Paging Dr. Manners STAT to L & D: A guide for physicians and medical students

This blog has achieved 600 hits in a just over a week. In order to keep that momentum going, we are firing up another Dr. Manners post. It has quickly become apparent that there is a humorless void regarding residency, particularly in OBGYN, that we hope to fill.

Last week, we reviewed the decorum that can maximize the working/learning/teaching environment in the operating room. And just the other day, our guide to signout/handoff styles got some attention, so it got us thinking about doing a Dr. Manners guide for Labor and Delivery, possibly one of the most exciting and much-anticipated rotations in medical school. OBGYN rotations are usually spoofed magnificently at medical school class skits, but we digress.

I can remember being introduced to the concept of professionalism as a medical student and it quickly became apparent that it was becoming more and more of an issue because "how-one-should-act" on the wards was up to the examples set by the team the student was on.

Professionalism should not be taught to medical students/residents like a parent talking down to a child because lectures on professionalism quickly become "how-to-behave" lectures that quickly turn people off.

The purpose of Dr Manners is to provide a new paradigm, using humor and our collective real life experiences as medical student, resident and fellow to teach professionalism.

This week we break down what Blueprints OBGYN (mehh), First Aid OBGYN (not bad, decent for step 2/3), and CaseFiles Obstetrics and Gynecology (my favorite) fail to give advice on: professionalism (aka how-to-avoid-awkward-moments) on Labor and Delivery.

Please note that this is for Physicians of all levels too: residents, fellows, attendings, staff MDs, etc...and while the examples given below may be relevant for academic settings, just like the OR post, anyone who works on labor and delivery will appreciate the advice given here. Hit the jump for the guide on handling yourself on Labor and Delivery.

1. Jimmy Choos/Kenneth Coles don't go with scrubs

Most surgical rotations...it’s obvious you have to wear scrubs. But OBGYN is not like surgery and here is why: most of the time surgeons change from scrubs to "clinic clothes" because their patients don't disrupt their clinic by coming in 3+ and pushing.

Typically, the private practice OBGYN sees patients in their clinic, which is (usually) in the hospital- a quick jaunt away from Labor and Delivery-where anything can go down with any of his/her patients, at any time. This culture pervades down to trainees and that is why few OBGYNs get uptight when trainees see clinic patients while donned in scrubs. 

The point here is not to URGE scrub wearing in clinic, but, ultimately, to know what attire (shoes are a major part of this equation) you will need for your OBGYN rotation. Are you on L&D? Don't show up in clinic clothes unless you rock ratty sneakers or comfortable (ratty) flats with them because THEY ARE GOING TO GET SOILED – and soiled hardcore! 

Also nothing is more embarrassing then wearing scrubs with nice dress shoes!

2. "So what is the pathophysiology behind pre-eclampsia?"

Not the question to ask while the team is stabilizing a patient in the midst of an eclamptic seizure. Same goes for the crash c-section. Residents are bad about getting caught up in a moment, but can you blame them? Their undivided attention should be on performing the task at hand. Once things are controlled - which they usually will be - then questions can flow and such an environment should be fostered by the senior resident once the emergency has come to pass.




Also, when asking questions during a delivery (c-section or vaginal), be aware of the fact that the patient IS NOT UNDER GENERAL ANESTHESIA AND CAN HEAR WHAT YOU ARE SAYING...so not the time to say, while fixing a 4th degree laceration for example:

"So...I read in BLUEPRINTS that 4th degree lacerations are associated with fecal incontinence issues...gosh, that has got to really suck!" or 

"[sigh] it looks like a bomb went off in here" or

"all this extra tissue is not making this repair easy" or

“I can’t tell what goes back together with what”
…you get the gist.

Yes, "Johnny intern," it does suck, but so does the unprofessionalism that you show toward the patient by providing this play-by-play during the repair...the supervising resident SHOULD direct the teaching during a procedure- just be aware of the situation, of the resident operating, and when in doubt, save the question for a better, more appropriate opportunity.

3. "The Patient in 10 doesn't want to see a male."

This is more for the resident running the labor board...Contrary to popular belief, this does not happen that often, but it does occasionally and while it is important to be sensitive, full disclosure is necessary on the part of the physician. For example, when I was the third year resident, I managed ALL labor patients...I was also the "first responder" to any and all emergencies on L & D. So when a patient would come in and "declined" the services of a male physician - No problem - BUT I would always have a frank, graciously sensitive, conversation about the fact that my role is to manage all of the labor patients, "I would be the first to respond," "my focus is on you and your baby," etc. In many cases, these conversations were directed to the husband as well as the mother-to-be. I never pushed it though...I just wanted them to be fully informed up front.

While we dance around what being culturally sensitive really is: I think it is more than just a nurse saying "The patient in 10 doesn't want a male, period." I always felt that since my primary responsibility was ALL patients on L & D, particularly those in labor, it was best FOR ME to at least meet them. Perhaps this is a mildly paternalistic, perhaps a little arrogant, but I just saw it as a way of being transparent, being safe and knowing my unit, while being respectful.

4. L&D Nurses RULE!

First of all, L & D is not like ANY other place in the hospital...its closest relative is the ER, but that is a distant relationship primarily because there can be a tremendous amount of downtime on L & D and this is usually not the case in the ER - but when L & D is busy, YOU NEVER STOP! When it comes to L & D nurses, knowing some of these basics will make your life a lot easier:

a) Remember, chances are, these nurses have been at that institution/in obstetrics way longer than you have been a resident/medical student so show them some respect...too many residents come in and start acting like they are hot stuff which disrupts the work environment. Fine, you want to be bossy - get your ego trip on - wait until you are a senior resident (AND EVEN THEN, I would STRONGLY DISCOURAGE IT!). Furthermore, no medical student or junior resident should be arguing with the nursing staff...if there is an issue, speak to your supervising resident or attending immediately.



b) ALWAYS introduce yourself to the nurse and get to know their name. Again, this is SO important, if not the golden rule on L&D. Residents: you need to know who the charge nurse is for the shift because he/she is the gatekeeper of your staff (and your ability to get stuff done).


c) if you want to score points, when ordering food on Labor and Delivery, include the nursing staff...they are just as tired and hungry as you are at 1am. They might pass up your massive order from the corner Wing Street, but include them...you are a team (and don’t forget to include your attending!) Eating is such a staple of L & D's everywhere, that the Food Network should consult with the L&D staff for what local carry-out places are best! 

5. Vaginal Deliveries

Most medical students have never witnessed a live birth. TV obviously doesn't do the process justice and half the time some students walk out with a "mortified" look on their face (residents can also walk out with this look on their face after a shoulder dystocia). Either way, there are some simple mores to 
follow when in the Labor and Delivery suite as a student and/or intern:

a) it’s a privilege to be part of a delivery and it is a pretty amazing experience (I became a father this past spring..truly a different perspective)...sidenote: keep in mind that the "miracle of birth" paragraph in your ERAS personal statement can be a bit passe, so be unique!

b) if you are going to GO PUSH WITH A PATIENT know what you are getting yourself into...The primiparous patient who is complete and 100% effaced as you are eagerly anticipating your first delivery...Get Comfortable…You might be in there for 3 hours. If you've ever hung out on an L and D without residents or students (most L& Ds in the US) the nurses become very skilled at knowing exactly when to call in the MD for delivery (because the MDs aren't in-house)

Bless you either way. I always loved it when students got excited about pushing patients, BUT they should have an expectation. Learning Point: "Laboring down” is never a bad thing early in the second stage.

c) KNOW WHERE THE STERILE GLOVES ARE...INTERNs and Medical students this one is for you! Usually they are in a drawer near the patient's bed. What is the first thing you need when attending a precipitous delivery? GLOVES! In a more controlled setting...Make sure YOUR gloves and an extra gown are on the sterile table...PULL THEM YOURSELF...and please don’t take ten minutes putting them on because you WILL miss the delivery!

d) if you are delivering, don't be afraid to touch the baby...and when the baby comes out...YOU will stand there in shock(maybe fear) for like 5 seconds BUT IT SEEMS LIKE AN ETERNITY for everyone else in the room...turn and place the baby in the OHIO (or on Mom). AND (goes without saying)...Please don't drop the baby!

6. C-Sections

YESSSS! Operating! Most medical students get their first operative experience on OBGYN doing cesarean sections...their role: using what seems like the damn "safety scissors" to cut suture. The culmination of your undergraduate degree and 2 years of medical school are reduced to cutting suture though "not too long" and "not too short" (so called the "2 short, 2 long" phenomenon by a colleague) This is like surgery hazing 101...you can never win! This is something I would not get too stressed about it...because like I said, you will never win. Just laugh it off, don't take it personal and everytime someone grabs for suture, grab the suture scissors!

Also, remember that the patient is in left lateral decubitus position...SO ALL THAT IRRIGATION YOU JUST USED...yeah it is going to seep through the drape onto your feet...so wear the knee high shoe covers...Hell, just wear them on L and D...actually on second thought that "swishing" sound can get annoying so don't do that...

7. Eating 

You don't need a hall pass, take time for lunch but don't disappear for 2 hours when triage is slammed. Attention Residents: medical students are not there to pick up your "carry-out" from the “Mandarin Garden” Chinese joint down the street...unless of course you are paying for them!

8. "You Down with NCB, yeah you know me!"

Natural Child Birth (NCB) is a topic I covered in my running diary of Ricki Lake's documentary, “The Business of Being Born.” I have no problem here except that in my experience (BEWARE: Recall BIAS in play) these patients end up having some inverse self-fulfilling prophecy (i.e, they get sectioned, they get an operative delivery, etc) of what they intended their delivery to be like: a 'nice' benign vaginal delivery. 

However, if you end up having a patient who is down to NCB, be mindful of this and don’t walk in every half hour to “see how they are doing” or to “see if they are having any pain” while they are deep into their lamaze breathing on the birthing ball. They don't need q2 hours cervical exams either...

Alright, I think we hit most of the high points when navigating L&D. Again, the commentary here is based on my observations as a medical student and then from my perspective as a resident and again is meant for info-tainment! Stay tuned for the next installment of the blog: An MD's Guide to Survival in the Lab.