HEAD FIRST

Tenth Edition

The
OB/GYN
Clerk’s
Companion
2

Editorial Note
This Tenth Edition of Head First is based on the
original created by Harsh Hundal of Meds 1995.
The information provided herein is not the
standard but a series of guidelines to be followed
at your own discretion.

The following basic guide contains outlines of

admitting orders, chart notes, post-procedural
orders, and medications. They may need to be
modified based on the patient’s health status and
the individual resident or physician’s preferences.
 3
Table of Contents
Abbreviations 4
Admitting History & Physical 5

Antenatal Section
Chart Notes (Antenatal Rounds) 8
Orders Previas/Abruption 10
PIH 10
PPROM 11
IUGR 11

Delivery Room
Chart Notes (Postpartum Rounds) 12
Postpartum Delivery Note 13
Postpartum C-section Note 14
Orders - Admission Uncomplicated 15
Induction 15
Postpartum 16
Postpartum Problems 18

Gynecology
Chart Notes (Gyne Rounds) 19
Chart Notes (Operative Note) 20
Day Surgery Orders 21
Commonly Ordered Meds 22
LHSC Phone List 25
Hints & Tips 26
Objectives 27
4
Abbreviations
AAT activity as tolerated IPS integrated prenatal screen
A/N antenatal IUPC intrauterine pressure catheter
AUA average ultrasound age LFT liver function tests
AVSS all vital signs stable LOF loss of fluid
Ax assessment LMP last menstrual period
BM bowel movement LSCS lower segment c-section
BPP biophysical profile MCA middle cerebral artery doppler
BR bed rest MSS maternal serum screen
BRP bathroom privileges N normal
BS breath or bowel sounds NKDA no known drug allergy
C/S c-section NS normal saline
CtX contraction NST non-stress test
CVS chronic villous sampling NT nuchal translucency
Cx cervix O/E on examination
DAT diet as tolerated PIH pregnancy induced htn.
DR delivery room POD# post-operative day
Preterm premature rupture of
DV Ductus Venosus Doppler PPROM
membranes
premature rupture of
DVT deep vein thrombosis PROM
membranes
Dx diagnosis PTL preterm labour
d/c discharge PVR post-void residual
EBL estimated blood loss PVB per-vagina bleed
EDB expected date of birth Px physical
EFM electronic fetal monitoring RL ringer’s lactate
FHR fetal heart rate RTS real time scan
FMC fetal movement count SFH symphysis-fundal height
spontaneous rupture of
FSE fetal scalp electrode SROM
membranes
FTP failure to progress SS surgical screen
F/U follow up SVD spontaneous vag. del.
GA gestational age U/S ultrasound
GDM gestational diabetes mel. UA umbilical artery Doppler
Hx history VSR vital signs routine
IOL induction of labour WNL within normal limits
 5
Admitting History and Physical (Example)
ID: 29 y.o. G3T2P1A1L2 @ 37+5 GA
presenting with (contractions, PIH etc)

LMP: Aug 31/11

EDB: June 7/12 (by T1 u/s)
GA: 38 wks
RFA: SROM or PIH or threatened PTL, etc.

HPP: abdo pain radiating to back onset 0930 today

contractions now q5min lasting 30sec
SROM @ 1300hrs, clear fluid, ongoing leak
+ Fetal Movement. No Per Vaginal Bleeding
No GHTN. No GDM. No HSV.
Uneventful pregnancy

Antenatal tests: GBS +

A-ve, IPS -,
Rb nonimmune, HIV-, HBV-, VDRL –
G&C neg

Ultrasounds: list all ultrasounds and findings

Dec 11/11, 8 wks GA, SIUP
Mar 1/12 20 wks, normal anat
Apr/13 EFW<10ile, UA Doppler findings

OBHx: list yr/sex/GA/wgt/labour/Del mode& reason/Comps

2007, male, 40 GA, 8lb 12oz, SVD, PPH
2009, male, 38, 6lb 4oz, c/s for abnormal FHR, no comps
6
Gyn Hx (only if pertinent. Otherwise this is optional!):
Menarche @ 14
Regular menses Q21 days x 4days
Chlamydia tx’d 3 years ago. No PID
Paps UTD. Normal. (list if cervical treatments)

PMHx: healthy

PSHx: laproscopic appendectomy 2009

Meds: Celexa
PNV

ALL: Pen → rash

FHx: father DM2. Mother healthy

SHX: no smoking, etoh or ivdu concerns

O/E: (MAT Vitals) HR 99 BP 130/80 RR 18 Sa02 98%

Ra Tb 36.5
(FETAL VITALS) FHR 140, mod variability with
accels no decels.
RESP: AE clear to bases bilat, adventitial sounds
(crackles/wheezes)
CVS: NS1S2 no EHS, syst ejection murmur at LSB
ABDO: soft non tender with intermit palp
tightenings
no rebound
Leopolds = longitudinal lie, vx presentation,
back right
PELVIC: (to be done with MD in room only)
Cx = 4cm dilated, 50% effaced, vx (note who
done by)
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Invest: Hb 120 WBC 12 PLT 189
Ultrasound confirmed vx presentation
Note PIH labs if done

IMP: Healthy term multiparous female with SROM x 6hrs, clear in

active labour. GBS +.

PLAN : (list issues and plan for each issue)

1. term pregnancy in active labour
- admit
- intermittent auscultation (vs CEFM)
- epidural PRN

2. GBS + - Pen G

SIGN
Jane Doe cc3

Once finished page resident and review.

(resident to cosign that reviewed)
8
Chart Notes - A/N Rounds
Patient Age, GTPAL, Gestational Age

Problem List: Twins gestation

PIH
RH –ve

S/ General: OB: fetal activity? Bleeding? contr’ns?

Leakage? (always ask)
Issue specific: blurred vision, headache, epigastric
pain (ex PIH)

O/ MATERNAL VS: Temp - 37.1

HR -70
BP - 130-150/94-105
edema - pattern? How high? when it started?
reflexes - increased, clonus?
protein dip - trace to 1+
FETAL VS: HR 140

ISSUE DIRECTED EXAM:

(PIH= edema, reflexes, clonus, epig/RUQ tender?)
(abruption/chorio: tender uterus?)

Labs/ CBC - WBC/Hb/Plt LEs

24 hr. urine protein
Ultrasounds
NST - reactive?
 9
A/Plan: status resolving, worsening? (ex. Is PIH
progressing?)
Fetal concerns?
What orders or investigations to consider?

Sign Note, M3
10
Orders –
Previa/Abruption
DAT (NPO if active bleed) BR
w/ BRP
VSR (R/A if active bleed)
CBC (repeat if active bleed)
Coag. Screen (INR, PTT, Fibr.)
G & X-match 2 units at all
times
Orders –
PIH
DAT
Limited activity
Toxic Protocol vitals, Daily
Wgts.
CBC, LE’s, lytes, Cr (PIH labs-
daily initially then r/a)
24hr. urine protein (call
resident w/ results)

Kleihauer test (sometimes for

FMC bid
initial bleed)
FHR tid
FMC BID, FHR TID
NST (freq depends on UA
dopp & growth)
NST daily x 2, then 2/wk
US - growth/BPP/ UA Doppler
External Monitor if active bleed
initially then r/a
BPP twice/wk
NICU Consult (if <35 weeks)
US growth/placental location/
appearance
If NPO: IV D5W/0.9 NaCl @
125 cc/hr
NICU Consult (if <35 weeks)
 11
Orders – Orders –
PPROM IUGR
DAT DAT
BR w/ BRP BR w/ BRP
VSR (temps QID) VSR

CBC/diff q2d CBC, SS, LFT, Coag. Screen

G&T G&T
Urine R & M, C & S Urine R & M if indicated
Vag swab for C+S
FMC bid
FMC bid (on admission) FHR tid
FHR tid NST 3x/week
NST daily BPP, UA, MCA Doppler (freq
BPP twice/wkly depends on severity d/w
resident)
Limit use of antipyretic (ie. US growth q3-4wk
Tylenol) or you will mask NICU consult
chorioamnionitis!!!

Consider Mercer Protocol ie

<34 wks (copy in delivery
room)
NICU Consult (if <35 weeks)
12
Chart Notes – Postpartum Rounds

Example:
24 y.o. G2P1 POD #2 LSCS for FTP

S/ pain? Diet (tol CF, DAT?), flatus? voiding? Ambulating?

PVB, lochia?

O/ VS: febrile?, stable?

Wound: dressed, clear, dry, draining, erythema?
Chest: clear, crackles, wheezes?
Abd.: soft, uterus firm? non-tender?
Vag: ↑/↓ flow, clots
Legs : calf swelling/warmth (DVT?)
Lab results:

Ax/ doing well or not, what to reconsider

P/ possible d/c POD #3/4

Sign Note, M3

C/S routine: d/c Foley POD #1

d/c Dressing POD #1
d/c Staples POD #3

(Pt should be passing gas by POD #2 if SVD or by POD #2-3 if

C/S)
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Delivery Note – SVD
Example:

Del MODE: SVD vs. vacuum vs Forceps (if assist why?)

Anesthesia: epidural vs nitrous vs none
Attendants: staff/residents/ clerks

Findings: live vs vigorous ♀/♂ infant.

Apgars 8,9
Nuchal cord? (yes or no)
Placenta delivery (spontaneous vs manual
removal)
Placenta intact?
3 vessel cord?

COMPS: Shoulder dystocia? (yes or no, if yes list maneuvers)

episiotomy or tear? (degree?, Repaired w/ vicryl,
Hemostatic?)
PPH? (yes or no) meds given?

EBL: < 500cc

Disposition: Mom & babe stable in room

14
Delivery Note – C/S

Example:

Pre-op Dx - Abnormal FHR

Procedure - 1. Primary LSTCS (lower segment transverse c/s)
Post-op Dx - same
Surgeon - (staff)
Assist - (residents)
Anesthetist - (staff)
Anesthesia: epidural vs spinal
Findings: normal uterus, ovaries & tubes
Live or vigorous female infant
Fetal weight
Nuchal cords?
Apgars
placenta intact, uterus empty
note if plac sent to path
EBL - 1000 ml
Counts - correct
Comps - none
Disposition - stable, babe with mom or nicu? Fundus firm?

Sign Note, M3
 15
Orders – Admission Orders – Induction
Uncomplicated Direct
to DR

Use standard order sheet Use standard order sheet

16
Orders – Discharge Note (as dictated)
Date of admission:Jan 5 2012
Date of discharge: Jan 9 2012
Admission Diagnosis: parturition
Other diagnoses contributing to length of stay:
1. Gestational hypertension

Other diagnoses not contributing to length of stay:

1. Anemia

Infections or complications:
None

Operative procedures:
Jan 5 2012, lower segment cesarean section, Dr. R. Gratton

Discharge meds:
Ibuprofen 400 mg po four times daily
Tylenol 650 mg po four times daily
Morphine 5 po 4 times daily
Ferrous gluconate 300mg PO twice daily

ALL: NKDA

Active issues:
Postoperative c/section recovery
 17
Postpartum
Anemia
Resolving gestational hypertension

Hospital course:
Age, GTPAL, presented to OB triage @ weeks with…
Admitted, describe labour management
Serology protective?
Achieved what dilation
Consented for c/s for ? Indication
For further details refer to OR note
Post operatively did well?
Complications in hospital? Postpartum? How were
managed?
At time of discharge voiding well?, ambulating? Good supports
at home?
Minimal vag bleeding, passing gas
Describe physical exam
Recent labs
Planned follow up
Discussed concerning signs & symptoms

Sign, Cc3
Carbon copy fam doc, yourself & OB

Gyne follow same template but omit delivery details

18
Postpartum Problems
Anemia: if HB<100 and has had a BM
ferrous gluconate 300 mg po tid

Bowels: consider fleet enema x 1 prn if no BM after

day 2 or Dulcolax 1 tab x 1 (1 now, 1 in 12
hours) po/ sup prn

ENSURE NOT CURRENTLY BLEEDING! VITALS!

Fever: >38 in any of first 10 days except day 1 @38.5

? chorio –consider Amp/Gent/Flag
(obtain vag & urine C&S first) CBC
? consider PE
? breast engorgement/abcess?/mastitis
? wound infection

Remember the 5 W’s:

Wind - lungs (atelectasis) -first 24 hrs
Water - bladder (UTI) - variable
Wound - incision (cellulitis) - 2+ days
Walking - legs (DVT/thrombophlebitis) -5-7 days
Wonder Drugs -right away

Insomnia: consider ativan 1 mg SL qhs prn

Leukocytosis: if >20 consider: CBC, C&S, urine R&M, C&S

 19
Chart Notes – Gyne Rounds (Example)
50 y.o. POD # 1 TAH + BSO for Menorrhagia

Medical issues list, ie. 1. COPD

2. DM Type II
3. Wound infection

S/ Pain? Po fluids or DAT?

Flatus, voiding? Foley in or out
Ambulating?

O/ VS: febrile?, Stable? HR, RR, BP,

Urine output, TFI/Balance
CVS: N S1/S2, S3/S4, murmurs
Resp: chest sounds, BS bilat., crackles/wheezes?
Abd: BS, distension, tenderness
Wound: clean? Dry? Intact? Draining? erythema?
Vag: flow, clots, packing out?
Legs: calf swelling/warmth (DVT?)
Lab results:

Ax/ doing well or not, what to reconsider

P/ ? Consult
? Discharge

Sign Note, M3
20
Chart Note – Operative Note
Example:

Date & Time - September 3, 2013 08:00

Pre-op Dx - Menorrhagia
Procedure - 1. TAH
2. BSO
Post-op Dx - same
Surgeon - (staff)
Assist - (residents)
Anesthesist - (staff)
Anesthesia - GA
Findings - bulky fibroid uterus, normal ovaries &
tubes
EBL: 400ml
Counts: correct
Comps: none
Drains: none
Packs: (note if vag packing and foley in situ)
Disposition: stable

Sign Note, M3
 21
Orders – Day Surgery
Written on pink form:
DAT
AAT
VSR
IV RL @ 150 cc/hr, d/c WDW
Morphine 2-10 mg SC q4h prn (0.1 mg/kg)
Tylenol #3 / Plain 1-2 tabs po q4h prn
Gravol 50 mg IV/PO q4h prn
Ibuprofen 400 mg po q6h ATC
Morphine 5-10 mg SC q4h prn Breakthrough Pain
Gravol 50 mg IV/PO q4h prn Nausea
d/c home when stable & able
F/U with Dr _________ in 6wks
22
Commonly Ordered Meds
Analgesia: Morphine 2-10 mg SC q4h prn
Toradol 30 mg IV q6h prn (NOT TO PREGNANT
PTNTS)
Naprosyn 250 mg po tid prn (NOT TO
PREGNANT PTNTS)
Tylenol #3/pl 1-2 tabs po q4h prn
Percocet 1-2 tabs po q4h prn (for codeine allergy)
Ibuprofen 400 mg po q6h prn (NOT TO PREGNANT
PTNTS)
Tramacet 1-2tabs po q4h prn

Antiemetics: Gravol 50 mg IV/PO q6h prn

Maxeran 10 mg IV/PO q6h prn
Stemetil 10 mg IV/PO q6h prn
Ondansetron 4mg IV/PO q8h prn

Anticoagulant: Heparin 5000U SC bid

Fragmin 5000U SC OD

Anti-Constipation: Colace 100 mg po bid

MOM 30 cc po bid prn

Anti-Reflux: Diavol 15-30 cc po qid prn

Ranitidine 150 mg po bid prn
50 mg IV tid prn
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Commonly Ordered Meds Cont’d
Anti-Insomnia: Ativan 1 mg SL qhs prn
(Don’t use too liberally in elderly, can have bad
reactions)

Antibiotics:

(Chorioamnionitis therapy = amp, gent, flagyl)

Ampicillin 2g IV q6h
Gentamycin 120 mg IV q12h (gent. levels pre/post 3rd dose)
Flagyl 500 mg IV/PO q12h

(Preop)
Ancef 1g IV q8h

(GBS)
Penicillin G 5 million units IV then 2.5 million units Q4h if no allergy
(may substitute with Ampicillin 2G IV then 1g IV q4h, but Pen G is
better)
If NON-ANAPHYLACTIC reaction to Penicillin, 2nd line
is Ancef 2g IV then 1g IV q8h.
If ANAPHYLACTIC reaction to penicillin, and swab
proven sensitive to both erythromycin AND clindamycin
then 2nd line is Clindamycin 900mg IV q8h OR
Erythromycin 500mg IV q6h
If sensitivities unknown, or resistant to EITHER
clinda/erythro, then 3rd line is Vancomycin 1g IVq12h
24
Commonly Ordered Meds Cont’d

(Wound infection)
Superficial cellulitis – Keflex 500mg PO QID
Deep collection/fluctuant mass – add Flagyl 500mg PO TID

Endometritis
Keflex + Flagyl

(UTI Tx Macrobid, Amoxil, Cipro)

MacroBID 100mg PO BID
Amoxil 500 mg po tid
Ciprofloxacin 500 mg PO bid or 400mg IV bid
 25
Phone List
Individual Pager # Department Ext. #
Red Consultant 15600 Admitting 58116
Blue Consultant 15603 Security 52281
Red Resident on call 14465 Emergency 58141
Blue Resident on call 15009 Virology 64667
Gyn Resident 15499 Hematology 56495
A/N Resident on call 10394 Pharmacy 52162
Anaes. Consultant 15572 Blood Bank 58292
Anaes. Resident 15573 Microbiology 56495
Radiology 58297
Ultrasound 58296
Clerk Pager # OR 58226
OB Red 14925 & 14927 (night)
OB Blue 14920 & 15566 (night)
Gyn Gray 19544
Gyn Purple 14912

Red Team Physicians Blue Team Physicians

Consultants Pager # Ext. # Consultants Pager # Ext. #
Dr. Tracey Crumley 10803 66401 Dr. Saima Akhtar 15391 58002
Dr. Robert Di Cecco 10143 66152 Dr. Shannon Arntfield 18089 58289
Dr. Genevieve Eastabrook 18281 66091 Dr. Cynthia Chan 13979 58002
Dr. Robert Gratton 10116 64052 Dr. Barbra de Vrijer 16087 64052
Dr. Joanne Kirby 14629 58394 Dr. Laudelino Lopes 10424 61026
Dr. Yvonne Leong 15780 58223 Dr. Barry MacMillan 10196 66247
Dr. Jordan Schmidt 10762 66106 Dr. Michael Maruncic 15533 58193
Dr. Laura Sovran 15738 58223 Dr. Renato Natale 10407 66091
Dr. Angelos Vilos 17006 66104 Dr. Debbie Penava 10366 66401
26
Hints & Tips
General Hints:

If you want to be involved, stick with the resident. This ensures you are aware of what
is going on and around to help out.
No one gets along with everybody, but maintain a good attitude, and try to keep
positive and you’ll be sure to enjoy the rotation.
If paged, answer as soon as possible – things happen quickly in the DR, and promptly
answering pages ensures you won’t miss out on them.
Nights before call, make sure to get plenty of rest, you’ll need it.
Build a rapport with your labouring patients by checking in on their progress frequently.
Being seen regularly helps keep you involved.
Introduce yourself to the nurses and make sure your pager number is written on the
board so you will be called for deliveries.

Evaluation Tips:

Wait until after the first week to give out your evaluations.
Prior to taking the admission hx & px from the patient - sit down alone with the patient’s
chart and use the antenatal forms and referral notes to fill in as much of the hx first -
you’ll save yourself a world of time.
Keep track of good hx & px admissions from DR or A/N you’ve done for later chart
review evaluation.
Don’t sweat the exam, if you’ve been paying attention while in clinic and at teaching
sessions, you’ll be fine.
Evaluations should be distributed to varying levels of residents (not all R2’s)

Technical Hints:

Learn to do SFH and Leopold’s maneuvers early, you’ll be using them a great deal.
If cutting sutures, cut 1 cm above the knot unless requested otherwise, you can always
cut shorter but not longer.
Practice tying knots and suturing on breaks. You will be given more opportunities if you
can do these. Ask the OR nurses for extra sutures that you can take home for practice.
 27
Objectives
1. The
clerkship will demonstrate basic knowledge
and application of skills in women’s healthcare
required to function effectively as an
(undifferentiated) physician.
Obstetrics
2. Perform a focused history and physical examination in early
pregnancy.
3. Establish and confirm gestational age.
4. Identify risk factors during an initial antenatal assessment.
5. Identify relevant health issues in pregnancy.
6. Counsel patients with respect to nutrition, activity and exercise,
sexual activity, smoking and drug use in pregnancy.
7. Discuss the importance of routine prenatal laboratory
investigations, prenatal diagnostic options (IPS, Quad screen,
amniocentesis, CVS) and ultrasound assessment of fetal
morphology.
8. Identify the optimal time in pregnancy to order the various
prenatal diagnostic options and ultrasound.
9. Participate in ongoing antenatal care and investigations (GDM
screening, Rh prophylaxis, GBS screening, term cervical
assessment) to ensure maternal health and normal fetal
growth.
10. Demonstrate knowledge and management of obstetrical
complications seen in triage or on the antenatal ward
(decreased fetal movement, preterm labour, premature rupture
of fetal membranes, maternal hypertension, pre-eclampsia,
antepartum bleeding).
28
Obstetrics Continued
11. Describe normal and abnormal progress of lab or full
nulliparous and multiparous women.
12. Participate in intrapartum management including assessment
of labour, cervical dilation, fetal position.
13. State the criteria for ensuring antenatal fetal well-being (non-
stress test, biophysical profile) and intrapartum fetal health
(intermittent and continuous fetal heart rate monitoring).
14. Perform a vaginal delivery under supervision and actively
manage the third state of labour.
15. Participate in or observe a caesarean section.
16. Identify a first, second and third degree obstetrical laceration.
17. Define and participate in the management of post-partum
haemorrhage.
18. Support women in their effort to breast-feed.
19. Identify and manage post-partum complications (voiding
difficulty, nerve injury, venous thromboembolism, perineal and
bowel care, depression).
20. Describe normal healing at 6 weeks post-partum.
21. Provide counselling regarding risks and success rates of VBAC
(vaginal birth after caesarean section).
22. List contraceptive options post-partum.
 29
Gynaecology

23. Perform a focused (including menstrual, contraceptive, sexual

and gynaecologic) history in ambulatory patients presenting
with gynaecologic problems.
24. Perform a complete physical exam with emphasis on the
gynaecologic exam (abdominal exam, bimanual pelvic exam,
speculum exam and Pap smear) in ambulatory patients
presenting with gynaecologic problems.
25. Develop a differential diagnosis and management plan for
common gynaecologic problems (dysmenorrhea, dysfunctional
uterine bleeding, contraception, infertility, pelvic mass,
menopausal symptoms, post-menopausal bleeding, pelvic
relaxation and urinary incontinence).
26. Outline an approach to diagnoses and management of patients
presenting to emergency or urgent care with acute
gynaecologic problems (first trimester bleeding, pelvic
infection, pelvic pain, wound infection and acute bleeding).
27. Participate on the gynaecologic surgical team providing
perioperative care and assist in common gynaecologic
surgeries (laparoscopy, vaginal and abdominal hysterectomy,
repair of pelvic prolapse and urinary incontinence).
28. Diagnose, investigate and manage post-operative complication
(VTE, PE, UTI, infection).
29. Describe the importance of screening of cervical cancer and
current screening programs.
30. Discuss the results of an abnormal PAP smear and outline
appropriate follow-up or investigation.
31. Identify the signs and symptoms of gynaecologic malignancies
(vulvar, cervical, endometrial, ovarian).
30
Gynaecology Continued

32. List the important investigations for gynaecologic malignancies

(colposcopy, cervical or vulvar biopsy, endometrial biopsy,
Ca125, pelvic exam).
33. Conduct patient-centered interviews that explore the patient’s
feelings, idea, impact on function, and expectations.
34. Develop therapeutic relationships with patients characterized
by compassion, empathy, respect and collaboration regarding
management decisions.
35. Discuss access to abortion in Canada and how patients in
London and Southwestern Ontario access services at LHSC.
36. Describe how new patients requesting abortion are assessed
and how they are screened prior to booking a procedure date.
37. List the different methods of abortion and which are
appropriate based on gestational age and patient selection.
38. Describe a first trimester D&C including the technique and
potential complications.
39. List contraceptive options post abortion and follow up available
to each patient.
40. Describe the psychosocial variables that place women at risk
for unintended pregnancy and how they shape decision-
making.
41. Recognize personal beliefs regarding abortion and, through
values clarification, discover ways to suspend judgment and
avoid bias in Options counseling.
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Notes: