OBJECTIVES FOR OBSTETRICS AND GYNECOLOGY CLERKSHIP

These objectives outline the minimum knowledge of women's health care that we expect no matter what your future field will be. Within the bounds of available time and these objectives, you can decide to emphasize different aspects of the course, i.e. if you're going into radiology you may want to concentrate on ultrasounds, or if you're interested in cardiology you may want to concentrate more on the way pregnancy affects the heart or on diagnosis of congenital heart defects. You will have opportunities to pursue special interests in presentations among the students and for your teams.

Success on this rotation depends on good communication with your team. The schedule is complex. Let your teams know what interests you, and let them know where you are and what you are doing if it varies from your schedule. Don't tell your team what doesn't interest you.

Performance Objectives (also denoted with "-" within other categories)

GYN

Perform at least 3 pap smears. Be sure to look up results even if you don't see the patient in follow-up, so that you can see if your specimen was adequate.
Counsel at least 5 women about contraceptive options.
Interpret Pap results and recommend treatment for at least 3 patients.
Observe colposcopy at least once.
Incorporate age appropriate counseling and screening tests (i.e. Pap smear, STD risk assessment, dietary counseling, osteoporosis prevention, etc.) into an annual exam.

OB

Read the chapter on normal labor and delivery before your first call night.
Provide postpartum discharge instructions for at least 5 women.
Follow at least 3 patients through the entire course of labor, delivery, postpartum, and newborn exam.
Be actively involved in the labor and deliveries of at least 5 women.
Do at least two new ob visits in clinic.
Auscultate fetal heart rate with fetoscope and with Doppler.

Surgery

Do at least 2 preoperative H&P's for surgeries that you will observe; this includes day surgery patients. Write preop and postop orders on these patients.
Do ward round daily, always following patients on whom you did the initial H&P.
Write daily postop notes in which you anticipate common postoperative complications that must be ruled out on all postop patients - i.e. atelectasis, anemia, ileus, nausea, UTI, wound infection, DVT.
For day surgery cases that you pre-op, see them prior to discharge and call them at home 1-2 days after surgery to inquire how they are doing.

Behavioral Objectives

Be where you are supposed to be promptly and stay until the team is done.
Tell your resident where you can be found.
If you must miss scheduled activities or are late, call your resident.
If you don't understand the schedule or the reason for the schedule discuss it with your team or with the course director or coordinator.
If you feel there is a personality conflict between you and a resident or attending, bring it to the course director early.
Make eye contact with your patients and with your team members.
Maintain confidentiality - i.e. h/o TAB, STD, HIV testing - look for and trust non-verbal cues about sensitive issues - when in doubt wait to ask until family members leave or withhold sensitive information when a family member is present.
If a patient states that she is uncomfortable with you, involve a resident or faculty in the discussion with the patient. If her behavior leaves doubt, it is preferable to reconfirm that the patient is comfortable rather than to continue with your interaction.
Always have a resident or faculty present when you do a pelvic exam.
Be assertive in suggesting a plan of care to your team, but wait until the team has approved your plan before suggesting it to the patient.
Be responsible for your ideas and actions, be ready to explain why you chose a given plan. Aim to have a better reason than "I was told to do this."
Sometimes students feel as though they are H&P machines for their teams. It is much more important to have continuity with patients than to write another admit note. On labor and delivery you should only see exam patients only when you are free to pick up another patient to follow.
When you are on the ob team, in order to gain continuity, it is OK to be late for or called away from clinic or postpartum rounds in order to attend a delivery. However, you must inform your resident that you are doing this. Likewise, if you are in surgery or working up a patient in GYN clinic or ER and this will make you late for call, let your resident know.

Obstetrics Objectives

Introduction/Orientation to Labor and Delivery

List 3 ways to diagnose pregnancy.
Describe 4 criteria for dating a pregnancy by clinical parameters (i.e. without ultrasound)
Describe the effects of pregnancy on cardiovascular, pulmonary, renal, and GI systems.
List 4 health habits that you inquire about during preconceptual counseling.
List 2 lab tests that you would order during preconceptual counseling.
Define "adequate" prenatal care as described by ACOG. List 3 pathological processes prenatal care is designed to diagnose, and what impact these diagnoses have on the pregnancy.
List 8 routine prenatal labs and reasons for each.
List 3 indications for an ob ultrasound for dating.
Differentiate among the terms position, presentation, station, effacement, dilation.
List 5 criteria used to describe basic fetal heart rate tracings. List 3 types of decelerations and the implications of each.
Describe 3 methods for pain control during labor.
Describe placenta previa, placenta accreta, circumvallate placenta, and succenturiate lobe.
Differentiate among 1st, 2nd, 3rd, and 4th degree obstetrical lacerations.
Define postpartum hemorrhage and describe 3 methods for treating it.
Describe 5 common problems that occur postpartum that women need to be warned about prior to discharge.
Describe how to treat an uncomplicated UTI in an ob patient and in a gyn patient.

Hypertensive Disorders

Define pre-eclampsia.
Describe 4 risk factors for developing pre-eclampsia and in general the treatment.

Infections

Define amnionitis and endomyometritis. List 3 risk factors for post-partum endo-myometritis. List the 3 most common bacteria that contribute to post-partum endo-myometritis.
Describe the 2 accepted maternal screening methods for reducing neonatal Group B strep infections.
List the 5 TORCH syndromes and the most common fetal effects of each.
Describe maternal screening for HIV infection. What is the aim of treating during pregnancy?

Premies and Postdates

Describe 2 risks involved in postdatism
Define preterm labor.
Define preterm contractions.
Define preterm ruptured membranes
Distinguish among risks for preterm labor and etiologies of preterm labor. List 5 of each.

Abnormal Labor

Define active labor and latent labor. Be able to distinguish between them.
Describe the normal labor curve for nullip- and multiparous women. Describe 3 options for managing failure to progress normally.
List 4 risks of multiple gestation.

Substance Abuse

Interview at least 4 women about use of substances, including tobacco and alcohol.
Counsel at least 2 women about smoking cessation.
Describe 3 community resources that are available for women with substance abuse problems.

Breast-feeding

Describe the role of oxytocin, prolactin, estrogen and progesterone in lactation.
Describe common management for nipple soreness.

Genetics

Describe the triple marker test and how to counsel women about this test.
List 3 indications for genetic amniocentesis.

Gestational Diabetes

Define gestational diabetes.
Describe how to screen for and who to screen for gestational diabetes, and 3 risks associated with it.

Ectopic Pregnancy and Spontaneous Abortion

Describe 4 possible etiologies of first trimester bleeding.
Describe 3 risk factors for ectopic pregnancy.
Describe 2 ways to diagnose a non-viable pregnancy.
Describe 3 risks for spontaneous abortion and 3 causes of spontaneous abortion.

Bleeding During Pregnancy

Describe 4 possible etiologies of third trimester bleeding.
Describe the psychology of pregnancy loss and grieving.

Oncology Objectives

Pelvic Mass

Differentiate signs and symptoms of benign vs malignant pelvic masses.
Describe the effect of endogenous and exogenous hormones on the ovary.
Describe 2 absolute indications for surgery on a pelvic mass.
List 4 risk factors for ovarian cancer.
List the 3 major classes of ovarian cancer and their benign counterparts.
List 3 criteria for surgically staging ovarian cancers.
Describe the incidence of ovarian cancers by age.
Describe the 5 year survival rates for ovarian cancers by stage and by tumor type.

Cervical and Vulvar Cancer

Describe how to stage cervical cancer.
Distinguish radical hysterectomy from simple hysterectomy.
Describe 2 possible treatments for invasive cervical cancer.
Describe the 5 year survival for cervical cancer by stage and tumor type.
Describe 3 signs and symptoms of vulvar cancer and 2 risk factors for vulvar cancer.
List 2 vulvar dystrophies and know how to distinguish them.

Endometrial Cancer and GTN

Describe 4 risk factors for endometrial cancer.
Describe how to diagnose and stage endometrial cancer.
List 2 methods for treating endometrial cancer.
Define gestational neoplastic neoplasia. List 2 risk factors for GTN. List 2 possible treatmentsfor GTN.

Gynecology Objectives

Contraception and Abortion

Name the four major categories of contraception, their effectiveness and use effectiveness, contraindications, pertinent exam and history to be noted prior to prescribing, and side effects.
Describe the three options available to women when pregnancy is diagnosed.

STD Screening and Prevention

List 6 guidelines that determine if a patient needs STD screening.
Name 6 common STD diagnoses, the symptoms and signs of each, and how to test for them.
Describe 4 methods for preventing STD's.
Describe the effectiveness at STD prevention of each contraception method.

Cancer Screening and Prevention

Describe the ACOG guidelines for cervical, ovarian, endometrial, breast, and colon cancer screening by age group.
List four components of the Bethesda system for classifying Pap results.
Describe 4 risk factors for cervical intra-epithelial neoplasia (CIN) and for cervical cancer.
List 3 treatments for CIN.
Distinguish between endometrial hyperplasia with and without atypia. Interpret endometrial biopsy results and recommend treatment.

Vaginitis

Define 3 causes of vaginitis, the signs and symptoms of each, an office-based test for each and how to treat each diagnosis.
Prepare and interpret at least 4 wet mounts.

Pelvic Pain - Acute

Describe the 5 most common items on the differential diagnoses for acute pelvic pain. Describe 5 signs, symptoms, or tests that would be available in a stat lab that enable you to distinguish among these items.
Distinguish an acute surgical abdomen from a non-surgical abdomen.
Describe 2 outpatient and one inpatient antibiotic regimen for treating PID.
List 4 criteria for admitting a woman with PID.
Describe the 2 most common PID pathogens and their relative incidence.
Describe the 4 risk factors for contracting PID.
Describe 3 possible sequelae of PID.

Pelvic pain - Chronic

Define chronic pelvic pain.
Describe 4 items on the differential diagnosis for chronic pelvic pain. Describe 4 signs or symptoms to help distinguish among these items.
Describe 2 theories regarding the pathogenesis of endometriosis.

Menopause

Define menopause.
Describe 4 signs and symptoms of menopause.
Describe 2 regimens for hormone replacement therapy (HRT).
Describe 3 pros and 3 cons of HRT.
Describe 2 contraindications to HRT.
You may not have an opportunity to counsel a woman about HRT but try to take the opportunity to ask a post-menopause woman why she chose to take or not take HRT.

Menstrul Cycle

Define the normal menstrual cycle, describe variations in normal at menarche and perimenopause.
Diagram the menstrual cycle, showing levels of ovarian and pituitary hormones.
Define dysmenorrhea and describe 2 common treatments for it.
Define premenstrual syndrome.
Describe the effects of hormonal variation on other systems ie headaches, seizure disorders, GI tract, sleep, mood.
Define abnormal uterine bleeding and list 3 common hormonal and 4 common non-hormonal causes of it.
Define the terms estrogen breakthrough, estrogen withdrawal, and progesterone withdrawal.

Infertility and Amenorrhea

Definite infertility.
Describe the three categories of infertility.
List 3 risk factors for infertility.
Define primary amenorrhea and describe 4 major causes.
Define secondary amenorrhea and 4 major causes.
Define hirsutism, describe its relation to anovulation, and list 3 major causes.

Urogynecology

Define 3 types of incontinence.
Describe 4 signs and symptoms of UTI.
Describe how to treat an uncomplicated UTI in an ob patient and in a gyn patient.
List 4 risk factors for UTI.

Breast disease

Describe the differential diagnosis for a breast mass by age, i.e. <30, 30-50, >50.
Describe 2 criteria for ordering a mammogram.
List 4 risk factors for breast cancer.
Define galactorrhea.
Define mastalgia.
Describe 2 risk factors for mastitis and the most common pathogen.

Sexuality

Define sexual orientation and gender dysphoria.
Identify the 4 phases of sexual response.
Explain the impact of pregnancy, the postpartum period, and menopause on sexuality.
Define sexual dysfunction. List 5 classes of drugs that may cause sexual dysfunction.
Take a sexual history from at least two women.

Physical, Emotional, and Sexual Abuse

Interview at least 4 women about history of these issues.
Describe 2 community resources are available for women with these problems.
Describe the cycle of abuse and 2 risk factors for being in an abusive relationship.

Pelvic Anatomy

Describe the course of the ureter.
Describe the blood supply and innervation of the uterus, ovaries, bladder and vulva.
Understand the repair of obstetric laceration.
Understand the embryology of the reproductive tract, and its relationship to uterine anamolies.