Other Resources (Not On Exam)

Global Health and Obstetrics

Reading: Shoulder Dystocia and the HELPERR Mnemonic

Manual Rotation of the OP Fetus

1. Can confirm with U/S
2. Fully dilated
3. Counsel pt regarding discomfort – if available can bolus epidural
4. Middle finger to base of occiput
5. Cupped hand over crown
6. Flex head c contraction while simultaneously rotating the shortest way to OA
7. Can have assistant milk the shoulder over

Vacuum Assisted Vaginal Delivery

1. Must be +2 station
2. Follow ABCD mnemonic
3. Pull with contractions
4. Reduce suction between contractions
5. Halt if:
   – 3 pop offs
   – No progress with 3 consecutive pulls
   – No more than 20 minutes

Correct Cup Placement

Minimize cephalohematoma and subgaleal bleeds

Cup Replacement and Removal

When placing, ensure that vacuum is free of any vaginal tissue

Remove cup when jaw is reachable

1) Position woman in dorsal lithotomy position

2) Perform bimanual examination to verify size and position of the uterus

3) Place speculum to visualize the cervix

4) OPTIONAL: Prepare the cervix with iodine or chlorhexidine.  Studies do not show benefit to prevent infections with this step, but also no harm has been show if this step is used.

5) Place Tenaculum:

Place the tenaculum on the anterior cervical lip, unless the uterus is retroflexed, in which case it has been shown to be beneficial to place the tenaculum on the posterior cervical lip.  OPTIONAL: The use of lidocaine anesthesia of the cervix prior to tenaculum placement.

 6) Paracervical Block:

• Inject 10 cc lidocaine at 4:00 and 8:00 on the cervical clock, at the reflection of the cervix from the vaginal mucosa. Inject as inserting and withdrawing the needle.  Injections including deeper injections of lidocaine into uterine muscle have shown improved anesthetic outcomes.                                                                                                                                                                          

7) Cervical dilation:

• No need to sound the uterus prior to dilating.
• Use tenaculum to straighten out the cervical canal/uterus.
• Start with a 5mm dilator and insert in the cervix, holding the dilator like a pencil in the center
• If cervix appears to be tight, hold dilator in the cervix for 20 seconds prior to removing. If easy passage, can remove immediately.
• Continue dilating with next size dilator in the same fashion until dilated to desired size. Dilate to the millimeter of the number of weeks estimated gestational age (i.e. If 7 weeks EGA, dilate to 7 mm cervical os opening).
• Routine cervical ripening is recommended by WHO for:
  • Adolescents < 18 years old
  • All pregnancies of EGA > 12 weeks
  • Nulliparous women > 9 weeks
  • Difficulties inserting dilators

in hopes of decreasing perforation in these high risk populations.

• Misoprostol 400 mcg is the recommended dose. Can be given 2 hours prior to procedure sublingually, or 3-4 hours prior to the procedure vaginally for best results.
• Osmotic cervical ripening with laminaria is also an option.

8) Aspiration:

• Create suction by closing the valves and pulling back on the plunger.
• Attach the sterile cannula.
• Insert the sterile cannula into the dilated cervix and into the uterus until the resistance of the fundus is felt.
• Open the valves to create suction and use a twirling and back-and-forth motion to aspirate the contents of the uterus. Aspiration should continue until the uterus has a gritty sensation and no additional tissue is passing through the cannula.
• You may need to empty the cylinder of the products of conception and continue with multiple passes, as the cylinder loses suction as it fills.

9) Evaluate the Products of Conception:

-Products of conception are best visualized with blood and mucous washed away through a mesh strainer. The products can then be placed in a clear glass dish with water and are best visualized with a backlight behind the glass.

10) Remove the tenaculum. Remove blood from the vaginal vault with cotton swabs or 4×4 gauze on a ringed forceps. Observe for bleeding.

11) Remove speculum and observe for bleeding for 15 minutes.

COMPLICATIONS AND MANAGMENT

• Difficult to place cannula: Can use a sterile sound and place the cannula over the sound.
• If no tissue passes through the cannula, the cannula may be clogged. Move around the cannula in the uterine cavity or remove the cannula completely and reinsert.
• Overdilation of the cervix can cause loss of suction and inability to aspirate contents. If this occurs, a larger cannula may need to be used.
• Post-procedure hemorrhage:  Risk factors include advanced-maternal age, increased parity, history of obstetric hemorrhage, fibroids, history of uterine scar
  • 2 large-bore IVs
  • Assess for cervical laceration
  • Bimanual massage
  • Uterotonics (Oxytocin 10-20 units, Ergonovine 0.2mg, buccal or oral Misoprosol 400 mcg)
  • Ultrasound for retained POCs

GLOBAL HEALTH WORK: What to ask before you go

Finances:
How much money do you need? What if you plan to travel back home? What if someone gets sick and you need to return urgently?

Work environment:
Organization: What is the structure of the facility? Is it run by local leaders or international doctors? What is the relationship of the foreign physicians with local physicians, leaders and workers?  What is the relationship between the organization and the community it serves? How do your skills fit with the needs of the community and the organization?
Scope of practice: What things will you have or not? Blood transfusions? Antibiotics? Access to OR? What is the specialist referral structure?

Personal Safety:
What is the personal risk of infection, violence, hunger?
What health insurance should you get? Will it cover transport back home for medical causes?

Travel with family:
Will you bring children? Where will they go to school? How about your partner?  What will your partner do there?

Motivations:
Why do you want to go? What if you get there and you don’t feel like you’re helping as much as you thought.

Strategies:
Talk, talk, talk. Ask anyone who’s had similar experience how it’s been. Definitely ask to speak to other physicians who have worked in the organization.

Self Care

Think about what you will do when –

– You’ve worked too many hours and you feel alienated from your work

– You feel under appreciated by your patients or local colleagues

– That one thing about the place you live that bugs you becomes overwhelmingly annoying

– Someone you love is sick or dies at home

– You have a bad outcome with a patient and their family blames you or the facility you’re working in

– You question the ethics of how you are practicing medicine

Strategies:

–  Do frequent check ins with yourself to address how you are feeling.

– At some point you will think “what is wrong with these people?!”It’s OK! Just make sure to get over it quickly.

– Have a fellow foreigner who can help you through hard times.

– Have local friends so you feel community even if you are far away from yours.

– Be flexible to a point, but set boundaries. Know what you will and will not do at work and in your scope of practice.

Resources:

Articles:

Sheather, J. and Shah, T. “Ethical Dilemmas in Medical Humanitarian Practice: Cases for reflection from Médicins Sans Frontières.” J Med Ethics.  2011;37:162e165.

Hottinger, D. “An Ethic for Working in Haiti.” Minnesota Medicine. August 2013.

Singer, P. “Beyond Helsinki: A Vision for Global Health Ethics.” BMJ 2001; 322

(For a very negative view on global health) Illich, I. “To Hell with Good Intentions.” Speech delivered at the Conference on InterAmerican Student Projects (CIASP). Cuernavaca, Mexico.  April 20, 1968

Organizations:

Doctors without borders

Peace Corp: Global Health Service Partnership

Mission Doctors (Catholic Organization, but connections with hospitals all over the globe)

Idealist.org: Lots of organizations advertise for international volunteers here. Definitely look well before you leap!

Health Insurance:

1st step is to see what your insurance covers, if you have any. Some partially cover transportation (even airlifts) back to the US.

International Medical Group

Medex

Additionally – all the major American health insurance companies (Cigna, Aetna, Blue Cross Blue Shield have international packages)

Funding:

Benjamin H Joseph, MD Fund – A good resources for medical students and residents

Global Health Toolkit:
Practical Resources for Docs Doing OB and Other Medical Care in Low Resources Settings

BOOKS

• Albert Schweitzer, a biography: Professor George Marshall and David Poling
• Pathologies of Power. Paul Farmer
• Cutting for Stone: Abraham Verghese
• I, Rigoberta : Rigoberta Menchu

ARTICLES

• Hottinger, D. “An Ethic for Working in Haiti.” Minnesota Medicine. August 2013.
• Illich, I. “To Hell with Good Intentions.” Speech delivered at the Conference onInterAmerican Student Projects (CIASP). Cuernavaca, Mexico.  April 20, 1968. (For a very negative view on global health)
• Marmot, M, “Health in an Unequal World” Lancet 2006; 368; 2081-94
• Nolan, A, “Four stages of spiritual growth in helping the poor” http://www.catholiccincinnati.org/wp-content/uploads/2011/02/FourStages_SpiritualGrowth_by_Nolan.pdf
• Sheather, J. and Shah, T. “Ethical Dilemmas in Medical Humanitarian Practice: Cases for reflection from Médicins Sans Frontières.” J Med Ethics. 2011;37:162e
• Singer, P. “Beyond Helsinki: A Vision for Global Health Ethics.” BMJ2001; 322

“I slept and dreamt that life was joy.

I awoke and saw that life was service.

I acted and behold, service was joy.”

-Rabindranath Tagore

_{Created by Andrew Smith, MD}