Professional Documents
Culture Documents
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.
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
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.
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
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.
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.
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
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.
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
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).
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.