YOUR ROLE AS A CLERK

Obstetrics & Gynaecology can involve assessing and caring for individuals at their most vulnerable. This includes difficult conversations and sensitive exams. Learning how to engage in these conversations is an important part of clerkship. 

**However, pelvic and rectovaginal exams should always be performed with the supervision of a resident, fellow, and/or staff. 

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Additionally, if you are unsure or uncomfortable with anything, please speak up or seek additional guidance.

Your resident is a great resource.

SEMINARS

• These can be didactic or interactive seminars targeted towards clerks. 

• Mandatory unless post-call.

• The start time of the seminars vary depending on the site. 

• If you’re on Gyne, you may either miss rounding or the beginning of the OR; therefore, try to meet the patient before the seminar if possible and let your team know when you can join them.

• If you’re on OB, you will do postpartum in-patient rounds before the seminar, and may be able to get the beginning of L&D handover (depending on the site and time of handover). You can excuse yourself and return to the Labor floor after the seminar. 

• If you’re in clinic, and clinical activity starts while you’re in the seminar (i.e. seminar is at 8am and clinic starts at 9am), let your preceptor or team know ahead of time when they can expect you. 

GRAND ROUNDS

• Fridays at 7:45am, information will be emailed to you. 

• This is typically a talk given by a guest speaker to the entire department with a question period at the end. This is a good opportunity to learn interesting topics from experts. 

• Mandatory unless post-call. 

CALL

• Overnight call or weekend call (day or night) consists of managing L&D as well as the Gyne service. These are typically separate during the weekdays. As such, you may be asked to see Gyne consults as well as Triage patients. 

• Weekday call: continue with your regular schedule during the day, then you’re on-call overnight. 

• Weekend call: your call starts during the day and continues overnight.

CLINIC

• Every clinic will run differently depending on the staff and the site. 

• Ask your staff if they would like you to see patients independently or with them. If you are uncomfortable with seeing patients on your own, let your staff know so that you may start off observing and then transition to seeing the patient independently. 

• Try to review the patient’s history prior to seeing them. 

• Perform a focused history and physical (i.e. abdominal exam). As always, do not perform pelvic or rectal exams on your own – you can do them with the staff after you have reviewed the history with them. 

• Once you are finished seeing the patient, review with your staff. Some staff may prefer to review while in the room with the patient. 

• Finish your note:

  • OB: Ontario Perinatal Record

  • GYN: Consult format for new patients, more focused notes for follow-ups 

  • Gyne Onc: Consult format for new patients, more focused notes for follow-ups

OPERATING ROOM

• Before the surgery:

  • If possible, read up on the case beforehand (i.e. the patient, the procedure, indications, possible complications, anatomy). Understandably, this may not always be possible if it is your first day or if your schedule changes on short notice. Ways to access the OR list will vary depending on the hospital.You can always ask your resident or staff the day before the OR if you are unsure. 

  • Make sure you have OR gear on: scrubs, hair cover, surgical mask with eye protection, shoe cover if needed.

  • Show up early and make sure you have introduced yourself to the patient before the case starts. Usually you’ll be with your Gyne team rounding on the in-patients before the OR, so you can meet the patient together.

  • Introduce yourself to the OR team, including the surgeon, the circulating nurse, the scrub nurse, and the anesthesiologist. Ask your resident or staff if they would like you to scrub in. 

  • Write your name, level of training, and glove size on the whiteboard in the OR. Ask the circulating or scrub nurse if they would like you to open the gloves and gown and sterilely hand them over to them. Sometimes the circulating nurse will prefer to do this step and will ask you to place your gloves and gown somewhere. Some sites prefer to not open the gloves until allergies are confirmed at the surgical timeout. 

  • Review the orders and notes required for the case and the post-operative period with your team. Offer to help or learn how to do it. 

  • It’s also a good time to discuss your learning objectives or goals with your resident (e.g. suturing, hand-tying, learning the pelvic anatomy, putting in a Foley).

  • Help with the OR set up and positioning of the patient. Ask how you can help if you are unsure. Do not touch the patient during the induction process (getting the patient under general anesthesia). If a Foley catheter is needed, offer to help or learn to do it. 

  • Do not touch anything that could be sterile (usually on blue or green sheets/towels). If you are unsure, ask before you touch something.  

  • You can start scrubbing when your resident or staff tells you to or when the patient is finished getting prepped. If you are unsure about how to scrub, ask for assistance. Double glove if possible. If you think you have contaminated yourself or if others have noticed possible contamination: speak up, be honest, and re-scrub. It happens! Always put the patient’s safety first.

• During the Surgery

  • You may be asked to: retract, suction, irrigate, hold the laparoscopic camera, or bottom-end (assist in the positioning of the uterus), cut sutures, or suture. 

  • Situational awareness: If it is not an appropriate time to advocate for your learning (i.e. if there is a complication, if the team is very focused on a difficult part of the surgery, or if there is a significant time constraint), then simply observe, listen to their instructions, and know that there will be more opportunities to get hands-on experience. 

• After the Surgery

  • You can help with:

    • Cleaning the patient. Dry the incisions with a clean sponge so that wound dressings will stick better. 

    • Bringing in the stretcher. Make sure the patient is covered first. Ask the nurse or Anesthetist before opening the main door.

    • Moving the patient from the operating table to the stretcher. 

    • Cleaning up the room. If unsure, ask the nurses if there is anything you can help with. 

    • Transporting the patient to the PACU. 

LABOUR AND DELIVERY (L&D)

• *Please see bottom for L&D Flow diagram.

• Your resident/fellow/staff will hold the pager/ASCOM phone and will delegate tasks to you. 

• Postpartum rounding:

  • *Please see the Notes and Templates section for guidance on notes for postpartum rounding. 

  • Early in the call shift, create a postpartum rounding list. Divide the list into post-op day (POD) 0, POD1, and POD2. Include all patients who have had a cesarean section, forceps, vacuum, or complications (usually third/fourth degree tears, PPH). Write down the patient’s room number, name, and post-op hemoglobin if available.

  • As a clerk, you will be responsible for seeing the POD0 and POD1s. You should ask them about the following: pain, ability to tolerate oral intake, voiding, passing flatus, ability to ambulate, and lochia. If they are POD0 or POD1, they may have a Foley catheter still in place and may not yet be passing flatus, which is OK. Please see the Notes & Templates section for full history details.

  • Vaginal deliveries typically get discharged 24 hours after delivery and cesarean deliveries typically get discharged 36-48 hours after delivery although may be discharged 24 hours after delivery if they are meeting discharge criteria.

  • Once a patient has a cesarean section, forceps, or vacuum delivery, it is helpful for you to start the discharge summary. This may be challenging on call, but will be super helpful for your resident. You can start this while they do the post-delivery orders and delivery note.

• Triage:

  • OB triage functions like an emergency department/walk-in clinic for any patient ≥ 20 weeks gestation. These patients come directly to triage for assessment. Common presentations include early or active labour, decreased fetal movement, vaginal bleeding, ruptured membranes, and accidents such as trauma/falls/MVCs. 

  • *Please see the Notes and Templates section for guidance on what to ask in OB triage. 

  • If the patient is stable, review the patient’s chart briefly before seeing them. 

  • Perform a focused history and physical exam. Save the pelvic exam for later, to be done with your resident, fellow, or staff. 

  • Try to formulate an assessment and plan (i.e. active labour to be admitted to L&D vs. early labour to be monitored at home etc.). 

  • Review with your team. 

  • Finish your note with a clear impression and plan.

• Deliveries:

  • Assist in deliveries as instructed by your team. Help with getting materials ready, such as lubrication for cervical exams. 

  • Depending on the type of delivery, you may be able to assist if it is straightforward. Oftentimes, you can help deliver the placenta. Do not be afraid to let the team know when you are uncomfortable, when you need some assistance, or when you’d like someone to walk you through the steps. It is also helpful to assist the patient in getting in the right position to push for vaginal deliveries. Follow the guidance of the team. 

  • Situational awareness: Some deliveries will be more difficult and will require a vacuum or forceps. In some cases, there may be more bleeding than expected after the delivery. In these situations, it is appropriate to step back and allow the team to focus on managing the situation at hand. There will be more opportunities to help with deliveries during your rotation. Follow the instructions of your team as they may ask for your assistance. 

  • After a vaginal delivery, you can help with: retracting for repairs of tears, cleaning the patient, cord gases, helping with the instrument and sponge counts, and cleaning the room.

  • For cesarean deliveries, follow the guidance above for your role in the operating room. You will have opportunities to get involved during the C/S.

  • Delivery notes are typically done by the resident, fellow, or staff. You may offer to help or learn. While the team does that, it’s a good time to start the discharge summary or finish any pending documentation from that delivery.

GYNAECOLOGY SERVICE

• Morning Rounds

  • *Please see bottom of page for Gyne Flow diagram. 

  • *Please see the Notes and Templates section for guidance on progress notes for Gyne. 

  • Pre-rounding: Arrive earlier than the scheduled rounding time to prepare the charts beforehand. Use the template of a progress note (i.e. SOAP – subjective, objective, assessment, plan). Print the list of patients (every site has a different system for this). Collect the pertinent investigations including blood work, vital signs, in’s and out’s. Write these pieces of information on the list for each patient. Once completed, photocopy your list to provide copies for your team. If you are unsure or have not done pre-rounding before, you can ask your resident to teach you.

  • Rounding: While the team rounds on each patient, fill out the progress note you have prepared. Your team will often state the findings of the physical exam out loud for you to write down. Clear impressions and plans are important as other services and the nursing staff will refer to this when trying to understand how the patient is progressing. 

• OR

  • You may be assigned to attend surgical cases in the OR. If so, please refer to the above guidance on your role in the OR. 

• Ward

  • Typically, the resident will hold the pager.

  • Similar to Internal Medicine, there are various patient care items and investigations that need to be coordinated during the day. This may include following up on results, consulting other services, following up with radiology regarding previously ordered investigations, etc. 

  • As such, the list of patients and action items is typically divided among team members. You may be responsible for following up on a particular patient or action items for the day. Write these down so you don’t forget.

  • Please notify your resident of any major updates that might change the management of the patient. Do not hesitate to contact your resident if you are worried about a patient. 

• Consults

  • Your resident or staff will tell you about new consults they would like you to see. 

  • Interview the patient and perform a preliminary physical exam. Do not do the pelvic exam on your own – this can be done afterwards when you see the patient again together with your resident/fellow/staff. After your initial interview and preliminary physical exam, collect your thoughts and review the case with your team. It may be helpful to write your consult note during the consult for efficiency. 

  • You can help prepare the patient for the pelvic exam by asking them to change into a gown before you see them again with your resident. Collect the materials needed for the pelvic exam if you have an idea of what will be done (i.e. speculum, lubricant, light source, etc.).

  • If the patient is unstable or if you are worried about anything, contact your resident, fellow, or staff right away.   

• Tuck-In Rounds 

  • Towards the end of the day, the team will “run the list” (go through each patient on the list and briefly discuss their status, any updates, and the plan moving forward). 

  • The team will go around to each patient, similar to the morning rounds, to complete this. This can be helpful in updating the patients and making sure everything is taken care of before the on-call team takes over. 

  • No notes are required for this unless there have been major changes in the patient’s condition or management plan.

GYNAECOLOGIC ONCOLOGY

• Some sites may offer this as part of the rotation. 

• Some sites may involve clerks during morning rounds. If it is not required at your site and you are interested, you can ask to join the team for morning rounds. 

• See above for information about your role in the operating room and in the clinic. 

UROGYNAECOLOGY

• Some sites may offer this as part of the rotation. If this is available at your site, you may have a few days assigned. 

• Typically involves clinics, including urodynamics, and ORs. 

REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY (REI)

• Some sites may offer this as part of the rotation. If this is available at your site, you may have a few days assigned. Given that the duration is short, you will likely only be asked to observe and occasionally help with history taking.  

• Typically involves clinics and procedure days, including IVF. Please discuss with your staff regarding your role as this will vary.