Women’s health is a rotation that PA students either hate or love; there are no tempered reactions. Those who love it will tell you that there is a great mix of experiences. It is a field that involves primary care, specialty care, management of chronic disease, acute care, oncology, and surgery. Just about the whole scope of medicine is practiced by these providers. Those who hate it may mention how busy and difficult the rotation is. There is a great deal to learn in just a few weeks, but if you find your passion for this field, you will enjoy the challenge.
I honestly didn’t know what to expect going into this rotation. I knew that I would be somehow involved in the process of birthing babies, and that thought was terrifying. There was an irrational nightmare in my mind that I would somehow slip and drop a newborn, killing it (apparently this is a common fear among students). I was also afraid of the impending pelvic exams. I could not help but worry that I would be awkward and stutter throughout the exam. (Normally I embrace my awkwardness, but not during pelvics!).
To my surprise, this was one of my favorite rotations and one that I learned the most from. Watching a baby come into the world is nothing short of a miracle (and no I did not drop any). And though gynecologic exams can be intimidating, they were never as awkward or as scary as I built them up to be in my mind. In fact, the pelvic exam was just another exam. So long as I kept the conversation going, there really was no difference between a pelvic and an abdominal exam. It is just part of the work of caring for your female patients (and an important part at that).
The only negative thing I will say about this rotation is that it was a VERY busy schedule at Penn State Hershey. Every few days I was moved to a different service, so that I might have two days on service with urogynecology and then three days with gynecologic oncology. Certain services required me to be there from 8a-5p while others had grueling shifts from 5p-7a. However, as frustrating as the schedule was, it was also amazing that I was able to experience so many different aspects of women’s health. I was fortunate to spend time in all of the following services: general gynecology, urogynecology, gynecologic oncology, obstetrics, minimally invasive gynecologic surgery (MIGS), gynecologic surgery, and reproductive endocrinology/infertility. The experience was challenging and unforgettable.
Speaking of unforgettable, there were several notable firsts during this rotation:
- First delivery – The first time I helped deliver a baby, I wasn’t expected to do much. The residents mostly had me stand back and watch. There were a few moments that made me nauseous, but it wasn’t as gross or as terrifying as Hollywood makes it out to be. It was a relatively quick birth. As the baby was born, I was overcome with awe at the fact that I was one of the first people this baby saw in his new world (perhaps I should feel sorry for him). After the baby was delivered, the resident asked me to deliver the placenta. This, I admit, was a little gross but also a cool experience. The technique requires you to apply gentle pressure on the cord while you massage the uterus (increases uterine tone). Gradually the placenta detaches and emerges. When the placenta gets about a third of the way out of the vagina, you actually grab it and twist to get it out. Then you must diligently inspect the placenta to make sure that you got ALL of it out (retained placenta causes post-partum hemorrhage).
- First C-Section – I went into this surgery expecting it to be bloody; it was bloodier than I thought. One of the amazing things about C-Sections is the speed with which they perform the procedure. After carefully dissecting away the abdominal muscles, a transverse (usually) incision is made into the uterus. Within a few seconds that baby is out, the cord is clamped/cut, the baby is passed to the pediatric team, and then fast work is done to stop maternal bleeding. If you think about it, by the end of pregnancy the uterus is receiving 1/5 of the woman’s blood supply. Also, the placenta is literally like a tap on a barrel, receiving nutrients by direct approximation to maternal blood vessels. So when you cut the uterus and separate the placenta, you have literally opened a faucet. The first time I saw this I mistakenly thought that something had gone wrong. I saw the providers pull the patient’s uterus outside of her body and begin vigorously massaging it (again this increases tone and constricts vessels). Everybody was perfectly calm except me (I said nothing but was sweating heavily under my surgical scrubs). Luckily, everything had gone according to plan. The bleeding soon stopped, the uterus was sutured back together, and layer-by-layer the surgical site was closed. Behind a privacy sheet, the mother was cradling her newborn baby, who was crying healthily. The mother had not felt the surgery and was beaming with pride.
- First Surgery – Until this rotation, I had not stepped foot inside an operating room. Out of all the big “firsts” that happened this rotation, this was probably the most intimidating and frustrating. It was intimidating because I was in a brand-new environment with its own special set of rules (that I was learning on the fly). It was frustrating because I was treated like a child (for good reasons). The scrub techs and nurses were immediately telling me “don’t touch that!”, “everything blue is sterile”, “just stand here and don’t move”. It is a little bit aggravating when everybody in the room expects you to screw up and contaminate the surgery. However, this only lasted for the first two surgeries. Once the staff became more comfortable with me in the room, they loosened up and allowed me to participate where there were opportunities. Generally my job was prepping the patient or retraction. However, on one surgery I was allowed to manipulate the uterus while the resident (via the Da Vinci robot) performed a hysterectomy.
- Practice reading Electronic Fetal Monitoring (EFM) strips prior to your Obstetrics experience. Initially EFM tracings might look as confusing as the first time you saw an EKG. Your preceptors will love to ask you about these since it is becoming the standard of care to perform EFM on almost every obstetric patient. Though at first they look like gibberish, EFM strips are actually simple to read. The only secret is repetitive practice. Eventually, you will begin to see things that you never saw before, and then it will just click. It will feel less like you are reading an EKG and more like you are evaluating someone’s heart rate or respirations. Actually, that is essentially what you are doing: you are assessing vital signs. The graph compares fluctuations in the baby’s heart rate with changes in abdominal pressure during contractions. There are many books and articles that will provide you with a simple step-wise process for evaluating these. There are also websites where you can practice. The major finding that you must be able to recognize is a late-deceleration, as this is a sign of placental insufficiency (not enough nutrients for baby).
- Know the causes of post-partum hemorrhage. Memorize the 4-T’s of post-partum hemorrhage: Tone, Tissue, Trauma, and Thrombin. Tone refers to uterine atony, a common cause of continued bleeding after birth. Rather than contracting/spasming (which is necessary to constrict vessels), the uterus remains distended after delivery, allowing the vessels at the site of placental attachment to spew blood like a faucet. The first step to correcting this is to give the uterus a deep tissue massage to stimulate prostaglandin release. If that fails, there are medications that may be given to increase uterine tone. Tissue most commonly refers to retained placental tissues within the uterus (again keeping those vessels wide open). Trauma, of course, refers to vaginal tears and other injuries sustained during delivery. And finally, thrombin refers to potential coagulopathies in the mother. Know these by heart not just to impress your preceptor, but also because they can save a mother’s life.
- Know the four things you ask every obstetric patient. Seriously, EVERY obstetric patient who walks through the door should be asked the same four questions during their triage. Are you having any spotting/bleeding? Are you having any vaginal discharge of any kind? Are you having abdominal pain/contractions? Can you feel the baby moving? This quick triage will rule out several major life/pregnancy-threatening conditions, and it will focus the rest of your history.
- Talk to your patients during pelvic exams. There is only one way to make pelvic exams comfortable for your patient, and that is for you to be comfortable. Even if you are nervous, the simple act of making small talk with your patient will do much to put her at ease during the exam. Ask her about her job or her hobbies. Even if you are not good at small-talk, explain the procedure to her as you perform it. Say anything, but say something. Your patients will appreciate it.
- Study Birth Control. This isn’t that difficult to memorize, and it will be a huge part of your discussions with patients, both in obstetrics and gynecology. Learn the advantages/disadvantages and some of the common misconceptions about each method of birth control. For instance, you will often have to clarify to patients that the Merena is not a form of abortion (study the mechanisms of action). You may also have to explain the risk of ectopic pregnancy with intrauterine devices (IUDs) or the role or progesterone in the body. Be prepared because these conversations happen almost every day.
- Smile and enjoy the experience. We were told before we started that preceptors expect us to be overwhelmed by this rotation. Frankly, few students feel competent in women’s health prior to their rotation (men especially). The major piece of advice we were given was just to smile and appreciate the opportunities you have as a student. As tough as it is, there are some amazing, life-altering experiences. Patient’s will share with you the most intimate and special moment in their lives. You will see things that you may never see again in your career. Allow your awareness of the specialness of these moments to dominate your experience. This might not only help you find your love/passion for women’s health, but also will be grade boosting in your preceptor evaluations.
- Learn to love the sound of a baby crying. Yes, crying. When you are on your obstetrics rotation, it is sometimes the most beautiful sound in the world. One particular patient encounter comes to mind. There was a young woman who was failing to progress in her vaginal delivery. Suddenly, the baby’s heart rate dropped into the 50s. After quick attempts to maneuver the mother failed to restore a normal heart rate, an emergency C-section was called for. The providers and nurses were moving fast and the operating room became so crowded that I was instructed to watch from outside. During the procedure, I went back to the patient’s room to speak to the grandmother, who was anxiously awaiting her daughter’s return. I did my best to calm her nerves and said that I would keep her informed. Watching through the window, I saw that the baby emerged from the womb ashen-colored and not moving. My heart sank as she was passed off to the pediatric team. A few, tense moments passed when suddenly the room was filled with a beautiful cry like a lion’s roar. Chills ran through my body and every hair stood on end. I cried, myself, outside. I got to go back into the patient’s room to inform the grandmother that a healthy grandchild had been born.