NSD birth

Today for the first time in my life I saw a live vaginal birth. It really is like squeezing a meatloaf through your nostril. I first saw the patient in outpatient clinic. She had come in for a check up and when the doctor checked her cervix decided to admit her. She has had 2 other children, so this third one was supposed to happen very fast. And it did. I arrived shortly after she began to push and made it just in time to see it all happen. It happened in the course of about 15 minutes. Dr. Yang gave her an analgesic injection and then made the opening larger. She asked the woman to push and the head began to come out. After one more larger push, the baby was out. I got to help clamp the cord and cut it. They then suctioned his mouth and nose and cleaned him up. He began to cry and the group of nurses in the room took him to show the mother. They then took him to the baby room. The doctor then let me help ease the placenta out, slowly twisting it around to keep the membranes intact. The placenta was warm and slippery, and I almost dropped it on the floor. I helped with the episiotomy stitching, which was the bloodiest part of it all. I began to feel a little woozy from it, which I didn't expect to happen since I had survived the rest of it without any problem. I was surprised that the woman seemed to be able to feel the needle going through her tissues. She seemed to be in pain, which made it a little worse for me. The doctor worked fast and she was all stitched and ready to move in about 5 minutes. Dr. Yang and I went to visit the baby in the nursery. He was all wrapped up like a burrito and resting. His face was a little edematous, which apparently happens when the woman squeezes her legs too much during the birth.

After speaking with Dr Yang about episiotomy, she told me that in Taiwan it is done because it heals more beautifully. By cutting with a knife, you create a straight edge to sew back together that heals in a more aesthetically appealing manner. The tissues did come together quite nicely when she finished with the stitching. She said that she has tried the natural way, by letting the tissues tear on their own, but it healed in a jagged way. She also said that women do not experience side effects from it. Episiotomy use in the US has declined in recent decades because of side effects.

This was an amazing learning experience for me. It makes me think about whether I want to have children or not. It looks rather painful and I don't tolerate pain all that well. But I learned so much about the process of having a baby and giving birth. This week in OB/Gyn has been a great experience.

OB/Gyn outpatient clinic

The last couple of days in outpatient clinic in OB/Gyn was quite busy. I have been able to shadow 3 different doctors and see their different styles and bed side manners. The nurses in the department are great and know exactly what the doctors want before they ask for anything. Most of the patients in OB/Gyn come in for itching, pap smears, or OB checks. I've gotten to see and do a lot in the last few days. I have learned how to do a pap smear and have been able to do a few. Some are easier than others because of the location of the cervix. Some are more posterior or superior than others. I've been able to watch a cervical biopy and cerivcal polypectomy, which to my surprise do not require anesthesia. The biopsy is take with a long jaw-like instrument that bites off pieces of the cervix. The polypectomy is really simple; you just grab it with a clamp and twist it to rip it out. The cervix apparently doesn't have many nerves, so cutting and pulling on it doesn't hurt.

One case that required cervical biopsy was an older woman who came in with her family and caregiver. She had been experiencing spotting for the last month and a half. So the doctor did a pelvic exam and found changes in the cervix that looked cancerous. It began to bleed a lot as soon as she touched it, so the biopsy was a bloody procedure. Dr. Yang also did a trans-vaginal ultrasound and said that the cancer looked like it was in the endometrium as well. She suspects squamous cell cancer either originating in the cervix or the endometrium.

I was also able to see a case of problems conceiving. The husband had already had his sperm checked, so the wife was coming in to check on her. The husband's sperm was normal. They have been trying for 2 years. Dr. Tsao was reassuring to the patient and then performed a hysteosalpingogram. This is an x-ray to test the pathway that sperm would travel in the uterus and fallopian tubes. Dr. Tsao injected contrast agent slowly into the cervix and took sequential pictures of the pelvis to see the ability of fluid to enter the uterus and fallopian tubes. This patient turned out to be normal.

I have also learned about IUD's and their placement. Many women in Taiwan use IUDs instead of hormonal contraception. The hormonal contraception that is available at Taipei Hospital through the national health insurance is apparently a high dose. Many woman in Taiwan do not like to take hormones because of the side effects of the high dose. Young women who have irregular menses are not usually given hormonal therapy because parents are afraid of growth retardation. The oral contraception available in the US is a low dose of estrogen, so is more commonly used. The doctor told me that most people use condoms as their contraception in Taiwan. This seems to be a good thing, as there don't seem to be a lot of cases of STDs. In the last few days I've only seen a few (at most 5) cases of STDs. I learned that HSV is more common in older woman than other STDs.

I've also learned that pregnancy terminations are done in Taiwan up until the 24th week. A woman came into the clinic who was about 24-weeks pregnant asking for a termination. She said that she had taken foreign diet pills and was concerned for the baby. So a dilation and curettage was scheduled for her next week. The intern also told me about a case of twins that were terminated earlier this month. The doctors are not required to do this procedure and can decline if they want.

Another woman came into clinic today asking to schedule her delivery. C-sections can be scheduled for woman if they want, but the national insurance plan will not cover the surgery without indications for it. The intern told me that it costs about $10,000 NT for the surgery, not including the anesthesia. This is inexpensive compared to the US.

In the midst of the business of clinic, Dr. Tsao taught me about IVF and ovarian cancer. He and the intern each gave a presentation about the subjects between patients in clinic. IVF is not done at Taipei Hospital, but Dr. Tsao told me that he has done it before. It is not covered by the national health insurance in Taiwan, so people must pay to do it. It is much cheaper in Taiwan than in the US. The intern's presentation covered everything about ovarian cancer. Ovarian cancer is not treated at Taipei Hospital and those patients are referred to a larger hospital. This hospital doesn't have radiotherapy equipment. There are many different types of ovarian tumors. I learned that bilateral ovarian tumors usually arise from metastases from the GI tract.

In OB/Gyn I have learned a lot about the reproductive health of woman. I've been able to watch numerous ultrasounds (trans-abdominal and trans-vaginal). I've learned a lot about how to read them. I've also seen ultrasounds of pregnant women and how to measure the baby. It has been a great week and I have learned so much. The department has taught me so much and I'm so grateful for the time they have taken to teach me.

OB/Gyn day 1

Given the things I learned in Pediatrics, I thought that this week in OB/Gyn I would not get to see a delivery at all. But the hospital's first birth for the month of June happened on the first day I was there. There was a scheduled C-section and the doctor told me to come and watch. I had been hoping to be able to see a birth in this department and I was so privileged to have the opportunity to see it happen. The intern in the department, Vicky, watched with me and explained some things. When we got to the surgery, the doctors had already started cleaning the area to prepare for the incisions. They then started cutting carefully through each layer of tissue separately, peeling them apart as they went through. After they cut through the endometrial layer, Dr. Tsao (my preceptor and head of the department) reached his hand in to find the head. He then took a tool that looks like a toilet plunger and grabbed the head. He moved it around in a circular pattern, which resembled stirring a large pot, and slowly pulled the head out. He wiggled the baby out, cut the umbilical cord, and then gently shook her to make her cry. She cried and the nurses cleaned her up and put a clip on the cord. A newborn baby is bluer than I expected and it took a while for her to turn pink. They woke the mother up to show her the baby while the surgeons were working to start closing everything. Stitching each layer of tissue took just as long as getting the baby out. They started with the endometrial layer and have to make sure that there is no fluid leaking out of the incision. They cauterize where needed to stop bleeding and fluid leaking, and then move to the uterus, peritoneal sac, abdominal muscles, fascia, fat and skin. The skin is stapled shut and the mother is wrapped in bandages and a brace. Seeing this surgery was amazing to say the least, but also a great learning experience. Seeing tissues in their live form is so different from the cadavers. And birth is nothing short of incredible; seeing new life for the first time is indescribable.

Outpatient clinic in OB/Gyn consists of A LOT of PAP smears. Women older than 30 in Taiwan are allowed to get one per year with the National Insurance. There are 4 basic cancer screenings that Taiwanese people do yearly: cervical, breast, colon and oral. Each of these cancers have a better prognosis when caught early. So many women come to get their screening. It is very fast as they usually don't really have to speak to the doctor unless there is a problem. The nurse and intern take care of most of them. They even let me try to do one. It is a really simple procedure but I think I will need to work on it a little more. Between cases, Dr. Tsao presented about acute abdominal pain in urgent care. I learned a lot from his presentation. He went over differential diagnoses for abdominal pain and how to treat it. He told us about the more emergent cases and which you need to rule out first. He also did several ultrasounds and I got to hear a baby's heartbeat and watch its heart beating. He showed me IUD placement and removal as well. In the afternoon, another doctor showed me a CT scan of a woman who has a ovarian cyst that is about 25 cm. It takes up a large portion of her lower abdomen. I imagine that after the surgery she will lose a few pounds. She is scheduled for surgery on Friday, so I'll be able to watch them remove it. She had initially declined surgery, but is now going to go through with it.

The first day in OB/Gyn was wonderful. It was definitely a day that I will not forget and I learned so much in such a short time. We have not studied the reproductive system yet, so this has been a crash course. I will definitely have a good head start in the things that we will study next year. I can't wait for the rest of the week.