Gynecology

WHNPs in specialty positions: Cultivating a new role in gynecologic oncology

Throughout my graduate education in nursing, I had no doubt that I ultimately wanted to focus my practice on women’s health. However, I did graduate with a fair amount of trepidation about the possibility that I had limited my options in the advanced practice arena, especially after I had chosen to narrow my focus to oncology. Over the next couple of years, I came to realize not only that my options as a women’s health nurse practitioner (WHNP) were more numerous than I had thought, but also that I would be able to help cultivate new roles within the profession as well. Continue reading »

Duke Team Reaches Milestone with Portable Cervical Cancer Screening Device

January was Cervical Health Awareness Month, and this year, that designation held special significance for Nimmi Ramanujam, professor of biomedical engineering and global health and director of the Center for Global Women’s Health Technologies.

Since 2012, she and her research team have been developing and testing a portable colposcope, called the “Pocket Colposcope,” to increase access to cervical cancer screening in primary care settings. Last month, 20 of these devices were produced for distribution to international partners.

SCREENING IS KEY TO EARLY DETECTION AND EFFECTIVE TREATMENT

According to the World Health Organization (WHO), more than 85 percent of the more than 270,000 annual deaths from cervical cancer occur in low and middle income countries. The disease is easily treatable if identified early, but because access to effective screening is limited in low-resource settings, early detection is often not possible.

And even if access to screening is available, for example via human papilloma virus (HPV) testing, a confirmatory test is needed before a woman can receive treatment. In the United States, this test is performed through colposcopy. However, a clinical colposcope is typically not available in a primary care setting, and in many low and middle income countries, often the alternative is to visualize the cervix with only the naked eye—a method that often results in missed diagnoses. The cost of a clinical colposcope—upwards of $20,000—presents yet another barrier.

The Pocket Colposcope is designed to address these barriers. It brings that secondary test—traditionally performed using a clinical colposcope by physicians at referral centers—to the primary care setting. In addition, it’s easy for a broad range of health care providers with different levels of training to use.

ABOUT THE POCKET COLPOSCOPE

After four generations of development, the team has created a beta prototype of the Pocket Colposcope in collaboration with product design and development company 3rd Stone Design, Inc.

The Pocket Colposcope is significantly less expensive, smaller and lighter than a traditional clinical colposcope. Weighing less than two pounds, it fits inside a pocket (hence the name). The device enables healthcare providers to zoom and capture images by pressing a button with their thumb. Images taken with the Pocket Colposcope are transmitted instantly to a smartphone, tablet or laptop.

Read more at Duke Global Health Institute

When the warrior is a woman

The number of women serving in the United States Armed Forces has increased rapidly over the past decade and a half. The U.S. Department of Veterans Affairs (VA) has been implementing major changes to meet the growing demand for healthcare services after these women have been discharged from the military, as well as for older female Veterans who left the service long ago. This article describes the many and varied types of healthcare services that are available for female Veterans. These services are provided by healthcare professionals, including nurse practitioners, working in VA institutions or in the community.

Women comprise about 15% of active-duty military force members and 18% of National Guard and Reserve force members.Women serve in nearly every area of the military—including as fighter pilots, gunners, warship commanders, and military police— in locations stateside and abroad. They serve in every branch of the military. When they are discharged from the military, they become Veterans. At this time, 2.2 million women in the United States are Veterans.1

How many women use VA healthcare services? How is this population characterized?

Since 2000, the number of female Veterans using healthcare services provided by the U.S. Department of Veterans Affairs (VA) has more than doubled, from nearly 160,000 in fiscal year 2000 to more than 390,000 in fiscal year 2013.This growth has outpaced that of male Veterans. Among all female Veterans who served during Operation Enduring Freedom, Operation Iraqi Freedom, and/or Operation New Dawn (OEF/OIF/OND), 59.7% have received VA healthcare.Of this group who have received VA healthcare, 90.6% have used it more than once and 57.0% have used it 11 times or more. In fiscal year 2013, the average age of VA healthcare users was 48 years for women and 63 years for men.2

The VA serves women in every age bracket.Among female VA healthcare users, 43% are aged 18-44 years, 46% are aged 45-64 years, and the remainder are aged 65 years or older. Reproductive-aged women Veterans receive the gynecologic and obstetric care they need, and those in the menopausal years, many of whom served during the Vietnam or Gulf War eras, can rely on receiving more intensive healthcare because of their age.

In fiscal year 2012, 57% of women Veteran VA patients had some level of service-connected (SC) disability—that is, an injury or illness that occurred or worsened during service in the military.3 If a Veteran receives SC disability status, her SC disability is then assessed and rated for severity from 0% to 100%. In fiscal year 2012, 30% of women Veteran VA patients had an SC disability rating of 50% or higher.2

Women Veterans have higher physical and mental health burdens than their non-Veteran counterparts, as well as health burdens equal to or worse than those of male Veterans.They have substantial chronic disease and mental health problems; top diagnoses include post-traumatic stress disorder (PTSD), hypertension, depression, hyperlipidemia, chronic low back pain, gynecologic problems, and diabetes mellitus (DM). Among female OEF/OIF/OND Veterans, 20% have been diagnosed with PTSD and 20% have responded “yes” when screened for military sexual trauma (MST).1 In addition, women are the fastest growing segment of the homeless Veteran population, and are more likely to be homeless with children.

Recent research shows substantial co-morbidities among women Veterans, with 31% having physical and mental health conditions (vs. 24% of male Veterans). For example, among female Veterans with DM, 45% have a co-morbid serious mental illness or substance use disorder. Among female Veterans with cardiovascular disease, 21% have major depressive disorder.

Certain health risks may depend on the era of service.1,5,6 For example, women who served during the Vietnam War may present with diseases related to exposure to Agent Orange, such as Hodg kin’s disease, multiple myeloma, certain softtissue sarcomas, respiratory cancers, non-Hodgkin’s lymphoma, peripheral neuropathy, type 2 DM, Parkinson’s disease, and ischemic heart disease. Those who served during the Gulf War may present with chronic fatigue syndrome, fibromyalgia, gastrointestinal disorders, fatigue, skin disorders, headache, muscle pain, joint pain, neurologic or neuropsychological signs or symptoms (S/S), sleep disturbances, cardiovascular S/S, abnormal weight loss, or menstrual disorders. OEF/OIF/OND Veterans may be more likely to present with musculoskeletal and connective tissue disorders, mild depression, major depression, and readjustment difficulties.

Do women Veterans seek healthcare outside the VA system? What do providers need to know?

Approximately 83% of women Veterans seek healthcare outside the VA, either exclusively or along with the care that they receive from VA providers.7 Many healthcare providers (HCPs) may not realize that their patients are Veterans. Because such a large proportion of female Veterans receive healthcare outside the VA, either at academic centers or in private community practices, HCPs need to understand these women’s unique needs.

What can HCPs do? Because many female Veterans do not always identify themselves as such, HCPs should ask their patients “Have you served in the military?” If the answer is yes, HCPs should obtain a military history (branch of military, dates of service, occupation, deployment, reason for separation), including a description of their experiences in the military, and be familiar with local VA facilities so that they can refer Veterans appropriately. Women are eligible for VA healthcare if they have an honorable discharge and have completed 2 years of active duty service, were deployed in OEF/OIF/OND, or have experienced MST. A Veteran remains eligible for VA healthcare even if actively serving in the Guard or Reserve. Small copayments for some services are required. The sidebars list services available to women Veterans and additional resources.

How has the VA changed the face of women’s healthcare?

The VA created the Women’s Health Program in 1988 to streamline services for female Veterans in order to provide more cost-effective medical and psychosocial care. At that time, 4.4% of Veterans were women. The program was realigned within the Office of Public Health and Environmental Hazards in 2007, which increased the scope to include all women’s services. When the VA made additional alignment changes in 2011, the Women’s Health Program became part of the Office of Patient Care Services (PCS), The program’s name was changed to Women’s Health Services (WHS) in August 2012. Becoming part of PCS opened opportunities for WHS to collaborate with Primary Care, Mental Health, and Specialty Care.

The motto for WHS is “You served, you deserve the best care anywhere!” Women Veterans using VA healthcare services can expect:

• Women Veterans Program Managers to assist them at every facility;

• Comprehensive primary care, mental health services, and emergency and specialty care delivered by proficient and interested providers;

• Privacy, safety, dignity, and sensitivity to gender-specific needs;

• State-of-the-art healthcare equipment and technology;

and

• Pharmacy services by mail-order and online.1 

The goal of the VA is to ensure that every woman Veteran has access to a VA primary care provider (PCP) who can meet all her primary care needs, including gender- specific care. This approach ensures high-quality healthcare, with special emphasis on continuity of care and a strong relationship between PCP and patient.

Under ideal circumstances, female Veterans should receive complete primary care from one Designated Women’s Health Provider (DWHP) at one location.To provide enough DWHPs, along with nursing support, the national WHS office sponsors a 2.5-day national mini-residency program for PCPs and primary care nurses and offers it several times per year. The VA has also developed online training for core topics in women’s health. Every medical facility, including Medical Centers and Community-Based Outpatient Clinics (CBOCs), should have at least two DWHPs. Currently, all VA healthcare systems and 84% of CBOCs have at least one DWHP. These providers have an interest and special expertise in caring for women Veterans, many of whom have multiple physical and mental health co-morbidities.

The VA is working hard to ensure that every woman Veteran has access to the right kind of care at the right time and place. Facilities across the country are adding specialized equipment (e.g., digital mammography, DEXA scans) for women, updating facilities to ensure privacy and security, and expanding staff to provide convenient, equitable care.6

How is the VA addressing gender differences?

Beginning in 2008, the VA started a Women’s Health improvement initiative to focus on gender disparity data.8 Between 2008 and 2011, the VA saw tremendous reductions in gender disparity for many care measures, including Hypertension in Ischemic Heart Disease, A1C Testing for Diabetes, Retinal Exam in Diabetes, Nephropathy Screening in Diabetes, Pneumococcal Vaccine, Colorectal Cancer Screening, Depression Screening, PTSD Screening, and Alcohol Misuse Screening. Despite nationwide emphasis on gender differences in a variety of physical and mental health issues, gender gaps persisted for achieving these goals: LDL <100 in Ischemic Heart Disease, addressing A1C >9 in Diabetes, LDL <100 in Diabetes, and Influenza Vaccine. Analyses of best practices among VA networks revealed improvement based on education, support of leadership, collaborations among programs (Women’s Health, Primary Care, and Health Promotion Disease Prevention), and systems redesign. Success required multidimensional and multidisciplinary intervention aimed at patients, providers, and systems of care.

Progress is being made. Disparities in the rates of screenings and immunizations given to women and men VA patients are shrinking.8 For example, in 2008, 86% of eligible women Veterans received flu shots versus 94% of men. By 2011, there was only a 1% difference. One hundred percent of VA web pages have at least one topic of interest to women Veterans. Nearly half of these pages link to a facility-specific women’s health page and nearly one-third have images of women.

How does the VA fare with regard to provision of mental health services for women?

The VA provides a comprehensive system of mental health services for all Veterans, including psychological assessment and evaluation, outpatient individual and group psychotherapy, acute inpatient care, and residential-based psychosocial rehabilitation.2 Specialty services target problems such as PTSD, substance use problems, depression, and homelessness.

The VA has outpatient, inpatient, and residential services for women Veterans who have experienced MST and provides free care for all mental and physical health conditions related to MST.2 Veterans may be able to receive this free MST-related healthcare even if they are not eligible for any other VA care. An SC disability rating is not required, nor is the Veteran required to have reported the MST when it happened or have documentation that it happened. Every VA medical center has an MST Coordinator who specializes in this type of care and assists Veterans to access needed care. To accommodate female Veterans who do not feel comfortable in mixedgender treatment settings, many VA medical centers have women only programs or have specialized women’s treatment teams.

The VA offers a variety of programs designed to assist homeless Veterans, including special populations such as women with families.2 Programs include outreach and prevention, temporary and transitional housing, and permanent housing with supportive services. Among the homeless Veteran population, nearly 8% are female.2

The VA has dramatically increased mental health services because of the growing number of women Veterans, who use mental health services in larger numbers than their male counter-parts.Since 2012, more than 1,000 mental healthcare providers and more than 200 administrative support staff were hired, with a goal of hiring 1,600 providers and 300 support staff in 2013 alone.9 Mental health professionals include psychiatrists, psychologists, social workers, mental health nurses, licensed professional mental health counselors, licensed marriage and family therapists, and addiction disorder therapists. In addition, Veterans are being hired as Peer Specialists (up to 800 positions) who provide support to other Veterans. The number of phone lines for the Veteran Crisis Hotline has been increased by 50% to handle the additional volume of phone requests for mental healthcare services.

What type of maternity care does the VA offer?

Many female Veterans who served in OEF/OIF/OND are of reproductive age. Among these women, 81.1% were born in or after 1970 and 54.6% were born in or after 1980.2 With larger numbers of reproductive-aged women Veterans, the VA has recognized the need for expanded maternity care services. Maternity care is provided through outside community providers; costs are paid by the VA.10 The VA covers standard prenatal care, laboratory services, ultrasounds, and delivery costs. If a woman requires specialty care (such as Cardiology) during her pregnancy, her HCP can network within the VA if that service is available. Otherwise, necessary care is handled by other community providers. Each VA Medical Center has a Maternity Care Coordinator who contacts every pregnant Veteran at least every 2 months to review her physical and psychological needs, to ensure that she has the supplies and educational services that she requires, and to keep the Veteran in contact with her primary care and mental healthcare teams as needed. The newborn’s hospital healthcare is covered from birth through 7 days of life.10

What is the VA’s vision with regard to women’s healthcare?

The vision of the VA is to provide the highest quality care to every woman Veteran. Care of the highest quality….

• ensures that each woman Veteran coming to the VA will have her gender-specific primary care needs met by a proficient and interested PCP.

• includes privacy, dignity, and sensitivity to gender-specific needs.

• ensures that healthcare equipment and technology are state-of-the-art.

• ensures gender parity in performance measures.

• provides the right healthcare in the right place at the right time.

• builds necessary efficiencies into the delivery of women’s healthcare.

Each VA facility assesses its needs, strengths, and challenges to create a plan that works for its population of women Veterans, its areas of expertise, and its facilities, equipment, and staffing capacity. The VA is committed to exploring new approaches and pilot programs, all of which are designed to raise the standard to provide the best care anywhere.11 Beyond healthcare, the VA has a full range of benefits for women Veterans, including education and job training, vocational rehabilitation, benefits assistance, home loans, life insurance, and survivor and death/burial benefits.1 The VA is encouraging everyone to rethink the term Veteran (that former warrior might be a woman), to recognize the vital role women play in the military, and to appreciate what it means to be a woman Veteran.

Patrice C. Malena is Women Veterans Program Manager at Hampton VA Medical Center in Hampton, Virginia. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article. The content of this article does not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

References

1. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. A Profile of Women Veterans Today. Rethink Veterans: Who is the Woman Veteran? April 2012.

2. Department of Veterans Affairs. Office of Public Affairs Media Relations. Women Veterans Health Care Fact Sheet. Updated July 2014.

3. Department of Veterans Affairs. Sourcebook: Women Veterans in the Veterans Health Administration, Volume2: Sociodemographics and Use of VHA and Non-VA Care (Fee). October 2012.

4. Department of Veterans Affairs. Report of the Under Secretary for Health Workgroup. Provision of Primary Care to Women Veterans. November 2008.

5. Department of Veterans Affairs. Office of Public Affairs. Federal Benefits for Veterans, Dependents and Survivors. Last updated April 21, 2015.

6. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. On the Frontlines of VA Women’s Health: Enhancing Services for Women Veterans. August 2011.

7. Women Veterans Health Care. Resources for Non-VA Providers, Medical Students. Page last updated June 3, 2015.

8. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group, Office of Patient Care Services. Gender Differences in Performance Measures VHA 2008-2011; June 2012.

9. Department of Veterans Affairs. Office of Public and Intergovernmental Affairs. VA Hires More Mental Health Professionals to Expand Access for Veterans. February 11, 2013.

10. Department of Veterans Affairs. Women Veterans Health Care. FAQs. June 3, 2015.

11. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. Guide to Moving Forward in Providing Comprehensive Health Care to Women Veterans. August 2008.

Strategies for effective group prenatal care with pregnant adolescents

Managing the prenatal care of adolescents is both challenging and rewarding. Given adolescents’ developmental needs, group prenatal care (GPC) such as that modeled after Centering- Pregnancy is particularly well suited to members of this age group. The authors share their strategies for providing developmentally appropriate GPC for adolescents.

Most females receive prenatal care via a traditional model focused on screening for health-related complications. A healthcare provider (HCP) offers this care on an individual and regular basis throughout the pregnancy. At minimum, each visit involves assessment of maternal weight and blood pressure (BP), fundal height, and fetal heart rate. The initial visit is more comprehensive than subsequent visits, and includes taking a personal and family history, conducting a complete physical examination, and ordering laboratory tests. Education is provided about prenatal care and avoidance of risky behaviors. Subsequent visits include screening for problems and provision of information about nutrition, pregnancy complications, childbirth, and infant care. When indicated, special fetal assessment tests may be recommended and the need for genetic counseling discussed.1

In 1993, CenteringPregnancy (CP) was introduced as an alternative model for delivering prenatal care.2,3 The CP model provides comprehensive prenatal care to small groups of women at similar points in their pregnancies. For participants in this group prenatal care (GPC) program, learning and support are enhanced by group dynamics and by the HCP’s leadership.Compared with traditional care, CP has been associated with improved patient satisfaction, knowledge, and attendance; similar or superior maternal/newborn health outcomes; and greater affordability.4-10

The advent of the Affordable Care Act of 2010, with its provision of access to healthcare for additional millions of Americans, has created a distinct need for innovative, cost-effective, high-quality prenatal care models. GPC can be both safe and affordable, provided at convenient times for better access, and directed at meeting a group’s special needs. GPC is ideal for pregnant adolescents: Management of adolescent pregnancy in group settings has been shown to foster optimal maternal and neonatal outcomes.4-7,11,12 The authors, with many years’ experience in delivering prenatal care to adolescents using the group model, discuss their own program.

Background information on CenteringPregnancy

The authors’ adolescent GPC approach was based on principles of CP. According to Rising,developer of CP, attending prenatal sessions can result in better pregnancy outcomes, with less maternal stress, lower rates of substance abuse, improved labor progress, higher infant birth weights, and higher 5- minute Apgar scores. The CP model, which includes essential components of traditional prenatal care within a group framework, integrates three major components of prenatal care: health assessment, interactive learning, and community building.13 CP groups comprise 8-12 females at similar points in their pregnancies. After a one-onone prenatal visit with an HCP, participants attend regular group sessionslasting 1.5-2 hours, usually held in the late afternoon or early evening, for the remainder of their care. The sessions, typically led by an HCP and a nurse, meet every 4 weeks until the 28th week and then every 2 weeks until delivery.

At the start of every group session, each participant has a quick private visit with a nurse and an HCP for checks of weight, BP, fundal height, and fetal heart tones and for an opportunity to ask personal questions. During this time, the other participants chat or watch an educational video. Once individual checks are done, the group session begins. Topics discussed include nutrition, exercise and relaxation, discomforts of pregnancy, childbirth preparation, infant care and feeding, postpartum concerns, contraception, communication/self-esteem, and parenting skills. Participants are encouraged to ask questions, which can help others with similar concerns,12 and they are invited to bring a partner or a family member. Additional prenatal visits are necessary only if problems with the pregnancy arise or if a participant requires a confidential private exam.

The CP structure comprises 13 essential elements,14 which are also used in the authors’ prenatal program: (1) Health assessment occurs within the group space; (2) Women are involved in self-care activities; (3) A facilitative leadership style is used; (4) Each session has an overall plan; (5) Attention is given to the core content, but emphasis may vary; (6) There is stability of group leadership; (7) Group conduct honors the contribution of each member; (8) The group is conducted in a circle; (9) Group composition is stable but not rigid; (10) Group size is optimal to promote the process; (11) Involvement of family support is optional; (12) Opportunity for socializing within the group is provided; and (13) There is ongoing evaluation of outcomes. Primary differences between CP and traditional prenatal care are the time spent in care and the opportunity for group interaction. Traditional visits usually last 5-10 minutes, whereas CP visits are about 90 minutes long. This amount of time allows participants to grow comfortable with their HCPs and each other, which enhances discussions and learning. In addition, belonging to a group can help participants feel valued and important, and provide support during the pregnancy.12

Adolescents and group prenatal care: Literature review

Adolescence is a challenging stage of life, but when pregnancy complicates the picture, additional physical, social, and emotional stresses must be managed. Because pregnant adolescents are more likely than their non-pregnant counterparts to be in a lower socioeconomic bracket, they are less likely to receive adequate prenatal care unless it is accessible and affordable. GPC may be optimal for these individuals; not only can it be offered at convenient times and be covered by Medicaid, but it is also geared toward adolescents’ developmental level and learning needs.15,16 To ascertain  what the literature shows in terms of the usefulness of GPC for young females, especially adolescents, the authors searched the CINAHL and Medline databases for studies and systematic reviews reported from 2010 through 20115. Table 1. Selected studies on group prenatal care can be accessed here. 4 5,7,11,12,17-21

Authors’ experiences and strategies

The authors’ outpatient prenatal program was affiliated with a large urban medical center and enrolled adolescents aged 12-19 who were African American (65%), Caucasian (20%), Latino (10%), or Southeast Asian (5%). Most participants came from low-income families receiving public assistance. Initial training for the program’s staff was provided by two CP consultants during a 2-day workshop on content and process. Funding for the training came from the program’s budget; ongoing training for new staff was derived from continuing education funds and a community agency grant.

A nurse practitioner (NP), midwife, or nurse who saw prospective program participants at their intake and first obstetric visit invited  them to join the GPC program. The authors expected that all recruited adolescents would participate in the program, but they made exceptions when a patient needed individual care because of privacy concerns or a conflict with another participant. Each group was managed by an HCP (either an NP or a midwife) and a nurse. A social worker performed psychosocial evaluations and was available to address psychosocial concerns, and a nutrition specialist performed one-on-one  assessments early in the pregnancy and participated in a group discussion of prenatal nutrition and meal planning. The group meeting room accommodated 15 people and was set up to be comfortable and welcoming— similar to a setting for a baby shower. The CP model recommends that participants sit in a large circle with no table, but the authors used the existing large oval table in their space, which did not seem to affect group interactions. Educational aids available in the room included models of a bony pelvis, fetus, uterus, and dilating cervixes; posters; and a TV with a DVD player and videos to reinforce topics such as maternal nutrition, vaginal and cesarean delivery, and newborn and self-care.

The first GPC session took place when participants were at 12-16 weeks’ gestation. For scheduling purposes, the groups were referred to by their due dates (e.g., the September/October group). As with the CP program, at the start of each session, a nurse weighed each participant and checked her BP. Next, the participant lay on a small firm couch and an HCP assessed fundal height and fetal heart tones and obtained other relevant information. A curtain divider between the couch area and the group meeting area ensured privacy. During the initial group meeting, the HCP and the adolescents reviewed “Teen Rules for Group Prenatal Care” as follows:

• Be sensitive to others’ confidential information: “What is said in group stays in group.”

• Discuss who should be allowed to come to group (usually one guest who was a partner, friend, or mother figure, but no children).

• Behave politely and respectfully toward other group members (e.g., when one person is talking, others should listen).

• Do not use hand-held electronic devices during the sessions.

• Encourage everyone to be involved in discussions, and reinforce that no one should dominate or be excluded.

• Describe how group works: weight, urine sample, and fundal height measurement, followed by the education component, with the option of being seen individually after group as needed.

• Know the danger signs of pregnancy.

• Know how to contact the practice and use the after-hours oncall service for labor and emergencies.

In the authors’ program, 3-4 groups attended GPC sessions once weekly in the afternoon. Participants received phone reminders the day before the sessions; any transportation problems were resolved at this time. Although 8-10 participants were assigned to each group, only 5-6 attended regularly. Postpartum group reunions—including the infants— were scheduled to occur 4- 6 weeks after the last girl in each group had delivered. However, because of low participation, these sessions were discontinued.

At first, GPC participants kept copies of their health records. When the authors’ practice converted to an electronic health record (EHR) system, this information was stored on a laptop. Patient encounter forms were printed prior to group meetings for easy completion with billing codes and designations of return visits. GPC visits were reimbursed the same way as an individual visit. Some insurance was fee-forservice, but most patients were covered by Medicaid managed care programs that reimbursed globally. The prenatal portion was then applied to the adolescent   program budget and the delivery portion to the midwifery budget. Table 2 lists websites specific curriculum content for adolescent GPC and general information on teen pregnancy. Topics of greatest interest to participants in the authors’ program included preparation for labor and birth, pain management, bringing baby home, bottle feeding versus breastfeeding parenthood, relationships with their boyfriend, and contraception.

Table 3 lists GPC activities that the authors found particularly useful. GPC worked best when HCPs were facilitators of group activities rather than lecturers of content. The adolescents appreciate knowing what they could expect from their HCP as well as what was expected of them. HCPs reinforced the confidentiality of patient information and demonstrated respect to gain the trust and confidence that promote regular group attendance and participation. In the authors’ experience, HCPs who were seasoned clinicians, had senses of humor, were approachable, and had knowledge of community resources were best suited as GPC providers.  Group attendees completed a satisfaction survey at the last session. Over the years, the surveys demonstrated high satisfaction with the program, especially with regard to its structure, the knowledge it imparted, the relationships it fostered, and the preparation it provided for labor, delivery, and newborn care.

Discussion

Initiating a GPC model requires considerable planning and commitment. The authors learned the importance of gaining commitment to the program from everyone involved, from the clerical staff to the HCPs themselves, because they all needed to adapt to a new way of providing care. Periodic retreats were held to address the challenges that arose as the program was implemented.

The GPC program needed to be budget neutral; ensuring that reimbursement covered costs meant having at least 6-8 patients per session. Given the substantial no show rate among adolescents, the groups were intentionally overbooked. Obtaining funding for training and costs for snacks was an ongoing challenge. The program received contributions from various community organizations, and small grants were sought.

Regular planning time was essential for the administrative support staff to schedule groups, assign HCPs, write grants, and perform program evaluation. Nursing staff members took responsibility for setting up the room, providing handouts and snacks, and following up on no-shows. HCPs were busy managing traditional patients before and after groups, so a pre-group huddle was used to prepare co-leaders for the session.

The conversion to EHRs was an added challenge, particularly because laboratory test and ultrasound order entries and follow-ups became an HCP task rather than a nursing one. A laptop and Wi-Fi access were required to manage the EHR during the group sessions. The commitment of all staff to GPC and allocation of extra time were essential to successful transitioning to this system.

This GPC model encourages mutually beneficial relationships between pregnant adolescents and obstetric HCPs and provides opportunities for interdisciplinary collaboration.22,23  The authors’ program included a strong collaboration with the pediatric resident clinic, wherein GPC participants transitioned into well-child care groups that encouraged follow-up visits and immunizations. In addition, the authors had collaborative arrangements with the pediatric dental clinic and hospital social work department.

Conclusion

Given the developmental needs of adolescents, GPC provides a satisfying experience for both those who are pregnant and their HCPs.24   The authors modeled their program after CP principles for evidence-based care. 4-6,8,11 They created a supportive environment for prenatal care and helped adolescents learn the essentials about pregnancy, labor delivery, and postpartum and newborn care, with the goal of optimizing outcomes for both mother and child.

Joanne B. Stevens is Associate Professor at the University of Tampa, Department of Nursing, in Tampa, Florida. Elizabeth Cooper is Professor Emeritus in Obstetrics and Gynecology at the University of Rochester in Rochester, New York. Stasha Roberts is an alumna of the University of Tampa and an advanced registered nurse practitioner. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 7th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.

2. Thielen K. Exploring the group prenatal care model: a critical review of the literature. J Perinat Educ. 2012; 21(4):209-218.

3. Rising SS. Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery. 1998; 43(1):46-54.

4. Tanner-Smith EE, Steinka-Fry KT, Gesell SB. Comparative effective of group and individual prenatal care on gestational weight gain. Matern Child Health J. 2014; 18(7):1711-1720.

5. Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obset Gynecol.  2012;206(5):415.e1-7.

6. Kennedy HP, Farrell T, Paden R, et al. A randomized clinical trial o group prenatal care in two military settings. Mil Med. 2011;176(10):1169-1177.

7. Barr WB, Aslam S, Levin M. Evaluation of a group prenatal care-based curriculum in a family medicine residency. Fam Med. 2011;27(2):138-145.

8. Teate A, Leap N, Rising SS, Homer CS. Women’s experience of group antenatal care in Australia—the CenteringPregnancy Pilot Study. Midwifery. 2011;27(2):138-145.

9. Novick G, Sadler LS, Knafl KA, et al. The intersection of everyday life and group prenatal care for women in two urban clinics. J Health Care Poor Underserved. 2012;23(2):589-603

10. Gaudion A, Menka Y. ‘No decision about me without me’: centering pregnancy. Pract Midwife. 2010; 13(10):15-18.

11. Tandon SD, Colon L, Vega P, et al. Birth outcomes associated with receipt of group prenatal among low-income Hispanic Women. J Midwifery Womens Health. 2012;57(5):476-481.

12. Ickovics JR, Reed E, Magriples U, et al. Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled study. Psychol Health.2011;26(2):235-250.

13. Rising SS. Group prenatal care. UpToDate. Last updated April 29, 2015.

14.  Rising SS. Kennedy HpP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health. 2004;49(5):398-404.

15. Grady MA, Bloom, KC. Pregnancy  outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health. 2004;49(5):412-420.

16. Feldman JB. Best practice for adolescent prenatal care: application of an attachment theory perspective to enhance prenatal care and diminish birth risks. Child Adolesc Soc Work J. 2012;29(2):151-166.

17. Cypher RL. Collaborative approaches to prenatal care: strategies of successful adolescent programs. J Perinat Neonatal Nurse. 2013;27(2): 134-144.

18. Hale N, Picklesimer AH, Billings DL, Covington-Kolb S. The impact of Centering Pregnancy Prenatal Care on postpartum family planning. Am J Obstet Gynecol. 2014;210(1):50.e1-7.

19. Homer CS, Ryan C, Leap N, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2012;14(11): CD007622.

20. Novick G, Reid AE, Lewis J, et al. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol. 2013;209(2):112.e1-6.

21. Tanner-Smith EE, Steinka-Fry KT, Lipsey MW. Effects of CenteringPregnancy group prenatal care on breastfeeding outcomes. J Midwifery Womens Health. 2013;58(4):389-395.

22. Picklesimer A, Heberlein E, Covington-Kolb S. Group prenatal care: has its time come? Clin Obstet Gynceol. 2015;58 (2): 380-391.

23. Stevens J, Iida, H. Implementing an oral health program in a group prenatal practice. J Obstet Gynceol Neonat Nurs. 2007;26(6):244-249.

24. Ellison T. Group prenatal care: a pilot study evaluating patient satisfaction. Unpublished Honor’s Senior Thesis. Department of Nursing, The State University of NY at Brockport; 2010.

Web resource

A. npwomenshealthcare.com/?p=4641

Diagnosis and management of pelvic organ prolapse: The basics

Pelvic organ prolapse (POP) is a prevalent condition that can cause uncomfortable sensations of vaginal bulging, painful intercourse, and even stress urinary incontinence. This article presents a simple, evidence-based approach to diagnosing and managing POP that women’s healthcare providers can implement.

Pelvic organ prolapse (POP) is a common condition that occurs when one or more pelvic structures—the bladder, the urethra, the uterus, or the rectum—deviate from their normal anatomic position and bulge against the vaginal vault.Sometimes the prolapse is so severe that the affected area protrudes through the vaginal opening. The underlying cause of POP is a weakening of the pelvic floor muscles (PFMs) and fascia that support the pelvic organs.2

Risk factors

Loss of PFM tone may be caused by a variety of factors. One common risk factor for POP is multiple vaginal deliveries, particularly in those women who have experienced prolonged labor, instrumented delivery, and/or delivery of infants weighing more than 9 lb. In fact, women who have delivered vaginally, compared with those who have undergone cesarean section, have twice the risk of developing symptomatic POP.Women who have had pelvic floor trauma during childbirth or pelvic surgery such as hysterectomy are also at increased risk for POP.

Other risk factors for POP include conditions that increase intra-abdominal pressure such as chronic constipation, chronic cough, and work involving prolonged heavy lifting.3,4 Still other contributing factors are excess body weight, aging, menopause (related to loss of collagen), genetic predisposition, prolonged standing, and activities that involve jumping (e.g., trampoline use).5 Overweight and obesity are particularly strong risk factors: Studies have shown that the risk for symptomatic POP rises 3% with each unit increase of body mass index (BMI), and that women whose BMIs exceed 25 kg/m2, as compared with women whose BMIs are below 25, are twice as likely to develop POP.3,4 Health conditions that may disrupt pelvic neuromuscular function—and therefore increase the risk for developing POP—include multiple sclerosis, neuromuscular injuries related to childbearing, and spinal cord injury.5-7

Clinical picture

Many women with mild POP are asymptomatic. A woman with symptomatic POP may report feeling pressure or fullness in the pelvis, a pulling sensation in the groin or lower back, or vaginal bulging—all of which may ease up when she lies flat. She may describe a feeling that something is falling out of the vagina or even have a visible bulge from the vagina. Either way, she may experience vaginal pain or discomfort, particularly when having sex.4,6

Urinary symptoms of POP may include stress urinary incontinence (SUI), difficulty voiding, a sensation that one cannot empty the bladder completely, urinary frequency, urinary urgency, or nocturia. With some forms of POP, urinary symptoms are actually masked. Bowel symptoms of POP may include pain with defecation, fecal incontinence, or other types of defecatory dysfunction. A patient with a rectocele may report that she needs to press between the vagina and rectum to help her defecate.

The healthcare provider (HCP) must take a thorough history regarding these symptoms, as well as a detailed gynecologic, obstetric, sexual, and surgical history, to determine contributing factors. In addition, the HCP needs to identify chronic health conditions or situations that could be contributing to longer-than-average periods of elevated intra-abdominal pressure. These include chronic constipation and smoking or respiratory conditions that cause chronic cough.1,4 As part of the behavioral history, the HCP needs to ask about the patient’s exercise regimen (e.g., Does she lift weights? Does she do jumping jacks or use a trampoline?), whether the patient has gained weight recently, and whether the patient’s occupation may require her to perform heavy lifting or stand for long periods of time.

Physical examination

Because many patients have more than one type of prolapse, the HCP needs to examine each area of potential involvement within the vaginal vault separately. Performing each component of the pelvic exam with an individual focus results in greater accuracy of diagnosis.

Grading system

Various grading systems are available to determine the severity of POP based on physical examination. In this article, the authors use the Baden-Walker Halfway Scoring System, which assigns these gradations of severity:

• Grade 0: no prolapse;

• Grade 1: the lowest part of protrusion extends halfway to the hymen;

• Grade 2: the lowest part of protrusion extends to the hymen;

• Grade 3: the lowest part of protrusion extends halfway past the hymen; or

• Grade 4: the greatest degree of protrusion is observed.8, 9

The other commonly used grading system, albeit more complex than the Baden-Walker system, is the Pelvic Organ Prolapse Quantification (POP-Q) system.10

Inspection of external genitalia

Once the required equipment is assembled and available and the patient is placed in the lithotomy position, the exam begins with an inspection of the external genitalia.1,9,11 In a woman with normal findings, the vaginal introitus may be small or wide, depending on her sexual status, and hymenal remnants may be observed. Abnormal findings may include dry tissue, bruising, lesions, discharge,or prolapsed vaginal tissue. The introitus may gape open if vaginal vault/uterine prolapse is present. If prolapse is observed on inspection, the HCP should check for ulcerations. In severe POP, the prolapse may be observed on inspection even if the patient has not been asked to strain.

Speculum examination

During the speculum examination, the HCP inspects the vaginal mucosa for symmetry, atrophy, and any other abnormalities such as ulcerations or discharge that might explain the presence of symptoms.9 First, the speculum is placed into the vaginal vault and the cervix is inspected. Next, as the speculum is slowly removed, the vaginal mucosa is observed for any abnormalities such as abrasions or descent of the vaginal apex while the patient is asked to perform the Valsalva maneuver.The extent to which the cervix or the vaginal vault follows the speculum through and out of the vagina is noted.1

Next the HCP inserts the posterior blade of the speculum into the vagina, applying gentle pressure first to the posterior wall while asking the woman to perform the Valsalva maneuver to look for the extent of anterior compartment protrusion at the lowest point of the descent. The HCP then rotates the blade, applying gentle pressure to the anterior vaginal wall to determine if any prolapse is present in the posterior compartment and to what degree—based on the Baden-Walker system (Table).9,11

The patient may be concerned about leaking urine or stool when asked to bear down during these exams. The HCP should provide reassurance to her and equip the room with waterproof pads and hygiene products such as tissue or unscented, hypoallergenic moist cloths for cleaning as needed.

Bimanual examination

A bimanual exam is performed to evaluate the size and shape of the uterus and ovaries and to check for the presence of abdominal masses. The uterus should feel smooth and round and move slightly with manipulation. The ovaries, if palpable, should be no larger than the size of an almond. All organs should be non-tender on examination. The bimanual exam can help identify other pathologies that might be contributing to the chief complain of pelvic pressure and other reported symptoms.

During this exam component, the HCP can assess the adequacy of the patient’s vaginal muscle tone in supporting the pelvic organs by having her contract the PFMs. While performing this assessment, the HCP needs to determine whether voluntary or involuntary contractions are occurring, whether muscles remain in a contracted state, and whether the PFMs do not contract at all, even when the patient is asked to contract them.9

Examination while patient is standing

The inspection exam with Valsalva straining is repeated while the patient is standing. This exam provides the best estimation of the extent of prolapse as it relates to normal daily activities.9 Depending on the patient’s symptoms, the HCP may also perform a rectal exam with the patient standing to check for an enterocele as the cause of the symptoms.9 If the small bowel is involved, it will be palpable in the cul-de-sac.

Differential diagnoses

Differential diagnoses to consider when assessing a woman for POP include adnexal, uterine, and other genital tract masses that may cause symptoms similar to those of POP; and urinary tract infection (UTI).9 If the patient has urinary symptoms, a urinalysis is done to evaluate for UTI.9

Treatment

Treatment for POP is based on severity of the prolapse and the patient’s preferences, health, and symptoms. Conservative options, though associated with few adverse effects and cost-effective, tend to work only for milder forms of POP and require a high level of commitment from the patient. Examples of conservative options are behavior modification (e.g., weight-loss diet, smoking cessation), PFM strengthening, and pessaries.9,12 Goals of conservative therapy are to improve symptoms, reduce POP progression, and delay or avoid surgery.

Pelvic floor muscle strengthening

If POP is grade 2 or lower, PFM strengthening, including Kegel exercises, can improve symptoms of pelvic pain, vaginal pressure or bulging, and SUI.12,13 Evidence regarding the efficacy of PFM strengthening in improving POP symptoms and degree is limited, but recent studies have shown significant improvement with this approach.13,14 For a patient who wants to learn to perform Kegel exercises, she should start slowly and increase gradually, with the goal of performing 10 contractions held for 10 seconds each, 2-3 times daily.12,15

Pessary

The pessary, a flexible plastic or medical-grade silicone device that comes in a variety of sizes and shapes, can be used to treat any grade of POP.1 It is inserted into the vaginal vault to support weakened PFMs and prevent bulging. The pessary is a good choice for a woman with bothersome POP symptoms who is not a candidate for or does not desire surgery. The pessary may be used for temporary symptomatic relief while awaiting surgery. Potential adverse effects of the pessary include changes in voiding patterns, vaginal irritation, and vaginal ulcers or excoriations.12 Pessary use is avoided if a woman has a large vaginal outlet or a short vagina, and it may be challenging if a woman cannot insert or withdraw the device on her own.15 A woman may receive assistance from a home health nurse or return to the office at regular intervals to have the device removed, cleaned, and replaced, although the frequency with which she needs to return for pessary followup or periodic cleaning has not been established.12

Surgery

Surgery is an option for a woman whose symptoms are adversely affecting her quality of life. Several different surgical procedures are available. Colporrhaphy is done to repair the anterior or posterior vaginal wall in a woman with cystocele or rectocele. The affected organ (i.e., the bladder or rectum) is moved back into normal position and the affected vaginal wall is tightened to better support the organ. Surgical implantation of transvaginal mesh for correcting POP has become more common because of the higher rates of success compared with traditional colporrhaphy.16 However, postoperative complications (e.g., mesh erosion, operative site pain, painful urination) may arise, and longterm efficacy of the treatment has not been established.16-19

Patient counseling

If conservative management is desired and the grade of POP is 2 or lower, HCPs should counsel patients with regard to performing Kegel exercises and on behavior modification strategies, which include weight loss; smoking cessation; and avoidance of straining with bowel movements, prolonged standing, lifting, and exercise involving jumping. Patients need to know that conservative measures can be quite helpful in reducing POP progression. Patients also need to understand the risks of surgery, which include incontinence and erosion or contraction of the mesh.17

Referral

Need for referral depends on the plan for POP management and the HCP’s skills in diagnosing and managing the condition. If POP is only mildly bothersome, the HCP may choose to begin PFM strengthening and fit the patient with a pessary.13 Referral to a specialist is made if the diagnosis is uncertain or if surgical evaluation is desired. In addition, patients may be referred to a pelvic floor physical therapist for intense and focused assistance with PFM strengthening to relieve symptoms.

Conclusion

Pelvic organ prolapse can be an embarrassing, bothersome problem for women. HCPs need to know the risk factors and symptoms associated with POP, how to evaluate for the condition on physical exam,and the various treatment options that are available. Treatment choice is based on symptom severity and patient preference. Referral to a specialist is recommended when factors related to evaluation and treatment begin to exceed an HCP’s scope of practice.

Brittany S. Nutt is a DNP graduate of Texas Woman’s University in Dallas and a Women’s Health Nurse Practitioner in the United States Air Force. Susan Chaney is Master of Science Program Coordinator and Professor and Catherine Hill is Clinical Faculty, both at Texas Woman’s University in Dallas. Catherine Hill is also Managing Partner of Texas Nurse Practitioner Associates, LLP, in Dallas. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Physician. 2010;81(9):1111-1117.

2. American College of Obstetricians and Gynecologists. Frequently Asked Questions: Gynecologic Problems. FAQ012. Pelvic Support Problems. May 2011.

3. Gyhagen M, Bullarbo M, Neilsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in a singleton primiparae after vaginal or caesarean delivery. BJOG. 2013;120(2):152-160.

4. Rogers RG, Fashokun TB. An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapseUpToDate. Last updated February 19, 2015.

5. Lukanovic A, Drazic K. Risk factors for vaginal prolapse after hysterectomy. Int J Gynaecol Obstet2010;110(1):27-30.

6. Handa VL. Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirthUpToDate. Last updated May 27, 2015.

7. Mahajan ST, James R, Frasure H. Pelvic floor disorders and multiple sclerosis: are patients satisfied with their care? Int J MS Care. 2014;16(1):20-25.

8. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. 2007;110(3):717-729.

9. Fashokun TB, Rogers RG. Pelvic organ prolapse in women: diagnostic evaluationUpToDate. Last updated June 15, 2015.

10. Persu C, Chapple CR, Cauni V, et al. Pelvic Organ Prolapse Quantification System (POP-Q) – a new era in pelvic prolapse staging. J Med Life. 2011;4(1):75-81.

11. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination. Fifth Edition. St. Louis, MO: Mosby; 2003.

12. Hagen S, Thakar R. Conservative management of pelvic organ prolapse. Obstet Gynaecol Reprod Med2012;22(5):118-122.

13. Braekken IH, Majida M, Engh ME, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010;203(2):170.e1-7.

14. Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomized controlled trial. Lancet, 2013;383(9919):796-806.

15. Choi KH, Hong JY. Management of pelvic organ prolapse. Korean J Urol. 2014;55(11):693-702.

16. Turgal M, Sivaslioglu A, Yildiz A, Dolen I. Anatomical and functional assessment of anterior colporrhaphy versus polypropylene mesh surgery in cystocele treatment. Eur J Obstet Gynaecol Reprod Biol. 2013;170(2):555-558.

17. Dietz HP, Hankins KJ, Wong V. The natural history of cystocele recurrence. Int Urogynecol J. 2014;25(8): 1053-1057.

18. Walter JE; Urogynaecology Committee, Lovatsis D, et al; Society of Obstetricians and Gynaecologists of Canada. Transvaginal mesh procedures for pelvic organ prolapse. J Obstet Gynaecol Can. 2011;33(2):168-174.

19. Altman D, Vayrynen T, Axelsen S, Falconer C; Nordic Transvaginal Mesh Group. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med. 2013;364(19): 1826-1836.

Using simulation to practice and perfect gynecologic procedure skills

Minimally invasive office gynecology procedures such as endocervical polypectomy and endometrial biopsy are routinely performed by women’s health nurse practitioners (WHNPs). To ensure patient safety and comfort and to avoid complications, the WHNP must have knowledge of indications and contraindications, as well as skills needed to perform each of these procedurecompetently and efficiently. WHNP programs provide didactic and clinical instruction for these skills, often in a supervised clinical simulation format. However, the fast-paced clinical setting does not necessarily provide novice WHNPs or WHNP students with an environment conducive to feeling confident when they first perform these office gynecology procedures on their own.1

Simulation learning is a valuable strategy for acquiring skill and confidence in performing clinical procedures. The Institute of Medicine report, To Err is Human: Building a Safer Health System, recommends simulation learning as a means to help prevent errors in the clinical setting.2 Simulation learning provides a controlled, risk-free environment for learners that allows time for adequate practice to acquire skills and confidence.

The purpose of this article is to provide examples of simulation modules that can be used to review and practice the required steps previously learned to promote confidence prior to performing endocervical polypectomy or endometrial biopsy on a patient. The materials used in these simulation modules are readily available outside the clinical learning lab. Novice WHNPs who have not yet performed endocervical polypectomy or endometrial biopsy in clinical practice, WHNPstudents, and even instructors and preceptors for WHNP students, may find these simulation modules helpful. The photographs in this article are screen shots from the simulation modules.

Endocervical polypectomy

Case study presentation

A G4 P2204, 29-year-old female presents to the clinic with this complaint: “I’ve been spotting after sex for the past 2 months.” She denies vaginal discharge or odor. Her last menstrual period occurred 1 week ago and was described as heavy without visible clots. She is married and sexually active with one partner. The vaginal ring is used for contraception. The WHNP performs a speculum examination, which shows a thin, 2-cm-long, red, pedunculated growth protruding from the cervical os. Given the patient’s presenting complaint and physical exam findings, the WHNP thinks that a pathology report will confirm a diagnosis of endocervical polyp.

Indications for procedure

The purpose of an endocervical polypectomy is to remove the pedunculated growth from the cervix and rule out malignancy of the tissue. Although fewer than 5% of all endocervical polyps are malignant, all of them should undergo biopsy.3 Removal is indicated to stop intermittent spotting and bleeding symptoms related to the polyp.4

Diagnosis

The diagnosis in this case is endocervical polyp. The ICD-10 code for endocervical polyp is N84.1. The current procedural terminology (CPT) code for an endocervical polypectomy is 58999.

Procedure directions

Prior to the procedure, the WHNP reviews risks and benefits with the patient and obtains her signature on the consent form. The WHNP confirms any allergies with the patient, especially those related to solutions that may be used to cleanse the cervix. A urine pregnancy test is obtained if the patient is sexually active and premenopausal. Endocervical polypectomy is contraindicated during pregnancy because increased blood flow to the cervix may result in substantial bleeding. The WHNP assists the patient in reclining in the dorsal lithotomy position on the exam table, with both feet placed in the stirrups, provides appropriate draping, and confirms her comfort.

After washing the hands and applying clean gloves, the WHNP inserts an appropriate-size speculum into the vagina and visualizes the cervix with the polyp protruding from the endocervical canal (Photograph 1). A benign endocervical polyp is thin, red, and smooth in appearance.5 Caution to proceed is exercised if the endocervical mass appears thick. Cervical cancer, an endometrial polyp, and uterine fibroids may resemble an endocervical polyp.5

The WHNP cleans the cervix with povidone iodine or other appropriate antiseptic solution. The WHNP then inserts a small sterile cotton swab just inside the endocervical canal and moves it in a clockwise direction completely around the inside of the canal to confirm the location of the polyp base. If the WHNP cannot locate the polyp base or freely move the swab in the cervical canal, the procedure is halted and the patient is referred to a gynecologist for further evaluation of the endocervix and endometrial cavity with a hysteroscope.

Otherwise, the next step is to securely close a ring forceps around the endocervical polyp as close to the base as possible and twist the polyp in a clockwise direction, applying gentle tension. The WHNP continues twisting the polyp until the base is no longer attached to the cervix. The specimen is then placed in a container of liquid formalin (Photograph 2). If bleeding is observed at the site, the WHNP applies pressure using a large cotton swab. If necessary, a silver nitrate stick or Monsel’s solution can be applied to manage bleeding. The speculum is then gently removed, and the patient is slowly assisted into an upright sitting position, with her stability assessed.

The WHNP confirms that the patient’s identification information is on the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form always includes the patient’s name, second patient identifier, date and time of collection, specimen source, diagnosis, and practitioner’s name.

Post-procedure patient education

The WHNP informs the patient that vaginal spotting/bleeding is not uncommon a few hours after the procedure. A peri-pad is offered to the patient, who is advised to avoid placing anything into the vagina for a few days post-procedure. The patient is asked to notify the WHNP if any of these situations occur: pelvic pain not relieved with a non-steroidal anti-inflammatory drug (NSAID), malodorous vaginal discharge, continuous bright red vaginal bleeding, or fever.6

Description of the simulation 

Supplies (Table 1) may be purchased from a medical supplier, a craft store, a grocery store, or an online store. Most supplies are disposable, but some are reusable. Simulation learning is a cost-effective way to practice procedures. This endocervical polypectomy

simulation can be performed at a cost of about $6.

Step-by-step simulation assembly and video link

Cut off a 5-cm piece of red chenille pipe cleaner. Insert the pipe cleaner into the center of a hot dog, leaving approximately 2-3 cm of it on the outside of the hot dog. Readers can access a video link for the endocervical polypectomy simulation.  This video is the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Endometrial biopsy

Case study presentation

A 55-year-old menopausal patient presents to the clinic with this complaint: “My period has come back on. I’ve been spotting and bleeding from my vagina intermittently for the past 3 months.” The woman’s last menstrual period took place when she was 52 years old. The patient, a widow, has not had sexual intercourse in the past 2 years.

Indications for procedure

The purpose of an endometrial biopsy is to rule out endometrial cancer. Based on the American Congress of Obstetricians and Gynecologists’ Committee Opinion Number 557, an endometrial biopsy should be performed for  women older than 45 years as a first-line screen for abnormal uterine bleeding (AUB).7 Another indication for an endometrial biopsy is exposure to unopposed estrogen in a woman younger than 45 who experiences persistent AUB after failed medical management.7

Diagnosis

The diagnosis in this case is postmenopausal bleeding. The ICD-10 code for postmenopausal bleeding is N95.0. The CPT code for an endometrial biopsy without cervical dilation is 58100.

Procedure directions

Prior to the procedure, the WHNP reviews risks and benefits with the patient and obtains her signature on the consent form. The WHNP confirms any allergies with the patient, especially those related to solutions that may be used to cleanse the cervix. A urine pregnancy test is obtained if the patient is sexually active and premenopausal. Endometrial biopsy is contraindicated during pregnancy. The WHNP assists the patient in reclining in the dorsal lithotomy position on the exam table, with both feet placed in the stirrups, provides appropriate draping, and confirms her comfort.

After washing the hands and applying clean gloves, the WHNP performs a bimanual exam to determine the position of the uterus and cervix and the presence of any tenderness or masses in the pelvis. The WHNP inserts an appropriate-size speculum into the vagina to visualize the cervix, which is then cleaned with povidone iodine or other appropriate antiseptic solution (Photograph 3). After confirming patency of the cervical os and measuring the depth of the uterus with a uterine sound (i.e., sounding the uterus), the WHNP obtains a sterile endometrial pipelle and inserts it into the cervix and uterus.

Difficulty inserting the pipelle may be due to a natural curvature in the cervix or uterus. Depending on this curvature, the WHNP may need to use a sterile method to slightly bend the tip of the pipelle in order for it to slide completely into the uterine cavity. The WHNP may need to apply an instrument, such as a tenaculum, a ring forceps, or a long hemostat to the cervix to help straighten the natural curvature of the cervix and uterus, ensuring that the patient is prepared for the use of an additional instrument (Photograph 4).

Once the pipelle is inserted to the top of the uterine fundus, the WHNP pulls back rapidly on the piston as far as it will go to create suction. The WHNP passes the pipelle in and out between the fundus and internal cervical os 3 or 4 times while continuously turning it a full 360°, rolling it between the thumb and index finger. Endometrial tissue will begin to collect inside the pipelle. Once an acceptable amount of tissue is visualized, the pipelle is removed from the uterus. The WHNP carefully expels the tissue from the pipelle by pushing the piston forward into a plastic container of formalin, and confirms that a sufficient amount of tissue has been collected (Photograph 5). The vaginal speculum is then gently removed. The patient is slowly assisted to an upright sitting position and her stability is assessed.

The WHNP confirms that the patient’s identification information is on the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form always includes the patient’s name, second patient identifier, date and time of collection, specimen source, diagnosis, and practitioner’s name.

Post-procedure patient education

The WHNP informs the patient about the most common symptoms experienced with an endometrial biopsy, which include pelvic pain, vaginal bleeding, and fainting.8 The patient is advised to notify the WHNP if she experiences

uterine cramping lasting longer than 48 hours or not resolved with an NSAID, malodorous vaginal discharge, heavy vaginal bleeding, or fever.6

Description of the simulation 

Supplies (Table 2) may be purchased from a medical supplier, a craft store, a grocery store, or an online store. Most supplies are disposable, but some are reusable. Simulation learning is a cost effective way to practice procedures. This simulation endometrial biopsy can be performed at a cost of about $5. Readers can access a video link of the endometrial biopsy simulation. This video is the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Conclusion

Women’s health nurse practitioners are important performers of minimally invasive gynecology procedures such as endocervical poly pectomy and endometrial biopsy. However, the fast-paced clinical setting may not provide the novice WHNP or WHNP student with an environment conducive to mastering newly learned skills. Simulation learning has educational and clinical benefits to enhance practice.9 In a controlled, simulated environment, individuals can focus on achieving competency, efficiency, and confidence when performing these procedures.9, 10

Aimee Chism Holland is Assistant Professor at the University of Alabama at Birmingham School of Nursing. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.  The author heartily thanks Mr. James Clark, Instructional Design Specialist at the UAB School of Nursing, for recording these procedures for her.

References

1. Nakajima AK, Posner GD. Human Simulation for Women’s Health. New York, NY: Springer Publishing Company; 2012.

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in American, Institute of Medicine; 2000.

3. Beckmann C, Ling F, Herbert W, et al. Obstetrics and Gynecology. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.

4. Stewart EA. Endometrial polypsUpToDate. October 21, 2013.

5. Hoffman BH, Schorge J, Schaffer J, et al. Williams Gynecology. 2nd ed. New York, NY: McGraw Hill; 2012.

6. Sulik S, Heath C. Primary Care Procedures In Women’s Health. New York, NY: Springer Publishing Company; 2010.

7. American Congress of Obstetricians and Gynecologists. ACOG committee opinion no. 557. Management of acute abnormal uterine bleeding in non-pregnant reproductive aged women. Obstet Gynecol. 2013;121(4): 891-896.

8. Blumenthal PD, Berek JS. A Practical Guide to Office Gynecologic Procedures. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.

9. Cooper S, Cant R, Porter J, et al. Simulation based learning in midwifery education: a systematic review. Women Birth. 2012;25(2):64-78.

10. Nitschmann C, Bartz D, Johnson NR. Gynecologic simulation training increases medical student confidence and interest in women’s health. Teach Learn Med. 2014;26(2):160-163.