What was a memorable patient or experience that I’ll carry with me?

There was a 19 year-old female patient who came in complaining of a “cyst” at her vulva. She said that she has had a history of getting them, and the most recent episode was a month before, where she had to get it drained at a hospital. This time, the affected area was at a different location; extended from the left side of the mons pubis, down to the middle of the vulva, and had developed an abscess. Her pain was so severe that she had trouble sitting and walking. This patient stood out to me for multiple reasons. The first reasons were due to her young age, and that she had been dealing with this recurrent issue. I felt terrible that she had to experience this, and even worse with the visible and audible pain she was in during I&D. 

The patient had already been given some morphine while waiting for the OBGYN team to see her. When the local analgesic was injected, it still caused the patient so much pain that she was screaming. She had already signed a consent form prior, but during the procedure, she was begging the team from going any further. Her pain control was so difficult that she was given an additional dose of morphine in order for the procedure to continue.

Throughout the encounter, I watched as the second year resident professionally proceeded with the I&D. I admired the way the provider kept her focus, in order to give her patient the best treatment. At the end of the procedure, the patient had felt much better and was so thankful. I was glad to have been present to offer the patient a hand to hold, and to witness the professionalism of the resident and the relief of the patient.

 

Exposure to new techniques or treatment strategies – how did that go?

On my OBGYN rotation, I was surprised to learn all the work that goes in prior to getting ready for delivery. I learned about the usefulness of fetal monitoring tracing, and the need for routine checks on the mother to see if she is having adequate contractions, and if her cervix is properly dilating and effacing. There were different indications to start the induction of labor, as well as multiple techniques that could be used (ie: Pitocin, Cervidil (Dinoprostone), cervical foley balloon). I was particularly surprised to learn about the intra-cervical tools. I found it difficult to watch the insertion of these, as the process was painful for the mothers.

The deliveries, on the other hand, were amazing to be a part of. I have always wanted to witness a live birth. I never would have imagined that I would be so lucky to be on a rotation that would offer me this opportunity. In total, I was able to participate or observe 5 vaginal deliveries, and scrub-in to 3 cesarean sections. The first NSVD was intense. The mother was not pushing well due to fatigue, and the baby’s crown was stuck at the vaginal introitus. The main providers had to take turns trying to expand the outlet for the baby and coach the mother, additional help needed to be called, the mother had to undergo an episiotomy, and multiple birthing maneuvers were utilized. It felt like the whole process took a stressful 15 to 20 minutes, and I remember feeling nervous for the mother and her baby. In the end, the baby was delivered soundly, with a high APGAR score, and did not suffer from shoulder dystocia. 

In the last NSVD I participated in, I was able to draw cord blood and deliver the placenta. After, I helped to clean up the patient and return her to a comfortable position. Even though these actions would not seem big to the seasoned provider, I was thankful for the experience of feeling part of the team. 

In the last cesarean section I scrubbed in for, closing the patient’s tissue layers was difficult. The patient had her small bowel seeping out from above her uterus, where multiple attempts were performed to anesthetize the patient to relax so that the bowels could be put back in place. Additionally, the patient had managed to move her hand during closing, and placed it right on the surgical field. All these incidences made for another interesting memory I would keep from my OBGYN rotation. 

 

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

I realize that I need to improve on my patient history taking. I find myself getting flustered during my interview on the questions I need to ask, and feeling rushed to not take too long before reporting to the overseeing medical provider. My plan for improving this is to mentally prepare before talking with the patient. I would try to think about what are the important questions to ask. If there is no time prior, I will make sure I thoroughly go through the OLD CARTS, and ask any other pertinent questions. It would also be important for me to think of possible differentials, in order for me to formulate good questions to help rule them in or out. I also try to remind myself that a good history can help lead to a diagnosis a majority of the time, so I should not be worried about taking a little extra time than usual.

Another issue that needs improving is when it comes to emergency visits. I am nervous to waste too much time asking nonessential questions that may waste precious time that could be used to immediately address the patient problem at hand. To improve this, I know that I need more practice interviewing patients. By getting more experience, I will start to understand what questions are necessary versus what questions can wait until the patient is stabilized/pain-managed.

 

How your perspective may have changed as a result of this rotation?

Prior to this rotation, I never considered the pain and emotions involved in the OBGYN specialty. As much as there was happiness in the wellness visits of OB patients, and joy in the delivery room when the baby arrives; I also noticed there to be pain, suffering, and grief. An example was when mothers needed the induction of labor with intra-cervical techniques, such as the foley balloon or Cervidil (Dinoprostone). The mothers were often sensitive in that region, and in great discomfort during the insertion process. Another example is during the labor processes, when mothers would be moaning and yelling from their rooms for help to deal with their contraction pain. Delivery itself caused fatigue and pain for the mothers. I watched as a patient received an emergency episiotomy without any anesthesia, for the greater good to quickly and safely deliver her baby; with the subsequent repair after delivery. There was another patient who came in after a spontaneous abortion at home. It was heartbreaking to hear that the pregnancy was considered “threatened” for 2 months prior, due to bleeding, and she believed that it may be due to her age. I could not even imagine her grief, as this pregnancy was wanted. In addition, she had to undergo removal of products of conception from her vaginal vault, which caused her excruciating pain. From all these experiences from this rotation, I have an even greater respect for mothers and their pregnancy struggles, as well as women in general, for the physical and emotional pain they have had or may need to endure.

Intracervical Foley Catheter Balloon Versus Dinoprostone Insert for Induction Cervical Ripening: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Lixia Zhu, Cong Zhang, Fang Cao, Qin Liu, Xing Gu, Jianhao Xu, Jianqing Lihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6283136/pdf/medi-97-e13251.pdf

 

On my OBGYN rotation, I have noticed two main tools used for the induction of cervical ripening: foley catheter balloon and Cervidil (Dinoprostone). I was curious about which method is more effective for labor induction. This article is a systematic review and meta-analysis, published in 2018 in Medicine (Baltimore) journal. Their objective was to “perform a meta-analysis to compare the efficacy and safety of the intracervical Foley catheter and the dinoprostone insert for cervical ripening for successful labor induction”. They searched PubMed, Embase, and the Cochrane Library for related articles, with inclusion criteria of primigravida, singleton pregnancy, patients between 37 and 42 weeks, vertex presentation, Bishop score ≤3, intact membranes, use of intracervical foley catheter or Dinoprostone insert, outcome of cesarean delivery rate and induction-to-delivery interval. 8 studies fit the inclusion criteria, with a total of 1191 receiving Foley catheter balloon and 1199 receiving the Dinoprostone insert.

• • 19.5% of patients with Foley catheter balloon vs 21.4% receiving the Dinoprostone insert had received cesarean section. 
  • There was no statistically significant difference in both groups’ induction-to-delivery interval (after a random-effects model was used). Found that moderate balloon volume (30mL) and higher dose of Dinoprostone (>6mg) was related to shorter intervals.
  • 3/8 studies found Dinoprostone insert to be associated with shorter time to delivery, while 4/8 found Foley catheter balloon to be associated with shorter time to delivery. ⅛ found no difference between the two methods.
  • No difference was found in maternal complications (ie: post partum hemorrhage, maternal infection, uterine hyperstimulation) and fetal outcomes (ie: APGAR at 1 and 5 minutes)
  • Concluded that theres comparable efficacy with both methods.