Life update and Obstetrics & Gynecology rotation

Hello my readers!

I sit here on a Sunday night alongside Hubby, kiddo is fast asleep, the kitchen is clean, laundry is in the dryer. Garbage/recycling collection day is tomorrow and that has been placed outside (hoping for no racoons!)

Plants in the rain – front porch.

We are in our new house – for the past month and loving it! We don’t have couches yet, or the dining table or even our new mattress (but we got our new bed frame delivered today). We do have a coffee table which overlooks our pool and the ravine. I am almost done putting together my office space with a little meditation corner on the floor. (My family med board exam is coming up next year! ARGHH) This is our home and it will take a while for everything to come together and I couldn’t hope for anything better. One day at a time.

In between all this craziness of moving from Kingston -> Oshawa, Internal medicine -> ObGyn, PGY1-> PGY2, moving to our new home I have been MIA on my site. Could you blame me? When I finally sit at the end of the day (or on post call days), kiddo is at daycare and I just want to sit on the patio and do nothing / watch mindless trash TV and do nothing. Enough is enough – time for an update!

After my IM rotation, I completed two blocks of ObGyn and now I am on an elective rotation where I am in gyne clinics. (Total three months of ObGyn Feb, July, August. Now September is just in gyne clinics).

Just as how I wrote about my Internal Medicine days I wanted to write a similar post.

Disclaimer: The views expressed here are my own and do not reflect the views of the program that I matched at.

On non-call days:

Non-call days are clinic days. Before the rotation begins we are assigned a preceptor and we would attend their clinic on the days we are not in the hospital. Usually clinic begins at 9 am and goes on until 4 / 4:30 pm. I love clinic days, they are busy but I love the normal hours and lots of learning! Sometimes if our preceptor does not have clinic we can attend another preceptor’s clinic days if they do not already have a resident attending.

Preceptors are particular about residents wearing formal wear and white coat in clinic.

The clinic I attend in the GTA has a very multicultural/diverse patient population and it is quite refreshing!

I see patients who are coming in for prenatal, postpartum visits, postmenopausal bleeding/dysfunctional/abnormal uterine bleeding, contraception counselling, pap smears/ abnormal pap results, IUD insertions and string checks, endometrial biopsies, pessary removal/cleaning and reinsertion or those who need new pessaries, lichen sclerosus follow ups, incontinence etc. All of these are referrals made by family doctors to the obgyn doctor.

Sometimes if there is no clinic and I am not on-call at the hospital, I can go to the hospital to attend colposcopy clinic. Colposcopy is if a patient has an abnormal pap test and needs to be seen at this special clinic to get a better look at the cervix. A vinegar-like solution is sprayed on the cervix to visualize any abnormalities on the cervix that may need a biopsy (to rule out any precancerous tissue).

When I am practicing I want to be a family doctor who is comfortable doing women’s health procedures and knowledgeable about it as well. That’s why I wanted to do an elective in just gyne to get more practice -> IUD insertions, endometrial biopsies, pessaries, contraception counselling, prenatals and postpartum visits etc.

Perks -> I have much improved in detecting FHR using a doppler (quicker than before), click click NOT whoosh whoosh! Hint: If you hear whoosh whoosh this is coming from the placenta, you don’t want that. It is the sweetest sound ❤ The happiness seen in most to-be Moms (especially first time pregnant) is super awesome!

Research -> I began my research project in the clinic! It is directed towards pregnant women and their thoughts on the COVID vaccine. I have a few people who have submitted their responses, I am quite interested to see what the results will be. Resident research day is Feb 2022!

On call days (6 days in ObGyn rotation – on call Q4day/every 4 days):

6 x 24 hour shifts every block (1 block is one month). I have completed three blocks of ObGyn.

Reach the hospital at 7:30 am, head over to the L&D floor.

Residents get an on call room which is nice! It has a bed, a microwave & fridge, a phone and lamp. In this hospital there is only one resident and one attending present for 24 hr shift.

I throw my bags in the on call room, change into hospital scrubs and head over to the L&D main meeting area. I get a hold of the resident pager from the receptionist. I am responsible for various pages that I will be called for in the next 24 hours -> mainly for postpartum patients on the other side of the floor. For example: pain medications, hypotension/hypertension, low platelets, other abnormal test results (liver enzymes, urine culture, blood culture etc.) and also paged for the most commonly asked question by patients….WHEN can we leave the hospital, discharge orders!?? 😉

Ok back to what I was saying ….hospital scrubs, get a hold of the resident pager, say good morning to the wonderful hard working nurses, write my name on the L&D board (resident for today and glove size) and then meet my attending!

The attending from the shift before (overnight) discussed those on the L&D board – room by room, when the patient came in, induction/not, any complications in the pregnancy, GBS status (group B strep), how are they progressing etc. Information is also noted on the board (name, their nurse, when they were last checked/how dilated they are, their GBS status etc.). Those who had recently delivered c-section/vaginal/still births were also reviewed incase there was anything for our shift to keep an eye on.

Next, we move onto the triage board. Triage is when pregnant women come in for various reasons: their water broke, they are in labour and having more frequent contractions, premature rupture of membranes, hypertensive, decreased fetal movement, unexpected vaginal bleeding/pain/cramping, scheduled induction dates, scheduled C-section, weekly NST (non stress test) etc. A lot of reasons really!

Next, we discuss if there is anyone that needs to be seen/reviewed/followed up on from a consult in the ER or other gyne patients.

Once all this is reviewed, I have a few mins of one-on-one time with my attending if I was working with them for the first time. What year I was in, what specialty, what are my goals? Here’s a tip that I found worked all the time – I was direct with my attending. If I wanted lots of hands on experience and practice I would tell them “If you are comfortable and the patient is comfortable, I would appreciate lots of hands-on practice.” As soon as I said this, they are more likely to let me practice!

ObGyn is a lot about hands-on practice and doing! I used to have such a difficult time differentiating how dilated and effaced a cervix was! (Well, ok I still do, but now at least I know what I am looking for and I am not THAT far off – I say 3 cm, attending says, more like 2 cm). Embarrassing story alert: when I started my first block of OB, I was checking to see how dilated a patient was and I confidently stated that the patient was 8-9 cm dilated. Of course the patient was happy, her partner was happy, yay things were progressing! My attending checked the cervix next to confirm and said “Sorry to disappoint but you are only 3-4 cm dilated.” Thankfully I was wearing a mask and no one could tell my face was beet red. I apologized profusely and almost RAN out of that room. My attending was super chill and said “Don’t stress you were likely still in the vagina and not further up feeling the cervix. It happens, just practice more.”

Out of all of the times I ARMed/AROM (artificial rupture of membranes) a patient, I was successful ONCE.

Artificial rupture of membranes (https://medicalguidelines.msf.org/viewport/ONC/english/5-3-artificial-rupture-of-the-membranes-51416971.html)

I can successfully insert cervidil to induce, check for pooling and swab to test for ferning to see if patient had ruptured/amniotic fluid. I know to use an ultrasound to check for positioning of baby. I know how to read an NST report (note the FHR baseline, variability, accelerations, any decels).

NST (https://www.motherbabycare.in/2019/03/non-stress-test-nst.html)

As for delivering a baby (vaginal deliveries), I have always had an attending present – I have delivered on my own but there was the attending was nearby. Complicated deliveries with shoulder dystocia, twins, breech etc. the attending obviously did those. I am able to draw cord blood gases and deliver the placenta. If there are tears I still require practice repairing these (why are one-handed ties so complicated)!

As for C-sections, I have scrubbed in on a few to be second assist. Most of the time though, during these C-sections I stay back on the floor and see patients in triage, answer pages or incase I needed to be there a vaginal delivery.

Call shifts differed in how busy they were and how much sleep I got. There were maybe only 3 call shifts where it was not that busy – meaning not many deliveries and slow triage visits. It felt odd for me to be sitting in my call room not being paged/called to assess patients. Compared to Internal med (0 hours sleep!), I used to get at least 3 hours of sleep overnight. Yay!

The attending would get paged from the ER for consults and then I would go see the patient, H&P, assess and report back to my attending and then we would go see the patient together. The consults I have seen were patients who were still bleeding after a miscarriage and D&C, abdominal pain from ovarian cysts, tubo ovarian abscess, sickle cell pain crisis during pregnancy etc.

Interesting things I learned/instances while in my Obgyn rotation (in addition to what I have mentioned above):

Residents are also responsible for filling out the intrapartum/oxytocin/postpartum order sets. The more scut work you do, if you are proactive and have orders ready to go, attendings & nurses appreciate this! Physicians in Ontario will have access to Connecting Ontario. It is a portal where you can access most healthcare records of patients from most Ontario hospitals (if they are connected). I found it very helpful to look up the latest labwork, GBS status & ultrasound results of those who came to triage (sometimes their fam docs/OBs haven’t faxed in prenatal records to L&D yet). Once again attendings and nurses appreciate you for having this info handy in your triage note.

For triage patients in pain my usual orders were: Morphine 10mg and Gravol 50mg orders both IM x 1 NOW.

There is only one anaesthesiologist available, so there are patients who want epidurals and don’t get around to getting one because the anaesthesiologist is in a surgery, kind of sucks really!

Babies come FAST and FURIOUS. Especially those patients who are having their 3rd or 4th kid! There have been instances where a patient is wheeled onto the floor screaming in pain and the baby is out in a few minutes!! We barely had time to wear gloves!

I once walked into a room to introduce myself to the laboring Mom, “Hello I’m Dr. R the resident! So how are we doing in here, ready to get the excitement going?” *GUSH!* membrane rupture! The timing could not have been more perfect.

Wear shoes that do NOT have holes for fluids to seep through. You WILL get blood and fluids on your shoes. So either wear booties over your running shoes or buy shoes that do not allow fluids to get through to your socks 😉 I bought these from Walmart -> Dr. Scholl’s Women’s Jane Shoes. Plus they were super comfy being on my feet most of the day.

When patient comes in because they have decreased fetal movement and we are trying to find the heartbeat – I didn’t realize I hold my breath the entire time, hoping and praying we hear one. So far, I have not had a time where we didn’t find a heartbeat or that I attended a still birth delivery/C-section.

Only until I scrubbed in on a C-section did I realize how MAJOR a surgery it is! I had a C-section two years ago and I did not take my pain and the healing process serious enough.

In summary, women are freakin’ AMAZING. Paps, mammograms, menopause, fatigue from cycles of heavy bleeding, postmenopausal bleeding, procedures, OCPs/IUDs/tubal ligation/biopsies etc. We get pregnant, we carry a life within us for 40 weeks, complicated/uncomplicated pregnancy, our body goes through so many changes. Painful contractions, vaginal delivery / a C-section, a major abdominal surgery and then we try to heal from that pain – all the while trying to care for our babies, or for those who have had a loss the feeling is beyond words can describe. The struggles of breastfeeding/pumping/choosing not to. Taking care of the little one, postpartum blues/depression and the list goes on.

If anything, my obstetrics & gynecology rotation definitely reinforced my love for incorporating Women’s Health into my future family medicine practice. So much respect.

Leave your thoughts below.

Peace, Love & Happiness.

I leave you with a picture of my Buddha garden.

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