ASSOCIATION OF PROFESSORS OF GYNECOLOGY AND OBSTETRICS

Learning Outcomes

Students rotating on the Obstetrics and Gynecology clerkship require basic knowledge related to commonly-used surgical instruments. Knowledge of instruments and their use will be helpful for students on all surgical specialties, both in the third and fourth years of medical school. When students are more knowledgeable, teachers may be more likely to allow them to participate in the operating room (OR). Holding instruments, suturing and other involvement in the OR may help students understand their ability and interest in surgical specialties and may be a powerful recruitment tool for the specialty.

The main learning outcomes for this module are to:

1. Identify and properly hold basic surgical instruments used in common obstetrical and gynecologic operations:
   A. Scalpel (10-blade, 15-blade)
   B. Scissors (Metzenbaum, Mayo-Curved, Mayo-straight, Suture)
   C. Needle driver
   D. Clamps (Heaney, Zeppelin, Kelly, Kocher, Allis, Hemostats, Tonsils, Right Angle, Babcock)
   E. Retractor (Richardson, Bladder Blade)
   F. Forceps (Russians, Adsons, Pick-ups with teeth)
   G. Electrosurgical unit
   H. Skin stapler
   I. Suture (Free-ties)
   J. Needles (“Stick”-ties)
2. Demonstrate proper technique for holding and manipulating each instrument
3. Document competency using a checklist

Best Practices

The introduction to surgical instrumentation should be taught by an experienced instructor (resident, fellow, faculty, scrub technician or nurse) with a relatively small group of students (<20) during the orientation to the Obstetrics and Gynecology clerkship. The ideal module includes a C-section simulator model, an abdominal hysterectomy simulator model and the actual surgical instruments. However, if these are unavailable, photos of the instruments or online pictures or videos of the instruments may be utilized, as well as online videos of a C-section or abdominal hysterectomy. You can also simply describe verbally the steps of the surgery, the choice of instrument, and why it is used.

Materials

For this module you will need the following:

1. A faculty member, resident, fellow, senior medical student, scrub technician, or a scrub nurse to teach the names, uses, and proper handling of each instrument
2. A C-section surgical tray with all necessary instruments
3. An abdominal hysterectomy tray with all necessary instruments
4. A C-section simulator module (Found on ACOG website, CREOG section, Surgical Curriculum in Obstetrics and Gynecology, Cesarean Section)  (http://cfweb.acog.org/scog/ ) *
5. An abdominal hysterectomy module (Found on ACOG website, CREOG section, Surgical Curriculum in Obstetrics and Gynecology, Abdominal Hysterectomy) (http://cfweb.acog.org/scog/) *
6. Checklist for C-section instruments (Included in this module)
7. Checklist for abdominal hysterectomy  instruments (Included in this module)

* Access to these links is restricted to ACOG members.

Module Flow for C-section (45 minutes)

1. The module begins with the instructor  reviewing each instrument with the learner from the C-section surgical tray
   A. Point out the unique features of the instrument so the learner can visually identify it and understand the reasons for its use
   B. Demonstrate how to hold the instrument
   C. Demonstrate how to manipulate the instrument
   D. Explain how, where and why the instrument is used in a particular step of the C-section
2. Allow the learner to visualize, hold and manipulate each instrument
3. Demonstrate the steps of a C-section using the simulator
   A. Link the steps of the C-section with each instrument
   B. Review how to hold the instrument
   C. Review how to manipulate the instrument
   D. Review how, where and why the instrument is used in each step of a C-section
4. Perform an assessment of the learner using the C-section checklist
   A. State each step of a C-section and ask the student what instrument would be used, ask them to identify the instrument, hold and manipulate it correctly.

Use the following scenario to perform an assessment of the learner:

Ms. Winters is a 22-year-old female who has been laboring for the last 6 hours, but has made no cervical change during that time. At 5cm/100%/-1 station the decision was made to perform artificial rupture of membranes to speed up labor. Two hours after rupture of membranes with clear fluid, no cervical change had occurred and the decision was made to augment labor with oxytocin. Two hours later, an intrauterine pressure catheter was placed as the maximum oxytocin dose per protocol had been reached. Contractions were shown to be adequate, and after obtaining informed consent from the patient, the decision was made to proceed with a primary low transverse c-section.

The learner’s tasks are to:

1. Identify the common surgical instruments used in a C-section
2. Demonstrate how to hold and manipulate the instrument for each step

Module Flow for Abdominal Hysterectomy (45 minutes)

1.  The module begins with the faculty member reviewing each instrument with the learner from the abdominal hysterectomy surgical tray
   A. Point out the unique features of the instrument so the learner can visually identify it and understand the reasons for its use and when
   B. Demonstrate how to hold the instrument
   C. Demonstrate how to manipulate the instrument
   D. Explain how, where, and why the instrument is used in a particular step of the abdominal hysterectomy
2. Allow the learner to visualize, hold, and manipulate each instrument
3. Demonstrate the steps of an abdominal hysterectomy using the simulator
   A. Link the steps of the abdominal hysterectomy with each instrument
   B. Review how to hold the instrument
   C. Review how to manipulate the instrument
   D. Review how, where, and why the instrument is used in each step of an abdominal hysterectomy
4. Perform an assessment of the learner using the abdominal hysterectomy checklist
   A. State each step of an abdominal hysterectomy and ask the student what instrument would be used, ask them to identify the instrument, hold and manipulate it correctly

Use the following scenario to perform an assessment of the learner:

Ms. Winters is a 48-year-old female who has failed conservative treatment for menorrhagia and uterine fibroids. On exam she has a 20-week size uterus and you are taking her to the operating room for a total abdominal hysterectomy.

The learner’s tasks are to:

1.  Identify the common surgical instruments used in an abdominal hysterectomy
2. Demonstrate how to hold and manipulate the instrument for each step

Checklist

Performance Assessment

The provided checklists can be used for performance assessments. Each assessment should take about 15 minutes per student.

Practical Tips

We suggest that surgical instrumentation be introduced in the third year of medical school, proximate either to the Ob-Gyn or Surgery rotations. Performance assessment may take place after the Ob-Gyn rotation or at the end of the third year.

Resources

CREOG Resident Education Committee: Surgical curriculum for residents in obstetrics and gynecology. Chair and editor, Patrick Duff, MD; 2002.

Cesarean Section

Abdominal Hysterectomy