Lesson 1, Topic 1
In Progress

The Medical Assistant’s Role in Examinations, Diagnostic Procedures, and Treatments

April 11, 2024

Learning Objective: Examine the medical assistant’s role in assisting with examinations, diagnostic procedures, and treatments for the female reproductive system.
In this section, we discuss the medical assistant’s role in gynecologic and obstetric procedures. A medical assistant has two roles in these situations:

                • Assist the provider in any way needed
                • Be there for the patient by helping her to be as comfortable as possible during her time in the healthcare facility
When we make the patient feel comfortable, we help establish a trusting relationship with her. This enables her to share the information the provider needs to give her the best possible care.


Assisting with the Gynecologic Examination
Learning Objective: Describe the medical assistant’s role in assisting with the gynecologic examination.
      The need for an annual pelvic examination is being debated in the medical community. Currently, the American College of Obstetricians and Gynecologists (ACOG) recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms. This examination is done to evaluate the reproductive organs and diagnose and treat any abnormalities of those organs.
      A breast examination is considered part of the gynecologic examination. A clinical breast examination should be done every 1 to 3 years. The provider examines the breast, underarm area, and just below the clavicle.
Setting Up for a Gynecologic Examination
      A medical assistant is responsible for setting up the examination room and making sure that all of the supplies are available for a gynecologic examination. The following is a list of supplies needed for a routine gynecologic examination:
                • Patient’s health record
                • Laboratory requisition slips
                • Patient gown and drape
                • Lubricant
                • Examination light
                • Cervical spatula or cytobrush
                • Microscope slides (direct smear method)
                • Fixative (direct smear method)
                • Plastic-fronded broom (liquid-based method)
                • Liquid preparation container (liquid-based method)
                • Vaginal speculum
                • Sterile swabs
                • Fecal occult blood test cards with developer
                • Biohazard waste container
All items should be placed within easy reach for the provider and organized in a logical manner.


Preparation for the Gynecologic Examination
At the time the appointment was made, the patient should have been advised not to douche or have sexual intercourse for 24 hours before the examination. This allows the vaginal discharge to be properly evaluated and ensures accurate results of cytologic studies. Before the provider begins the pelvic examination, the medical assistant should obtain a complete gynecologic history. After documenting the patient’s history and chief complaint, the medical assistant should prepare the room and the patient for the examination (Procedure 28.1).
      The following should be included in the gynecologic history:
                • Age at menarche
                • Details about the regularity of the menstrual cycle, the amount and duration of menstrual flow, and a history of menstrual disturbances and their treatment
                • Any current indicators of infection, including vaginal discharge, pelvic pain, and urinary difficulties
                • Description of any breast abnormalities and the date of the patient’s last mammogram
                • Date of the last Pap test
                • Sexual history; sexually transmitted infection (STI) history
                • Number of times pregnant and the number of pregnancies carried to more than 20 weeks
                • Date of last menstrual period (LMP)
                • Lifestyle factors, including diet, exercise, smoking, and alcohol use


Assisting with an Examination
The pelvic and breast examination can be an embarrassing and emotionally difficult medical experience. In our society, reproduction is not openly talked about. Aside from the embarrassment, many women fear the provider’s findings. By behaving in a professional manner, explaining what is going to happen, and showing a genuine interest in the patient’s concerns, the medical assistant can help lay to rest most of the patient’s anxieties and fears.
      The medical assistant is responsible for supporting the patient and assisting the provider during the procedure. The procedure should be fully explained to the patient to prevent unnecessary embarrassment and discomfort. During the explanation, the medical assistant has the opportunity to provide patient education. This should be done using terms that are easy for the patient to understand. The medical assistant should remain in the examination room to provide reassurance to the patient and legal protection for the provider.
      The patient should be instructed to empty her bladder, completely disrobe, and put on an examination gown. Some providers prefer that the patient put the gown on with the opening in the front, whereas others prefer the opening in the back. As the medical assistant, you should be aware of your provider’s preference and instruct the patient accordingly.


Pap Test and Other Guidelines for Women
                • Women ages 21 to 29 should have a Pap test alone every 3 years. HPV testing alone is not recommended.
                • Women ages 30 to 65 should have a Pap test and an HPV test (co-testing) every 5 years (preferred). It also is acceptable to have only a Pap test every 3 years or an HPV test every 5 years.
                • If you have had a hysterectomy, you still may need screening. The decision is based on whether your cervix was removed, why the hysterectomy was needed, and whether you have a history of moderate or severe cervical cell changes or cervical cancer. Even if your cervix is removed at the time of hysterectomy, cervical cells can still be present at the top of the vagina. If you have a history of cervical cancer or cervical cell changes, you should continue to have a screening for 20 years after the time of your surgery.
                • You can stop having cervica cancer screening after age 65 years if the following conditions apply:
                              • You do not have a history of moderate or severe abnormal cervical cells or cervical cancer, and
                              • You have had either three negative Pap test results in a row or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past 5 years.
Cervical cancer screening. Patient Education FAQ085. Washington, DC: ACOG: 2017. Available at hwww.acog.org/Patients/FAQs/Cervical-Cancer-Screening.


Breast Examination
The first part of the gynecologic examination is the breast examination. The exam begins with the patient in the sitting position to allow for a visual check of the breasts. The gown should be adjusted so that the breast tissue can be easily exposed. After the visual inspection, the patient will be placed in the supine position. The medical assistant should be prepared to help the patient to lie down on the examination table. The footrest should be extended, and a small pillow may be placed under the patient’s head for comfort. If needed, the gown and drape should be adjusted to protect the patient’s modesty. Palpation will be used to determine if there is thickening or lumps in the breast and collar bone area. The provider will instruct the patient to place her arms above her head to allow assessment of the underarm area using palpation. When the examination is complete, the gown is readjusted to cover the breasts. The provider may choose to discuss breast self-examination with the patient at this time or may inform the patient that the medical assistant will explain the technique at the end of the examination.
      According to the American Cancer Society, research has not shown a benefit for a patient or provider breast exam when women are also getting mammograms. It is recommended that women with an average risk of breast cancer start having yearly mammograms by age 45. It is optional to start earlier.
      It is important for all women to know what is normal with their breasts. Any abnormality should be reported to their provider. Some providers still recommend monthly breast self-exams (BSEs) to be done after the menses. Procedure 28.2 describes how to perform a BSE. It is helpful for the medical assistant to provide the patient with a brochure showing the technique. It is also recommended to show the technique on a model (FIGURE 28.3). If possible, the patient should demonstrate the technique back to the medical assistant. This practice helps the medical assistant to determine if the patient understood the coaching.


Warning Signs of Breast Cancer
                • Change in the skin (redness, warmth, darkening of the color, dimpling, puckering)
                • Lump or hard area inside the breast or in the axilla area
                • Change in the size or shape of the breast
                • Change in the nipple (inverted or pulling in appearance, rash, sore, or drainage)
                • Pain that does not go away

FIGURE 28.3  Coaching a patient regarding the breast self-exam.

Abdominal Examination
While the patient is in the supine position, the provider will palpate the abdomen. This is done to confirm normal symmetry of the pelvic organs and detect any masses. The provider also watches for any signs of discomfort or pain that could indicate a problem.


Pelvic Examination
For the pelvic examination, the patient is placed in the lithotomy position. This can be an awkward position for the patient to assume without assistance, and it may be embarrassing to the patient. If needed, the medical assistant should be available to help the patient into this position. Never place the patient in the lithotomy position until the provider is ready to begin the examination. When you assist the patient into the lithotomy position, always keep her totally covered.
      You should stand at the patient’s side so you can observe her yet still be able to move quickly (if needed by the provider). First, the provider inspects the external genitalia and palpates the perineal area. The patient may be asked to bear down to show any muscular weaknesses that may be the result of lacerations in the perineal body during childbirth. A third-degree laceration may have involved the rectal sphincter and may cause rectal incontinence.
      Next, the vaginal speculum is inserted for examination of the cervix and the vaginal canal to obtain the Pap specimen. The speculum should be prewarmed with warm water. Have the patient take some deep breaths to help relax the abdominal muscles. The normal cervix points posteriorly and has smooth, pink, squamous epithelium. Abnormalities most frequently seen are ulcerations (erosions), Bartholin cysts, and cervical polyps. Because erosions cannot be palpated, inspection is the only method of detecting them. Healed lacerations from childbirth are common in a patient who has had multiple deliveries. Pregnancy increases the size of the cervix, and hormone deficiency causes it to atrophy. The vaginal wall is reddish pink and has a corrugated appearance from the overlapping tissue (rugae) lining. Vaginal infections change the appearance of the vaginal mucosa.
      After inspecting the vaginal wall, the provider may collect a specimen for a Pap test. When the specimen has been obtained, the medical assistant may be responsible for labeling it and preparing it for transport to the cytology laboratory. Be sure to follow laboratory instructions during the preparation to avoid having to repeat the examination.
       After removal of the vaginal speculum, the provider does a bimanual examination. For a bimanual examination, two gloved fingers are lubricated with a water-soluble jelly (lubricant) and inserted into the vaginal canal, and the other hand palpates the abdomen over the pelvic organs and the mons pubis (FIGURE 28.4). The uterus is examined for shape, size, and consistency, and its position is noted. A normal uterus is freely movable with limited discomfort. A laterally displaced uterus is usually the result of pelvic adhesions or displacement caused by a pelvic tumor. The fallopian tubes and ovaries are evaluated. Normal tubes and ovaries are difficult to palpate, which is why the provider may have to press firmly in the pelvic area, causing minor discomfort for the patient. A digital rectal exam may be done at this time. This involves the insertion of a gloved finger into the rectum. A small amount of stool is left on the glove and can be used for a fecal occult blood test.

FIGURE 28.4  Bimanual examination.

Post-Examination Duties
When the examination is finished, help the patient into a sitting position and into the dressing room, if needed. Following the Standard Precautions established by the Occupational Safety and Health Administration (OSHA), remove the examination equipment and supplies while the patient is dressing so that when the provider returns to talk to the patient, the room is neat and clean. Once the patient has left, the room should be sanitized, disinfected, and restocked as necessary so it is ready for the next patient.


Contraception
At the time of a gynecologic examination, a provider may discuss contraception with the patient. A woman’s choice of a contraceptive method is based on many factors. To make an informed choice, a patient should know the risks, benefits, side effects, costs, failure rates, and convenience of each available method. In addition, although condoms are only moderately successful at preventing pregnancy, they should be used consistently to prevent the transmission of STIs. The medical assistant may help provide patient education on contraceptive methods. TABLE 28.3 summarizes the characteristics of various contraceptive methods.


Barrier Methods
Barrier methods of contraception either kill sperm (through the use of a chemical spermicide) or prevent them from entering the cervical os. These methods, which are relatively inexpensive, include the condom, diaphragm, and cervical cap or sponge. Each method must be used every time the person has intercourse, which means the patient must be motivated to follow through on using it. Patient education on the use of a diaphragm includes the following instructions:
                • Examine the diaphragm before each use by holding it up to a bright light to check for holes or cracks.
                • Place 1 to 2 tablespoons of spermicidal jelly or cream into the diaphragm dome before insertion.

TABLE 28.3

Commonly Used Contraceptive Methods

                • Leave the diaphragm in place for 6 hours after intercourse; do not douche until after you have removed it.
                • Before repeated intercourse, add spermicide to the outside of the diaphragm with an applicator. Do not remove the diaphragm until 6 hours after the last intercourse.
                • After removal, wash the diaphragm with soap and water, allow it to air dry and inspect it for breaks or holes before storing.
                • Have the diaphragm refitted if the following occurs:
                • You gain or lose more than 10 to 15 pounds
                • You have a miscarriage, give birth, or undergo any type of pelvic surgery
                • You have difficulty voiding or moving your bowels with the diaphragm in place
      The cervical cap is a thimble-sized, domed barrier device that fits over the end of the cervix. It also is used with spermicidal jelly (FIGURE 28.5).

FIGURE 28.5  Cervical cap with spermicide.

      If used properly, the cervical cap is 92% to 96% effective. An advantage of this barrier method is the cap can be inserted up to 12 hours before intercourse and can stay in place for up to 72 hours without a decrease in effectiveness or safety. The cervical sponge contains spermicide and can also be inserted hours before intercourse and is effective for 24 hours. If always used as directed, the sponge is 80% to 91% effective.

Hormonal Contraceptives
Hormonal contraceptives are a highly effective and reversible form of contraception. They work by preventing ovulation, changing the cervical mucosa, affecting sperm mobility, and preventing the thickening of the endometrial wall. Hormonal contraceptives include the following:
                • Birth control pills or patch
                • Vaginal ring
                • Depo-Provera injections
                • Hormonal implants
      Besides being a highly effective method of birth control, oral contraceptives can be used to treat a wide range of gynecologic conditions, including menstrual irregularities, premenstrual syndrome (PMS) symptoms, and anovulation. They also can be used to prevent ovarian cysts and may be prescribed to increase bone density. However, to be effective, the pills must be taken daily, at the same time each day. Failure rates are associated with noncompliance and can range from less than 1% (in highly compliant women) to greater than 15% (in those who do not take the pills as prescribed). Oral contraceptive pills (OCPs) can have serious side effects. Patients should be informed of conditions that require immediate medical attention. These can be remembered with the mnemonic ACHES: abdominal pain (new and severe), chest pain (new and severe), headaches (new or more frequent), eye problems (blurred vision or vision loss), and severe leg pain. These symptoms may indicate the formation of a blood clot in the abdomen, chest, or leg. They may also be signs of a stroke. Blood clot formation and stroke are the most serious complications of OCPs.
      A type of oral contraception, the extended cycle pill, limits the number of menstrual periods to four a year. Patients are more likely to have spotting and breakthrough bleeding with this hormone therapy than with the traditional 28-day birth control pill. The extended cycle pill is designed to be taken once a day for 84 days, and then an inactive dose is taken for a week, during which the woman would menstruate. A combination birth control pill that contains both estrogen and progestin may be prescribed for women suffering from premenstrual dysphoric disorder (PMDD); it is also useful for treating acne in female patients at least 14 years of age who have started menstruating.
      As mentioned, hormonal contraception also can be delivered via a transdermal patch. The patch is a 1¾-inch square that slowly releases estrogen and progestin through the skin into the bloodstream. It is considered as effective as oral contraceptives in women who weigh less than 198 pounds; however, the patch is still a very effective method for women who weigh more than that. Current research shows that the risk of blood clots with the contraceptive patch is similar to the risks observed with oral contraceptives. However, cigarette smoking increases the risk of serious cardiovascular side effects, especially if the patient is over age 35. Patients should be told not to apply any creams or oils at the application site, change the patch weekly for 3 consecutive weeks, and go patch free the fourth week, allowing menstruation to occur. The patch can be applied to the buttocks, lower abdomen, and upper body but not to the breasts. The woman can bathe, shower, and swim while wearing the patch, but if it comes off, it should be replaced immediately.
      The vaginal ring contraceptive device is made of flexible plastic and is inserted into the vagina. The ring slowly releases estrogen and progestin to prevent pregnancy and provide effective contraceptive action for 1 month after insertion. The device is 2 inches in diameter and can be inserted anywhere in the vagina; however, the deeper it is placed, the less likely it is to be felt after insertion. Side effects of the vaginal ring are similar to those of other hormonal contraceptives, and it may increase the risk of heart attack, stroke, and blood clots. When the patient first starts using the ring, an additional method of birth control must be used for the first week. If the ring falls out, it should be rinsed with warm water and reinserted within 3 hours. If it is out for longer than 3 hours, contraception is not certain, and the patient should use another birth control method for 1 week.

FIGURE 28.6  Intrauterine device.

      Depo-Provera is an injectable contraceptive that contains high doses of progestin. Each dose prevents pregnancy for up to 3 months, but women must be compliant in returning to the healthcare facility for follow-up and repeat doses every 9 to 13 weeks. The first injection should be administered within the first 5 days of the menstrual period for birth control coverage. This is a highly effective method of contraception and is ideal for women who either do not comply with a birth control regimen or do not want to take a pill every day. However, using Depo-Provera for 2 years or longer may increase the risk of bone loss and the eventual development of osteoporosis. Almost all patients using the injections experience some menstrual irregularities, but these usually subside after two doses. Women using this form of hormonal contraception are not at risk for the side effects of estrogen exposure, such as the increased risk of blood clots and cardiovascular disease.
      A birth control implant is a single, flexible rod, about the size of a match, that is inserted under the skin of the upper arm. The birth control implant releases a low, steady dose of progestin. This suppresses ovulation, thickens cervical mucus to block the passage of sperm, and thins the endometrial wall to prevent implantation. It prevents pregnancy for up to 3 years after insertion. Hormonal implants have risks and contraindications similar to those of other hormonal types of contraception.


Intrauterine Devices
The intrauterine device (IUD) (FIGURE 28.6) is a T-shaped plastic frame with threads attached that the provider inserts into the uterus to prevent pregnancy. Two general types of IUDs are available: the copper type and the hormonal type. Both products inhibit fertilization by blocking the sperm’s journey to the fallopian tubes, and if fertilization does occur, they prevent the embryo from implanting into the uterine wall. In addition, the copper type of IUD releases copper, which acts to slow sperm in the cervix. The hormonal types of IUDs release progestin, which reduces sperm mobility and prevents the thickening of the endometrial wall during the menstrual cycle. Both types of IUDs are extremely effective at preventing pregnancy (over 99%); the copper type can remain in place for as long as 10 years, whereas the hormonal type must be replaced every 3 to 5 years. The copper IUD may temporarily increase vaginal bleeding and menstrual pain. The hormonal IUD results in both decreased menstrual flow and cramping. To remove an IUD, the provider gently withdraws it by pulling on the IUD string. In rare instances, it must be removed surgically.


Permanent Methods
Both male and female patients can undergo surgical procedures that are considered permanent contraceptive methods. Vasectomies in the male were addressed in Chapter 27. For the female, a bilateral tubal ligation can be performed in which a portion of both fallopian tubes is excised or ligated. The cost and rate of complications are higher for tubal ligations than for vasectomies. In addition, tubal ligations must be done on an outpatient basis with general anesthesia, so the woman has that additional risk. Both procedures can be reversed, but not always successfully.


28.6 Critical Thinking Application
When directed by the provider, Peggy provides patient education regarding contraceptives. She has asked Jill to create a reference sheet that covers all birth control options, their characteristics and side effects, and any patient education details that might be appropriate. What should Jill include?


Assisting with Diagnostic Procedures
Learning Objective: Describe the medical assistant’s role in assisting with diagnostic procedures.
The medical assistant can play an important role when assisting with diagnostic procedures in obstetrics and gynecology. The following sections discuss that role.


Specimen Collection
During a pelvic examination, several types of specimens may be collected. If the pelvic exam is part of a wellness examination, a specimen for a Pap test may be collected. If the provider wants to evaluate endocrine function, a maturation index may be ordered. If the pelvic examination is for a possible vaginal infection, a specimen may be collected for culture or observation under a microscope.


Pap Test
The two methods of specimen collection for a Pap test are the direct smear method and the liquid-based method.
Direct Smear Method
                1. The specimen is collected with a cervical spatula.
                2. The cells are placed (smeared) directly on a microscope slide.
                3. A fixative must be applied immediately to the slide before it is sent to the laboratory.
Liquid-Based Method
                1. The specimen is collected with a plastic-fronded broom.
                2. Cells are suspended in a bottle of preservative by rinsing the broom in the specimen vial.
                3. The results of the Pap test are often reported using the Bethesda system.


Pap Test Results
The Bethesda system is often used to report the results of a Pap test. This system looks at the squamous cells and the glandular cells separately.
Squamous Cells
                • Negative for intraepithelial lesion or malignancy: normal epithelial cells, no precancerous findings.
                • Atypical squamous cells (ASC):
                              • Atypical squamous cells of undetermined significance (ASC-US): Squamous cells do not appear completely normal but do not clearly suggest precancerous cells. Most often means there is an infection.
                              • Atypical squamous cells cannot exclude a high-grade squamous intraepithelial lesion (ASC-H): Minor changes with unknown causes that are at risk of progressing to a high-grade lesion (HSIL).
                • Low-grade squamous intraepithelial lesions (LSILs): Mild cell changes that may be classified as mild dysplasia. These abnormalities are often caused by human papillomavirus (HPV) infection.
                • High-grade squamous intraepithelial lesions (HSILs): Severe abnormalities that have a higher likelihood of progressing to cancer if left untreated. May be classified as moderate or severe dysplasia. Includes carcinoma in situ (CIS), severe changes that appear similar to cervical cancer but have not spread beyond the surface of the cervix.
                • Squamous cell carcinoma: Cervical cancer.


Glandular Cells
                • Atypical glandular cells (ACG): Glandular cells do not appear normal, but it is not clear what is causing the changes.
                • Endocervical adenocarcinoma in situ (AIS): Severely abnormal cells are found, but they have not spread beyond the glandular tissue of the cervix.
                • Adenocarcinoma: Cancer of the endocervical canal and possibly endometrial, extrauterine, and other cancers.


Maturation Index
A maturation index is an endocrine evaluation that can assist in the diagnosis and treatment of infertility issues, amenorrhea, menopause, or postmenopausal bleeding. Cells are collected from the vaginal wall and treated much like a Pap test specimen. If the provider orders a maturation index, it must be indicated on the cytology request form.


Vaginal Infections
Earlier in this chapter, common vaginal infections were discussed. A pelvic exam needs to be done to determine what type of vaginal infection is occurring. For many vaginal infections, a sterile swab is used to collect a sample of the discharge. The secretion is then swabbed on the microscope slide, and the provider looks at it under a microscope. Common infections, the infectious agents, and the type of specimen and test used to identify each include the following:
                • Candidiasis (yeast infection): The provider tests for the presence of Candida albicans. A small amount of discharge is placed on a slide, and a drop of a 10% solution of potassium hydroxide (KOH) is added. The KOH dissolves other cellular debris so that the provider can see the yeast buds.
                • Trichomoniasis: A small amount of discharge is placed on a slide, and a drop of saline is added. The provider is looking for Trichomonas vaginalis, which appears as a pear-shaped organism with a flagellum (tail) that moves it around.
                • Chlamydia: A sterile swab is used to collect a specimen from the endocervical canal. The swab is then placed in a tube containing a transport medium and sent to the lab for testing. The causative organism frequently is Chlamydia trachomatis.


Assisting with Treatments
Learning Objective: Describe the medical assistant’s role in assisting with treatments.
As with diagnostic procedures, a medical assistant can have a role in assisting with treatments. The following sections discuss the medical assistant’s role in assisting with treatments in obstetrics and gynecology.
Special Procedures
There are a number of gynecology-related special procedures that a patient may undergo related to an abnormal Pap test result. Let’s look at the three most commonly performed procedures:
                • Cryotherapy
                • Colposcopy with or without a biopsy
                • Loop electrosurgical excision procedure (LEEP)


Cryotherapy
Depending on the condition of the cervix, cryotherapy, or the application of freezing temperatures, may be used to treat chronic cervicitis and cervical erosion. Freezing causes cellular necrosis, and in approximately 1 month, the dead cells are replaced with healthy cells. The procedure involves placing a probe against the problem area on the cervix and applying liquid nitrogen to the area for approximately 3 to 4 minutes or until the site is frozen. The patient may experience some pain for about 30 minutes after the procedure and a slight watery discharge for up to a week. If any signs of infection, foul discharge, or pain develop, the patient should call the provider’s office. Advise the patient not to engage in sexual intercourse for 1 month and to expect a heavier than usual menstrual flow for the first cycle after the procedure.


Colposcopy with or without a Biopsy
Colposcopy is the visual examination of the vagina and cervical surfaces with a colposcope (FIGURE 28.7). The colposcope is a microscope with a light source and a magnifying lens that can be used during a vaginal examination to do the following:
                • Locate and evaluate abnormal cells
                • Detect cancer of the cervix in the early stages
                • Examine tissue from which an abnormal Pap test result has been obtained
                • Monitor areas of the cervix where malignant lesions have been removed
      The provider may wash the cervix with acetic acid to remove mucus and allow the provider to see abnormal areas more easily.       In addition, the acetic acid will stain the abnormal areas white. An iodine solution (Schiller’s or Lugol’s solution) may also be used. This iodine solution will stain normal tissue brown, leaving abnormal tissue unchanged.
In combination with a colposcopy, a cervical biopsy may be performed. A major advantage of obtaining a biopsy during colposcopy is that the instrument permits visualization of the suspicious area so that the biopsy can be taken from the most atypical site. Multiple biopsies may be taken. The provider is looking for abnormalities on the cervix and will take a biopsy specimen when one is seen. You may be receiving the sample from the provider. It is very important to accurately label each specimen container with the location of the biopsy. The provider uses the face of a clock to determine the location of the biopsy. The specimen container label should indicate that location (e.g., 2:00). Silver nitrate sticks or Monsel’s paste may be used to stop the bleeding from the biopsies.

FIGURE 28.7  Colposcopic appearance of normal cervix (A) and abnormal cervix (B).

      Colposcopy is a relatively safe, painless procedure performed in the provider’s office. Discomfort may occur when the speculum is inserted into the vagina to improve visualization of the tissue. Discomfort and bleeding can occur when tissue is taken in a biopsy. The patient should be instructed to use a sanitary pad, as there may be bleeding from the procedure. The provider may recommend that the patient avoid using tampons, douching, or having intercourse for 7 to 10 days after the procedure.


Loop Electrosurgical Excision Procedure
Depending on the results of the cervical biopsy, the patient may need a more extensive procedure, conization, in which a cone-shaped wedge of cervical tissue is removed for treatment or further analysis. More often, a less-invasive LEEP is performed. For this technique, a local anesthetic is injected into the cervix, and a wire loop is inserted into the vagina. A high-frequency electrical current running through the wire is used to remove abnormal tissue from both the cervix and the endocervical canal. Like conization, LEEP can be used as a diagnostic tool to collect biopsy samples and as a treatment to remove abnormal tissue (FIGURE 28.8).


Obstetrics
Learning Objective: Examine the medical assistant’s role in assisting with the obstetrical examination.
      Pregnancy can be the most exciting and terrifying experience for a patient, especially the first time around. As a medical assistant working in obstetrics, it is important to be able to reassure the patient while remaining professional. The next section discusses the examinations and procedures related to prenatal and postpartum care.


Assisting with the Prenatal Examination
Learning Objective: Describe the medical assistant’s role in assisting with the prenatal examination.
      During the prenatal examination, the medical assistant is responsible for setting up the prenatal and obtaining the necessary health history information during the initial prenatal visit. There will also be lab work to be completed and ordered. For subsequent visits, a less extensive history will be taken, as well as the routine tests described later.


Prenatal Record
At the first prenatal examination, an extensive health history will be taken. This history can help to identify any risk factors for the patient. Frequently, the first prenatal visit is the first comprehensive physical examination that the patient has had in a long time. The health history can point out pregnancy-related risk factors and overall health-related risk factors that can also be addressed. The following information should be collected when creating the prenatal record for a patient:
                • Demographic information
                • Menstrual history
                • Obstetric history
                • Medical and surgical history
                • Family and social history


Menstrual History
The prenatal record should include the first day of the last menstrual period. This is used to determine the estimated date of delivery (EDD). It is also important to know the normal cycle length for the patient and if this last menstrual period was “normal.” The medical assistant should also ask if the patient was using contraception when she became pregnant. If she was, the method being used should be documented.


Obstetric History
The provider will need to have a complete history of previous pregnancies. This will help to determine any risk factors for the current pregnancy. The following information should be included in the obstetric history (FIGURE 28.9):
                • Dates of deliveries
                • Types of deliveries (vaginal or cesarean); if cesarean, the type of incision should be noted
                • Birth weight and gestational age of previous infants
                • Complications of previous pregnancies
      There are some specific terms related to an obstetric history that you should be familiar with. TABLE 28.4 lists those terms and their definitions.
      A prenatal record includes documenting the gravida, para, and abortion information. As a medical assistant, you should be able to determine those numbers after obtaining the obstetric history from a patient. It is important to remember that gravida and para refer to the number of pregnancies, not the number of babies. A twin pregnancy is considered just one pregnancy. If this was the first pregnancy for the patient and the pregnancy went to term (38 to 40 weeks), she would be gravida: 1 and para: 1.
      Gravida is the number of pregnancies, regardless of the number of weeks the patient was pregnant. If a patient has three children and had a spontaneous abortion at 8 weeks, her gravida number would 4.

FIGURE 28.8  Colposcopic view of cervix (A) and LEEP biopsy of abnormal cells (B).

FIGURE 28.9  Pregnancy history form from SimChart for the Medical Office.

      Para is the number of pregnancies that have gone to the age of viability (20 weeks). In the above scenario, the patient’s para number would be 3, as the spontaneous abortion happened before 20 weeks.
      The abortion information refers to the termination of a pregnancy before the age of viability (20 weeks). The abortion could be spontaneous, therapeutic, or elective. All would be included in this number. Some providers want this further defined as to which category of abortion. In our above scenario, the patient’s abortion number would be 1.


28.7 Critical Thinking Application
Jill is interviewing a new OB patient. The patient tells Jill that this is her fourth pregnancy, and she has two children. She had two early miscarriages. What would her gravida number be? What would her para number be? What would her abortion number be?


Medical and Surgical History
There are medical and surgical conditions that could affect a patient’s current pregnancy. Common chronic conditions, such as diabetes, hypertension, asthma, and mitral valves prolapse, should be included in the prenatal record. The management of these conditions could change with pregnancy. Less common conditions, such as thyroid disorders, systemic lupus erythematosus, and bleeding disorders, can also affect the patient and the fetus. To help both, the provider needs to be aware of these conditions and the treatment being followed.
      Certain infections can affect a pregnancy. A history of certain STIs can put the patient at risk for complications. Pelvic inflammatory disease (PID) can cause scarring of the fallopian tubes, which increases the risk of an ectopic pregnancy. Genital herpes and other infections can be transmitted to the newborn during delivery. If the provider is aware of those conditions, plans can be made to protect both the mother and the baby.
      If the patient has had any type of abdominal surgical procedure, it could affect the pregnancy or delivery. If there is a history of a prior ectopic pregnancy, this would be a risk factor for another one. If there is a history of a uterine puncture or any uterine incision, the patient and provider will need to talk about a possible cesarean section.


Family and Social History
Many conditions have a genetic component. Obtaining an accurate family history can help determine if the patient or the infant is at risk. With this knowledge, the patient and the provider can be prepared. Additional testing may be included during the prenatal period for a patient with certain factors in the family history. Conditions that could be of concern include the following:

A family history of genetic disorders should also be documented in the patient’s family history. These disorders can include the following:
                • Down syndrome
                • Neural tube defects ( spina bifida, meningocele, anencephaly)
                • Hemophilia
                • Sickle cell anemia
                • Cystic fibrosis (CF)
                • Phenylketonuria (PKU)
      Other family history information that should be noted would include a history of twins in the family, food allergies, and a family history of recurrent miscarriages or stillbirths.
      The social history includes tobacco, alcohol, and recreational drug use. This information can be used for patient education as it relates to pregnancy. Nutrition and exercise are an important part of pregnancy. Finding out if the pregnant patient follows a particular diet, such as vegan or vegetarian, will provide the opportunity for patient education regarding nutritional needs during pregnancy. Employment is also part of a social history. This can point out any occupational duties that could be affected by a pregnancy, such as working with certain chemicals or physical activities that should not be done when pregnant.
      Collecting all of the components discussed previously is a great start to completing the patient’s prenatal record, in addition to supplying the provider with the information needed to provide excellent care during the patient’s pregnancy.
      The prenatal record will continue to be updated throughout the pregnancy. Clinical data will be added at each prenatal visit. The medical assistant will also be checking with the patient to see if there have been any changes or additions to the initial demographic and historical information.

First Prenatal Examination
The physical examination during a first prenatal visit includes an overall assessment of the woman’s health status. This would include vital signs, weight, and urinalysis. The medical assistant must prepare the patient. The patient should be asked if she needs to empty her bladder. If she does, she should collect a urine specimen for a routine urinalysis and a possible pregnancy test. The medical assistant should also prepare the exam room, ensuring that the supplies and equipment necessary to obtain pelvic measurements, perform serologic tests, and prepare for laboratory tests are available. The provider will assess the heart, lung, and thyroid. A physical examination will be done to rule out any other abnormalities. Next, the provider performs an obstetric examination that includes measurement of the height of the uterus and an internal or pelvic examination. A Pap test may be performed if one has not been done in the past year.

Pregnancy Test
There are two types of pregnancy tests. One is done with a urine sample, and the other is done with a blood sample. Both tests are looking for hCG levels. Blood tests are usually performed at the provider’s office or laboratory. Urine tests can be performed at the provider’s office, or the patient may do a home pregnancy test.
      Whether the test is performed at home or in the office, the process is very much the same. A sample of the urine is placed on the test stick, and then the user waits for the results. Some test sticks will show a plus sign for a positive test and a minus sign for a negative test. Other tests will actually display the term pregnant for a positive test or not pregnant for a negative test.
      The estimated date of delivery (EDD), or due date, will be determined at this visit. There are a number of ways to determine the due date. One method is using a gestational wheel (FIGURE 28.10). With this method, the arrow is lined up with the first date of the LMP, and the EDD is shown at the 40-week mark. The EDD may also be calculated by the electronic health record (EHR) or determined by ultrasound.

FIGURE 28.10  Gestational wheel. From Jarvis C: Physical examination and health assessment, ed 6, St. Louis, 2012, Saunders.

A series of blood tests are also performed during the initial prenatal visit. Prenatal blood and laboratory tests include the following:
               • Hematocrit and hemoglobin levels to check for anemia.
               • Blood type and Rh with antibody screening for possible Rh incompatibility (FIGURE 28.11).
               • Rubella titer to determine whether the mother is immune to German measles; rubella infection during pregnancy can cause multiple birth defects, including deafness, vision disorders, and intellectual disability.
               • Syphilis screening; if the result is positive, antibiotic treatment is initiated to protect the fetus from congenital syphilis.
               • Hepatitis B screening because this virus can be passed to the fetus in utero.
               • Human immunodeficiency virus (HIV) screening is suggested; if the result is positive, treatment of the mother greatly reduces the risk of transmission to the fetus.
               • Gonorrhea and chlamydia cultures to prevent infection of the baby at birth.
               • Urinalysis to detect protein, white blood cells, or glucose.
Any concerns that the patient has should be noted and reported to the provider. The medical assistant should be prepared to suggest community resources that can provide assistance to new parents, such as the following:
               • Childbirth and parenting classes
               • Infant cardiopulmonary resuscitation (CPR) courses
               • Nutritional counseling, if needed
               • Contact information for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which helps lower-income expectant mothers get nutritious food

FIGURE 28.11  Hemolytic disease of the newborn. From Hagen-Ansert SL: Textbook of diagnostic sonography, ed 7, St. Louis, 2012, Mosby

Hemolytic Disease of the Newborn (HDN)
The blood is tested for the presence of D antigens to determine if someone’s blood type is Rh positive or Rh negative. Rh-positive blood has D antigens; Rh-negative blood does not. If the blood type with Rh factor shows that the mother has Rh-negative blood, there is a concern that hemolytic disease of the newborn (HDN) could develop if the fetus is Rh positive. HDN is also known as erythroblastosis fetalis. If the mother is Rh negative and her fetus is Rh positive, the mother will form antibodies to the Rh-positive factor. Future Rh-positive pregnancies will be in jeopardy because the mother’s anti-Rh antibodies will cross the placenta and destroy fetal blood cells (see FIGURE 28.11).
      HDN can be prevented by giving the mother Rh immune globulin products. RhoGAM, or anti-D immune globulin, is given at 28 to 30 weeks of gestation to Rh-negative mothers, regardless of the father’s Rh type. After delivery, the cord blood is tested, and a dose of RhoGAM is given within 72 hours of delivery, but only if the baby is Rh positive. RhoGAM is also given for miscarriages or abortions. The immune globulin prevents the infant’s Rh-positive cells from stimulating the mother’s immune system, thus preventing HDN.
Return Prenatal Visits
The return prenatal visits follow a regular schedule:
                • Every 4 weeks through 28 weeks’ gestation
                • Every 2 weeks through 35 weeks’ gestation
                • Every 1 week until delivery
       In follow-up prenatal visits, the medical assistant should collect a urine specimen for urinalysis, weigh the patient, measure her blood pressure, and answer questions about diet and health habits. The mother should gain approximately 10 to 12 pounds in the first half of pregnancy and another 15 to 17 pounds during the second half. Experts believe that a healthy weight gain is somewhere between 25 and 35 pounds.


Fetal Heart Tones
A Doppler monitor may be used to hear the baby’s heart tones somewhere between 9- and 12-weeks’ gestation. Once recorded, the fetal heart rate is assessed at each subsequent visit. It is important to remember that a fetal heart rate should be between 120 and 160 beats per minute. If you get a reading of between 60 and 100 beats per minute, you may be assessing the patient’s heart rate and not the fetal heart rate.

FIGURE 28.12  Fundal height measurement.

Fundal Height Measurement
Fundal height measurement is routinely done during the return prenatal visit. As the uterus grows during pregnancy, it will rise into the abdominal cavity. Between weeks 8 and 13, the fundus (the top of the uterus) can be palpated above the symphysis pubis. The fundal height measurement is taken with a flexible tape measure, measuring from the symphysis pubis to the fundus of the uterus. The height is measured in centimeters (cm) and most often matches the number of weeks the patient has been pregnant. For example, if the patient is 25 weeks pregnant, the provider would expect to see a fundal height measurement of 25 cm (FIGURE 28.12). This is only considered accurate for the first and second trimesters. If the fundal height measurement does not match the number of weeks pregnant, this could signal an issue with the pregnancy. Fundal height measurements that are either larger or smaller than expected could indicate the following:
                 • Slow fetal growth (intrauterine growth restriction)
                  • A significantly larger than average baby (fetal macrosomia)
                 • Too little amniotic fluid (oligohydramnios)
                 • Too much amniotic fluid (polyhydramnios)
If the provider suspects an issue, an ultrasound would likely be ordered to determine what was causing the unusual measurements.

Postpartum Visit
Learning Objective: Describe the medical assistant’s role in assisting with the postpartum visit.
      The patient should return about 6 weeks after delivery for a postpartum visit. At this visit, the provider will do a pelvic examination to make sure everything is healing. If a cesarean section was done, the incision site would also be checked for healing. If the patient is interested in using contraceptives, the provider will talk about contraceptive choices. If the patient previously used a diaphragm, the fit will need to be checked. There may also be a discussion about how breastfeeding is going. Any of the patient’s questions about care for the baby should be answered at this visit.
      The postpartum visit is also an opportunity to see how the patient is doing emotionally. The provider will ask questions about the patient’s moods and check for signs of postpartum depression.
Postpartum Depression
• The incidence of postpartum depression (PPD) is not clear, but an estimated 10% to 20% of women struggle with major depression before, during, and after delivery of a baby. Fewer than half of these are diagnosed in routine office visits.
• Postpartum depression can be diagnosed a month to a year after childbirth. Women with a history of depression during pregnancy should be monitored for signs of postpartum depression for a minimum of 4 months.
• Risk factors include a history of depression, abuse, or mental illness; smoking or alcohol use; anxiety during pregnancy and fears over childcare; lack of financial resources and secure relationships; a fussy or colicky infant; and lack of social support.
• Symptoms of postpartum depression include anorexia and insomnia; irritability and anger; overwhelming fatigue; loss of interest in sex and lack of a feeling of joy in life; feelings of shame, guilt, or inadequacy; severe mood swings; difficulty bonding with the baby; withdrawal from family and friends; and thoughts of harming oneself or the baby.
• Postpartum depression must be detected as soon as possible so that treatment can begin; untreated postpartum depression may last for a year or longer. Treatment includes both counseling and antidepressant medication.
      The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for perinatal depression (between the 28th week of pregnancy and the 28th day after birth). Healthcare professionals working with the perinatal population should use the EPDS as a routine part of postnatal care because the EPDS is a valid and reliable means of detecting PPD. This screening tool is user-friendly, easy to administer, and easy to score. A score of 9 to 13 is considered the cutoff for PPD; the mother should be referred for further evaluation or treatment. Users may reproduce the scale without further permission, providing they respect the copyright by quoting the names of the authors and the title and the source of the paper in all reproduced copies. The EPDS can be accessed at the American Academy of Pediatrics website:
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Documents/Postnatal%20Depression%20Scale.pdf.

FIGURE 28.13  Ultrasound of a fetus. Courtesy of Megan Pepper.

      Medical assistants should set up for this visit just as they would for a pelvic examination. You should also be aware of the patient’s mood and body language. These can alert you to potential issues with postpartum depression. You should also have a list of provider-approved resources for the patient regarding postpartum depression or breastfeeding issues.

Assisting with Diagnostic Procedures
Learning Objective: Describe the medical assistant’s role in assisting with diagnostic procedures.
     Throughout the pregnancy, there are special tests and procedures that may be done to assess the status of the pregnancy. In the next section, we will explore some of the more common tests and procedures.

Ultrasound
Ultrasound exams are typically done once during the first trimester and then again between weeks 18 and 20 to assess fetal development and thereby confirm the age of the fetus and proper growth (FIGURE 28.13). The sex of the baby can also be determined at that time. It is best if the patient has a full bladder for the ultrasound. The full bladder provides a great “window” for the sound waves to travel through, allowing for the best possible images. The patient should be instructed to drink two or three 8-ounce glasses of water 1 hour before the scheduled ultrasound.

Laboratory Testing
Between weeks 15 and 18 of pregnancy, the provider may suggest that the patient have a maternal blood screen in order to detect any risk of fetal and chromosomal disorders. This could be a triple screen test (also known as AFP Plus and multiple marker screening) or a quad screen test. Both tests screen for the following:
                 • Alpha-fetoprotein (AFP)
                 • Human chorionic gonadotropin (hCG)
                 • Estriol
      The quad screen also tests for inhibin-A. These tests are used to evaluate if there is an increased chance of certain chromosomal conditions, such as Down syndrome. The alpha-fetoprotein evaluates the chances of neural tube defects, such as spina bifida.
      If the patient is at risk for gestational diabetes, the provider will likely order a glucose challenge test. Risk factors for gestational diabetes include the following:
                 • A body mass index (BMI) before pregnancy of 30 or higher
                 • A mother, father, sibling, or child with diabetes
For a glucose challenge test, the patient must drink a glucose solution. One hour later, a blood test will be done to measure the glucose level. A blood glucose level of 130 to 140 milligrams per deciliter (mg/dL) is considered normal. If the result is higher than that, a glucose tolerance test may be ordered. The glucose tolerance test involves having the patient fast overnight before coming in for a blood glucose reading. The patient will then drink another glucose solution and have her blood glucose level checked every hour for the next 3 hours. If two out of the three readings are higher than normal, the patient would be diagnosed with gestational diabetes.
      Group B streptococcus is a common bacterium found in the intestines. It is usually harmless in adults, but in newborns it can cause group B strep disease. This is a serious illness for newborns. A group B streptococcus culture of the lower vagina can be performed between weeks 32 and 36. If the result is positive, the mother is treated with intravenous (IV) antibiotics to prevent fetal exposure during vaginal birth.

Amniocentesis
Amniocentesis involves needle aspiration of approximately 2 tablespoons of amniotic fluid after week 14 of pregnancy. The aim is to detect genetic and chromosomal abnormalities or inherited metabolic disorders (FIGURE 28.14). Potential complications include the following:
                 • Miscarriage
                 • Fetal injury
                 • Infection
                 • Premature labor
                 • Maternal hemorrhage
Results take up to 2 weeks.

Chorionic Villus Sampling
Chorionic villi are tiny placental projections, the cells of which have the same genetic material found in fetal cells. Chorionic villus sampling (CVS) involves the removal of a small piece of the chorionic villi, either transvaginally or through a small incision in the abdomen (FIGURE 28.15). Cellular screening at 8- to 12-week gestation provides early detection of genetic or chromosomal disorders. Potential complications include the following:
                 • Accidental abortion
                 • Infection, bleeding
                 • Fetal limb deformities
Results are available within several days.

FIGURE 28.14  Amniocentesis. From Shiland B: Mastering healthcare terminology, St. Louis, 2016, Elsevier.

FIGURE 28.15  Chorionic villus sampling (CVS). From Shiland B: Medical terminology and anatomy for ICD-10 coding, St. Louis, 2012, Mosby.

Recognizing Domestic Abuse
Learning Objective: Explain how to recognize domestic abuse.
      There are federal laws in place that require many insurance plans to provide coverage for certain preventive health services without any cost-sharing for the patient. Included in the preventive health services are screening and counseling for interpersonal and domestic violence. Working in healthcare gives us an opportunity to provide support and resources for someone who is dealing with domestic violence. As a medical assistant, you should be looking for possible signs of abuse, such as the following:
                • Unusual or frequent bruises or fractures
                • Attempts to hide the bruises with makeup or clothing
                • Low self-esteem
                • Being extremely apologetic and meek
                • References to the partner’s temper
      If you notice any of these signs, you should make the provider aware of them. Even a patient who shows no signs of abuse should be asked if he or she feels safe in the home.
      The healthcare facility should put together a list of resources for patients who may be victims of domestic abuse. Having a list of shelters, advocacy groups, emergency contact phone numbers, and transportation services to give patients may provide them with the resources they need to make the decision to leave the abusive situation.
      Abuse does not just happen in marriages or committed relationships; it can also occur in a dating relationship. We should be observing all patients for possible signs of abuse. Here are three national helplines with websites that patients could be referred to:
                • National Domestic Violence Hotline: 800-799-SAFE (7233) or TTY 800-787-3224; www.thehotline.org
                • National Dating Abuse Helpline: 866-331-9474 or TTY 866-331-8453; www.loveisrespect.org (live chat is available); text “loveis” to 77054
                • Office on Women’s Health: www.womenshealth.gov/relationships-and-safety/relationships-and-safety-resources