H&P/ SOAP notes:

OBGYN – H&P #1

OBGYN – H&P #2

OBGYN – H&P #3

Journal Article and Summary:

Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage

This was an interesting article based on a novel intrauterine device that uses suction to compress the uterus to control postpartum hemorrhage. It has received high praise for its rapid response, ease of use, low side effects, and effectiveness of managing postpartum hemorrhage. This was a prospective, observational treatment study in 12 US medical centers that was published this year. It is called the Jada system, which, was specifically designed to offer rapid treatment, by applying low-level intrauterine vacuum to facilitate the physiologic forces of uterine contractions to constrict myometrial blood vessels and achieve hemostasis from postpartum hemorrhage.

The multicenter study included 107 patients (mean age, 29.7 years) with postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 of whom received any study treatment with the device attached to vacuum. More than half (57%) of the participants were White, and just fewer than one quarter (24%) were Black. Treatment was successful in 94% (100/106) of participants, with definitive control of abnormal bleeding, occurring in a median of 3 minutes after attachment to vacuum.

The authors felt that when medications alone are ineffective at controlling bleeding, tamponade is often added to put outward pressure on the inner wall of the uterus for 12 to 24 hours. Although tamponade is effective in approximately 87% of atony-related cases of postpartum hemorrhage, the use of outward pressure on the uterine walls is counterintuitive if the ultimate goal is uterine contraction.

To use the device, the distal end is inserted into the uterus, and a cervical seal, positioned just outside the cervical os, is filled with 60 to 120 cc of sterile fluid. The proximal end is attached to low-level vacuum at a pressure of 80 ± 10 mmHg. The device is left in place with continued suction for at least 1 hour after bleeding is controlled, at which time the suction is disconnected and the cervical seal is emptied. The device remains in place for at least 30 minutes, during which the patient is observed closely.

In summary about 75% to 80% of cases stop bleeding within 5 minutes and the whole process can take up to 2 hours.

Site Evaluation Presentation Summary:

Professor/ PA Melendez was both my preceptor and site evaluator since he worked in the OB/GYN department at Woodhull Medical Center. He is generally a busy man as we had to reschedule a few times but was able to meet with him when we worked together. He was very welcoming and organized as he had our schedule ready on my first day. During my first evaluation we spoke about my first week in Labor and Delivery where I was able to observe two vaginal deliveries and also examine a delivered placenta. Additionally I was able to learn about the management of expectant mothers and the role midwives and nurses plays in labor and delivery. I also presented common drugs that were used during labor and delivery like oxytocin and misoprostol for induction of labor, labetalol to control gestational/chronic hypertension, and magnesium sulfate for preeclampsia complications. His comments on my focused history and physical were appreciated and we spoke about the occurrence and treatment options of condylomata accuminata. During my final evaluation, I was working in the gynecology service and was fortunate to had the liberty of working alongside him. Again we went over common drugs used in gynecology and I presented my journal article which he found interesting and we talked about postpartum complications, treatments and how the mechanism of a vacuum device could assist in uterine contraction and clearing of retained products/blood. Moreover we went over both my history and physicals per my request and he was surprised to find a 71 year old with herpes. He also gave feedback on what is necessary for a prenatal visit documentation and we went over testing and plans.

Typhon Log:

OB/GYN Typhon Log

Self-Reflection:

I can honestly say I was partially excited going into my OB/GYN rotation as the thought of bringing new life into the world was exhilarating and wonderful. However I knew to curtail my expectations as I was forewarned that being a male may literally close curtains. My peers and upper classmates had told me that when given a choice some females may feel uncomfortable with a male student. Conversely I felt as though most women were acceptable of a male student taking part in there care sans a few who preferred females only. I believe it stems from a comfort and confidence level, both on part of the patient and the provider, or in my case the student. Sometimes if you feel awkward, embarrassed, or lacked interest, patients can tell and that in turn may cause reason to refuse students taking part in a women’s health. This was found to be true and also shared opinion amongst providers and students. I had asked one of the best young male attending’s at Woodhull, Dr. Jones whether he felt it was hard for him as a male to be caring for females only. He had explained that throughout his training there are always those who may not prefer a male provider but sometimes it would be there only option. However the best thing to do is to be knowledgeable, confident, and treat patients with respect, and in turn the women would trust you. Additionally I asked my preceptor, PA Melendez, whose patients are primarily Spanish speaking, he does attribute his success in the field to his culture and being able to relate to his patients. He agreed that being able to speak Spanish and also act as a clinician benefits his patients because in the Spanish/Latin culture they hold clinicians with such high regard and reverence. So I was happy that my overall experience was not as bad as others made it out to be.

Some cons about this rotation was that on certain scheduled weeks, where you are working nights and mostly “on-call” it may not be busy and you literally have a lot of down time, which is good for studying and doing homework. What I did enjoy was working in clinic as you got to see a variety of patients from gynecological problems to prenatal care visits. While in OB/GYN you perform a more focused history and physical exam, which is different from say family medicine. New questions and things that I had to focus on was, there obstetrical history, last menstrual period, last screenings like pap and mammography. As well as the usual medical, surgical history, medications, allergies etc. with the requirement of asking about family history of breast, ovarian, endometrial, and colon cancer. Likewise it was my experience of taking histories that two physicians commended me for gathering and presenting a thorough history.

I really enjoyed working with PA Melendez and understood why students would show up extra early or fight to work with him. He treats you more like a provider and has you take the lead for each patient. Taking a history, performing a physical exam, and tackling the documentation on their medical record. He was one of a very few that allowed students to perform clinical breast and pelvic exams. I was able to gain a lot of experience, and found that I need to be more precise with my placement of the speculum, in that it should go deeper into the vaginal vault prior to opening it. I was also able to do a few pap smears and assist with an endometrial biopsy. I would highly recommend working with him whenever possible as he allows you to be apart of the care team.

Lastly I wanted to reflect upon my labor and delivery experience. I always thought that procreation might very well give us a purpose beyond our individual selves. To be apart of that moment when the baby is brought into the world was something I was excited for. Unfortunately at Woodhull they primarily have midwives taking care of the patients in labor and PA’s are mostly needed during C-sections. Also not every midwife is willing to teach or take a PA student during deliveries. However there was one, Ms. Desimone, who was receptive to students and really invited me to take part in exams and procedures. It was difficult for me to perform cervical checks and accurately estimate a mother’s dilation, effacement and station; nonetheless I was grateful for the opportunity and will further expand my knowledge through video learning. She was also magnificent in teaching me the importance of fetal monitoring and why it is so important, along with the basics of interpreting it. I was fortunate to watch a couple of vaginal deliveries but never made my way to a C-section. I was surprised at how long a mother would be in labor but how quick a baby is born. IT was amazing to see the point when a mother is giving every ounce of energy she has to bring her joyful baby into this world and then the immediate bond they have outside when it rests on her chest, and solidifying the start or continuation of her family. Although they say childbirth can be horrible, horrific, traumatic, and painful, it is truly a magnificent experience to watch.

Just a reminder to myself one of my fondest memories was being able you ultrasound a 16 week pregnant patient with twin gestations. I was able to find the heart/beat, and follow along their anatomical development. It was so very heartwarming and amazing to see.