Women’s Reproductive Health Foundations of Clinical Medicine December 2014

Women’s Reproductive Health Section

3 Conflict of Interest Disclosure No financial conflict of interest Very strong feelings on the subject 3

Women’s Reproductive Health Section By the end of the section students will accomplish the following objectives:

Women’s Reproductive Health Section Objectives Describe the steps of the physical exam of a female patient for routine gynecologic care and obstetric care. Recognize gross and microscopic findings of normal female anatomy. Recognize gross and microscopic findings of common pathology in female anatomy.

Women’s Reproductive Health Section Objectives Know how a menstrual cycle occurs and what can interfere with normal menstrual function. Understand the pharmacology of the menstrual cycle and how medication can be used to influence the cycle. Appreciate the causes of early pregnancy loss and it ’ s physical and emotional sequelae. Understand the role of screening and diagnostic imaging as it applies to women ’ s reproductive organs.

Women’s Reproductive Health Section Objectives Describe normal pregnancy function and the process of labor and delivery. Recognize the signs and symptoms of pre- eclampsia and know the clinical management of hypertensive disease in pregnancy. Know the normal structure and function of the female breast, distinguish between normal and abnormal gross and microscopic anatomy and understand the benefits of breastfeeding.

Women’s Reproductive Health Section Objectives Know the common methods of contraception and the risks and benefits of each. Appreciate the role that family planning plays in the lives of patients and physicians. Consider your own values as they apply to patient care in the domain of reproductive health and family planning.

Women’s Reproductive Health Section Objectives Describe clinical findings and treatments for common sexually transmitted infections and non-infectious vaginitis. Know the methods of screening, diagnosis and treatment for the most common gynecologic cancers. Recognize normal changes in the menopausal female, including prolapse and pelvic floor dysfunction. Understand the available treatment modalities.

Women’s Reproductive Health Section Objectives Understand the definition, causes, presentations and treatments of infertility. Describe normal and abnormal puberty and be able to recognize clinical findings for each. Consider the impact of sexuality on patients’ lives and on the doctor-patient relationship. Recognize common emergencies in women ’ s health and develop a management plan for each.

Women’s Reproductive Health Section Core Topics –Gender specific physical exam (anatomy) –Diagnostic modalities (pathology, radiology) –Normal physiology –Pathophysiology –Management (pharmacology)

Anatomy

Diagnostic Imaging

Physiology/Pharmacology

Pharmacology

Values Clarification Values: a standard for guiding actions and making choices. –Personal –Professional

Everyone stand up We all do things that we “know better” not to do even though we know the consequences –Sit down if you smoke –Sit down if you ever eat too much –Sit down if you cross in between cars –Sit down if you work too hard –Sit down if you do not maintain the recommended 30min cardio 3 days a week

Values Clarification Choosing freely from alternatives after thoughtful consideration of the consequences of each alternative Prizing, cherishing, being happy with the choice and willing to affirm the choice publicly Acting, doing something with the choice doing something repeatedly, in a consistent manner Raths LE, Harmin M, and Simon S. Values and teaching: working with values in the classroom. Columbus, Ohio: Charles E. Merrill, p. 30.

Values Clarification Please complete the following exercise on your own.

Values Clarification Abortion decisions are the responsibility of the pregnant woman and her physician –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification Amniocentesis should be required as part of prenatal care. –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification Individuals who carry abnormal genes should not have children. –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification Couples who knowingly choose to have a child with a birth defect should be financially responsible for all of the child's health care and educational needs. –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification There are good reasons a minor should involve her parents in an abortion decision –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification A minor should be required to involve her parents in an abortion decision. –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification It is better to have an abortion at 8 weeks than at 18 weeks gestational age. –A. disagree –B. choosing –C. prizing –D. acting

Values Clarification A woman having her 4 th abortion is just as justified as a woman having her 1 st –A. disagree –B. choosing –C. prizing –D. acting

Obstetric History and Physical Exam Abigail Wolf, MD Obstetrics and Gynecology Sidney Kimmel Medical College

Obstetric History and Physical Exam Objectives – List components of obstetric history – Describe steps of obstetric physical exam – Identify significant positive and negative findings – List the cardinal movements of labor and the steps of a vaginal delivery – Recognize the importance of diagnosing pregnancy

Obstetric History All reproductive age women are pregnant until proven otherwise.

Obstetric History All pregnant women have an ectopic pregnancy until proven otherwise.

Obstetric History Chief Complaint: 25 year old G4 P1021 with LMP______ and EDC_____ presents at ____ weeks EGA complaining of ______

Obstetric History Gravidity: number of pregnancies Parity: outcome of pregnancies full term deliveries >37 weeks preterm deliveries weeks abortions/ectopics/< 22 weeks number of living children

Obstetric History G4 P1021 Four total pregnancies One full term delivery Two deliveries < 22 weeks One living child

Obstetric History LMP: first day of last menstrual period EDC: estimated date of confinement (delivery) EGA: estimated gestational age

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Obstetric History Common complaints: Contractions Loss of Fluid/Rupture of Membranes Vaginal Bleeding Decreased Fetal Movement

Obstetric History Chief Complaint: 25 year old G4 P1021 with LMP 4/10/10 and EDC 1/15/11 presents at 38 4/7 weeks EGA complaining of painful contractions.

Obstetric History Cardinal Questions Are you bleeding? Do you have any leaking fluid? Are you having contractions? Is the baby moving well?

Obstetric History HPI= Present pregnancy 1. Has this been a normal pregnancy? 2. Were all lab studies obtained and normal? 3. Was an ultrasound obtained and normal?

Obstetric History Pregnancy History: date outcome i.e. parity mode of delivery anesthesia complications

Obstetric History Remaining history: gynecologic history PMH PSH medications allergies social history family history

Obstetric Physical Exam Vital Signs maternal fetal

Fetal Vital Signs

Obstetric Physical Exam Heart Lungs Breast Abdomen Pelvic Extremities

Obstetric Physical Exam Abdominal exam: acuity location of pregnancy age/size of pregnancy presentation/lie/position of pregnancy

Presentation: fetal part closest to birth canal –Cephalic/vertex or breech Lie: relation of the long axis of the fetus to the mother –Longitudinal or transverse Position: relation of the fetal presenting part to right or left of the maternal pelvis –Left or right

Obstetric Physical Exam Pelvic Exam: external genitalia vagina cervix uterus adenexa

Obstetric Physical Exam Diagnosis of labor: contractions with cervical change

Uterine Contractions

Cervical Change Dilatation –Progress from closed to 10 cm dilated Effacement –Shortening or thinning of the cervix from 2 cm length to paper thin

Obstetric Physical Exam Cardinal Movements of Labor engagement flexion descent internal rotation extension external rotation

Vaginal Delivery assess position fetal head crowns protect perineum nasal/oral suction assess for nuchal cord deliver anterior shoulder deliver posterior shoulder deliver remaining fetus clamp and cut cord deliver placenta assess for lacerations

Indications for Cesarean Section before labor Previous uterine incision/cesarean section Non-vertex presentation Placental abnormality Infectious disease (HSV or HIV) Severe preeclampsia Multiples Other

Indications for Cesarean Section in labor Non-reassuring fetal monitoring due to –Umbilical cord prolapse –Placental abruption –Placental insufficiency –Other Arrest of dilation Arrest of descent

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