Operational Obstetrics & Gynecology
The Health Care of Women in Military Settings
2nd Edition
Table of ContentsPage 1
Table of Contents
Introduction...... 1
Military Medicine...... 1
Women’s Health Care...... 1
Women in the Military...... 2
Purpose of this Manual...... 2
Routine Gynecologic Care...... 4
Annual Exam...... 4
Chief Complaint...... 4
Medical History...... 4
Medications...... 4
Menstrual History...... 5
Pregnancy History...... 5
Contraception...... 5
Nutrition...... 5
Exercise...... 5
Mood...... 6
Physical Exam...... 6
Weight...... 6
Blood Pressure...... 7
Face and Eyes...... 7
Ears...... 7
Thryoid...... 7
Lungs...... 7
Heart...... 7
Breasts...... 7
Abdomen...... 7
Pelvic Exam...... 7
Pap Smear...... 8
Cultures...... 8
Rectal...... 8
Urine...... 9
Wet Mount...... 9
Mammography...... 9
Breast Self-Exam...... 9
Immunizations...... 10
Counseling...... 10
Plan...... 10
Pap Smears
The Cervix...... 11
The Pap Smear...... 11
Position the Patient...... 12
Field Expedient Exam Table...... 12
Pad the Stirrups...... 13
Inspect the Vulva...... 13
Warm the Speculum...... 13
Insert the Speculum...... 13
Field Expedient Speculum...... 14
Start with the Spatula...... 14
Rotate the Spatula...... 14
Sample the Squamocolumnar Junctions...... 15
Make a Thin Smear...... 15
Spray Immediately...... 15
Next Use a Brush...... 15
Insert and Rotate 180 Degrees...... 15
Dysplasia...... 16
Mild Dysplasia...... 16
Moderate Dysplasia...... 17
Severe Dysplasia...... 18
Carcinoma in Situ...... 18
Invasive Cancer of the Cervix...... 19
Adenocarcinoma of the Cervix...... 19
Visible Lesions on the Cervix...... 19
Colposcopy...... 19
Actinomycosis...... 20
AGUS...... 20
Atrophy...... 20
ASCUS...... 20
Candida...... 21
Chlamydia...... 21
CIN...... 22
Coccoid Bacteria...... 22
Condyloma...... 22
Drying Artifact...... 22
Endocervical Cells Not Present...... 23
Endometrial Cells Present...... 23
Estrogen Effect...... 23
Gardnerella...... 24
Herpes...... 24
HPV...... 24
Inadequate Smear...... 24
Inconclusive Smear...... 25
Inflammation...... 25
IUD Changes...... 25
Koilocytosis...... 25
Leptothrix...... 25
Nuclear Atypia...... 26
Reparative or Reactive Changes...... 26
SIL...... 26
Squamous Metaplasia...... 26
Trichomonas...... 27
Birth Control Pills...... 28
Benefits of BCPs...... 28
Risks of BCPs...... 28
Which Pill to Start...... 29
Starting the Pill...... 29
When are the Pills Effective?...... 29
Skipped a Pill...... 30
History of Migraine Headaches...... 30
High Blood Pressure...... 30
Diabetes...... 30
Blood Clot History...... 31
Non Availability of her Pill...... 31
Postponing a Period with BCPs...... 31
Side Effects...... 32
Breast Tenderness...... 32
Nausea...... 33
Weight Gain...... 33
Headaches...... 33
Moodiness or Depression...... 34
Vaginal Dryness...... 34
Decreased Libido (Sex-Drive)...... 34
Painful Menstrual Cramps...... 34
Continuous Birth Control Pills...... 35
No Period or very Light Period...... 36
Spotting Between Periods...... 37
Periods at the Wrong Time...... 37
Antibiotics...... 38
Thinks she may be Pregnant...... 38
Emergency Contraception...... 38
Overdose...... 39
Other Contraceptive Methods...... 41
Condoms...... 41
Diaphragm...... 42
DMPA (Depot Medroxyprogesterone Acetate)...... 43
Female Condom...... 45
Contraceptive Vaginal Film...... 46
Contraceptive Foam...... 47
Contraceptive Vaginal Gel...... 47
Intrauterine Device (IUD)...... 48
Norplant...... 51
Rhythm...... 53
Vaginal Suppositories...... 54
Tubal Ligation...... 54
Vasectomy...... 55
Withdrawal...... 55
Bleeding...... 57
Normal Bleeding...... 57
Abnormal Bleeding...... 57
Overview...... 57
Pregnancy Problems...... 58
Mechanical Problems...... 58
Hormonal Problems...... 58
Malignancy...... 59
What to do First...... 59
Heavy Periods...... 59
Light Periods...... 60
Late for a Period...... 61
Irregular Periods...... 61
Too Frequent Periods...... 61
Constant Bleeding...... 62
Hemorrhage...... 63
Vaginal Discharge and Itching...... 65
Overview...... 65
History...... 65
Physical Exam...... 65
Laboratory...... 66
Treatment...... 66
Ectropion, Erosion or Eversion...... 66
Cervicitis...... 67
Chlamydia...... 67
Foreign Body...... 67
Bacterial Vaginosis...... 68
Gonorrhea...... 68
Infected IUD...... 69
PID: Mild...... 69
PID: Moderate to Severe...... 69
Trichomonas...... 70
Yeast (Monilia, Thrush)...... 71
Human Papilloma Virus...... 72
Clinical Warts...... 72
Subclinical Warts...... 72
Treatment...... 72
Persistence of Virus...... 73
Transmission...... 73
Dysplasia...... 73
Relation to Cancer...... 74
Evualuation...... 74
The Vulva...... 75
General...... 75
Bartholin Cyst and Abscess...... 75
Chancroid...... 76
Condyloma Lata...... 76
Contact Dermatitis...... 77
Epithelial Polyp...... 77
Granuloma Inguinale...... 78
Herpes Vulvitis...... 78
Hypertrophic Vulvar Dystrophy...... 79
Inclusion Cyst...... 80
Itching...... 80
Labial Abscess...... 81
Lichen Sclerosis...... 81
LGV...... 82
Melanosis...... 83
Molluscum Contagiosum...... 83
Paget’s Disease...... 83
Pediculosis Pubis (Pubic Lice)...... 84
Primary Syphilis...... 84
Runner’s Rash...... 85
Scabies...... 85
Skene’s Gland...... 86
Tinea Cruris (Jock Itch)...... 87
VIN...... 88
Vulvar Cancer...... 88
Vulvar Hematoma...... 88
Vulvar Dystrophy...... 89
Vulvar Vestibulities...... 90
Yeast (Candida, Monilia)...... 90
Problems with Menstruation...... 93
Normal Menstrual Flows...... 93
Cramps...... 93
Breast Pain...... 94
Midcycle Pain...... 95
Acne...... 95
Headache...... 95
Fluid Retention...... 96
Abdominal Bloating...... 96
Depression and Irritability...... 97
Abdominal and Pelvic Pain...... 98
Uncertainty of Diagnosis...... 98
Pain and Bedrest...... 98
Pain and Fever...... 98
Chronic Pain...... 99
Pregnancy Test...... 99
BCPs and Pain...... 99
Pregnancy and Bleeding...... 99
Threatened Abortion...... 100
Ectopic Pregnancy...... 100
Placental Abruption...... 100
Placenta Previa...... 101
IUD Problems...... 102
Ovarian Cyst...... 102
Ruptured Ovarian Cyst...... 102
Unruptured Ovarian Cyst...... 103
Torsioned Ovarian Cyst...... 103
Dysmenorrhea...... 103
Mittelschmerz...... 104
Functional Bowel Syndrome...... 104
Gastroenteritis...... 104
Diverticular Disease...... 104
PID...... 105
PID: Mild...... 105
PID: Moderate to Severe...... 105
Endometriosis...... 106
Appendicitis...... 107
Bowel Obstruction...... 107
Degenerating Fibroid...... 108
Infected or Rejected IUD...... 108
Cystitis...... 108
Pyelonephritis...... 109
Problems with Urination...... 110
Painful Urination...... 110
Gonorrheal Urethritis...... 110
Non-gonorrheal Urethritis...... 111
Herpes...... 112
Yeast, Trichomonas...... 112
Urinary Frequency...... 112
Blood in the Urine...... 112
Bad Urinary Odor...... 113
Cannot Urinate...... 113
Bladder Training...... 113
Involuntary Loss of Urine...... 114
Stress Incontinence...... 114
Irritable Bladder...... 114
Urethral Diverticulum...... 114
Unpredictable Urine Loss...... 115
Urinary Urgency...... 115
Stress...... 115
Pyelonephritis...... 115
Breast Problems...... 116
Breast Development...... 116
Breast Examination...... 116
Breast Self-Exam...... 118
Mammography...... 119
Ultrasound...... 119
Breast Biopsy...... 120
Supernumerary Breasts...... 120
Supernumerary Nipples...... 120
Inverted Nipples...... 120
Adolescent Breast Problems...... 120
Pregnancy Changes...... 121
Puerperal Mastitis...... 121
Nipple Laceration...... 121
Cyclic Breast Pain...... 122
Non-cyclic Breast Pain...... 122
Nipple Discharge...... 122
Fat Necrosis...... 123
Paget’s Disease...... 123
Breast Mass...... 123
Breast Cyst...... 124
Fibroadenoma...... 124
Breast Cancer...... 124
Menopause...... 126
Definition...... 126
Symptoms...... 126
Associated Medical Problems...... 126
Clinical Presentation...... 127
Philosophy of Management...... 127
Benefits of Treatment...... 127
Risks of Treatment...... 128
Alternatives...... 128
Standard Treatment...... 129
Birth Control Pills...... 130
Risk of Pregnancy...... 130
Libido (Sex Drive)...... 130
Follow-up...... 131
Sexual Assault...... 132
Outline of Management...... 132
Assign Staff Member...... 132
Serious Injuries Come First...... 132
Notify Authorities...... 133
Notify the Chaplain...... 133
Consent...... 133
Gather your Supplies...... 133
Labels...... 133
Materials Needed...... 134
History...... 134
Gynecologic History...... 135
Clothing...... 135
Physical Exam...... 135
Photographs...... 135
Head Combings...... 135
Mouth...... 135
Torso and Arms...... 136
Hands...... 136
Pubic Hair Combings...... 136
Inspect the Vulva...... 136
Visualize the cervix...... 137
Vaginal Swab...... 137
Chlamydia Culture...... 137
Gonorrheal Culture...... 137
Rectal Examination...... 137
Bimanual Exam...... 138
Betadine Douche...... 138
Let the Patient Shower...... 138
Blood and Urine Tests...... 138
Offer Antibiotics...... 138
Emergency Contraception...... 139
Follow-up Exam...... 139
Medical Release...... 140
Write your Report...... 140
Give Evidence to Investigator...... 140
Give Specimens to your Lab...... 140
Give Instructions to Patient...... 140
Special Case of Children...... 141
Normal Pregnancy...... 142
Diagnosis of Pregnancy...... 142
Pregnancy Tests...... 142
Prenatal Care...... 143
Check Weight...... 143
Check Blood Pressure...... 143
Measure Fundal Height...... 144
Listen for the Heartbeat...... 144
Check for Edema...... 144
Check Protein and Glucose...... 144
Ask about Fetal Activity...... 144
Any new Symptoms?...... 145
Nutrition...... 145
Prenatal Vitamins...... 145
Laboratory Tests...... 145
Ultrasound Scan...... 146
Estimating Gestational Age...... 146
Fetal Heart Beat...... 147
Disability...... 147
Maternal Skin Changes...... 147
Exercise in Pregnancy...... 148
Nausea and Vomiting...... 148
Heartburn...... 149
Sciatica...... 149
Carpal Tunnel Syndrome...... 149
Upper Respiratory Infections...... 150
Antibiotics During Pregnancy...... 150
Other Drugs During Pregnancy...... 151
Immunizations During Pregnancy...... 152
Thermal Stress...... 152
Noise...... 152
Vibration...... 153
Chemical Solvents...... 153
Heavy Metals...... 153
X-rays During Pregnancy...... 153
Radiation Exposure...... 153
CRT Use and Pregnancy...... 154
Diving While Pregnant...... 154
Hyperbaric Treatment...... 154
Pregnant Aircrew Members...... 155
Abnormal Pregnancy...... 156
Miscarriage...... 156
Abortion...... 156
Threatened Abortion...... 157
Complete Abortion...... 157
Incomplete Abortion...... 158
Inevitable Abortion...... 159
Septic Abortion...... 160
Unruptured Ectopic Pregnancy...... 161
Ruptured Ectopic Pregnancy...... 161
Blood Transfusion...... 162
First Trimester Trauma...... 163
Later Trauma...... 164
Placental Abruption...... 165
Placenta Previa...... 165
Toxemia of Pregnancy...... 166
Pre-eclampsia...... 167
Eclampsia...... 169
HELLP Syndrome...... 169
Normal Labor and Delivery...... 170
Labor...... 170
Latent Phase Labor...... 170
Active Phase Labor...... 171
Progress of Labor...... 171
Delivery of the Baby...... 172
Delivery of the Placenta...... 173
Managing Labor and Delivery...... 173
Initial Evaluation...... 173
History...... 174
Risk Factors...... 174
Vital Signs...... 175
Contractions...... 175
Fetal Heart Rate...... 175
Urine for Protein and Glucose...... 175
Estimated Fetal Weight...... 176
Dilatation and Effacement...... 176
Fetal Orientation...... 176
Leopold’s Maneuvers...... 177
Status of Fetal Membranes...... 177
Blood Count...... 177
Management of Early Labor...... 178
Monitor the Fetal Heart...... 178
Electronic Fetal Monitors...... 179
Pain Relief...... 180
Second Stage Labor...... 182
Preparing for Delivery...... 182
Delivery...... 183
Episiotomy...... 183
Anesthesia...... 184
Clamp and Cut the Cord...... 184
The Placenta...... 184
Uterine Massage...... 185
Post Partum Care...... 185
Problems During Labor and Delivery...... 188
Preterm Labor...... 188
Premature Rupture of Membranes...... 189
Abnormal Presentation...... 190
Prolonged Latent Phase Labor...... 191
Arrest of Active Labor...... 191
Shoulder Dystocia...... 193
Breech Delivery...... 195
Twin Delivery...... 196
Prolapsed Umbilical Cord...... 196
Cord Around the Neck...... 197
Retained Placenta...... 197
Post Partum Hemorrhage...... 198
Chorioamnionitis...... 198
Group B Streptococcus...... 199
Post Partum Fever...... 200
Care of the Newborn...... 201
Dry the Baby...... 201
Replace the Wet Towels...... 201
Position the Baby...... 201
Suction the Airway...... 202
Evaluate the Baby...... 202
Color...... 202
Ventilate if Necessary...... 203
Check the Heartbeat...... 203
Keep the Baby Warm...... 203
Assign Apgar Score...... 204
Breast-feeding...... 204
Field-Expedient Bottle...... 204
Vernix...... 205
Meconium...... 205
Eye Prophylaxis...... 205
Vitamin K...... 205
Umbilical Cord Care...... 205
Medical Support of Women in Field Environments...... 207
Pre-deployment Planning...... 207
AMAL and Sick Call Block...... 207
Command Pregnancy Policy...... 209
Pre-Deployment Screening...... 210
Pre-Deployment Briefing...... 210
Urination Issues...... 211
Menstruation Issues...... 212
Bathing...... 213
Quarters...... 213
Clothing...... 214
Liberty Risks...... 215
Leadership...... 215
Host Nation Issues...... 216
Pregnancy...... 216
Noise...... 217
Heat...... 217
Organic Solvents...... 217
Lead, Cadmium, Mercury...... 217
Low Frequency, Whole Body Vibration...... 217
Prolonged Standing...... 217
STDs and Safe Sex...... 217
Aerospace Medicine Issues...... 218
Gravitational Forces...... 218
Decompression Sickness...... 218
Antorhropometrics...... 219
Pregnancy in Aviation...... 219
The Prisoner of War Experience
The Prisoner of War...... 221
Sexual Abuse...... 221
The Total Soldier...... 222
Pre-Deployment Planning...... 222
The Typical Repatriated Soldier...... 222
Stresses of Captivity...... 222
Recovery...... 223
Appendix A: OPNAVINST 6000.1A - MANAGEMENT OF PREGNANT SERVICEWOMEN
Appendix B: Ultrasound Measurements in Pregnancy
Appendix C: Gestational Age Calculator
Appendix D: SF600 Gynecologic Consultation Overprint
Appendix E: Menstrual Flow Record Cards
Table of ContentsPage 1
Acknowledgments
<small>A single person cannot produce a project of this magnitude. In preparing both the 1st and 2nd editions of Operational Obstetrics & Gynecology, I received invaluable assistance from many individuals. Among them are:
Table of ContentsPage 1
<small>From the Army</small>
Lieutenant General Ronald R. Blanck, MC, USA
Major General James Peake, MC, USA
Brigadier General Bettye H. Simmons, AN, USA
Brigadier General Kevin C. Kiley, MC, USA
Colonel Daniel F. Battafarano, MC, USA
Colonel Carla Hawley-Bowland, MC, USA
Colonel Rhonda Cornum, MC, USA
Colonel Gary Davis, MC, USA
Colonel Margaret J. Knapp, MC, USA
Colonel John M. Powers, MC, USA
Colonel Iris West, MC, USA
Colonel Steve Yevich, MC, USA
Colonel Craig H. Llewellyn, MC, USA (Ret)
MSG James T. Bates, USA
SFC Robert P. Roemer, USA
SFC Bruce Ward, USA
From the Navy
Vice Admiral Richard K. Nelson, MC, USN
Vice Admiral Harold M. Koenig, MC, USN (Ret)
Vice Admiral Donald F. Hagan, MC, USN (Ret)
Rear Admiral Joan M. Engel, NC, USN
Rear Admiral Robert W. Higgins, MC, USN (Ret)
Rear Admiral James Johnson, MC, USN
Rear Admiral Richard A.Mayo, MC, USN
Rear Admiral R.C. Melendez, DC, USN
Rear Admiral William R. Rowley, MC, USN
Rear Admiral James H. Black, MC, USN (Ret)
Captain Michael R. Ambrose, MC, USN
Captain Mary A. Anderson, MC, USN
Captain Kathleen Bailey, NC, USN
Captain Lee D. Bown, NC, USN
Captain David Brice, MC, USN
Captain Thomas R. Defibaugh, MSC, USN
Captain John Fahey, MC, USN
Captain Susan A. Flood, NC, USN
Captain William Frank, MSC, USN
Captain James Frazier, MC, USN
Captain H. John Gerhard, MC, USN
Captain B. Gail Goff, MSC, USN
Captain Konrad E. Hayashi, MC, USN
CaptainJanet L Higgins, NC, USN
Captain Dave Hyland, MC, USN
Captain Richard R. Jeffries, MC, USN
Captain W. Robert Kiser, MC, USN
Captain Joel Lees, MC, USN
Captain Davonne Loup, MC, USN
Captain Charles J. Macri, MC, USN
Captain Donald Mason, MC, USN
Captain Jay R. Montgomery, MC, USN
Captain Charles B. Mount, MSC, USN
Captain Patricia Murphy, NC, USN
Captain John Murray, MC, USN
Captain John Nickle, MC, USN
Captain Robert B. North, Jr., MC, USN
Captain Frank Nuar, MC, USNR
Captain Donna Perry, NC, USN
Captain Jerry Ragland, MC, USN
Captain Terry Reiley, MC, USN
Captain Steve Remmenga, MC, USN
Captain Adam Robinson, MC, USN
Captain David Sack, MC, USN
Captain Dave Snyder, MC, USN
Captain Robert Spiro, MC, USN
Captain Don Sprague, MC, USN
Captain Richard Stock, MC, USN
Captain Glenn N. Wagner, MC, USN
Captain Steve Warlick, MC, USN
Captain Natalie Willenberg, MC, USN
Captain Steve Yakavon, MC, USN
Captain Jeffery M. Young, MC, USNR
Captain H.B. Etienne, MC, USN (Ret)
Captain John Nash, MC, USN (Ret)
Captain John Noll, MC, USN (Ret)
Captain Thakor G. Patel, MC, USN (Ret)
Captain Henry Schwarz, MC, USN (Ret)
Commander Steve Acher, MC, USN
Commander Mark Austin, MC, USN
Commander Linnea Axman, NC, USN
Commander Tamara C. Babb, MC, USN
Commander Michael Bandy, JAGC, USN
Commander Barney R. Barendse, NC, USN
Commander David Beardsly, MC, USN
Commander Brad L. Bennett, MSC, USN
Commander Monte L. Bible, MC, USN
Commander Victoria A. Cassano, MC, USN
Commander Soren Christensen, NC, USN
Commander Bruce A. Cohen, MC, USN
Commander James R. De Voll, MC, USN
Commander Robert Frick, MC, USN
Commander Dave Gillis, MC, USN
Commander Terry A. Harrison, MC, USNR
Commander Susan B. Herrold, NC, USN
Commander Tim Hinman, MC, USN
Commander Mary Owens, NC, USN
Commander James Phelan, MC, USN
Commander Paul Rocereto, MC, USN
Commander Dennis Rowe, MC, USN
Commander Scott W. Shiffer, NC, USN
Commander Erica L.Spence, NC, USN
Commander Tommy C. Stewart, NC, USN
Commander Amy Suggs, NC, USN
Commander Nancy Swanson, NC, USN
Commander Jennifer Town, NC, USN
Lieutenant Commander Josephine Brumit, NC, USN
Lieutenant Commander Brian Belson, MC, USN
Lieutenant Commander Ann Fallon, MC, USN
Lieutenant Commander David A. Lane, MC, USN
Lieutenant Commander John W. LeRoy, MSC, USN
Lieutenant Commander Jennifer Polano, MC, USNR
Lieutenant Commander Steve Presley, MC, USN
Lieutenant Youssef H. Aboul-Enein, MSC, USN
Lieutenant Paul Antony, MC, USN
Lieutenant Chris Alewine, MC, USN
Lieutenant Dennis Ashley, MC, USN
Lieutenant Thomas A. Craig, MC, USN
Lieutenant Angela Gardner, USN
Lieutenant Jennifer M. Jagoe, MC, USN
Lieutenant Frederick E. Yeo, MC, USN
HMCM (AW) Reynaldo Angeles, USN
HMCM (SW) J.E. Lambert, USN
HMCM (SW) Mark R. Weldon, USN
HMC (SW) Joe Fischer, USN
HMC Charles Herbert, USN
HMC Sally Hobson, USNR
HMC (SW/FMF) Mike Judson, USN
HM1 Michael J Brady, USN
HM2 Christina Kenny, USN
HM2 Aretha Paschel-Alexander, USN
HM2 Nona Sanders, USN
From the Marine Corps
Major Anne Shuford, USMC
Captain Lorrie Kovacs, USMC
1st Lieutenant Julie Ward, USMC
1st Lieutenant Jennifer M. Wolfe, USMC
MGySgt Pat McLane, USMC
MSgt Marian P. Frayser, USMC
GySgt Shawnee J Miller, USMC
SSgt Sara M. Gross, USMC
Sgt Vicki R. Courson, USMC
From the Air Force
Lieutenant Colonel Michael W. Spatz, MC, USAF
Lieutenant Colonel Chris Zahn, MC, USAF
Lieutenant Colonel Susan E. Northrup, MC, USAF
From the Coast Guard
Captain Paul Higgins, USPHS
Lieutenant Commander Sharon L. Ludwig,USPHS
MCPO Glenn Proctor, USPHS
From the United States Public Health Service
Captain William H.J. Haffner, M.D., USPHS
Others
Ms. Ann Ballard, Bureau of Medicine and Surgery
Mr. Henry "Hank" Champagne, Naval School of Health Sciences
Ms. Patty Chilis, RDMS, Evanston Hospital, Evanston, IL
Mr. Walt Dumbeck, Naval School of Health Sciences
Ms. Laura Franz, Bureau of Medicine and Surgery
Ms. Judy Goldman, Naval School of Health Sciences
Ms. Margaret M. Grey, Federal Bureau of Investigation
Mr. Jan K. Herman, Bureau of Medicine and Surgery
Ms. Carol Kuzmanic, Evanston Hospital, Evanston, IL
Ms. Jeri L. Lockman, MSN, ARNP, Office of Medical Services, U.S. Department of State
Gretchen McCoy, MD, U.S. Department of State
Ms. Evelmer Poole, Armed Forces Institute of Pathology
Ms. Susan E. Rist, MCAS Miramar, CA
Ms. Tracy Roberts, Medical Photography, Evanston Hospital, Evanston, IL
Mr. Jerry Robinson, Center for Health Education and Studies, U.S. Army Medical Department
Mr. Al Smith, Naval School of Health Sciences
Ms. Kristine Vehlow, Evanston Hospital, Evanston, IL<small>
James E. Yoder, MD, MPH, FBIHQ Health Care Programs Unit, Federal Bureau of Investigation