Obstetrics and gynecology clerkship

OB/GYN overview

What is obstetrics and gynecology? [1]

What does an OB/GYN specialist do?

OB/GYN clerkship overview

Clerkship structure

  • The length of an OB/GYN rotation varies between 4–8 weeks, depending on the medical school, and usually includes the following:
    • Obstetrics: both outpatient prenatal care and inpatient labor and delivery (2–4 weeks)
    • Gynecology: outpatient, operating room (OR), and inpatient (2–4 weeks)

Clinical skills

  • Taking a comprehensive OB/GYN history
  • Performing a physical exam (including pelvic and breast examination)
  • Understanding the basics of perinatal care
  • Understanding the basic OB/GYN diagnostic procedures
  • Recalling the basic surgical skills and principles of sterile technique.
  • See “Objectives” in the “Clinical tasks” section below for more information.

Daily schedule

Please note that the following schedules are meant to provide a general idea of an OB/GYN clerkship timeline and will vary among different medical institutions and programs.

Inpatient service

  • Gynecology service
    • 06:00–07:00 a.m.
      • Pre-rounding of the surgical patients you were assigned to
      • Completing all notes on your patients and placing them in the chart before the round starts
      • Sign-out of the overnight patients by the overnight residents/healthcare providers; be sure to take notes on your patient!
    • 07:00–07:30 a.m.
      • Walking rounds (also called bedside rounds) with the chief resident and the interdisciplinary team (if needed)
      • These rounds mainly focus on critical and new patients.
    • 07:30–08:00 a.m.
      • Sit-down rounds with gynecology department attendings and residents [2]
      • These rounds allow for a more detailed assessment of the patient status and are performed away from the patient.
    • 08:00–noon
      • Attending surgeries; completing perioperative paperwork (see the “Notes” section below)
      • Patient consultation/teaching rounds
      • Morning lectures/conferences
    • Noon–01:00 p.m.: lunch break
    • 01:00–04:00 p.m.
    • 04:00–05:00 p.m.: informal evening sign-out
  • Obstetrics service
    • 07:00–07:30 a.m.
      • Sign-out of the overnight patients by the overnight residents/healthcare providers
      • Walking rounds (also called bedside rounds) with the chief resident
    • 07:30–08:30 a.m.: sit-down rounds with obstetrics department attendings and residents
    • 08:30–10:30 a.m.: board rounds with the multidisciplinary team (e.g., nursery, family physicians)
    • 10:30–noon
    • Noon–01:00 p.m.: lunch break
    • 01:00–04:00 p.m.
    • 04:00–05:00 p.m.: sit-down rounds with obstetrics department attendings and residents

Outpatient service

  • 08:00–08:30 a.m.: review of patients' charts and history prior to visit
  • 08:30–noon
    • History taking and physical examination of the ambulatory patients
    • Presentation of the patients to the attendings
    • Assistance with obstetrical/gynecological procedures during outpatient visits
  • Noon–01:00 p.m.: lunch break
  • 01:00–05:00 p.m.
    • Afternoon patients consultation and examination
    • Finishing outpatient notes and/or other tasks

Evaluation and grading

  • Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
    • Clinical grade
    • Examination (usually shelf exam)
    • Possibly other assignments

General tips

  • Self-care: The OB/GYN clerkship can be challenging, both in terms of the workload and the emotional fatigue you will be experiencing on a daily basis. Make sure to take care of yourself during this time. If you have a rough day, take a night off from studying to relax and get as much sleep as you can.
  • Be empathetic: The birth of a child is a life-changing event for many families. During your rotation, you will often witness such events; ensure that you are respectful and empathetic to the family members at all times.
  • Be ready to help: Given the dynamics of an OB/GYN clerkship, it is hard to predict when the next opportunity to get involved will arise, so always be prepared.
  • Bring extra scrubs: A big part of your OB/GYN rotation will be spent in the operating rooms (OR) and on the labor and delivery (L&D) floor, where there is a much higher chance of coming into contact with bodily fluids.
  • Listen to the nurses: The OB/GYN nurses are a valuable source of information and will be able to offer important advice during your rotation.

AMBOSS study plans

  • AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including OB/GYN: https://go.amboss.com/ob-gyn [3]

Clinical tasks

Objectives

By the end of this clerkship, a medical student is expected to acquire a comprehensive understanding of the specialty and a number of relevant clinical and surgical skills.

  • Clinical skills
    • Being able to perform a medical interview and physical examination (pelvic and breast examination included) of an OB/GYN patient
    • Understanding the physiologic changes during female sexual maturation, pregnancy, and menopause
    • Understanding the basic principles of prenatal, intrapartum, and postpartum care
    • Making a differential diagnosis of the congenital and acquired diseases of the female reproductive system
    • Being able to outline the most common complications of pregnancy and childbirth, as well as their management principles
    • Reading and interpreting the results or relevant diagnostic studies (e.g., fetal biophysical profile, Pap smear results, biopsy findings)
  • Surgical skills
    • Understanding the principles of sterile technique
      • See pre-surgical infection prevention measures for detailed instructions for scrubbing in, donning and doffing gowns, and putting on sterile gloves.
    • Mastering the basic surgical skills (e.g., knot tying, suturing)
    • Observing and understanding basic gynecologic procedures (e.g., laparoscopy, endoscopy, curettage)
    • Observing and understanding basic obstetric interventions (e.g., Cesarean section, hysterectomy)
    • Understanding the principles of OB/GYN perioperative care
    • Being able to perform basic nursing procedures (e.g., Foley catheter placement)

Pre-rounding

Rounding

See “Rounding” in the “Clerkship guide” article for more information.

Notes [4]

  • As the format of the preoperative, operative, and postoperative notes for gynecology patients is the same as the surgery notes (see the surgery clerkship article for more details), this section will mainly focus on the format of the obstetric notes.

Common abbreviations for patient notes

G1 means that a woman has been pregnant once; it does not stand for the number of living children that resulted from this pregnancy.

Vaginal delivery note

  • A spontaneous vaginal delivery (SVD) note should begin with the date of the delivery and patient's name, age, gravidity, and parity.
  • The position of the fetal occiput (e.g., LOA) and a brief description of the newborn (e.g., viability, Apgar scores, weight at birth) should follow. See the newborn infant article for more information.
  • The presence of any obstetric complications during childbirth should also be documented (e.g., perineal laceration).
  • An SVD note should also mention whether meconium suction or nuchal cord reduction was performed (if so, how many loops of nuchal cord were wrapped around the baby).
  • Another important point to describe in the note is the placenta, its mode of delivery (e.g., spontaneous or manual), the cord , and whether the cord was clamped and cut.
  • The perineal lacerations and their management should be described as well (e.g., types of sutures, use of local anesthetic).
  • Lastly, estimated blood loss (EBL) should be documented.

Example

  • Date: 05/12/2020; 06:46 p.m.
  • Patient A, 21 yo, G1P1001, normal SVD of a viable female infant, position LOA, APGARs 7 and 9, 2950 g
  • First-degree perineal laceration, no sutures
  • DeLee suction at peritoneum, reduction of nuchal cord x 2
  • Spontaneous delivery of an intact placenta; the 3-vessel cord was clamped and cut.
  • EBL = 360 cc , both mother and infant stable

C-section operative note

  • A C-section note is very similar to a typical operative note; however, it includes a couple of distinct features:

Example

Postpartum/postoperative note

  • During your OB/GYN rotation, you will be expected to check on patients who have just given birth.
  • This note generally follows a usual SOAP (Subjective, Objective, Assessment, and Plan) format.
    • Subjective
      • Does the patient experience any pain or any other symptoms?
      • Is there any vaginal or surgical incision bleeding?
      • Can the patient tolerate P/O nutrition?
      • Does the patient have bowel movements or pass flatus?
      • Is the patient able to void and ambulate?
      • Did the patient start breastfeeding?
    • Objective
      • What are the findings of the general physical exam?
      • Where is the uterine fundus palpated?
      • What are the characteristics of the uterus on palpation (e.g., tender, firm, boggy)?
      • If any sutures were applied, what are the local findings?
      • Is there any edema or tenderness in the extremities?
      • What are the most recent lab results (including CBC and CMP)?
    • Assessment: includes the number of the postpartum/post-op day (PPD), how the delivery was concluded, and mention the complications that occurred (if any)
    • Plan: will focus on the findings addressed in the subjective field, as well as other additional OB/GYN aspects, such as:
      • What are the next steps of postpartum management?
      • When is the patient being discharged?
      • Was the patient advised on contraception?

Example

Date: 02/27/2020; 05:03 p.m.

  • S: patient C, 28 yo, G2P1102, ambulating without difficulty, tolerates P/O nutrition, passes flatus
  • O: Tcurrent (Tc) 98.6 ; Tmax 99.3 ; P 100; BP 125/70; RR 15
    • The patient is AAOx3 ; NAD ;
    • Cardiovascular (CV): RRR ; no murmurs/rubs/gallops
    • Pulmonary: CTAB
    • Breasts: nonengorged; Colostrum is expressed bilaterally.
    • Abd: soft, nontender; uterine fundus at 1 fingerbreadth below the umbilicus, firm, nontender
    • Pelvic exam: nontender perineal suture, no bleeding
    • Ext: no lower extremity edema
    • Labs: Htc: 31%; RPR, HIV neg
  • A: patient W, 28 yo, G2P1102, SVD, PPD #1; Patient and infant are stable.
  • P: Repeat CBC. Continue postpartum care.

Magnesium note

Example

Date: 04/29/20; 02:25 p.m.

Never forget to add the date, time, and signature to all of your notes and orders.

Presenting your patient

See “Presenting patients” in the “Clerkship guide” article for more information.

Orders

See “Placing tentative orders” in the “Clerkship guide” article for more information.

Conferences and tasks

See “Attending meetings and conferences” in the “Clerkship guide” article for more information.

Prenatal and outpatient tasks

  • During the OB/GYN clerkship, you will have the opportunity to spend time in various OB/GYN outpatient settings.
  • The outpatient settings will vary greatly depending on the medical institution you will have your clerkship in, but most will include the following:
  • As a student, your role in these settings will also vary significantly.
    • In some settings (e.g., fertility clinic) you will most likely be shadowing.
      • Even though shadowing does not require your active involvement, it can be a valuable learning experience.
      • Pay attention to how the physician interacts with the patients.
      • If unfamiliar topics come up during the visit (e.g., prenatal genetic testing), make a note and look up the topic later during the day. .
    • In other settings (e.g., resident prenatal care clinic), you might be the one who sees patients first and then presents the patients to the resident or the attending.
    • You may be asked to see the patients together with the physician/resident and required to perform specific tasks during those visits (e.g., measure the fundal height, check the fetal heart rate with a Doppler).
    • If you are unsure of what your role is, make sure to ask your attending/resident.
  • If you know in advance which clinic you will be working at, consider reviewing some of the relevant topics the day before (e.g., if you're assigned to the urogynecology department, review fecal/urine incontinence and pelvic organ prolapse).
  • If religious/personal reasons prevent you from participating in the family planning clinic, consider talking to your clerkship director at the beginning of the rotation to make alternative plans. For example, if you are scheduled to spend two mornings in the family planning OR, you may be able to participate in the menopause clinic instead.

If for any religious/personal reasons you do not feel comfortable working in the family planning clinic, talk to your clerkship director at the beginning of the rotation to make the necessary adjustments.

Labor and delivery tasks

As most of the surgical gynecologic tasks are similar to those you will perform during the surgery clerkship (for more information, see the surgery clerkship article) this section will mainly focus on the labor and delivery tasks and skills.

General considerations

  • As a medical student working in the labor and delivery (L&D) unit, you will be able to perform multiple tasks, ranging from patient triage to assisting with C-sections.
  • Because of the high patient volume on the L&D floor, working these shifts can be both exciting , and challenging .
  • Compared to other rotations, where you will likely have the same patients to follow, pre-round, present during rounds, write notes and complete tasks for, the patients you take care of on L&D will likely be different every single day.

Shifts

  • L&D shifts are typically 12 hours. .
  • You may have to arrive 30 minutes earlier to receive the sign out and stay 30 minutes later to give the sign out to the night team.
  • Depending on the clerkship, it may be possible to work both day and night shifts.

Team

  • Intern
    • Often sees patients in triage, performs C-sections based on the institution
    • Third-year students often spend a lot of time with the intern.
  • PGY2: often performs C-sections
  • PGY3 and PGY4
    • Serve as “chiefs” of the labor floor
    • Help manage patient flow and assist with complicated deliveries (i.e., forceps/vacuum deliveries) and C-sections
  • Attendings
    • Depending on the hospital, there may be a combination of private attendings (those who work in private practice but are affiliated with the hospital) and physicians who are employees of the hospital system.
    • In addition, many hospitals have begun to employ “laborists” who work in shifts, primarily on the labor floor, and do not have outpatient practices. They usually supervise residents and see patients that show up without their own provider.
  • Midwives: may work in conjunction with the residents (e.g., helping to see patients in triage and conducting low-risk deliveries) or may have their own practice
  • Physician assistants
    • Help in triage, help put in orders, perform cervical checks on patients
    • Serve as surgical assistants during C-sections
  • Nurses
    • L&D nurses do the majority of labor support for the patient .
    • Nurses have a lot to teach you, so try to spend some time learning from them if your schedule permits.
  • Anesthesiologists

The OB/GYN physician usually just comes in towards the very end to deliver the baby (unless there are any intranatal complications).

Duties

  • Triage
    • See incoming patients; preview their prenatal records
    • Write admission notes for incoming patients
    • Perform short OB-focused history (see “Obstetric history” in the section above), that should assess the presence of the following:
      1. Bleeding: If present, describe the amount, color, and associated symptoms.
      2. Leakage of fluid: If present, confirm its origin .
      3. Fetal movement: Describe the frequency, intensity .
      4. Contractions: Describe the frequency, duration, intensity, and associated symptoms .
      5. High blood pressure: See the hypertensive pregnancy disorders article for more information.
    • Perform an OB-focused physical exam (see “Physical examination” in the section above).
  • Vaginal deliveries: The following actions should only be performed on patients you have previously met or worked with.
    • Monitor and actively participate in the management of patients during labor.
    • Observe/assist/perform uncomplicated vaginal deliveries under supervision.
    • Observe/assist/perform placenta delivery repair under supervision.
    • Observe/assist/perform perineal lacerations repair under supervision.
    • Monitor and actively participate in the postpartum management of patients.
    • Tip: It is good practice to meet all patients on the labor floor at the beginning of your shift. Take this opportunity to record critical information from each one, as it will help assist you in most deliveries that occur during your shift.
  • C-sections
    • Observe/assist during C-sections (under supervision).
    • Offer to place the Foley catheter. .
    • Help prepare the patient by putting on Venodyne boots.
    • Tip: Ask the patient if there is anything you could do to make her more comfortable (e.g., offer the patient to lean into you, which can help with maintaining the proper posture during the epidural injection). If she is nervous, she may appreciate chatting with you during the procedure as a distraction.

Never go into the delivery room of a patient you have never met before (unless your supervisor asks you to).

Clinical skills (H&P)

History taking (OB/GYN)

  • Because of the intimate aspect of OB/GYN H&P, it is important to establish a private and relaxing setting for all OB/GYN patients.
  • For the same reasons, some OB/GYN patients may not be comfortable with the presence of students in the examination room, so if you are asked to leave the room, do not be discouraged. Instead, look for other patients who are more comfortable having you assist.
  • It is advisable that you choose a patient with a relatively routine OB/GYN condition (e.g., ectopic pregnancy, PID) for H&P during your OB/GYN rotation.
  • See the OB/GYN: history and physical examination and medical history articles for more information.

Physical examination

Never perform a breast or pelvic exam without the supervision of your attending physician!

Example of an OB/GYN patient H&P on admission

  • Date/time: 04/11/2020; 08:54 AM
  • Patient: patient E, 50 yo, G3P3003
  • Chief complain: vaginal bleeding
  • History of presenting illness: The patient reports that the bleeding started 5 days ago when she noticed some spotting in her underwear. For the past 2 days the bleeding flow has increased (the patient had to use 3 pads/day). She has never had similar episodes. The patient reports no associated symptoms or precipitating events.
  • Past gynecologic history
  • Past obstetric history
    1. NSVD on 03/06/2001; term pregnancy; boy; 2900 g; no perinatal complications; nl child development
    2. NSVD on 11/07/2003; term pregnancy; boy; 3100 g; no perinatal complications; nl child development
    3. NSVD on 06/08/2010; term pregnancy; boy; 3700 g; second-degree perineal laceration; no other perinatal complication; nl child development
  • PMH
    • H/o DM diagnosed 5 years ago; HTN diagnosed 2 years ago
    • Current medication: metformin, metoprolol
    • NKA
    • Surgery Hx: neg
    • FHx: Father - CAD; mother - none
    • SHx: Uses alcohol occasionally (1–2 drinks in weekends); 35-pack-year history of smoking; no drug abuse
  • PE
    • Vital signs: T 98.8°F; P 87 bpm; BP 135/90 mm Hg; RR 18/m; SaO2 99% at room air
    • General: AAOx3; NAD
    • Eyes: clear, pale conjunctivae
    • Ears, nose, throat: no complaints
    • CV: RRR
    • Pulmonary: CTAB
    • Breasts: symmetric; no palpable masses
    • Abd: nontender, soft on palpation; no palpable masses; nl bowel sounds
    • Pelvic exam: no lesion of external genitalia or vagina
    • Bimanual exam: mobile, anteverted uterus and adnexa; no palpable masses
    • Rectal exam: soft stool palpated; no bleeding or hemorrhoids
    • Ext: mild lower extremity edema; nonpitting; 1+
  • Assessment: A 50 yo menopausal woman, G3P3003, with a 5-year history of diabetes mellitus, a 2-year history of hypertension, and 35-pack-year history of smoking presents with progressive vaginal bleeding that started 5 days ago without any prior inciting event.
  • Plan

Top 10 obstetrics and gynecology topics

There is a lot of material to know for your OB/GYN shelf. Here are the top 10 most commonly tested topics that you should definitely include in your shelf preparation schedule:

  1. Prenatal care
  2. Pregnancy
  3. Hypertensive pregnancy disorders
  4. Childbirth
  5. Congenital TORCH infections
  6. The menstrual cycle and menstrual cycle abnormalities
  7. Benign breast conditions
  8. Breast cancer
  9. Cervical cancer
  10. Ovarian tumors

Evaluation and grading

General considerations

  • Determinants of your OB/GYN clerkship grade vary both by school and program but generally comprise:
    • The clinical grade, which consists of:
      • Evaluation of clinical performance by preceptors (attendings, residents, and interns)
      • Observed H&P
      • Patient presentations
      • Patient write-ups
      • Admission orders
      • Clinical logs
    • Examination: consists of a standardized shelf exam and/or sometimes in-house exams
    • Additionally, programs may have graded final projects for the clerkship, such as a case report or lecture on a patient's rare disease/presentation.
  • See “Evaluation and grading” in the “Clerkship guide” article for more information.
  • As the biggest component of your final grade will depend on your clinical performance, it is important to have your A-game on from the very first day of your clerkship.
  • Most of the tips on how to impress your preceptors are covered in the “Clerkship guide” article.

Preparing for questions from attendings (“pimping”)

Gynecology topics

Obstetrics topics

OB/GYN shelf exam

General information

  • The OB/GYN shelf exam covers a significant amount of material, so it is important to get started on it as early as possible .
  • The question format closely mimics the difficulty and style of questions that appear on the USMLE (MD students) or COMLEX (DO students) clinical exams.
  • Consider taking as many OB/GYN practice questions as possible (including questions from the AMBOSS Qbank).
  • There are two basic types of shelf exams:
    • Standardized exams (NBME® for MD, or NBOME® COMAT for DO), which are usually a part of the final grade
    • Sometimes in-house exams by clerkship programs

Shelf exam content

  • General topics and systems include:
  • Physician tasks include:
    • Applying foundational science concepts: 8–12%
    • Diagnosis (knowledge pertaining to history, exam, diagnostic studies, & patient outcomes): 45–50%
    • Health maintenance, prevention & surveillance: 13–17%
    • Pharmacotherapy, intervention & management: 20–25%
  • See “Evaluation and grading” in the “Clerkship guide” article for more information.

AMBOSS study plan

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including OB/GYN: https://go.amboss.com/ob-gyn [3]

Resources

AMBOSS offers a comprehensive library with over 50 OB/GYN articles and 300+ questions that will help you prepare for your OB/GYN shelf exam. If you want more study material, here is a list of additional resources:

Reading materials

  • Practice Bulletins from ACOG: concise, evidence-based recommendations from the American College of Obstetrics and Gynecology. You can access these through PubMed or the ACOG website . [7]
  • Case Files: Obstetrics and Gynecology is a popular textbook for people who learn best from cases.
  • NEJM Journal: offers a daily newsletter (subscription) with the summaries and results of the most recent research studies

Phone apps

  • CDC app: a useful app for side effects and contraindications to different types of contraception
  • ASCCP app: the latest updates on cervical cancer screening and management guidelines
  • MDCalc: can be filtered by OB/GYN for the most common equations used in the field
  • Epocrates, Reprotox : can be referenced for more information on safe medication during pregnancy
  • ACOG app: up-to-date information on resources and tools in women’s health.
  • LactMED: a good source to use when looking for drugs that are safe to use during breastfeeding
  • Pregnancy Due Date & Fertility Care: a free app for patients that allows them to record their weight, heart rate, blood pressure, ultrasound findings, and fetal movements and share them with clinicians

Websites

  • Bedsider: a patient-friendly website discussing various methods of contraception as well as other topics about sexual health. For patients unsure of what type of contraception they would like to use, you can give them the link of the website to explore at home on their own time, then discuss it with you at the next visit. [8]
  • Geeky Medics: a great tool for OSCE prep, in both video and written forms, that goes over most of the things you will need during your rotation
  • ACOG website: a great source for information on what to expect from your rotation and how to apply for OB/GYN residency [7]
  • Youtube: The Association of Professors of Gynecology and Obstetrics has an excellent video series designed for the 3rd year clerkship students.[9]
  • Online Med Ed videos: Watch these videos right before or at the beginning of your clerkship to help get you ready for the wards.

Preparing for residency application

Please see the article “Residency applications” for general information. Here are some further things to keep in mind of OB/GYN:

Letters of recommendation

Research opportunities

  • A great addition to your residency application is research experience in the OB/GYN field.
  • While OB/GYN has not historically been a field that considers research mandatory, as the field gets more competitive, having proof of your commitment to research , can give you extra credit.
  • There are several opportunities and topics that you could cover during your OB/GYN research:
    • OB/GYN subspecialties
    • General medical fields, including:
      • Global health and advocacy
      • Epidemiology
      • Genetics and basic science
  • Attending medical student and OB/GYN department research days can offer some ideas on how to conduct research and which topics to focus on.
  • Focus your efforts on publishing a single abstract and manuscript from the same project rather than engaging in multiple projects simultaneously.

Other considerations if you want to specialize in OB/GYN

  • During the preclinical years
    • Work hard to do well on your Step 1 exam. OB/GYN is becoming more competitive and thus, is forcing more programs to use Step 1 scores as a screening metric.
    • Get involved with your school’s OB/GYN interest group .
    • Consider other activities related to OB/GYN such as Medical Students for Choice, volunteering at a Women’s Health Clinic, or joining the ultrasound club .
    • Going to conferences (national or local) is a great way to meet OB/GYN specialists and further explore your interest in the field.
    • Focus on quality over quantity, as it is much more impressive to be the leader of your school’s Women’s Health Clinic and or start one new IUD program than it is to be a member of 4 different organizations with no particular results in any of them.
  • During the third year
  • During the fourth year
    • If you do not honor your OB/GYN rotation during the third year, you still have the chance to honor your OB/GYN sub-internship early during the fourth year (i.e., in July) .
    • Consider away rotations at programs you are interested in .
    • Create your residency program list strategically and with guidance from advisors .

Focus on the quality of your extra-curricular activities rather than quantity.