©2003 Brookside Press
Pregnancy in the wrong place • Dizziness, fainting D&C
• 97% tubal ectopic. Physical Findings Laparoscopy
Incidence about 1%, but higher with: • Pelvic mass (either from the Laparotomy
• Tubal disease/surgery enlarged ectopic, or from the corpus Methotrexate
• Previous EP luteum cyst that accompanies many • CBC, Platelets, Liver function
• Current IUD use early pregnancies of all types) tests, Renal panel
• Assisted reproduction • Pelvic tenderness, localized or • 50 mg/sq.meter body surface
Special issues: generalized area is given as a single injection.
Majority in distal half of tube. These • Abdominal distension • Quantitative HCG day #4 and day
may resolve spontaneously. • Hypotension, tachycardia, #7
Isthmic ectopic: rupure early tachypnea • HCG levels should fall >15% from
Cornual ectopic: rupture early and Laboratory day #4 to #7
hemorrhage with sig. risk of death. • UCG positive. • If HCG levels don't fall >15%,
• Serial Quant/ HCGs are low and then give second dose of
Symptoms
don’t double every 2 days methotrexate
Without rupture, may be none Usual
• Progesterone levels are sometimes
pregnancy symptoms (fatigue, breast
very low (<5). Expectant Management
tenderness, amenorrhea) plus:
Ultrasound • works best when plateau or falling
• Vaginal bleeding • Sac and FHB outside the uterus HCG, and initial HCG is <1,000,
• Abdominal pain • Nothing in the uterus and HCG in asymptomatic women – 75-
• Right shoulder pain (blood irritates above discriminatory zone (1500?) 90% success
undersurface of right • Free fluid in abdomen Followup HCG, Rhogam
hemidiaphragm, stimulating phrenic • May be misleading
nerve, causing referred pain)
• Urge to defecate Culdocentesis
Electronic Fetal Monitoring OB-GYN 101 Facts Card ©2003 Brookside Press

Continuously records instantaneous Bradycardia (sustained <120 BPM) Late decelerations are repetitive,
FHR and UCs. caused by increased vagal tone. gradual slowings of FHR toward the
end of the contraction cycle. Utero-
Originally, EFM thought to prevent Short term variability 3-5 BPM placental insufficiency. If persistent,
stillbirth, brain damage, seizure Reduced variability: a threat to fetal well-being.
disorders, and CP. Overly optimistic.
• normal during fetal sleep
Most of these are not intrapartum Variable decelerations are variable
• Following narcotic administration
problems, but antepartum events. in onset, duration and depth. They
Nonetheless, EFM remains useful. • fetal anomalies or injury may occur with contractions or
• With hypoxia and acidosis between contractions. Abrupt onset
2 types: Long-term variability: broad-based and Represent a vagal response to
swings in fetal heart rate, occurring up some degree of umbilical cord
• Internal: most accurate, bur to several times a minute. Acceleration compression.
requires ROM. in response to fetal movement, 15
• External: usually accurate enough • Mild 70 BPM and < 30 seconds.
BPM above the baseline or more,
• Severe < 60 BPM x 60 seconds
Tachycardia (Sustained >160 BPM)i lasting 10-20 seconds, reassuring.
Prolonged decelerations last more
• Fever Tachysystole: persistently > 5 CTX in than 60 seconds and occur in
• Chorioamnionitis 10 minutes in 1st stage of labor. isolation. Causes include maternal
• Maternal hypothyroidism supine hypotension, epidural
• Drugs (tocolytics, Vistaril, etc.) Early decelerations: synchronized anesthesia, paracervical block,
• Fetal hypoxia, anemia, heart failure, exactly with the contractions. Innocent tetanic contractions, and umbilical
arrythmia fetal head compression. cord prolapse.
• Most not indicative of fetal jeopardy
Endometrial Cancer OB-GYN 101 Facts Card ©2003 Brookside Press
and/or hysteroscopy. Recent advances
Single most common genital tract in ultrasound technology have led to Other factors influencing treatment
malignancy in women. Lifetime risk increased use of this technique, include tumor grade, histologic
about 2%. Peak incidence age 50-65. particularly when combined with subtype, age, race, depth of
intracavitary infusion of saline to endometrial penetration through the
Arises from the uterine lining. Mostly outline the endometrial structures more uterine wall, and presence or
occurs among women with chronic, clearly. absence of positive peritoneal
unopposed estrogen, eg chronically cytology and distant metastases.
anovulatory patient or obese patient Treatment varies, depending on the
extent of the cancer. One factor Prognosis for the lower stage, better
Abnormal bleeding is the classical influencing choice of treatment is the differentiated tumors is excellent.
symptom. During the hyperplasia staging of the disease: Typical management of these
stage, abnormal bleeding develops patients consists of:
which is evaluated by sampling of the • Stage I: Cancer limited to the
uterine body (corpus) • Staging the cancer.
endometrium. The hyperplasia is
• Stage II: Cancer extends into the • TAH/BSO for Stage I and some
treated with progestins, and a
cervix, but not beyond the uterus. Stage II patients
subsequent cancer avoided.
• Stage III: Cancer extends beyond • Whole pelvis irradiation for more
the uterus, but only so far as the advanced cases
Thus, a common approach to a woman • Additional irradiation to periaortic
at risk for endometrial cancer (post- peritoneum, adnexa or vagina
• Stage IV: Cancer extends into the areas if metastases are present
menopausal, for example), is to
bladder, bowel, or to distant sites • Possible chemotherapy
sample the endometrium whenever
• Surveillance for recurrence.
abnormal bleeding is encountered. Within each stage are subgroups (eg,
There may be exceptions to this Stage IA, IB, IC)
general approach, but sampling may
involve endometrial biopsy, D&C,
Endometriosis OB-GYN 101 Facts Card ©2003 Brookside Press
• 12% to 32% of women undergoing • No laboratory tests that are
Endometriosis is the abnormal location
laparoscopy for pelvic pain specific for endometriosis.:
of normal endometrial tissue in the
• 21% to 48% of women undergoing • Some women with endometrioisis
body, and is associated with pain, scar
laparoscopy for infertility have a persistent complex or
tissue formation, and infertility. The
most common locations for these • 50% of teenagers undergoing solid adnexal mass on
laparoscopy for chronic pelvic pain ultrasound, CT or MRI.
implants are in the pelvis, but it can be
found virtually anywhere in the body, or dysmenorrhea • Elevated serum CA-125.
Symptomatic endometriosis presents
The cause is not known, but different with a chronic (more than 6 month) Rx:
theories can, in part, explain the history of steadily worsening pelvic
existence of endometriosis.: pain. A second classical symptom is • Birth Control Pills, cyclic or
painful intercourse on deep continuous
• Implantation Theory: Menstrual penetration. Less common is painful • GnRH Agonists x 6 months
reflux bowel movements. Half of women with • Danazol x 9-12 months
• Coelomic Metaplasia Theory: endometriosis have no symptoms. • Progestins
Peritonum holds some • Conservative Surgery
undifferentiated cells which can • Definitive Surgery
Physical findings include:
differentiate into endometrial cells.
• Adnexal tenderness and thickness
The incidence of endometriosis in
general unknown. For women • Tender nodules along the
undergoing gynecologic surgery uterosacral ligament, at the junction
of the bladder and the uterus, and
• 6% to 43% of women undergoing over the uterine corpus.
sterilization • Many women have no positive
physical findings.
Environmental Issues OB-GYN 101 Facts Card ©2003 Brookside Press
and is heard by the fetus. A woman
Fetal enzyme systems may not exposed to 115 dB of loud rock music Organic solvents, such as
function properly if subjected to can protect her own hearing, but the turpentine, fuel, oils, lubricants, and
unusually high temperatures. The fetus will still be exposed to 100 dB paint thinner may have adverse
important thing to avoid is elevation of sound. Continuous exposure to 85 dB effects on a developing fetus.
the core temperature. and above is considered dangerous to
the hearing. The greatest risk comes from
Pregnant women are at a ingestion of these solvents, or by
disadvantage in hot environments: Pregnant women should avoid any chemical spills with contamination of
exposure to ambient noise greater than the skin. Inhalation, though less
• They have a high metabolic rate t. likely to delivery significant quantities
• Their surface area to mass ratio is 104dBA (corresponding to the need for
double hearing protection), unless of the material, should also be
unfavorable. avoided.
absolutely essential for quickly moving
• When they vasodilate to shunt
blood to their skin for cooling, their through a high noise area.
It is very important to avoid maternal
CV system is slow to compensate, exposure to lead, cadmium and
leading to easy fainting. Low frequency, whole body vibration
can be problematic for a developing mercury.
The abdominal wall muffles noise only pregnancy.
somewhat so very noisy areas may Typical CRT (Cathode Ray Tube)
pose problems for the developing This is the type of shaking vibration exposure poses no threat for the
fetus, including hearing loss. one might experience if operating a pregnant woman, either from
jackhammer or driving at high speed electromagnetic radiation (EMR) or
There is an approximately 15 dB over a highway with many potholes from eyestrain.
attenuation (quieting) of sound as it
passes through the mother's abdomen
Episiotomy OB-GYN 101 Facts Card ©2003 Brookside Press
but the few you have are more likely
Sometimes, a small incision is made in If the fetal head is still too big to allow to be the trickier 3rd and 4th degree
the perineum to widen the vaginal for delivery without tearing, the lacerations involving the anal
opening, reduce the risk of laceration, lacerations will likely extend along the sphincter and rectum.
and speed the delivery. line of the episiotomy. Lacerations
through the rectal sphincter and into
the rectum are relatively common with If you perform a mediolateral
There are two forms, midline and episiotomy, you will avoid the 3rd
mediolateral. this type of episiotomy.
and 4th degree lacerations, but you
may open the ischio-rectal fossa to
A mediolateral episiotomy avoids the contamination and infection and
problems of tearing into the rectum by increase the intrapartum blood loss.
directing the forces laterally. However,
these episiotomies bleed more, take
longer to heal, and are generally more
uncomfortable after delivery.

If you don't perform an episiotomy, you


are increasing the risk of vulvar
lacerations, but these are usually (not
always) small, non-threatening
lacerations that will heal well without
further complications. There may be no
A midline episiotomy is safe, and laceration at all.
avoids major blood vessels and
nerves. It heals well and quickly and is If you perform a midline episiotomy,
reasonably comfortable after delivery. you will have fewer vulvar lacerations,
Estimating Gestational Age OB-GYN 101 ©2003
Nägele’s Rule: Assuming normal, Anatomic Rules:
regular periods, every 28 days,
ovulation occurs on about day • 12 weeks - the uterus is just
#14. The EDC is calculated by barely palpable above the pubic
adding 280 days to the first day of bone
LMP. • 16 weeks - the top of the uterus
is 1/2 way between the
An alternative is to add 7 days to symphysis and the umbilicus.
the LMP, subtract three months, • 20-22 weeks - the top of the
and add one year. These uterus is at the umbilicus.
calculations are made easier with • At full term, the top of the
the use of a pregnancy wheel. uterus is at the level of the ribs.
(xyphoid process).
McDonald’s Rule: The distance
from the pubic bone up over the Ultrasound Accuracy
top of the uterus, in centimeters, is • CRL in 1st trimester ±3 days
approximately equal to the weeks • BPD in 2nd ±10-14 days.
of gestation, from about mid- • BPD in 3rd trimester ±3 weeks
pregnancy until nearly the end of
pregnancy.
Fetal Position OB-GYN 101 ©2003
• ROP (right occiput posterior) Posterior: Favored by some
Presentation = Head/breech/TL
pelvic shapes
Position = orientation within canal Breech uses same terms, but the
fetal sacrum is the landmark:
• May seem more deeply
Anterior Fontanel
• LSA (Left sacrum anterior) engaged in the pelvis than it
Diamond shape = Forehead is.
Posterior Fontanel • LST (Left sacrum transverse)
• LSP (Left sacrum posterior) • Babies can deliver in the
Y shape = Occiput
• RSA (Right sacrum anterior) posterior position, but the
• RST (Right sacrum transverse) pelvis needs to be large and
• RSP (Right sacrum Posterior it usually takes longer.
• Forceps often used but
Cliinical Significance: controversial whether fetus
Anterior: Easiest way to deliver delivered in the posterior
Occiput Anterior (OA) for most pelvic shapes. position, or rotated with
Usually easiest position for the Transverse: Common in early forceps to anterior position.
fetal head to traverse the maternal labor, head should rotate anterior
pelvis. as it descends. If not:
• LOA (left occiput anterior) • Head too big, or
• LOT (left occiput transverse) • Maternal pelvis flat, and
• LOP (left occiput posterior) • May need C/S
• ROA (right occiput anterior)
• ROT (right occiput transverse)
Fetopelvic dysproportion OB-GYN 101 Facts Card ©2003 Brookside Press
time, and within 20% of the actual
Fetopelvic disproportion is any Clinical Pelvimetry birthweight in 95% of cases..
clinically significant mismatch between Simple digital evaluation of the pelvis,
the size or shape of the presenting part allows the examiner to categorize it as
of the fetus and the size or shape of probably adequate for an average Clinical estimates by an experienced
the maternal pelvis and soft tissue. sized baby, borderline, or contracted. examiner, based on feeling the
Other methods include the following: mother's abdomen, are, in some
studies, just as accurate as
The problem of disproportion may be
• Diagonal conjugate:The distance ultrasound (in other words,
based strictly on size, or the way the somewhat reliable).
from the sacral promontory to the
fetus is trying come out. Should a fetus
exterior portion of the symphysis
attempt to come through the birth
should be > 11.5 cm. Monitoring the progress of labor is
canal in the occiput posterior position,
• Measure the bony outlet. Greater another technique that is used to
it is more difficult for the fetal head to
than 8 cm bituberous (or bi-ischial, assess the presence or absence of
negotiate the turns.
or transverse outlet) is normal. fetopelvic disproportion. This
• Feel the ischial spines prominence technique hinges on the belief that if
Even if highly accurate measurements or flatness. Prominence narrows the the fetus is too big to come through,
of the maternal pelvis and fetal size transverse diameter of the pelvis. there will be an arrest of progress of
were possible (and they are not), it • Feel the pelvic sidewalls: Parallel labor. After confirming that the arrest
would still be difficult to predict (OK), diverging (even better), or is not due to other factors (inadquate
successful vaginal delivery. All converging (bad). contractions, for example), and
measurements are essentially static, allowing adequate time for the arrest
and do not take into account the Ultrasound estimates of fetal weight to resolve, fetopelvic disproportion is
inherent "stretchiness" of the maternal are based on mathematical modeling. presumed to be present and
pelvis or the compressibility of the Ultrasound comes within 10% of the operative delivery (usually cesarean
fetus. actual birthweight two-thirds of the section) is undertaken.
Fibroids OB-GYN 101 Facts Card ©2003 Brookside Press
• Pain: This may take the form of and observed over time, with the
Uterine leiomyomas are common, expectation that at menopause, they
menstrual cramps, painful
benign, smooth muscle tumors of the will regress.
intercourse on deep penetration,
uterus. They are found in nearly half of
pain of acute fibroid degeneration,
women over age 40 and infrequently For those with significant symptoms,
and chronically inflamed fibroids
cause problems. Synonyms include very large fibroids, or rapidly growing
with a dull, aching or heaviness that
Fibroids, Myomas, and Leiomyomata. fibroids, a number of treatments can
is mostly constant.
• Infertility be considered:
Fibroids tend to grow under the • Pelvic Pressure • Hysterectomy
influence of estrogen, and regress • Stress Urinaty Incontinence • Myomectomy: For women who
when the estrogen levels are reduced. wish to preserve their
• Ureteral Obstruction
Thus, growth frequently occurs during childbearing capacity.
pregnancy, followed by regression The uterus is irregularly enlarged and • Birth Control Pill/Progestins
following delivery. After the onset of somewhat asymmetrical. It may be • GnRH Analogs (temporary Rx)
menopause, fibroids generally regress. tender and may assume very large • Embolization (experimental)
sizes. The fibroid uterus is very firm.
Low-dose birth control pills leave
circulating estrogen levels the same (or The diagnosis may be confirmed by:
reduced) and do not stimulate fibroid
growth. • Ultrasound
• MRI and CT Scanning
Symptoms might include: • Laparoscopy
• Histology
• Heavy menstrual flows
• Bleeding between periods In most cases, no treatment is
necessary. The fibroids are measured
Flying OB-GYN 101 Facts Card ©2003 Brookside Press

For the occasional traveler with an Fetal risks include exposure to noise,
uncomplicated pregnancy, flying is not heat, chemicals, organic solvents, and
known to be associated with any low-frequency, whole-body vibration.
significant risks. After the 36th week of
pregnancy, many obstetricians restrict For these reasons, there is general
flying because the patient may not be agreement to restrict pregnant
able to get immediate care if she aircrewman from participating in high-
should go into labor. performance aircraft flights. There is
less agreement in the area of
Flying as a professional occupation helicopters and multiengine, fixed-wing
while pregnant is a more complex aircraft.
issue, involving fetal risks, maternal
risks and aircrew performance. Whether to allow a pregnant
aircrewmember to continue her flight
The maternal risks include decreased duties should be individualized, after
balance, decreased motion tolerance, considering the stage of pregnancy,
decreased g-tolerance, gas the presence or absence of risk factors
compression/recompression effects. for her pregnancy or her flight crew
During the second and third trimester, performance, her company's rules, and
placental abruption caused by the the degree of exposure to potentially
shearing force of inadvertently falling harmful stressors in the aviation
or striking the abdomen violently is a environment.
relatively common occurrence.
Urinary Frequency, Odor OB-GYN 101 Facts Card ©2003 Brookside Press
bladder won’t recover its tone in 48
Urinary Frequency Bad Urinary Odor is usually a hours, so wait 5 days.
The overwhelming number of patients symptom of either a urinary tract
complaining of urinary frequency will infection (cystitis) or a vaginal infection.
have one of the following problems: Try to determine why the patient
couldn't void. She may have recent
Certain foods are associated with an
• Bladder infection (accompanied by trauma to the perineum or vagina,
unusual odor in the urine (asparagus), which caused swelling in the area of
dysuria).
as are certain antibiotics (ampicillin). the bladder or urethra, obstructing
• Excessive fluid intake (particularly
just before bedtime). flow. She may have a pelvic mass
• Increased stress. If the patient cannot urinate at all, she (ovarian cyst, uterine fibroids,
• Some pelvic mass which is pressing will be in extreme distress with a pregnancy, etc.) which has distorted
on the bladder distended, tender bladder. the anatomy and functionally
blocked the urethra. She may have
Blood in the Urine Insert a Foley catheter and allow the herpes and cannot urinate because
In women of child-bearing age, not urine to begin draining. After the first of the severe pain, which is caused
postpartum and not menstruating, the 500 cc, clamp the Foley to temporarily by urine flowing over open ulcers.
most frequent cause is cystitis. stop draining for 5-10 minutes before
allowing another 500 cc to drain. Outside of postpartum or post-
Following antibiotics, If all symptoms Continue to drain urine in 500 cc surgical circumstances, being
resolve and the hematuria does not increments until empty. Severe bladder unable to urinate is very rare in
return, no further evaluation is cramps may occur if the entire bladder women, and not a good sign. Urinary
necessary. is drained at one time. Leave the Foley retention is a common presentation
in place for a day or two to allow the of MS. If it does not respond to 5
bladder's muscular wall to regain its' days of Foley placement, urologic
normal tone. If truly overstretched, the consultation/evaluation is needed.
Group B Strep OB-GYN 101 Facts Card ©2003 Brookside Press

Group B Strep (GBS) is a source of • Delivery at <37 weeks gestation


vaginal/rectal culture for strep.
Those who are positive are treated
significant morbidity and sometimes • Ruptured membranes 18 hours or as above... those who are negative
mortality. Many women are longer (some say 12 hours or are not treated.
asymptomatic carriers. longer)

Although GBS infections among the


• Fever during labor of 100.4 or Some physicians use both methods,
greater screening everyone at 36 weeks, but
newborn are uncommon, it is possible also treating high-risk patients.
to reduce the frequency of neonatal Treatment consists of:
GBS. A variety of schemes to reduce
perinatal GBS infections have been • Penicillin G, 5 million units IV,
proposed. followed by 2.5 million units IV every
4 hours until delivery, or
Two standard ways are to treat on the • Ampicillin 2 gm IV, followed by 1 gm
basis of risk or on the basis of IV every 4 hours until delivery, or
screening cultures.
• Clindamycin 900 mg IV every 8
hours, or
Using the risk factor approach, women
with any of the following risk factors • Erythromycin 500 mg IV every 6
are treated for possible GBS: hours until delivery, or
• Other broad-spectrum antibiotics if
• Previous infant with invasive GBS clinically indicated
disease
• Documented GBS bacteruria during
Culture screening may be a little more
effective. At about 36 weeks gestation
this pregnancy
women are screened with a
Genital Herpes OB-GYN 101 Facts Card ©2003 Brookside Press
• Acyclovir 200 mg orally five times a Suggested regimens (CDC) for
A tingling or itching sensation suppressive therapy include:
day for 7-10 days, OR
precedes the development of painful
• Famciclovir 250 mg orally three
blisters on both sides of the vulva. The • Acyclovir 400 mg orally twice a
times a day for 7-10 days, OR
blisters then break open, releasing day, OR
clear fluid, and form shallow ulcers, • Valacyclovir 1 g orally twice a day
• Famciclovir 250 mg orally twice a
filled with grayish material. The ulcers for 7-10 days.
day, OR
then crust over and when the crusts fall Preferred treatment (recurrence) • Valacyclovir 500 mg orally once a
off, the underlying skin looks normal. day, OR
The process takes 7-10 days. Re- • Acyclovir 400 mg orally three times • Valacyclovir 1.0 gm orally once a
occurrences are common. a day for 5 days, OR day.
• Acyclovir 200 mg orally five times a
During the ulcerative stage, the pain day for 5 days, OR During the ulcerative stage, skin
may be so intense as to require • Acyclovir 800 mg orally twice a day bacteria (strep, staph, coliforms) can
narcotic analgesia. Urinating during for 5 days, OR attack the exposed ulcers, causing a
this time can be extremely painful and • Famciclovir 125 mg orally twice a bacterial infection of the ulcer. This
may require a Foley cather. day for 5 days, OR is particularly true of large or
• Valacyclovir 500 mg orally twice a multiple, confluent ulcers. These
day for 5 days. women may benefit by the use of
The diagnosis is made by the typical antibiotics such as amoxicillin, any
appearance and may be confirmed • Valacyclovir 1.0 g orally once a day
for 5 days. cephalosporin or erythromycin, even
with a herpes culture. though those drugs will have no
Some have recurrences as often as effect on the course of the viral
Preferred treatment (initial outbreak) every few weeks. For these, component of the herpes.
"suppressive therapy" can be helpful.
• Acyclovir 400 mg orally three times
a day for 7-10 days, OR
Granuloma Inguinale OB-GYN 101 Facts Card ©2003 Brookside Press

This is a chronic, progressive, Treatment is


ulcerative, sexually-transmitted
disease, involving the vulva, vagina or • Trimethoprim-sulfamethoxazole one
cervix. double-strength tablet orally twice a
day for a minimum of 3 weeks, or
The initial lesion is a papule which
undergoes central necrosis to form a • Doxycycline 100 mg orally twice a
clean, granulomatous, sharply-defined day for a minimum of 3 weeks, or
ulcer. This process continues, with
development of multiple, confluent
ulcers, which may be painful or • Ciprofloxacin 750 mg orally twice a
painless. The ulcers have a beefy red day for a minimum of 3 weeks, or
base which bleeds easily.
Pseudobuboes in the groin can be felt. • Erythromycin base 500 mg orally
four times a day for a minimum of 3
The diagnosis is confirmed with biopsy weeks, or
of the ulcer, showing Donovan bodies
on H&E stain or Giemsa stain. • Azithromycin 1 g orally once per
week for a minimum of 3 weeks.
This condition is rare in the United
States, but somewhat more common in Therapy should be continued until all
the tropical areas of southern Africa, lesions have healed completely.
India and New Guinea.
GTD OB-GYN 101 Facts Card ©2003 Brookside Press
• Ultrasound scans show absence of • No pregnancy for 1 year
Gestational trophoblastic disease
a fetus and a "Swiss Cheese" • If any significant rise in HCG,
(GTD) represents a spectrum of
appearance within the placenta methotrexate therapy
proliferative trophoblastic
• Tissue resembles cluster of grapes • Hysterectomy is OK if no further
abnormalities. These abnormalities
include hydatidiform mole (complete childbearing is desired.
GTD produces larger than usual
and incomplete), and gestational amounts of HCG. Women with GTD Partial Mole
trophoblastic tumors (metastatic and tend to have more trouble with nausea A fetus, amnion and fetal circulation
nonmetastatic). and the incidence of early but severe are usually present. Triploidy
pre-eclampsia is relatively high. (69,XXX or 69, XXY, with one
Hydatidiform Mole maternal and two paternal haploid
In the classical case of hydatidiform Following D&C, 80% are cured with no complements) is typically found.
mole: recurrence of this molar pregnancy. In
20%, a trophoblastic tumor develops. Choreocarcinoma
• A fetus and amnion never form Most of these are invasive mole. A few The most dangerous form of GTD. If
• Hydropic swelling of the chorionic are choriocarcinoma. untreated, it is often swiftly fatal, with
villous stroma, and absence of
distant metastases in the lungs, liver
blood vessels within these villi.
Treatment and brain. Most cases are sensitive
• Most (85%) chromosomes are to methotrexate, however, and cures
46XX, but of totally paternal origin • Chest x-ray (pulmonary metastases) are common if aggressively treated
• Varying degrees of trophoblastic • D&C early in the course of the disease.
epithelial proliferation • Serial Quantitative HCG levels
• Patients present with bleeding in the every 2 weeks until HCG falls to
first (or early 2nd) trimester, normal levels
sometimes profusely. • Then monthly HCG levels for 1 year,
watching for recurrence
Vulvar Hematoma OB-GYN 101 Facts Card ©2003 Brookside Press
and limit swelling and further half the cases, no bleeding point will
A vulvar hematoma is usually the bleeding into the hematoma. ever be found. Opening them
consequence of a "straddle" injury. introduces bacteria into an otherwise
When a woman falls while straddling a sterile hematoma. Particularly in
fixed structure, such as chair, railing, • A Foley catheter is inserted and left
in place. The local swelling may be operational settings, ice, Foley and
sawhorse or fire hydrant, it is a bedrest are usually better choices
common occurrence that the peri- sufficient to impair voluntary voiding
and the Foley is much easier to for treatment.
clitoral vessels on one side or the other
will be crushed against the pubic bone. insert earlier in the process.
This results in a vulvar hematoma. In following these, it may prove
• Bedrest for several days to a week. useful to measure the hematoma
with a tape measure to compare the
Most of the vulvar enlargement is soft size over time. As they are feeling
tissue swelling, but some is due to an • Appropriate analgesia. Initially, this less pain, patients will often feel that
encapsulated hematoma. may need injectable narcotics. the hematoma is enlarging. Having
Later, oral narcotics and then objective measures of its' size will be
Diagnosis is made on the basis of NSAIDs will give satisfactory very reassuring to the patient.
history of a fall and the typical physical results.
findings of unilateral swelling and pain.
Dramatic resolution will occur. When
Clinical management consists of: completely healed in a few weeks, the
vulva will look normal and function
normally.
• An icepack is placed over the
perineum and left in place for 24-48
hours. This will help control the pain Most of these hematomas will not
require surgical exploration and
drainage. If you explore them, in about
Hypertension Issues OB-GYN 101 Facts Card ©2003 Brookside Press

During the middle TM, BP (both Toxemia of pregnancy is a clinical Pre-eclampsia


systolic and diastolic) normally drop syndrome characterized by sustained Toxemia of pregnancy is subdivided
below early levels. In the 3rd TM, BP elevated BP (>140/90), protein in the into two categories: pre-eclampsia
usually rises to approximately pre- urine, fluid retention and increased and eclampsia. The difference is the
pregnancy levels. reflexes. It occurs only during presence of seizures in women with
pregnancy and resolves completely eclampsia.
Hypertension is the sustained elevation after pregnancy. It is seen most often
of BP above 140/90. The diastolic as women approach full term, but it The definitive treatment of pre-
pressure elevation is probably the can occur as early as the 22nd week of eclampsia is delivery. The urgency
more important of the two. pregnancy. It's cause is unknown, but of delivery depends on the
it occurs more often in: gestational age and the severity of
MAP = ((2 x diastolic) + (systolic))/3 the disease. To prevent seizures,
• Women carrying their first child
MgSO4 is given.
• Multiple pregnancies
During the 2nd TM, if the average of all • Pregnancies with excessive
MAPs ≥ 90, there is a significant amniotic fluid (polyhydramnios) HELLP Syndrome
increased risk for perinatal mortality, • Younger (<17) and older (>35) • Hemolysis
morbidity and impaired fetal growth women • Elevated Liver Enzymes
dynamics. During the 3rd trimester,
MAP ≥ 105 indicates increased risk. Diagnosis • Low Platelets
The presence of hypertension and
Women with pre-existing HPN face proteinuria are essential to the
increased risks for diminished uterine diagnosis of toxemia of pregnancy.
blood flow, pre-eclampsia, stroke.
Cause(s) of Toxemia of Pregnancy
The cause or causes are not known.
Immunizations OB-GYN 101 Facts Card ©2003 Brookside Press
pregnant women if they are at
Immunizations during pregnancy must increased risk of these conditions.
be carefully considered, weighing the
risk of the immunization against the
risk of acquiring the disease for which • Measles, mumps and rubella
the patient is being immunized. vaccine. Do not give to a woman
while pregnant but defer until after
the pregnancy.
Some immunizations are generally
considered safe...some are not. Here
is a partial listing of some of the • Yellow Fever. Can and should be
immunizations considered during given to pregnant women traveling
pregnancy. to areas where Yellow Fever
endemic.
• Tetanus Booster. Safe during
pregnancy. • Polio. Can and should be given to
pregnant women traveling to areas
where polio is endemic.
• Diphtheria Toxoid. Safe during
pregnancy.
• Anthrax Immunization. Do not
administer during pregnancy.
• Hepatitis B vaccine. May be safely
given to pregnant women who are
at high risk of exposure. • Immune globulin. May be given any
time it is clinically indicated.
• Influenza or pneumococcal
immunization. May be given to
Urinary Incontinence OB-GYN 101 Facts Card ©2003 Brookside Press

Loss of urine when straining (stress • Kegel exercises (periodic tightening Involuntary loss of urine upon
urinary incontinence) affects nearly all of the muscles of the pelvic floor 10- standing or arising suggests the
women at some time in their life 15 times a day for 4 weeks). presence of a urethral diverticulum.
• Frequent emptying of the bladder This outpouching of the urethra
If a woman's bladder is full enough and and "double voiding" (re-emptying collects and holds urine, releasing it
she strains hard enough, some urine the bladder 10-15 minutes after the at unpredictable times. Nothing short
will escape, due to the shortness of her initial void) to keep the bladder as of surgery is likely to help this
urethra, the fragility of the normal empty as possible. particular problem.
continence mechanism, and its
vulnerability to trauma during
• Elimination of caffeine, alcohol and
Unpredictable loss of urine not
tobacco (common bladder irritants)
intercourse and childbirth. associated with urgency or activity
which may aggravate the
suggests a neurologic cause. Such
incontinence.
Genuine stress incontinence which conditions as multiple sclerosis,
occurs more or less daily and requires • A course of oral antibiotics to spinal cord tumors, spinal disk
the patient to wear a pad to avoid eliminate the chance that a sub- compression and other neurologic
soiling her clothing will require clinical cystitis is aggravating the problems should be considered.
gynecologic or urologic consultation incontinence.
and usually surgery to repair the Women with an "irritable bladder" will
anatomic defect. complain that when they suddenly get
the urge to urinate, they must find a
Lesser degrees of stress incontinence bathroom within 1-2 minutes or else
can be treated by: they will actually lose urine
involuntarily. Medication can control
this.l
Initial Labor Evaluation OB-GYN 101 Facts Card ©2003 Brookside Press
• Are you allergic to any medication?
An initial evaluation is performed to: Dilatation, Effacement, Station
• Do you normally take any
• Evaluate the current health status of medication?
• Have you ever been hospitalized for Membranes (Intact/ruptured)
the mother and baby,
• Identify risk factors which could any reason? • Nitrazine positive (blue)
influence the course or • Pooling of fluid in the vagina
Vital signs (Afeb, < 140/90)
management of labor, and • Ferning on a glass slide
• Determine the labor status of the
mother. Contractions (Q 5 min x 50 sec) Maternal pelvis
(Adequate/inadequate)
Certain key questions will provide FHR (120-140 BPM)
considerable insight into the patient's
CBC
pregnancy and current status:
Urine protein/glucose (< 1+)
• What brought you in to see me?
• Are you contracting? When did they EFW (Avg ~ 7 ½ #)
start?
• Are you having any pain? Fetal orientation
• Are you leaking any fluid or blood?
When did that begin? • Cephalic
• Have there been any problems with • Breech
your pregnancy? • Transverse lie
• Has the baby been moving Leopold’s Maneuvers
normally?
• When did you last eat? What did
you have?
Pregnancy Lab Testing OB-GYN 101 ©2003
Initial Lab Tests • HIV Subsequent Lab Tests
• Gonorrhea
• Serum AFP at 15-18 weeks
Shortly after registration, initial
• Chlamydia
laboratory tests are ordered. Later in • Targeted (Level II) ultrasound
pregnancy, other tests are usually • Pap scan for women at high risk at 16-
performed. Physician preference and 20 weeks
patient population guide some of the Other lab tests as indicated by
choice of these tests, but commonly- individual circumstances. For example, • Hbg/Hct at about 28 weeks
ordered tests include: • Sickle screening for black patients • Glucose screening at about 28
weeks (50 g oral load with 1-hour
• Hemoglobin and hematocrit • Tay-Sachs screening for Ashkenazi glucose test)
(HGB/HCT) Jewish patients
• Antibody screen and Rhogam for
• White blood cell count (WBC) • Thalassemia screening for patient's Rh negative women at 28 weeks
of Mediterranean extraction.
• Urinalysis (UA) • Vaginal/rectal culture for Group B
• Blood type and Rh Strep at about 36 weeks

• Hepatitis B Screen
• Rubella Titer
• Atypical antibody screen
• Thyroid Stimulating Hormone (TSH)
• Serologic test for syphilis (RPR or
VDRL)
Labor OB-GYN 101 Facts Card ©2003 Brookside Press
• Regular, frequent contractions the past, labor is generally quicker,
Labor consists of regular, frequent, lasting about 6-8 hours.
that may or may not be painful.
uterine contractions which lead to
• Contractions wax and wane
progressive dilatation of the cervix.
• Dilate only very slowly Dilatation and effacement occur for
• Can talk or laugh during Ctx. mechanical and biochemical
Braxton-Hicks contractions occur prior reasons.
• Lasts hours to days.
to the onset of labor. These innocent
contractions can be painful, regular, Active phase labor shows rapid change
and frequent, but usually are not. Descent means that the fetal head
in dilatation, effacement, and station.
descends through the birth canal.
The "station" of the fetal head
The cause of labor is not known but Active phase labor lasts until the cervix describes how far it has descended
may include both maternal and fetal is completely dilated: through the birth canal.
factors.
• Are at least 4 cm dilated.
• Regular, frequent contractions This station is determined relative to
The first stage of labor is that portion the maternal ischial spines, bony
leading up to complete dilatation. The are usually moderately painful.
• Progressive cervical dilatation of prominences on each side of the
first stage can be divided functionally maternal pelvic sidewalls.
into two phases: the latent phase and at least 1.2-1.5 cm per hour.
the active phase. • Not talking or laughing during
their contractions. "0 Station" ("Zero Station") means
that the top of the fetal head has
Latent phase labor precedes the active Progress of Labor descended through the birth canal
phase of labor. Characteristics of For a woman experiencing her first just to the level of the maternal
women in latent phase labor: baby, labor usually lasts about 12-14 ischial spines. +1 and -1 are cm
hours. If she has delivered a baby in above and below the spines.
• < 4 cm dilated.
Lactation OB-GYN 101 Facts Card ©2003 Brookside Press
avoiding any manual stimulation will • Galactosemia in the newborn
The alveoli of the breast secrete milk facilitate this resolution. • Maternal HIV
into the glandular lumen. Each
alveolus is surrounded by smooth • Untreated tuberculosis
muscle that, when contracted, After delivery, a small amount of dark- • Illegal drug users
squeezes the milk out of the alveolus yellow liquid can be expressed from • Excessive alcohol intake
and into the duct system that ultimately the breasts. This is the precursor of • Active herpes on the breast
leads to the nipple. This milk ejection milk, is rich in minerals and protein, but • Hepatitis B carriers
system is triggered by the release of has less sugar and fat than mature • Cytomegalovirus
maternal oxytocin from the anterior milk. It also contains antibodies that • Maternal exposure to
pituitary. Nipple stimulation provokes are helpful in protecting the newborn. radioisotopes
this response, as can a variety of other
stimuli (e.g. sound of a crying baby). Milk OCPs
After several days, the colostrum The AAP has determined that OCPs
becomes whiter with production of are compatible with breastfeeding.
Each act of nursing reinforces They are often started around 6
lactation. Women who do not breast mature milk. This has the same
mineral and protein content as weeks PP, but may be started as
feed will notice breast engorgement early as discharge from the hospital.
during the first few days following colostrum, but has increased amounts
delivery. They will produce some milk of fat and carbohydrates. Nursing
and may experience some breast mothers will produce > 600 ml/day. As a general rule, medications that
discomfort. So long as the breasts are are OK during pregnancy are OK
not stimulated (by emptying the milk or Breastfeeding is convenient, free, and while breastfeeding.
stimulating the nipples), this provides considerable satisfaction to
engorgement will gradually resolve and most mothers and babies Little other than normal cleanliness
milk secretion will stop. Wearing a well- is required to care for the lactating
fitting bra, the use of ice packs, and Contraindications to Breast Feeding breast.
Lichen Sclerosis OB-GYN 101 Facts Card ©2003 Brookside Press
report complete remission of
Lichen sclerosis is one form of vulvar Lichen sclerosis can occur in any age symptoms.
dystrophy. With lichen sclerosis, the group, is not related to lack of
skin of the vulva is too thin. estrogen, and its' cause is not known.
Traditional therapy consists of
Clinically, women with lichen sclerosis As a general rule, topical steroids give
complain of chronic vulvar itching and only very limited relief and if used for 2% testosterone propionate in
irritation. Tissues may be fragile, tear any length of time (more than 2 weeks) petroleum jelly, applied 3 times a
easily and result in superficial bleeding. can make the condition worse because day for 3 to 6 months or until the
Using only casual observation, the they tend to thin the skin even more. symptoms are relieved. Then the
vulva may appear normal, but closer The important exception to this rule is applications are gradually reduced to
inspection will reveal a whitish the topical synthetic fluorinated a level of one or two applications per
discoloration and loss of anatomic corticosteroid, Clobetasol, which has week.
differentiation of the vulvar structures. been very effective in eliminating
symptoms and restoring the normal
It may be difficult, without a vulvar anatomy of the vulva.
biopsy, to distinguish lichen sclerosis
from the other forms of vulvar 0.05% clobetasol propionate cream is
dystrophy (hypertrophic vulvar applied to the vulva twice daily for one
dystrophy and mixed dystrophy). For month, than at bedtime for one month
this reason, women suspected of and then twice a week for three
having lichen sclerosis usually undergo months. It is then used as needed one
vulvar biopsy to confirm the diagnosis. or two times per week. Using this
approach, 95% of patients will notice
significant improvement and 75% will
Lymphogranuloma Venereum OB-GYN 101 Facts Card ©2003 Brookside Press
intercourse or make intercourse
Lymphogranuloma venereum is an basically impossible. Because Azithromycin is effective
uncommon sexually-transmitted against other presentations of
disease caused by a variant of Chlamydia trachomatis, it is likely,
Chlamydia trachomatis. Confirmation of the disease is optimally but unproven that use of multiple
achieved with a positive Chlamydia doses over several weeks would be
trachomatis serotype culture from a effective against LGV (Azithromycin
Following initial exposure, there is mild, bubo. Often, less specific tests, such
blister-like formation which is 1.0 g orally once weekly for 3 weeks)
as serum complement fixation test with
frequently unnoticed. Within the acute and convalescent samples are
following month, there is ulceration of used. In many operational settings,
the vaginal, rectal or inguinal areas. At none of these tests are available and
this stage, the disease is very painful, the diagnosis is made by history of
particularly with walking, sitting and exposure, visual appearance of the
with bowel movements. The stool may lesions and known prevalence in the
be blood-streaked. population.

Hard tender masses (buboes) arise in Optimal treatment is:


the inguinal area at this stage and are
characteristic of the disease.
Doxycycline 100 mg orally twice a day
for 21 days, or
As the disease progresses untreated,
extensive scarring in the rectal area
may require surgery to enable normal Erythromycin base 500 mg orally four
bowel movements. Scarring in the times a day for 21 days.
vaginal area can lead to painful
Breast Pain OB-GYN 101 Facts Card ©2003 Brookside Press
clinically bothersome, it is called
Among the common causes of non- A second common area for chest wall cyclic breast pain or mastodynia.
cyclic breast pain are trauma, infection, pain is along the costal margin. Direct
and chest wall pain underlying the pressure on the costochondral
breast tissue (muscle strain or overuse cartilage, without compressing breast If examined during this time, these
of the pectoralis major muscle). Breast tissue, will duplicate the pain. women also often have significantly
cancer rarely causes breast pain in the Compressing the chest wall with your enhanced nodularity of the breast
early stages and is not usually hands placed laterally to the breasts tissue. the combination of cyclic
suspected unless the symptoms will also duplicate the pain. breast pain and symmetrically
persist. Hormonal causes include thickened nodularity of the breast
functional ovarian cysts and tissue is often called fibrocystic
Trauma can include vigorous coughing disease (misnamed because it's not
pregnancy. or vomiting. The resulting strong, really a disease) or fibrocystic breast
sustained contractions of the changes.
Pain or soreness in the pectoralis intercostal muscles can lead to chest
major muscle is frequently found wall tenderness that may be perceived
among women who have recently by the patient as breast pain. Some women reducing caffeine
engaged in strenuous physical activity, (coffee, tea, cola drinks) and taking
and it represents a muscle strain. Vitamin E supplements (400 IU
Cyclic Breast Pain daily) has improvde their symptoms
Chest wall pain does not involve the During the days leading up to the
nipple or areola, while cyclic breast menstrual flow, the breasts normally
tenderness usually does. Treatment is are somewhat engorged and may be Any pharmacologic approach that
symptomatic, with rest, some somewhat tender. Following the onset suppresses ovulation will be very
stretching exercises, and non-steroidal of menstrual flow, these changes helpful, including OCPs, DMPA,
anti-inflammatory medication such as spontaneously resolve. If the Lupron, or Danocrine
ibuprofen or naproxen. tenderness is more than mild or is
Medications During Pregnancy OB-GYN 101 ©2003
Drug Categories • Metronidazole is safe after 14 • Miconazole is safe
• A, B, C, D and X weeks gestation. Safety prior to • Clotrimazole is safe
14 weeks hasn't been • Quinacrine is probably safe
Generalizations established. during pregnancy
• Acetaminophen is safe • Tetracyclines are unsafe at any • Chloroquine may cause
• Pseudoephedrine is safe time during pregnancy congenital defects with
• Guaifenesin is safe • Aminoglycosides are basically prolonged or high doses
• Diphenhydramine is safe safe during pregnancy, but • Pyrimethamine is safe after
• Local anesthetics (Xylocaine) is renal and ototoxicity are 1st trimester. Add folic acid
safe, but epinephrine may potential problems if the dose is supplement.
have unpredictable effects on high or prolonged. • Trimethoprim is safe after 1st
the maternal CV system • Clindamycin is safe trimester. Add folic acid
• ASA should not be taken. • Chloramphenicol is probably supplement.
• Codeine, Demerol, Morphine safe prior to 28 weeks • Primaquine may cause
and other narcotics are safe, • Sulfa drugs are safe prior to 34 hemolytic anemia in the
but the addictive potential weeks. After that, babies may presence of G6PD deficiency.
should be recognized. develop jaundice if exposed to You may use it if needed.
• Penicillins are safe sulfa.
• Cephalosporins are safe • Quinine is only to be used in
• Erythromycin is safe life-threatening, chloroquine-
resistant P. Falciparum
• Azithromycin is safe
infections
Menopause OB-GYN 101 Facts Card ©2003 Brookside Press
• Menopause is estrogen-
Menopause is the physiologic Menopause rapidly accelerates bone
deficiency.
cessation of ovarian function (and loss, resulting in osteopenia or
• Creates annoying problems,
menstrual flows) that occurs with osteoporosis. Increased risk factors for
largely corrected through ERT.
advancing age. Average age is 51. osteoporosis include:
• We should treat with estrogen to
• Slender build restore them to normal,
Ovarian function consists of ovulation,
• Tobacco
estrogen production, progesterone Estrogen Replacement Therapy
production, and androgen (primarily • Caucasian
testosterone) production. • Sedentary life style
• Chronic glucocorticoid use • Eliminates hot flashes/ sweats
• Bone density studies (Dexa Scan) • Moderate protection of bones
At menopause, the ovaries stop • Eliminate vaginal dryness
T-value of -2.5 = osteoporosis.
responding to FSH and LH. A • Improvse sleep, memory
osteopenic T-values of -1.0 to -2.5.
menopausal woman will have high
• CV risk +/- or sl. Increased.
levels of FSH and LH, but low levels of Naturalist philosophy: • No overall change in cancer risk.
estrogen (estradiol) in her
bloodstream. • Menopause is natural. • Increased breast Ca risk
• After ~ age 50 women should be • Decreased colon Ca risk
without any estrogen. • Death risk not affected.
Symptoms include:
• The role of medication is to help Extra calcium (1000-1500 grams of
• Hot flashes / night sweats adjust to not having any estrogen. elemental calcium/day). Regular
• Vaginal / skin dryness • Smallest amount of estrogen for the weight-bearing exercise is helpful,
• Diminished memory (forgetfulness) shortest period of time. but only to a limited extent.
• Mood changes Bisphosphonates, SERMs
Estrogen Deficiency philosophy:
• Sleeplessness
• Cessation of menstrual flows
Molluscum Contagiosum OB-GYN 101 Facts Card ©2003 Brookside Press
the patient remains contagious for as
This sexually-transmitted pox-virus long as she has them.
causes small, benign skin tumors to
grow on the vulva, which are usually
symptomless,but annoying..

The tumors appear as dome-shaped


lumps, 1-2 mm in diameter with tiny
dimples in their center, and contain a
white, cheese-like material.

Treatment involves scraping off the


lesion with a sharp dermal curette, and
then coagulating the oozing base with
Monsel's solution or AgNO3 sticks and
applying direct pressure. Cryosurgery
is also effective, as is the application of
trichloracetic or bichloracetic acid
directly to the lesion (taking care not to
disturb the surrounding normal skin.)
Using local anesthetic, electrocautery
may also be used.

Left alone, they will generally resolve


spontaneously after 6-12 months, but
Nausea and Vomiting OB-GYN 101 Facts Card ©2003 Brookside Press
"stretchy" and will tolerate such rapid (Scopolamine), Compazine,
These are common during pregnancy infusions well. Phenergan, and others have all been
but may be aggravated by strong used to good advantage in these
smells (food, garbage, machine oil, situations.
etc.) and motion. Symptoms appear After IV therapy, the woman is
quite early and are usually mild, generally feeling much better and can
requiring no treatment, disappearing by return to her duties. If this rehydration
the 16th week or sooner. Occasionally, is insufficient to suppress her
these symptoms are severe and symptoms, then a more prolonged
require intervention. course of therapy is recommended.

If a pregnant woman states, "I can't Try to avoid antiemetics in the


keep anything down," and has ketones pregnant patient as the long-term
in her urine, she must be re-hydrated consequences of most of the drugs on
with crystalloid such as 5% dextrose in a developing pregnancy are not well
lactated Ringer's solution (D5LR). One established. Nonetheless, the long-
liter is given in a short time (15-20 term results of protracted vomiting,
minutes), and the second liter given dehydration, electrolyte imbalance and
over an hour or two. Sometimes a third ketosis are known and unfavorable to
liter, given over several hours, will be the pregnancy, so if it appears that IV
necessary. While this rate of hydration hydration alone is not controlling the
would be much too fast for an older symptoms, move to antiemetics with
individual with heart disease, the dispatch.
cardiovascular system of a young,
healthy, pregnant woman is very Conventional doses of Antihistamines
(Benadryl), Anticholinergics
Nuchal Cord OB-GYN 101 Facts Card ©2003 Brookside Press

This is a frequent occurrence during During labor, the only indication of • If you can easily slip the cord
delivery. Nearly half of babies have the umbilical cord being wrapped over the baby's head, go ahead
the umbilical cord wrapped around around the baby may be variable and do that.
something (neck, shoulder, arm, fetal heart decelerations on the fetal
etc.), and this generally poses no monitor. These are generally timed • If the cord is relatively loose,
particular problemfor them. with contractions as that is the time and allows the baby to be born
the cord is stretched more tightly. with the cord around its' neck,
go ahead and do that.
In a fewcases, the cord
will be wrapped so • If the cord is tight and disallows
tightly around the any manipulation, double clamp
baby's neck (after the cord and cut between the
delivery of the head but clamps. This will free the cord.
before the shoulders With this approach, prompt
are delivered) that you delivery of the rest of the baby is
cannot get the rest of important as you have just cut
the baby out without off all blood flowin and out of
risk of tearing the the baby.
umbilical cord.
Nutrition OB-GYN 101 Facts Card ©2003 Brookside Press
constipation). Further increases of
A pregnant woman should eat a 200-300 calories/day are desirable as
normal, balanced diet for one person. a general rule.

This may prove difficult, particularly In theory, a pregnant woman should be


during the early part of the pregnancy able to meet all of her nutritional needs
when she may experience significant through a normal, well-balanced diet.
nausea. In practice, virtually no one can
maintain that balance throughout
It may also prove difficult later in pregnancy. Consequently, we
pregnancy when she feels hungry all recommend vitamin supplements to
the time. These women may find they overcome the dietary indiscretions that
do better by having more frequent (but are expected.
smaller) meals, or snacks between
meals of relatively nutritious but low Weight loss diets during pregnancy
caloric foods. should not be followed.

During pregnancy, the GI tract Large doses of vitamins are not only
becomes much more efficient at unnecessary, they may be dangerous
extracting nutrients. The positive effect to the mother and fetus. Take only a
of this is that even if the pregnant single multivitamin and possibly some
woman eats the same food as she did additional iron or folic acid, if medically
prior to the pregnancy, nature provides indicated.
for improved nutrition and results in
some increased weight. (The negative
effect is a tendency toward
Obtaining a Pap Smear OB-GYN 101 Facts Card ©2003 Brookside Press

Position the Patient Insert the speculum into the vagina, Make a Thin Smear and spray
Position the patient with her buttocks letting the speculum follow the path of Immediately
just at the edge or just over the edge of least resistance. Open the speculum
the exam table. If she is not down far and usually the cervix is immediately Next, use a "Cytobrush" to sample
enough, inserting the speculum can be visible. Lock the blades in the open the endocervical canal. Push the
more difficult for you and position, wide enough apart to allow cytobrush into the canal, no deeper
uncomfortable for her. complete visualization of the cervix but than the length of the brush (1.5 cm
not to far open as to be uncomfortable - 2.0 cm). Rotate the brush 180
Inspect the Vulva for the patient. degrees (half a circle) and pull the
• Skin lesions
cytobrush straight out.
• Masses The Ayer spatula is specially designed
• Drainage for obtaining Pap smears. The concave
• Discolorations of the skin Allow the slides to dry completely
end (curving inward) fits against the before placing them in the Pap
• Signs of trauma cervix, while the convex end (curving smear container.
• Pubic hair distribution (triangular = outward) is used for scraping vaginal
normal) lesions or sampling the "vaginal pool,"
• Insect movement (pubic lice) within Use a broom for liquid-based media.
the collection of vaginal secretions just
the pubic hair Insert the broom's long, central
below the cervix.
fibers into the endocervical canal.
Warm the vaginal speculum with warm The rotate the broom in a complete
water. Never use K-Y Jelly(r), Sample the SQJ circle, five times. Place it in the liquid
Surgilube(r), petroleum jelly or other In obtaining the Pap smear, it is media. The broom can also be used
lubricant to moisten the speculum as it important to sample the "Squamo- for conventional glass-slide Pap
may render your Pap smears columnar Junction." smears.
unreadable under the microscope.
Oligohydramnios OB-GYN 101 Facts Card ©2003 Brookside Press
reflect decreased (or absent) fetal
Oligohydramnios means too little renal output, congenital anomaly, or • Amniotic fluid index (AFI) of <7
amniotic fluid. abnormal membrane fluid transport. (or <6, or <5). AFI is the sum of
Regardless of it's cause, the single deepest pocket of
Amniotic fluid volume increases with oligohydramnios presents a threat to amniotic fluid in each of the 4
the duration of pregnancy, with about the fetus because the umbilical cord quadrants, in cm.
200 cc at 16 weeks to about a liter may be compressed more easily,
between 28 and 36 weeks. Then it falls resulting in impaired blood flow to the When present in a woman not in
slightly with approaching term, to about fetus. labor, consideration is given to
800 cc at 40 weeks. After 40 weeks, inducing labor early, depending on
the volume drops further. Several means of identifying the clinical situation. During labor,
oligohydramnios are used, and they oligohydramnios is sometimes
Amniotic fluid is removed by the fetal are not in complete agreement. The treated with amnioinfusion, a deposit
membranes, swallowed by the fetus, concept of oligohydramnios is of sterile fluid into the amniotic sac
and in the presence of ruptured universally accepted. The specific to expand the AF volume. This is
membranes, may leak out through the definition of oligohydramnios is not. most frequently done to relieve fetal
vagina. It is deposited in the amniotic Definitions have included: heart rate decelerations thought to
sac by the fetal membranes and by be due to umbilical cord
fetal urination. Any disturbance in the compresssion, or to try to clear
• Visibly reduced AFV on ultrasound some thick meconium that may be
normal equilibrium of fetal swallowing,
urinating, or amniotic membrane fluid present.
transport can result in • No vertical pocket of AF >2 cm
oligohydramnios.
• No two-dimensional pocket of AF >
Oligohydramnios is both a symptom 2 x 2 cm
and a threat. As a symptom, it can
Operative Delivery OB-GYN 101 Facts Card ©2003 Brookside Press
Any condition that increases the
Operative delivery means the use of maternal risk for pushing, including:
obstetrical forceps or cesarean section
• Stroke
to achieve the delivery. Operative
• Cerebral aneurism
delivery is indicated any time it
becomes safer to delivery the baby • Eclampsia
immediately than to allow pregnancy to
continue. Fetal malpresentation or malposition,
including:
Indications for operative delivery are • Fetal transverse lie
many, but a partial list includes: • Breech
• Maternal hemorrhage • Deep transverse arrest
• Uterine rupture • Face presentation, particularly
• Unremediable fetal distress mentum posterior
• Fetal intolerance of labor
These indications are sometimes
• Maternal exhaustion
relative, not absolute, and clinical
• Failure to progress in labor
judgment must be applied in any
• Failure of descent in labor individual clinical situation to determine
• Arrest of labor whether operative delivery is a good
• Uterine inertia idea or not. Other aspects of clinical
• Placenta previa judgment are the specific form of
• Placental abruption operative delivery (forceps vs.
• Previous cesarean section cesarean section) and the timing of the
• Previous perineal repair for operative delivery.
incontinence
• Fetal malformation
Ovarian Neoplasms OB-GYN 101 Facts Card ©2003 Brookside Press
• Clear cell carcinoma (usually the mid-60s. Ovarian cancer among
Ovarian neoplasms may benign or younger women is rare. Prior to age
malignant)
malignant. Some produce hormones. 30, the incidence is 5/100,000.
• Adneocarcinoma (malignant)
• Endometrioid Carcinoma
Primarily Cystic (malignant) Detection
• Mucinous cystadenoma (benign, Ovarian cancer can be difficult to
sometimes grow quite large) Dermoid tumors contain dermal detect. Unlike uterine cancer (that
• Serous cystadenoma (benign) element, incl. teeth, hair, sebaceous tends to cause visible bleeding at a
• Adenocarcinoma (malignant) glands, and thyroid cells. Usually relatively early stage), ovarian
benign, occasionally malignant. cancer usually remains symptomless
Primarily Solid Bilaterality is common. until fairly late in the disease
• Fibroma (benign)
process. Symptoms associated with
• Brenner tumor (usually benign) Ovarian Cancer ovarian cancer include pelvic
• Granulosa Cell tumor (malignant, The life-time risk is about 1%. OCPs discomfort and bloating.
produces estrogen) decreases the, as does pregnancy, Unfortunately, these symptoms are
• Thecoma (benign, produces tubal ligation or hysterectomy. so non-specific as to be nearly
estrogen, occasionally androgens) useless in evaluating a patient for
• Sertoli-Leydig Cell tumors Fertility-enhancing may increase the possible ovarian cancer. Further, by
(Generally benign, may produce risk of ovarian cancer. A family history the time a patient develops these
androgens and/or estrogen) of breast or ovarian cancer increases symptoms, the ovarian cancer has
• Dysgerminoma (malignant, but the patient's. BRCA1 or BRCA2 gene frequently spread to distant sites.
usually good prognosis) increases the lifetime risk to about 1/3.
Mixed Blood tests are of limited value.
• Dermoid (teratoma, usually benign, The incidence of ovarian cancer Serum CA-125 increases in the
may produce thyroid hormone) steadily increases with age, peaking in presence of most ovarian epithelial
Pain Relief During Labor OB-GYN 101 Facts Card ©2003 Brookside Press

Some women have virtually no pain 5 minutes after injection, the patient is Inhalation of 50% nitrous oxide with
and do not need any analgesia. pain free. The block will last 60-90 50% oxygen, can give very effective
minutes and can be repeated. Can’t pain relief during labor and is safe
The majority will have moderate use with compromised fetus. for the mother and baby. Safest
discomfort, particularly toward the end. when self-administered by the
Local infiltration of 1% lidocaine gives mother. If she feels dizzy or starts to
excellent anesthesia for perinuem. achieve anesthetic levels of the
Some will experience severe pain.
nitrous, she will naturally release the
• The injection is just below the skin, mask, reversing the effects of the
Analgesics prior to active labor (4 cm raising a small weal. nitrous oxide.
dilatation) will usually slow the labor • No need to infiltrate as there are
process, but in a prolonged latent very few nerves there. Less commonly used is a self-
phase), it may speed up labor. • Watch total dose of lidocaine. Max administered volatilized gas of
safe limit for 1% is 50 cc. methoxyflurane. It is capable of
Narcotics can be highly effective. achieving anesthetic levels and so
Generally safe for the baby, but better A pudendal block provides excellent
must be very closely monitored.
to avoid large doses at the end…avoid anesthesia to an area about the size of
respiratory depression in the newborn. a dinner plate, centered on the vagina.
Continuous Lumbar Epidural is
Perineum is innervated by the commonly used, a major anesthetic,
Keep antagonist (naloxone or Narcan) highly effective and safe. Inhibits
available to treat resp. depression. pudendal nerves that originate from
S3-S4, and pass close to the ischial maternal movement and may inhibit
pushing.
spine as it traverses the pelvic
Labor pain can be blocked by
sidewall.
interrupting nerves as they pass close Spinal used only during delivery but
to the cervix with a paracervical block. is very effective and safe.
Pap Smears OB-GYN 101 Facts Card ©2003 Brookside Press
specimen onto a glass slide, which is • HIV positive,
In the 1940's, Dr. Papanicolaou then processed and read by a immunocompromised, or DES
developed a technique for sampling cytotechnologist. Newer techniques daughters, continue annual
the cells of the cervix (Pap smear) to involve changes in specimen handling screening.
screen patients for cancer of the (fluid medium) and computer-assisted • Screening may stop following a
cervix. This technique very effective at screening, to improve accuracy. total hysterectomy (including the
detecting cancer, and pre-cancerous,
cervix), if the the patient is at low
reversible changes that lead to cancer.
Frequency of Pap Smears risk, and has had three
Until recently, most experts consecutive normal Pap smears
While not originally designed to detect recommended annual screening with within the last 10 years.
anything other than cancer, the Pap Pap smears for adult women. Some • High risk patients, incl: history of
smear is useful in identifying other, newer recommendations have evolved, cervical cancer, DES exposure in-
unsuspected problems: to improve the economic and medical utero, HIV positive,
• 90% of cervical cancers, efficiency of Pap smear screening. immunocompromised, and those
• 50% of uterine cancers. and These recommendations (ACS): tested positive for HPV, continue
screening indefinitely.
• 10% of ovarian cancers • Begin no later than age 21. • Screening may stop after age 70,
Because the Pap smear is a screening • < 21 if patient sexually active. (3 if patient low risk, and has had
test, it can have both false positive and years after initial intercourse.) three normal Paps over last 10
false negative results. So perform test • Once initiated, perform annually if years.
regularly glass-slide technique is used. If • May be omitted in the case of life-
liquid medium used, may be threatening or other serious
performed Q other year. illness.
A number of forms of Pap smears have
evolved. The standard, traditional Pap • > 30, after 3 consecutive, normal
technique involves smearing the Paps, may be reduced to every two
to three years.
PID OB-GYN 101 Facts Card ©2003 Brookside Press
generalized haziness due to edema. In T>100.4 , lassitude, and headache.
Pelvic Inflammatory Disease (PID) is a advanced cases, hydrosalpinx may be Symptoms more after the onset or
bacterial inflammation of the fallopian seen with ultrasound, CT or MRI. completion of menses.
tubes, ovaries, uterus and cervix.
From a clinical management point of Excruciating cervical motion pain is
Initial infections caused by STDs, such view, there are two forms of PID: Mild, characteristic. Hypoactive bowel
as gonorrhea or chlamydia. Secondary and Moderate to Severe. sounds, purulent cervical discharge,
infections often caused by multiple and abdominal dissension are often
non-STD organisms. Most have no present. Pelvic and abdominal
long-term adverse effects, but some Mild PID
Gradual onset of mild bilateral pelvic tenderness is always bilateral except
result in infertility, tubo-ovarian in the presence of an IUD.
abscess, and sepsis Iincreased risk for pain with purulent vaginal discharge,
tubal ectopic pregnancy. T<100.4, deep dyspareunia common.
Gram-negative diplococci in cervical
Moderate pain on cervical motion, discharge or positive chlamydia
Symptoms vary from trivial pelvic culture may or may not be present.
discomfort and vaginal discharge to purulent/mucopurulent cervical
discharge. Gram-neg diplococci or WBC and ESR are elevated.
incapacitating abdominal pain with
nausea and vomiting. Leukocytosis, positive chlamydia culture variable.
like fever, is variable. The Dx can be WBC may be sl. elevated or normal. These more serious infections
based on imprecise findings (uterine These cases are treated aggressively, require more aggressive
and adnexal tenderness without other usually with PO meds. Prompt management, often consisting of
explanation), or precise findings response. Sex partners treated. bedrest, IV fluids, IV antibiotics, and
(laparoscopic visualization of inflamed NG suction if ileus is present. A
tubes). Cervical cultures may or may Moderate to Severe PID more gradual recovery is expected
not be positive. Ultrasound findings Moderate to severe bilateral pelvic pain and it may be several weeks before
may be normal or may include a with purulent vaginal discharge, the patient is feeling normal.
Placenta Previa OB-GYN 101 Facts Card ©2003 Brookside Press
head can be palpated. If it is deeply
Normally, the placenta is attached to Clinically, these patients present after engaged in the pelvis, it is basically
the uterus in an area remote from the 20 weeks with painless vaginal impossible for a placenta previa to
cervix. Sometimes, the placenta is bleeding, usually mild. An old rule of be present because there is not
located in such a way that it covers the thumb is that the first bleed from a enough room in the birth canal for
cervix. This is called a placenta previa. placenta previa is not very heavy. For both the fetal head and a placenta
this reason, the first bleed is previa. An x-ray of the pelvis
There are degrees of placenta previa: sometimes called a "sentinel bleed." (pelvimetry) can likewise rule out a
placenta previa, but only if the fetal
A complete placenta previa means the Later episodes of bleeding can be very head is deeply engaged. Otherwise,
entire cervix is covered. This substantial and very dangerous. an x-ray will usually not show the
positioning makes it impossible for the Because a pelvic exam may provoke location of the placenta.
fetus to pass through the birth canal further bleeding it is important to avoid
without causing maternal hemorrhage. a vaginal or rectal examination in Patients suspected of having a
This situation can only be resolved pregnant women during the second placenta previa who are not in a
through cesarean section. half of their pregnancy unless you are hospital setting need expeditious
certain there is no placenta previa. transport to a definitive care setting
A marginal placenta previa means that where ultrasound and full obstetrical
only the margin or edge of the placenta The location of the placenta is best services are available.
is covering the cervix. In this condition, established by ultrasound. If ultrasound
it may be possible to achieve a vaginal is not available, one reliable clinical
delivery if the maternal bleeding is not method of ruling out placenta previa is
too great and the fetal head exerts to check for fetal head engagement
enough pressure on the placenta to just above the pubic symphysis. Using
push it out of the way and tamponade a thumb and forefinger and pressing
bleeding which may occur. into the maternal abdomen, the fetal
Placental Abruption OB-GYN 101 Facts Card ©2003 Brookside Press
abnormalities seen in complete whole blood transfusion will give
Placental abruption is also known as a abruptions. good results.
premature separation of the placenta.
All placentas normally detach from the
uterus shortly after delivery of the Clinically, an abruption presents after Patients not in a hospital setting who
baby. If any portion of the placenta 20 weeks gestation with abdominal are thought to have at least some
detaches prior to birth of the baby, this cramping, uterine tenderness, degree of placental abruption should
is called a placental abruption. contractions, and usually some vaginal be transferred to a definitive care
bleeding. Mild abruptions may resolve setting. While transporting her, have
with bedrest and observation, but the her lie on her left side, with IV fluid
A placental abruption may be partial or moderate to severe abruptions support.
complete. generally result in rapid labor and
delivery of the baby. If fetal distress is
A complete abruption is a disastrous present (and it sometime is), rapid
event. The fetus will die within 15-20 cesarean section may be needed.
minutes. The mother will die soon
afterward, from either blood loss or the Because so many coagulation factors
coagulation disorder which often are consumed with the internal
occurs. Women with complete hemorrhage, coagulopathy is common.
placental abruptions are generally This means that even after delivery,
desperately ill with severe abdominal the patient may continue to bleed
pain, shock, hemorrhage, a rigid and because she can no longer effectively
unrelaxing uterus. clot. In a hospital setting, this can be
treated with infusions of platelets, fresh
Partial placental abruptions may range frozen plasma and cryoprecipitate. If
from insignificant to the striking these products are unavailable, fresh
Polyhydramnios OB-GYN 101 Facts Card ©2003 Brookside Press
congenital anomaly, or abnormal polyhydramnios is not. Definitions
Polyhydramnios means too much membrane fluid transport. It is have included:
amniotic fluid. commonly seen in pregnancies among
diabetic women. • Visibly increased AFV on
Amniotic fluid volume increases during ultrasound. (Both fetal shoulders
pregnancy, with about 200 cc at 16 normally touch the inside of the
Polyhydramnios presents a threat to
weeks to about a liter between 28 and uterus. If there is so much fluid
the fetus and to the mother. It can lead
36 weeks. After 40 weeks, the volume present that the anterior shoulder
to PROM, premature labor and
drops further. AFV of more than 2 L is no longer touches the anterior
premature delivery. During labor, the
considered polyhydramnios. uterine wall, then polyhydramnios
risk of prolapsed fetal small parts and
is said to exist.
prolapsed umbilical cord is increased.
Amniotic fluid is removed by the fetal • Vertical pockets of AF >8 cm (or
For the mother, polyhydramnios may
membranes, swallowed by the fetus, 11 cm)
be severe enough to interfere with
and in the presence of ruptured breathing. In these cases, therapeutic • Amniotic fluid index (AFI) of >25.
membranes, may leak out through the amniocentesis can be performed to • Clinical palpation of a free-
vagina. It is deposited in the amniotic relieve (temporarily) the maternal floating fetus.
sac by the fetal membranes and by respiratory distress. When present in a woman not in
fetal urination. Any disturbance in the labor, consideration is given to
normal equilibrium of fetal swallowing, Several means of identifying inducing labor early, depending on
urinating, or amniotic membrane fluid polyhydramnios are used, and they are the clinical situation. Therapeutic
transport can result in polyhydramnios not in complete agreement. As with amniocentesis is used to treat
(sometimes called hydramnios).. oligohydramnios, although the concept maternal respiratory distress,
of polyhydramnios is universally although the AF tends to
Polyhydramnios is both a symptom and accepted, the specific definition of reaccumulate within a few days.
a threat. As a symptom, it can reflect
decreased (or absent) fetal swallowing,
Postpartum Care OB-GYN 101 Facts Card ©2003 Brookside Press

Lochia is vaginal discharge following Bladder distention is common, so void She may shower or bathe freely, but
delivery. Bleeding lasts 3-4 days, early and often prolonged standing in a hot shower
similar to heavy menses (lochia rubra). may lead to dizziness.
Then, it thins and become more pale Aftercramps: common, annoying, not
(lochia serosa). By day#10, is dangerous, disappear in a few days. After 3 weeks, the uterine lining is
white/yellow (lochia alba). Foul odor at normally completely healed and a
any time suggests infection. new endometrium regenerated. At
Oral analgesics for the first few days.
this point, most normal activities can
Check Temp periodically. T>100.4 x 6 be resumed, although strenuous
Swelling of the hands, ankles and face
hours suggests infection. physical activity is usually restricted
is common, particularly with IVs.
until after 6 weeks.
Absent pre-eclampsia, it is of no
Check BP several times 1st day and clinical significance, but may be
periodically thereafter. BP>140/90 can distressing. It resolves spontaneously. Sex can resume whenever she feels
indicate late-onset pre-eclampsia. Low like it. Most won't feel like it for a
BP may indicate hypovolemia. while, and perineal lacerations
Rh negative women who deliver Rh
generally take 4-6 weeks to
positive babies receive Rhogam
For several days, breasts make clear, completely heal. Dysparunia is much
yellow liquid (colostrum) This provides improved with the use of water-
After delivery, the mother needs time soluble lubricants.
nutrition and antibodies to babies.
to rest, sleep, and regain her strength.
Then, breasts engorge with milk
She may eat whatever appeals to her
(contains more calories from fat.) OCPs can be started any time
and can get up and move around
Engorgement can be uncomfortable. during the first few days post partum
whenever she would like. Prolonged
For women not breast-feeding, firm and are compatible with breast
bedrest is neither necessary nor
support of the breasts and ice packs feeding.
desirable.
help. Nipples are kept clean and dry.
Postpartum Fever OB-GYN 101 Facts Card ©2003 Brookside Press

Maternal febrile morbidity is classically • Breast tenderness and redness, • Ticarcillin/clavulanic acid 3.1 gm
defined as temperatures exceeding suggesting mastitis IV Q 6 hours
100.4 on at least two occasions, at • Perineum tenderness and redness, • Cefotetan 1-2 g IV Q 12 hours
least 6 hours apart. with wound infection

For patients with an obvious infection


• Rales, rhonchi or wheezes,
suggesting a respiratory source
and high fever, localizing signs and
septic in appearance, begin treatment • Calf tenderness, suggesting deep
immediately without waiting for the 6- vein thrombophlebitis
hour definition to be fulfilled.
Treat any specific source. However, in
many situations, there is risk of
Cultures from the urine and vagina multiple sources. Good choices for
(and sometimes blood) can be useful. such therapy include:
Similarly, a chest x-ray, may identify a
pulmonary cause for the fever.. • Ampicillin 2 gm IV Q 6 hours, plus
gentamicin 1.5 mg/kg (loading
Examine the patient, looking for dose) and 1.0 mg/kg Q 8 hours,
localizing signs that will guide you in plus clindamycin 900 mg IV Q 6
your therapy. Check for: hours

• Uterine tenderness, suggesting a


• Ampicillin/sulbactam 3 gm IV Q 4-6
hours
uterine or endometrial source
• Flank tenderness, suggesting
• Mezlocillin 4 g IV Q 4-6 hours
pyelonephritis • Piperacillin 3-4 g IV Q 4 hours
Pregnancy Lab Tests OB-GYN 101 ©2003
Subsequent lab tests consists
Some routine lab tests are done Follow-up tests may also be
of:
on all pregnant women at different needed, based on the original
times during the pregnancy. Other • Amniocentesis or CVS for screen. For example:
tests are done for a specific women age 35 at 10-17 weeks
indication. • Maternal serum AFP at 16-18 • A woman found to be very
weeks anemic might be evaluated
• Hemoglobin or hematocrit at 28 with serum folate and ferritin
As early in pregnancy as
weeks levels.
feasible, obtain:
• Serum glucose at 1-hour post • A woman failing her glucose
• Hemoglobin or hematocrit 50g glucose load at 28 weeks screening test will probably
• White blood count and platelet • Administration of Rhogam to Rh need a full glucose tolerance
count negative women test.
• Urinalysis
Other tests may be indicated,
• Blood group and Rh type
based on individual risk factors.
• Atypical antibody screen These might include screening for
• Rubella antibody titer
• RPR or VDRL • Sickle Cell disease (or trait)
• Hepatitis B screen • Thalassemia
• HIV • G6PD
• Pap Smear • tuberculosis.
• Chlamydia/Gonorrhea
Pregnancy Risk Factors OB-GYN 101 ©2003
• Pregnancy without family • Fetal growth retardation
Moderate increase in risk:
support • Heart disease class III or IV
• Age < 16 or > 35 • Preterm labor (34-37 weeks) • Hemoglobinopathy
• 2 spontaneous or induced • Previous hemorrhage • Herpes
abortions • Previous pre-eclampsia • Hypertension
• < 8th grade education • Previous preterm or SGA infant • Incompetent cervix
• > 5 deliveries • Pyelonephritis • Isoimmunization (Rh)
• Abnormal presentation • Rh negative • Multiple pregnancy (pre-term)
• Active TB • Second pregnancy in 9 months • > 2 spontaneous abortions
• Anemia (Hgb <10, Hct <30%) • Small pelvis • Polyhydramnios
• Chronic pulmonary disease • Thrombophlebitis • Premature rupture of
• Cigarette smoking • Uterine scar or malformation membranes
• Endocrinopathy • Venereal disease • Pre-term labor (<34 weeks)
• Epilepsy • Prior perinatal death
• Heart disease class I or II More than moderate increase in • Prior neurologically damaged
• Infertility risk: infant
• Infants > 4,000 gm • Severe pre-eclampsia
• Isoimmunization (ABO) • Age >40 • Significant social problems
• Multiple pregnancy (at term) • Bleeding in the 2nd or 3rd TM • Substance abuse
• Poor weight gain • Diabetes
• Post-term pregnancy • Chronic renal disease
• Congenital anomaly
Pregnancy Tests OB-GYN 101 Facts Card ©2003 Brookside Press
sensitivity of the test, while increasing drop. If the test kit calls for 4
The diagnosis of pregnancy is the chance of a false positive by only a drops of urine, use 4 drops of
accurately made with a urine small amount. serum.
pregnancy test. Current test kits are
highly specific and detect 35-30 mIU of
HCG (human chorionic gonadotropin, In an urgent situation, if a patient is This is an imperfect solution,
the pregnancy hormone) per ml of unable to provide urine for the test, because the forms of HCG
urine. The pregnancy test will be serum can be used in the urine test kit (pregnancy hormone) found in
turning positive at about the time of the in place of urine. serum are somewhat different from
first missed menstrual period. the forms found in urine. Further, the
• Draw blood into a test tube. serum proteins tend to sludge up the
test kit, both mechanically and
First morning urine is preferred biochemically. That said, using
because it is more concentrated. • Tape the test tube to the wall for serum instead of urine will work well
about 10 minutes (allow it to clot). enough for most purposes and can
Place the manufacturer-specified provide immediate insight into the
number of drops of urine in the • Using an eye dropper or a syringe patient's problem.
collecting area. Wait the time with a needle, draw off a small
specified. amount of serum (the clear, watery
part of the blood that's left at the top
In the event of an "equivocal" of the test tube after the blood has
pregnancy test...one that is not really clotted).
positive nor negative, additional urine
can be put through the test kit to boost • Use the serum instead of urine in
the sensitivity. Instead of using 3 drops the urine pregnancy test kit, drop for
of urine, you can use up to 6 drops of
urine. This will virtually double the
Pregnant Patient Education OB-GYN 101 ©2003
Duration of Pregnancy • Abdominal pain. Alcohol
• 280 days or 40 • Fever of 101 degrees or more. • None
• Due dates are not exact. • Pain with urinating.
Normal ± 2 weeks • Contractions or pelvic pressure Smoking
• Vomiting lasting > 24 • None
Prenatal Care Visits • Decrease in fetal movement.
• Routine laboratory tests Initial Toxoplasmosis
visit Premature Labor • Avoid contact with cat litter.
• Q 4 weeks until 28 wks. Know these warning signs:
• Q2 weeks, 29-36 • Uterine contractions Q10 Sex during Pregnancy
• Q week, 36-delivery • Cramps in the lower abdomen • OK in low risk pregnancy
• Backache • No blowing of air into the
Later lab tests • Pelvic pressure vagina
• Increased vaginal discharge
Emergencies Nutrition
• Any fluid leaking. Immediate Medical Advice • Normal balanced diet for one
• Vaginal bleeding. • Emergency Phone # person
• Sudden swelling. • Non-Emergency Phone # • PNV each day
• Bad headaches. .
• Changes in vision. Drugs
• Dizziness or fainting. • No drugs without checking first
• Sudden weight gain.
Prenatal Visits OB-GYN 101 ©2003
st
After the 1 prenatal visit: • Sustained BP of >140/90 may Check urine protein and glucose
indicate pre-eclampsia. If 1+ (30 mg/dl) protein or more, it is
Ask the patient about any interval • Use a tape measure to record the considered significant.
changes, vaginal discharge, bleeding, size of the uterus.
fetal movements, and contractions. For glucose, urine normally shows
The fundal height, measured in cm, negative or trace. If persistently 1/4
Check weight should be approximately equal to the (250 gm/dl) or more, it is significant.
Typical weight gain is about a pound a weeks gestation, from mid-pregnancy
week. Weight gain is usually slow until near term (MacDonald's Rule). Fetal movement is not usually felt by
during the first 20 weeks. Then, there The normal fetal rate is generally the mother until the 16th week (for
is usually rapid weight gain from 20 to between 120 and 160 BPM. women who have delivered a baby)
32 weeks. After that, weight gain to the 20th week (for women
generally slows and there may be little,
if any weight gain during the last few
• The rates are typically higher) in
pregnant for the first time).
early pregnancy, and lower (120-
weeks. 140) toward the end of pregnancy. Once they positively identify fetal
movement, most women will
Measure BP at each prenatal visit. • Past term, some normal fetal heart acknowledge that they have been
Blood pressure in early pregnancy will rates fall to 110 BPM. feeling the baby move for a week or
usually reflect pre-pregnancy levels. • No correlation between heart rate two, but didn't realize that the
and the gender of the fetus. sensation (fluttery movements) was
• 2nd trimester, BP usually falls below from the baby.
prepregnancy levels. Check for edema. Swelling of the feet,
• 3rd trimester, BP usually goes back ankles and hands is common during
pregnancy.
"Kick counts” (10 kicks before noon)
up to the pre-pregnancy level.
Preterm Labor OB-GYN 101 Facts Card ©2003 Brookside Press
• Regular, frequent uterine • Scan for fetal anomaly, errors in  If mild-moderate, steroids
contractions prior to the 38th week dating, oligo- or polyhydramnios. and observe
(some say 37th week). • fFN: If + then ↑risk of PTD  If severe, deliver
• If these contractions don’t change o GBS prophylaxis
the cervix, then this is “Threatened Treatment
Preterm Labor.” • >34 weeks - allow delivery
• If these contractions are associated • <34 weeks:
with progressive cervical dilatation o Steroids:
or effacement, then this is Preterm  Betamethasone 12 mg IM,
Laborl. and repeated in 24 hours, or
 Dexamethasone 6 mg IM Q
Causes: 12 hours x 4 doses.
• Usually unknown o Tocolytics:
• Associated with  MgSO4, or
o Placental abruption  Nifedipine, or
o Uterine overdistension  Terbutaline, or
o Infection (~50%), including  Ritodrine, or
ureaplasm, chlamydia,  Indomethacin (if <30 wks)
peptostreptococcus, BV o Try to postpone delivery for 48
hours (for maximimum steroid
Diagnosis: effect and to facilitate transfer to
• Regular, frequent (<Q10 min) high-risk pregnancy center).
contractions, accompanied by o If chorioamnionitis, antibiotics
cervical change over time. and deliver
• CBC (↑WBC suggests infection) o Placental abruption:
Primary Syphilis OB-GYN 101 Facts Card ©2003 Brookside Press

The distinguishing feature of primary • Benzathine penicillin G 2.4 million


consists of fever, muscle aches and
headache and may be improved by
syphilis is a painless ulcer on the units IM in a single dose
concurrent treatment with antipyretic
vulva, vagina or cervix. medication.
But for those allergic to penicillin, you
may substitute:
The ulcer: Both the patient and her sexual
• Doxycycline 100 mg orally twice a partner(s) need treatment.
• Is non-tender. day for 2 weeks, or Otherwise, she will be re-infected,
• Has a well-defined border. • Tetracycline 500 mg orally four even if the initial treatment is
successful. Further, syphilis,
• Has a smooth base. times a day for 2 weeks.
untreated, ultimately can lead to
• Starts as a macular lesion, forms a • Ceftriaxone 1 gram daily either IM permanent neurologic injury and
central papule, then erodes to form or IV for 8--10 days (possibly death, so full treatment of all sexual
an ulcer crater. effective). partners is very important.
• Is associated with enlarged, firm, • Azithromycin 2 grams PO once
mobile, non-tender regional lymph (possibly effective). Long term followup is needed to
nodes. make sure that the syphilis is
During pregnancy, of primary completely gone from the patient
Examination of surface scrapings of importance is that sufficient antibiotic and her sexual partner(s). The
lesion under darkfield microscopy will gets across the placenta and to the means to do that is complicated and
show the typical spirochetes. Serologic fetus. If not, fetal syphilis will be current CDC recommendations are
test for syphilis (VDRL, RPR) will be insufficiently treated. best followed.
positive.
Within 24 hours of treatment, you may
Optimal treatment is: observe the Jarisch-Herxheimer
reaction in patients. This reaction
Prolapsed Umbilical Cord OB-GYN 101 Facts Card ©2003 Brookside Press
the fetus is not immediately
If a portion of the umbilical cord comes Immediate delivery is the best solution. deliverable, then proceed with
out of the cervix or vulva ahead of the cesarean section.
fetus, this is called a prolapsed 1. Put the mother in the knee-chest
umbilical cord. position.
2. Use your hand in her vagina to
elevate the fetal head back up into
This can be a big problem: the uterus. This action may relieve
enough pressure on the umbilical
1. If the umbilical vein is obstructed, cord that oxygen can still get
but the arteries are still patent, then through to the baby.
the fetus will continue to pump 3. Don't be too reassured by feeling a
blood out to the placenta but get normal pulse in the umbilical cord
nothing in return. This will lead fairly between your fingers. The umbilical
rapidly to hypoxia (no fresh oxygen vein could still be obstructed even
coming in), and hypovolemia with normal arterial pulsations.
(shock, from reduction on available 4. Consider Terbutaline 0.25 mg SQ to
blood volume). stop contractions if delivery will not
be immediate.
2. if the cord is totally compressed, 5. Transport the mother in the knee-
hypoxia will develop relatively chest position and you with your
quickly, and be aggravated by the hand elevating the fetal presenting
bradycardia that accompanies the part to the cesarean section room.
obstruction of umbilical arteries. 6. If, on arrival, the baby is
immediately deliverable vaginally
None of this is good. (with forceps, vacuum extractor,
etc.), then that is a safe approach. If
Prolonged Latent Phase OB-GYN 101 Facts Card ©2003 Brookside Press
7.5-15 mg IM, Dilaudid 1-2 mg IM,
Labor is regular, frequent uterine etc.)
contractions leading to progressive
• Oxytocin stimulation
change in the cervix. Usually, labors
begin gradually, with very slow change
up to 4 cm. This part of labor is called
the latent phase. Latent phase labor
can last hours or days.

Prolonged latent phase:


• >20 Hrs. 1st baby
• >12 Hrs. 2nd baby
Risks:
• Exhaustion
• Chorioamnionitis
Treatments:
• Rest
• Ambulation
• Hydration
• Analgesia (narcotics such as
Demerol 50-100 mg IM, Morphine
Premature Rupture of BOW OB-GYN 101 Facts Card ©2003 Brookside Press
• Fetal fat cells (Nile Blue Stain)
Most membranes break during labor. If Remote from term, If
• In questionable cases, may inject
membranes rupture prior to labor, this chorioamnionitis not present,.
dye via amniocentesis and look for
is premature rupture of the Followi the mother's WBC and
leakage from the vagina.
membranes, or PROM. temperature, and the fetal baseline
At full term with no evidence of heart rate.
Obstetrical significance of PROM: infection, no treatment is necessary.
Most go into spontaneous labor within
• Labor needs to begin promptly or the next 6 hours.
infection will develop with bacteria
ascending through the birth canal.
After 6 hours of rupture, or if infection,
• In some cases of PROM, the induce Don’t give antibiotics unless
reason the membranes rupture infection present or as GBS
prematurely is because there is an prophylaxis (after 12 hours).
established infection which has
weakened the membranes.
When PROM occurs remote from term,
Confirm PROM with a sterile speculum two basic approaches can be taken:
examination.
• Induce labor, or
• Wait for the fetus to mature further.
Look for:
Pros and cons to each of these
• Visible leakage from the Cx.
approaches. If chorioamnionitis
• Pooled amniotic fluid present, begin antibiotics and induce
• Nitrazine positive fluid labor regardless of gestational age.
• Ferning
Pubic Lice OB-GYN 101 Facts Card ©2003 Brookside Press
vacuumed. Sources of cross-
Pubic lice (pediculosis pubis) is caused Without magnification, the brown spots contamination (shared clothing,
by the infestation of the pubic hair and can be seen, but most noticeable is the towels) eliminated. Sexual contacts
skin by tiny organisms that are just at movement of the lice. should be treated.
the limits of visibility without
magnification. Treatment may include: If conventional medication is not
available, petroleum jelly, applied to
Pubic lice can be spread through Nix cream (5% permethrin) applied to the affected area may prove
sexual contact, close living quarters, or the vulvar skin and left in place for 6-12 effective by suffocating the lice.
shared clothing. hours before washing off.

The patient will described moderately Kwell lotion or shampoo (1% lindane)
intense itching and may say, "I think I once after showering and left in place
see something moving down there." for 10 minutes before rinsing. This may
be repeated in 7 days if necessary. Do
Ideally, the patient is examined with not use more often or longer than this
good lighting and a magnifying lens. as lindane has neurotoxicity potential.
The lice can be seen moving along the
shafts of the pubic hair. Individual Mechanically removing nits and lice by
"nits" can be seen. These are small, combing the pubic hair with a fine
oval, gray eggs attached to the hairs. toothed comb.
Brown discolorations of the skin, when
closely examined, are seen to contain
Clothing and bed linens should be
lice excrement deposited just beneath
thoroughly washed and dried.
the skin.
Mattresses should be aired or
Retained Placenta OB-GYN 101 Facts Card ©2003 Brookside Press

After delivery, the placenta normally Guide one hand through the introitus • Curette the placental bed to
detaches from the inside of the uterus and cervix, into the uterine cavity. reduce bleeding, if necessary.
and is expelled. This takes a few
5. Insert the side of your hand in • Recovery is usually satisfactory,
minutes, up to an hour. but with > avg. post partum
between the placenta and the
uterus. You may need to push bleeding.
The 4 signs of placental separation: through the placental membranes to If extensive or complete:
1. Apparent lengthening of the visible accomplish this. • Placenta will only come out in torn
portion of the umbilical cord. 6. Using the side of your hand, sweep fragments.
the placenta off the uterus.
2. Increased bleeding from the vagina.
7. After most of the placenta is
• Bleeding will be considerable.
3. Change in shape of the uterus from
flat (discoid) to round (globular). detached, curl your fingers around • Multiple blood transfusions likely
4. The placenta being expelled from the bulk of it and exert gentle
downward and outward traction.
• Uterine artery ligation or
the vagina. hysterectomy may be needed.
8. Pull the placenta through the cervix.
After about 30 minutes of waiting, a • If surgery is not immediately
manual removal of the placenta is Be prepared to deal with an abnormally available, tight uterine and/or
undertaken. adherent placenta (placenta accreta or vaginal packing to slow the
placenta percreta). These may be bleeding.
Anesthesia: partial or complete.

• Rregional If partial/focal:
• General • Attachments can be manually
broken and the placenta removed.
• IV narcotics
Scabies OB-GYN 101 Facts Card ©2003 Brookside Press

Scabies is a skin infection with small The diagnosis is made by visualizing a Diphenhydramine 25-50 mg PO
(1/2 mm) mites, Sarcoptes scabiei. burrow and confirmed by microscopic every 6 hours will relieve some of
visualization of the mite, ova or fecal the itching, but will make the patient
The mites burrow into the skin, laying pellets in scrapings of the burrow sleepy.
their eggs in a trail behind them. About suspended in oil.
a month after the infection, there is a In severe cases, Prednisone 40 mg
hypersensitivity skin reaction, with Treatment is: PO QD X 2 days, then 20 mg X 2
raised, intensely itchy skin lesions, days, then 10 mg X 2 days will
most noticeable at night. 5% permethrin cream (Nix, Elimite) provide significant relief. This
applied to the skin from the neck down regimen should be used cautiously
The burrows (tunnels) from the mites and left in place for 10 to 14 hours in operational environments as it will
can be seen through the skin as thin, before washing off. Itching may persist suppress the immune system,
serpentine, scaly lines of up to 1 cm in for up to one month and should not be making the patient more vulnerable
length. They are most commonly found viewed as an indicator of failed to other problems.
in the fingerwebs, elbows, axilla, and treatment.
inner surface of the wrists. They are Unlike pubic lice, Sarcoptes scabiei
also seen commonly on the breast If permethrin is not available, 1% do not live long on clothing or bed
areolae of women and along the belt lindane(Kwell lotion or shampoo) once linens.
line and genitals of men. after showering and left in place for 10
minutes before rinsing. This may be
The infection is spread by skin-to-skin repeated in 7 days if necessary. Do not
contact with an infected person. use more often or longer than this as
lindane has neurotoxicity potential.
Sciatica OB-GYN 101 Facts Card ©2003 Brookside Press
stretching or compression of the • In order to maintain this semi-
Sciatica occurs in 30% of pregnant nerves within the pelvis. fetal position comfortably, it is
women and is characterized by sharp
necessary to place a small pillow,
pains in the hip and buttock on one or Treatment of sciatica:
folded blanket or towel between
both sides, shooting down the back of
• Avoid standing for long periods of the patient's knees. This will
the thigh. There may also be
time. absorb moisture, separate the
numbness of the anterior thigh on the
• When sleeping, assume a semi- legs, minimizing skin-to-skin
effected side.
fetal position, with both knees contact, and provide additional
drawn up and a pillow placed support to the legs. With practice,
The sciatic nerve (tibial and common this position will become very
between the knees.
peroneal nerve bound together) arises comfortable.
from nerve roots exiting the spine • When sitting, make sure the knees
are slightly flexed so that the knees • When sitting at a desk, posture is
between L4 and S3. Any compression very important.
of these nerve roots can lead to these are at least level with the hips or
symptoms. slightly higher than the hips.
• Sleeping with one leg straight and
the other knee drawn up is a bad
Sciatica can occur at any time, but position as far as the back is
pregnancy predisposes towards it: concerned. Torsion is placed on the
• Pregnancy causes an accentuated lower spine, aggravating any
lordosis of the spine. pressure on the sciatic nerve that
• Pregnancy causes weight gain may be present.
• Pregnancy softens the cartilage of • Sleeping on the side while pregnant
the sacro-iliac joint, de-stabilizing is a good, idea, but both knees
the pelvic architecture and should be drawn up (flexing the
increasing the likelihood of thighs). Either side will work well.
Shoulder Dystocia OB-GYN 101 Facts Card ©2003 Brookside Press
• Acute obstetrical emergency. o Large Episiotomy: If there is any o Unscrew the shoulders: like a
• Head is out, but shoulders stuck. restriction of the soft tissue, light-bulb. Rotate the posterior
• If not relieved, fetus will ultimately place an episiotomy large shoulder to the anterior
die. enough to accommodate the position.
• May lead to stretching or tearing of fetus you’re your hand for any o Cephalic replacement: flex the
the brachial plexus, causing Erb’s maneuvers that may be chin to the chest, push the
Palsy or Klumpke’s Palsy. necessary. fetus back inside, then C/S.
• More common among diabetic o MacRobert’s Maneuver: With the
women and large fetuses. woman on her back, push her
• Can’t be predicted or prevented. legs back against her abdomen.
o Suprapubic Pressure: Have an
Diagnosis: assistant push the fetal shoulder
down and away from the pubic
• “Turtle Sign” (after fetal head
bone while the woman is
delivered, head retracts back
pushing.
against perineum.
o Deliver the posterior arm: Follow
• Body of the baby fails to deliver
the posterior arm from the
after the head is already out.
shoulder to the elbow and finally
• Double chin on fetus. to the wrist. Grasp the hand and
pullit out toward you.
Treatment o Nudge the shoulders from
• Don’t pull down forcefully on the vertical (12 and 6) to slightly off
head. This can stretch or tear the axis (11 and 5, or 1 and 7
nerves in the arm. o’clock).
• Maneuvers:
Simple Ovarian Cysts OB-GYN 101 Facts Card ©2003 Brookside Press
intercourse. The cyst usually ruptures
An ovarian cyst is a fluid-filled sac within a month. An endometrioma is a form of an
arising from the ovary. ovarian cyst that results from ectopic
endometrial tissue being present in
If the cyst is small, its' rupture usually the ovary. During the normal cyclic
Functional cysts are common and occurs unnoticed. If large, or if there is
generally cause no trouble. During hormonal changes, this ectopic
associated bleeding from the torn endometrium responds with
ovulation a small ovarian cyst (<3.0 edges of the cyst, then cyst rupture
cm)forms. Large cysts (>7.0 cm) are proliferative growth, decidualization,
can be accompanied by pain. The pain and then sloughing, accompanied by
less common and should be followed is initially one-sided and then spreads
clinically or with ultrasound. bleeding. As the blood is trapped
to the entire pelvis. Rarely, surgery is within the ovarian capsule or stroma,
necessary to stop continuing bleeding. it gradually accumulates, forming a
Occasionally, simple cysts may:
chronic hematoma, known as an
• Delay menstruation A torsioned ovarian cyst occurs when endometrioma.
• Rupture the cyst twists on its' vascular stalk,
• Twist disrupting its' blood supply. The most troublesome aspect of
• Cause pain endometriomas from a diagnostic
Patients have severe unilateral pain standpoint is that they can mimic
95% of ovarian cysts disappear with signs of peritonitis (rebound any of the ovarian neoplasms.
spontaneously, usually after the next tenderness, rigidity). Treatment is Classically, the endometriomas have
menstrual flow. surgery to remove the necrotic adnexa. a ground-glass, slightly speckled
Mortality rates from this condition appearance on sonar, but may
Unruptured ovarian cys usually cause (without surgery) are in the range of demonstrate both cystic and solid
no symptoms, they can cause pain, 20%. components.
particularly with strenuous exercise or
Skenitis OB-GYN 101 Facts Card ©2003 Brookside Press

A Skene's gland is on each side of the Good choices for antibiotics would
urethral opening. It is normally neither include those most helpful for treating
seen nor felt, although close inspection urethritis:
will reveal the pinpoint openings of
these periurethral glands. • Cefixime 400 mg orally in a single
dose, OR
• Ceftriaxone 125 mg IM in a single
When infected, the Skene's gland will
dose, OR
become enlarged and tender.
• Ciprofloxacin 500 mg orally in a
single dose, OR
A simple incision and drainage of the • Ofloxacin 400 mg orally in a single
gland will generally result in complete dose,
resolution. Topical anesthetic (20%
benzocaine, or "Hurricaine") can be PLUS
applied to the cyst with a cotton-tipped
applicator and allowed to sit for 3-4 • Azithromycin 1 g orally in a single
minutes. A single stab wound by a dose, OR
scalpel opens the abscess and allows • Doxycycline 100 mg orally twice a
for drainage of the pus. day for 7 days.

Cultures, particularly for gonorrhea,


should be obtained.
Skin Changes in Pregnancy OB-GYN 101 Facts Card ©2003 Brookside Press
fine, faint, silvery-gray lines. Who gets
Over time, there is a darkening of the them and how severe they are is
maternal skin, in predictable ways. dependent on the genetic
predisposition of the mother and the
Chloasma is a darkening of the facial degree of mechanical stress placed on
skin, after the 16th week of pregnancy, the skin. There are no scientifically-
particularly in women with darker established methods to either prevent
complexions and significant exposure them or treat them. However,
to the sun.. After delivery, the skin generations of women have applied
clears, but for some individuals, a cocoa butter to the skin in the belief
persistent darkening of the skin that it is helpful.
remains.
A "linea nigra" is a dark line running
Spider telangiectasias are small, bright from the pubic bone up the center of
red, star-shaped skin discolorations the abdomen to the ribs. This appears
that blanch with direct compression late in pregnancy and is due to a
and then return as soon as the combination of increasing
compression is released. After concentration of melanocytes (skin
delivery, they will largely resolve, but cells capable of darkening) in that
some may remain. area, plus the high levels of
melanocyte stimulating hormone
Stretch marks occur primarily in late produced by the placenta.
pregnancy and are due to a separation
of the underlying collagen tissue. They
are dark red. After delivery, they will
gradually lighten, ultimately healing as
Trauma During Pregnancy OB-GYN 101 Facts Card ©2003 Brookside Press
adverse effects on the fetus, including
In the 1st TM, the uterus is protected placental abruption, preterm labor, Adverse effects, are immediate
within the pelvis. Trauma will either be premature rupture of membranes, (within the first few days of the
so severe as to cause a miscarriage or uterine rupture, and fetal injury. trauma). There is probably no
else it will have no effect. While trauma increased risk after excluding these
can cause 1st trimester loss, it is immediate adverse effects:
exceedingly rare in comparison with Rapid acceleration, deceleration, or a
other causes of miscarriage. direct blow to the pregnant abdomen • Placental abruption within the first
can cause shearing of the placenta 72 hours of injury.
away from its’ underlying attachment to • Rupture of membranes within 4
Catastrophic trauma includes maternal the uterus. (placental abruption. hours of injury.
death, hemorrhagic shock, multiple
compound fractures of the extremities, • Onset of labor within 4 hours of
liver and spleen ruptures, to name a Premature labor may be provoked, with injury that resulted in delivery
few. Catastrophic trauma during the 1st regular UCs beginning within 4 hours. during the same hospitalization.
TM is often associated with pg loss. Premature rupture of the membranes • Fetal death within 7 days of the
can also occur, within the first 4 hours traumatic event.
of injury.
Non-catastrophic trauma includes Uterine contractions following
bumps, bruises, fractures of small trauma are common, although
bones (fingers, toes), minor burns, etc. Uterine rupture can occur and usually premature delivery caused by
Non-catastrophic injuries may be results in fetal loss. preterm labor is not. Actual preterm
serious enough to require treatment, delivery resulting from premature
but are not associated with pg loss. The severity of the maternal injury may labor (in the absence of abruption)
not correlate well with the frequency of probably occurs no more frequently
2nd/3rd TM trauma has different adverse pregnancy outcome. among traumatized women than the
consequences. Here, even relatively general population.
minor trauma can have significant
Twin Delivery OB-GYN 101 Facts Card ©2003 Brookside Press

40% of twins present ceph/ceph. The • No large discrepancy in twin sizes. • With your hand in the vagina, feel
remainder pose some abnormal • Normal electronic fetal monitoring the fetal presenting part. If not
engaged, guide it down to the
presentation of one or both twins. pattern and normal progress
pelvic inlet. Gentle suprapubic or
Because of the abn. presentations and
• Resources for quickly changing to a fundal pressure is OK. Avoid
C/S for one or both twins. rupturing membranes until
the complexities of delivering twins,
many delivered by C/S. presenting part is engaged.
Mono-amniotic sac with breech/ceph
twins. Problem: "interlocking twins" so • As presenting part descends, ask
Some favor C/S for all twins feeling choose C/S. mother to bear down and usually
that this is probably a little safer for the the second twin will deliver as
babies and not appreciably more Vaginal delivery: easily as the first twin.
dangerous for the mother. Others offer • If fetal distress, then either
vaginal selectively. • After first twin delivers, Ctx’s slow or forceps or C/S for 2nd twin.
stop. Both placentas remain inside
Factors that can contribute a greater the uterus and attached.
degree of safety to vaginal delivery of • Don’t speed up this process, but
twins include: await the resumption of Ctx’s.
• Experience of the operator • Waiting could take a few minutes or
many minutes (even hours). While
• Cephalic/cephalic presentation waiting, monitor the second twin's
• Previous vaginal deliveries of the EFM
mother • If Ctx’s do not promptly resume,
• Not too big and not too small begin oxytocin.
Upper Respiratory Infection OB-GYN 101 Facts Card ©2003 Brookside Press
a slight increased risk of fetal
Most pregnant women will have at malformations. Late in the third
least one URI while pregnant. trimester, its' use is again restricted
because of its' somewhat
Drugs are to be avoided, but the unpredictable cardiovascular
following medications may be used to effects.
good advantage if necessary:
• Triprolidine. An effective
• Acetaminophen. This will effectively antihistamine, it is considered safe
relieve muscle aches and fever. It is during pregnancy.
considered safe during pregnancy.
(Category B drug, the same as Antibiotics may be needed for those
prenatal vitamins.) URI's complicated by bacterial sinusitis
or bronchitis. In this case, the following
• Guaifenesin. This expectorant is are safe:
considered safe during pregnancy.
The addition of codeine (safe) will • Penicillins
result in significant suppression of
cough.
• Cephalosporins
• Pseudoephedrine. This
sympathomimetic is a very effective • Macrolides
decongestant. It's use during the 1st
trimester is sometimes restricted
because of indirect data suggesting
Vaginal Discharge OB-GYN 101 Facts Card ©2003 Brookside Press
lesions, foreign bodies and odor. of an IUD. The uterus is mildly
Ask the patient about itching, odor, Palpate to determine cervical tender.
color of discharge, painful intercourse, tenderness. • Chancroid appears as an ulcer
or spotting after intercourse.
with irregular margins, dirty-gray
• Yeast has a thick white cottage- necrotic base and tenderness.
• Yeast causes intense itching with a cheese discharge and red vulva.
cheesy, dry discharge.
• Gardnerella has a foul-smelling, thin Laboratory
• Gardnerella causes a foul-smelling, discharge. Obtain cultures for chlamydia,
thin white discharge. gonorrhea, and Strept. You may test
• Trichomonas has a profuse, bubbly,
• Trichomonas gives irritation and frothy white discharge. the vaginal discharge in any of 4
frothy white discharge. different ways:
• Foreign body is obvious and has a
• Foreign body (lost tampon) causes terrible odor.
a foul-smelling black discharge.
• Cervicitis has a mucopurulent Test the pH. If >5.0, this suggests
• Cervicitis causes a nondescript cervical discharge and the cervix is Gardnerella.
discharge with deep dyspareunia tender to touch.
• Chlamydia may cause a purulent Mix one drop of KOH with some of
• Chlamydia causes a friable cervix
vaginal discharge, post-coital the discharge on a microscope slide.
but often has no other findings.
spotting, and deep dyspareunia. • The release of a bad-smelling
• Gonorrhea causes a mucopurulent
• Gonorrhea may cause a purulent odor confirms Gardnerella.
cervical discharge and the cervix
vaginal discharge and deep may be tender to touch. • Multiple strands of thread-like
dyspareunia. hyphae confirm the presence of
• Cervical ectropion looks like a non-
• Cervical ectropion causes a yeast.
tender, fiery-red, friable button of
mucous, asymptomatic discharge. tissue surrounding the cervical os. Mix one drop of saline with some
Physical Exam • Infected/Rejected IUD discharge ("Wet Mount
Inspect carefully for the presence of demonstrates a mucopurulent
cervical discharge in the presence
VBAC OB-GYN 101 Facts Card ©2003 Brookside Press
4. The more C/S the patient has, the 12. Those who C/S (failed VBAC)
At one time, women who had delivered greater risk of rupture during labor. after a lengthy labor will
by cesarean section in the past would 5. The greatest risk occurs following frequently have a longer
usually have another cesarean section a "classical" cesarean section. recovery and greater risk of
for any future pregnancies. The 6. The least risk is among those wth infection than had they
rationale was that if allowed to labor, a low cervical transverse incision. undergone a scheduled
many of these women with a scar in 7. Low vertical incisions probably cesarean section without labor.
their uterus would rupture the uterus increase the risk of rupture some, 13. Women whose first cesarean
along the weakness of the old scar. but usually not as much as a was for failure to progress in
classical incision. labor are somewhat less likely to
Over time, a number of observations 8. Oxytocin is associated with an be successful.
have become apparent: increased risk of rupture, either 14. Risk of rupture is about 1%, and
because of the oxytocin itself, or about 20% of those are
1. Most can labor and deliver
perhaps because of the clinical disastrous.
vaginally without rupturing their
circumstances under which it After counseling, many obstetricians
uterus, but some will.
would be contemplated. leave the decision for a repeat
2. Rupture may have consequences
9. Pain medication has not led to cesarean or VBAC to the patient.
from near trivial to disastrous.
greater adverse outcome. Both approaches have risks and
3. It can be very difficult to diagnose
10. The greatest risk of rupture is benefits, but they are different risks
a uterine rupture prior to observing
during labor, but some ruptures and different benefits. Fortunately,
fetal effects (eg, bradycardia).
occur prior to labor, particularly most repeat cesarean sections and
Once fetal effects are
classical incisions. most vaginal trials of labor go well,
demonstrated, even a very fast
11. Overall successful vaginal delivery without any serious complications.
reaction may not lead to a good
rates following previous cesarean
outcome.
section are in the neighborhood of
70%.
Vulvar Vestibulitis OB-GYN 101 Facts Card ©2003 Brookside Press
during intercourse. Others seem to affected area (perineoplasty) in
Vulvar vestibulitis is a condition of have acquired the condition. They selected cases.
uncertain cause, characterized by pain have painless intercourse initially, and
and burning in specific sites on the later develop the painful intercourse so
vulva. characteristic of this condition.

The pain is most noticeable during The diagnosis is based on the physical
intercourse and is very consistent, both examination, with persistent areas of
in character and location. tenderness to touch, located in the U-
shaped area surrounding the hymenal
The pain and tenderness is distributed ring. Biopsy is neither necessary nor
in a U-shaped pattern around the often done.
introitus and includes the hymeneal
remnants and up to 1 cm of skin Treatment is problematic. Antibiotics,
exterior to the hymen. Visually, the anti-fungals, anti-virals, estrogens, and
tender areas are reddened and steroids are often used and are often
touching them gently with a cotton- found to be ineffective. Antioxalates
tipped applicator will duplicate the pain (used with the theory that oxalates
they experience during intercourse (a provoke a skin reaction in this area)
positive "Q-Tip Test"). Biopsy of these are promoted by some, but
tender areas will show a generalized randomized studies demonstrate them
inflammatory pattern of non-specific to be no better than placebo.
etiology.
Several studies have demonstrated the
Some women with vestibulitis indicate efficacy of surgical excision of the
they have always felt this discomfort
Vulvar Intraepithelial Neoplasia OB-GYN 101 Facts Card ©2003 Brookside Press

VIN is a premalignant condition, which Milder forms of VIN may not be


if untreated can lead to invasive cancer obvious visually and special testing,
of the vulva. such as the use of Toluidine Blue
staining, may be necessary to identify
In the cervix, premalignant changes the area of abnormality.
occur (CIN I, CIN II and CIN III) which
precede the development of invasive The diagnosis is confirmed with vulvar
cancer by many months or years. biopsy.

In the case of the vulva, the same Treatment involves local excision, or in
principle applies, that there are selected cases laser vaporization.
premalignant changes which may Close follow-up is very important
ultimately lead to cancer of the vulva. should there be persistence or
The degree of change is similarly recurrence of disease.
labeled, VIN I, VIN II and VIN III (also
known as "carcinoma-in-situ).

Clinically, these patient usually present


with vulvar itching which does not
respond to anti-fungal agents. Closer
inspection visually will show the skin to
have a white discoloration which can
be enhanced with the application of
acetic acid.
Wet Mount OB-GYN 101 Facts Card ©2003 Brookside Press

Put a Tiny Amount of Discharge on a After the cell membranes are These clue cells are vaginal
Microscope Slide. Make this as small dissolved, the typical branching and epithelial cells studded with bacteria.
as possible. budding yeast cells can be seen. It resembles a pancake that has
Sometimes, it has the appearance of a fallen into a bowl of poppy seeds,
Add one drop of Normal Saline (0.9% tangled web of threads. At other times, but on a microscopic level.
NaCl) to the drop of discharge. Mix only small branches will be seen.
well on the slide. Make a 2nd slide in A normal vaginal epithelial cell is
the same way, using 10 percent KOH.. Yeast normally live in the vagina, but clear, with recognizable contents,
only in very small numbers. If you and sharp, distinct cell borders.
Place glass coverslips over the slides. visualize any yeast in your sample, it is
Remove excess fluid with tissue paper. considered significant. A clue cell appears smudged, with
indistinct contents and fuzzy, poorly
Wait 2 minutes for the cell membranes Trichomonas is best seen on the defined borders.
to dissolve, or heat the KOH slide to Normal Saline slide. These protozoans
speed the dissolving process. are about the same size as a white
blood cell (a little smaller than a
vaginal epithelial cell), but their violent
Examine the prepared slides under a
motion is striking and unmistakable.
microscope. The lowest power (~ 40X)
works the best.
Bacterial vaginosis (also known as
Gardnerella, hemophilus, or non-
Yeast (Candida, Monilia) is best
specific vaginitis) is characterized by
identified with the KOH slide.
the presence of "clue cells" visible at
both low and medium power.
X-ray Exposure OB-GYN 101 Facts Card ©2003 Brookside Press
circumstances. There appears to be a
All things being equal (which they threshold for fetal malformation or
never are), it is better to avoid x-rays death of at least 10 Rads, below which,
while pregnant. biologic effects cannot be
demonstrated. Allowing for a 10-fold
If indicated, (chronic cough, possible margin of safety, it does not appear
fracture, etc.), then x-rays are that any exposure below 1 Rad will
acceptable. have any harmful effects.

If you need an x-ray for a pregnant It would take about a thousand chest x-
patient, go ahead and get it, but try to rays to deliver this amount of radiation
shield the baby with a lead apron to to the unshielded maternal pelvis.
minimize the fetal exposure.
At the same time, our knowledge of the
In your zeal to shield the pregnant biologic effects or radiation may be
abdomen, be careful not to shield so incomplete, so it is better for pregnant
much that the value of the x-ray is women, as a rule, to avoid any
diminished. If the shielding is too high unnecessary exposure to ionizing
while obtaining a chest x-ray, you will radiation, and to use appropriate
have to obtain a second x-ray to shielding when it is necessary.
visualize the area shielded during the
first x-ray.

The risk to the fetus from radiation


exposure is minimal in these
Yeast Infections OB-GYN 101 Facts Card ©2003 Brookside Press
organisms when the discharge is • Miconazole 100 mg vaginal
Vaginal yeast infections are common, mixed with KOH. suppository, one suppository for 7
monilial overgrowths in the vagina and
days
vulvar areas, characterized by
Treatment may be oral: • Nystatin 100,000-unit vaginal
itching,dryness, and a thick, cottage-
tablet, one tablet for 14 days
cheese appearing vaginal discharge. • Fluconazole 150 mg oral tablet, one
The vulva may be reddened and • Tioconazole 6.5% ointment 5 g
tablet in single dose, intravaginally in a single
irritated to the point of tenderness.
or intravaginal: application
• Terconazole 0.4% cream 5 g
Predisposing factors • Butoconazole 2% cream 5 g intravaginally for 7 days
• Damp, hot environments intravaginally for 3 days • Terconazole 0.8% cream 5 g
• Broad-spectrum antibiotics • Clotrimazole 1% cream 5 g intravaginally for 3 days
intravaginally for 7-14 days • Terconazole 80 mg vaginal
Yeast is present in most vaginas in • Clotrimazole 100 mg vaginal tablet suppository, one suppository for 3
small numbers. A yeast infection is for 7 days days.
such large numbers as to cause the • Clotrimazole 100 mg vaginal tablet,
typical symptoms of itching, burning two tablets for 3 days If none of these products are
and discharge available, douching with a weak acid
• Clotrimazole 500 mg vaginal tablet,
solution (2 teaspoons of vinegar in a
one tablet in a single application
The diagnosis is often made by history quart of warm water) twice a day.
• Miconazole 2% cream 5 g
alone, and enhanced by the classical intravaginally for 7 days
appearance of a dry, cheesy vaginal • Miconazole 200 mg vaginal Reoccurrences are common .
discharge. It can be confirmed by suppository, one suppository for 3
microscopic visualization of clusters of days
thread-like, branching Monilia