The obstetrics and gynecology clerkship: building a better model from past experience

OBJECTIVE: The study was undertaken to identify factors contributing to the poor student perception of the obstetrics and gynecology clerkship. STUDY DESIGN: Third-year medical students at the University of Michigan complete an annual questionnaire about the overall quality of their clinical experiences. In addition, at the end of each rotation, the students complete an evaluation form assessing various aspects of their learning experience. We reviewed data collected from 2000 to 2002. We calculated effect sizes using mean scores and SDs to compare individual aspects of the learning environment across the clerkships. RESULTS: Twenty-six percent of the third-year medical students at the University of Michigan rated the strength of their obstetrics and gynecology experience as very or exceptionally strong. Compared with the other 6 clerkships, the rotation had one of the lowest ratings for overall quality. Aspects of the clerkship experience we identified as potentially explaining this overall poor rating include the clarity of the clerkship goals and objectives, clarity of expectations for student performance, accessibility of faculty, experiences in learning history-taking skills, experiences in learning physical examination skills, and student perception that they were treated in a respectful/professional manner. CONCLUSION: Aspects of the clerkship experience identified by this study as potentially explaining the low ratings of the obstetrics and gynecology rotation should be studied in greater detail. Addressing these factors will be critical for improving the overall student perception of the obstetrics and gynecology clerkship.     

Labor and delivery nurses: a survey of attitudes toward third-year medical students and their education

OBJECTIVE: Forty-six percent of third-year medical students at the University of Alberta rated labor and delivery nurses as a negative influence on their obstetrics and gynecology rotation. We hypothesized that the nurses would have mostly negative opinions toward students and their education. STUDY DESIGN: Labor and delivery nurses were surveyed with regard to their views on the following: (1) student learning objectives, (2) factors causing a patient to reject or accept a student, and (3) the role of the nurse in medical student education. RESULTS: Eighty-nine nurses ranked student tasks (objectives) as very appropriate, appropriate, neutral, inappropriate, and very inappropriate. History and physical examination, witnessing deliveries, assisting at deliveries, and following up women in labor were rated very appropriate or appropriate by more than 96% of nurses; 85% approved of students doing supervised deliveries. Nursing staff were equally divided in approving or disapproving of pelvic exams in labour and outpatient assessment by students. Artificial rupture of membranes, fetal scalp electrode application, and episiotomy repair were not approved of by more than 70% of nurses. The most important factors causing a patient to reject or accept a student were felt to be bedside manner and previous experience with a student, with least important being attractiveness, gender, and the nurse's opinion. Eighty-seven percent of nurses declared that one of their roles is to help students gain experience, but 71% said they would protect women from students with whom they were not comfortable. CONCLUSION: Labor and delivery nurses generally have a more positive attitude toward students and their learning than review of evaluations by the students would suggest. However, nurses have reservations about students performing technical procedures in the labor and delivery room. Creation of guidelines (objectives) with nursing input and better briefing of students with regard to nursing expectations may improve the student's experience.     

Anesthesia for obstetric patients with Gaucher disease: survey and review

Pregnancy and delivery in patients with non-neuronopathic Gaucher disease, whether treated with enzyme replacement or untreated, are usually uncomplicated. Various factors may influence mode of delivery, vaginal or cesarean section, as well as type of anesthesia, general or regional, used during delivery. This retrospective review was intended to highlight some of the practical issues relating to obstetric anesthetic management, based on a review of the literature and experiences from a large referral clinic for Gaucher disease. In the past decade, there were 16 deliveries in 11 women in our institution. There were five normal vaginal deliveries, two vacuum extractions, one placental extraction, and eight cesarean sections. Platelet counts were 27-215 x 10(9)/L. Two spontaneous deliveries and one vacuum extraction were performed under epidural anesthesia; two other women having vaginal deliveries and one vacuum extraction were given i.v. analgesia; the fifth was given i.v. patient-controlled analgesia. The placental extraction was performed under general anesthesia. Seven of the women having cesarean deliveries received spinal anesthesia; the breech presentation required general anesthesia. There were no anesthesia-related side effects or complications, although there were some instances of post-partum bleeding irrespective of enzyme therapy. Gaucher disease affects multiple organs and can be a challenge to the anesthesiologist. Based on this survey we suggest that anesthetic management requires particular attention to hematological parameters before delivery. A multidisciplinary approach and extensive communication among obstetrician, hematologist and anesthesiologist is required to anticipate the possibility of post-partum hemorrhage, and preclude skeletal damage.     

Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement

Obstetric risk has important implications for reporting and benchmarking quality in today's managed health care environment. Administrative data, including diagnosis related group (DRG) information collected by hospitals, is used by payers and governmental groups for reimbursement, monitoring quality, and setting financial rates. Obstetric conditions that affect the patient experience are coded but do not often contribute to the overall DRG assignment. This strategy, therefore, may provide comparisons that are misleading to consumers and payers. Additionally, financial rates often do not provide adequate reimbursement for the cost incurred in caring for high-risk patients. Finally, risk prediction strategies have historically been used to both identify vulnerable patients for early management and make more equitable comparisons of groups of patients.     

持续质量改进在预防会阴伤口感染的应用

目的探讨持续质量改进在预防会阴伤口感染的作用。方法对2003年住院分娩的产妇会阴伤口感染情况进行回顾性分析,确定目标,制定相关环节的改进方案,测定实施结果。结果2004、2005年会阴伤口感染率、线头炎发生率较2003年明显减少,差异有统计学意义（P〈0.05）。结论持续质量改进是一个不断的、渐进的、长期的过程,预防会阴伤口感染是产科工作者长期持续的工作;严格执行无菌技术操作,掌握熟练的缝合技术,选择易吸收的可吸收性的缝合线,术后适当的保洁护理和使用抗菌药物可有效地预防会阴伤口感染和线头炎的发生。     

高职产科学教学改革的实践

结合产科学的教学实践,从教学内容和课程体系改革、教学方法与手段的更新、强化操作训练、进行操作考核等方面,探讨高职产科学的教学改革措施,以全面提高学生素质,培养和造就适应社会需要的助产人才。     

妇产科抗菌药物临床应用调查分析

目的:了解妇产科临床抗菌药物使用情况,提高妇产科临床应用抗菌药物的合理性.方法:采用整群抽样的方法,回顾性地调查本院2004年1月～2006年12月妇产科住院患者抗菌药物的使用情况.结果:共调查5 817份病历,抗菌药物的使用率为44.15%,以预防性用药为主,占93.73%.结论:加强围术期抗菌药物使用的管理,提高抗菌药物的合理应用性.     

Vaginal morphology following hysterectomy

This study was designed to gain more information about morphology of the vagina after hysterectomy. The prospective clinical observations of patients subjected to abdominal or vaginal extrafascial or intrafascial hysterectomy with or without correction of anatomical urinary stress incontinence were included. The length, configuration and axis of the vagina were determined using a vaginal cast technic. Vaginal casts were prepared prior to and 6 months to 4 years after surgery. The gross appearance of the vagina after hysterectomy is affected by understanding normal pelvic anatomy an physiology, careful preoperative evaluation of pelvic defects, proper planning and competent performance of surgery. Proper handling of the endopelvic fascia and its condensations, the cardinal and sacrouterine ligaments, corrects preexisting weakness, provides vaginal suspension and prevents future vaginal disfigurement. Inadequate surgical technics result in magnifying preexisting weakness of pelvic supports. Successful surgery involves correcting the levator complex by reducing and shifting the levator hiatus ventrally. Reconstruction of the perineal body is essential. This study suggests a relationship between successful surgical treatment of urinary stress incontinence and reconstruction of pelvic supportive structures, with restoration of the physiological vaginal axis.     

Immunoperoxidase localization of papillomavirus antigens in cervical dysplasia and vulvar condylomas

Biopsies of 50 cases of cervical dysplasia (46 mild and 4 moderate) and 40 cases of vulvar condyloma acuminata (genital warts) were screened for the presence of papillomavirus antigens by means of a peroxidase-antiperoxidase method having immunospecificity against the genus-specific (common) antigen(s) of the papillomaviruses. With the use of this technique, on formalin-fixed, paraffin-embedded tissue, papillomavirus antigens were detected in cells with cytologic and histologic features of wart virus infection (so-called koilocytotic atypia). Cells showing a positive reaction for papillomavirus antigens were identified in 24 of 50 (48%) cases of cervical dysplasia and in 20 of 40 (50%) cases of vulvar condyloma. The results of this study provide specific confirmation of the presence of papillomavirus antigens in cervical dysplasia and suggest that the papillomavirus may be an important factor in the etiology of this disease.     

Growth of the ultrasound fetal femur length during normal pregnancy: Part I

The growth of the ultrasound fetal femur length during normal pregnancy is presented. A total of 1,016 measurements of the fetal fernur length from 14 weeks' gestation through term were taken. The growth of the fetal fernur deacribes an asymptotic curve similar to the growth of the biparietal diameter with comparable limits of 2 SD. From the serial measurements performed, the growth rate of the femur has also been calculated. This begins at 3.15 mm/wk and slowly decreases to 1.55 mm/wk toward 40 weeks' gestation. Femur measurements provide the first repreducible determinations of “length” of the fetus to be measured by ultrasound throughout pregnancy.