OBGYN&Tutorial&Notes&

Palpation)of)a)Pregnant)Abdomen:&
Instructions:&
&
1.&Have&each&student&perform&a&focused&physical&examination&including&inspection,&SFH&
measurement,&and&palpation&with&Leopold’s&maneuvers&and&auscultation&with&the&
Pinnard&stethoscope.&&
&
2.&Have&each&student&practice&presenting&their&findings&after&the&examination&is&
complete.&&
Eg.&Ms.&X&is&a&36&year&old&nulliparous&lady&who&is&at&38&weeks&gestation.&On&inspection&
the&abdomen&is&distended&consistent&with&pregnancy.&There&is&a&visible&linea&nigra,&no&
striae&or&bruising.&The&symphisofundal&height&is&38cm&and&is&consistent&with&gestation.&
On&palpation,&there&is&a&single&palpable&fetus,&longitudinal&lie,&cephalic&presentation&with&
the&back&to&the&maternal&right.&Liquor&volume&is&adequate.&The&fetal&HR&is&140bpm.&&
&
3.&Ask&any&of&the&following&questions:&
• What&is&the&purpose&of&lateral&palpation&
o Determines&the&lie&of&the&fetus&and&subjective&assessment&of&amniotic&fluid.&&
• What&is&the&definition&of&lie&
o Relationship&of&the&longitudinal&axis&of&the&fetus&with&respect&to&the&
longitudinal&axis&of&the&mother.&&
• Why&is&lie&important?&What&is&unstable&lie?&
o Lie&should&be&stable&by&38&weeks;&otherwise&you&would&be&concerned&
about&the&possibility&of&a&cord&prolapse.&&
o Unstable&lie&is&when&the&fetal&lie&changes&after&38&weeks&
• What&is&the&definition&of&engagement&
o Engagement&is&when&the&widest&part&of&the&fetal&head&(the&biparietal&
diameter)&has&passed&through&the&narrowest&part&of&the&maternal&pelvis&
(the&pelvic&inlet).&Clinically,&this&is&defined&as&when&2/5ths&of&the&head&is&
still&palpable&in&the&abdomen&or&when&the&head&is&at&station&0&(at&the&level&
of&the&ischial&spines)&in&a&vaginal&exam.&&
o This&is&important&because&if&engagement&has&occurred,&it&is&less&likely&that&
cephalopelvic&disproportion&will&be&encountered.&&
• What&is&the&purpose&of&measuring&the&abdomen?&What&are&the&normal&findings?&
o Measuring&the&abdomen&determines&the&symphyseal&fundal&height.&This&
measurement&should&be&done&in&cm.&it&should&equal&the&number&of&weeks&
gestation&+/b2cm&
• At&how&many&weeks&gestation&is&the&uterus&palpable&at…&
o Umbilicus&=&20&weeks&
o Xyphoid&sternum&=&36&weeks&
o Between&the&umbilicus&and&the&xyphoid&=&28&weeks&
• Where&do&you&listed&wit&the&pinnard?&What&are&you&listening&for?&
o Listening&over&the&fetal&back,&over&the&anterior&shoulder&
o Listening&for&fetal&heart&
• What&is&the&normal&heart&rate&
o 110b160&bpm&
&
&
&

& 1&
OBGYN&Tutorial&Notes&

Pelvic)Examination:)
)
Have&each&student&perform&a&pelvic&examination,&including&inspection,&speculum&and&
bimanual&exam&(have&students&describe&what&they&are&doing)&
&
Inspection&
• Scars&(vulval/perineal),&lumps/masses,&skin&changes&(atrophy,&condylomata,&
lichen&sclerosis)&PV&discharge/bleeding&
• Commenting&on&hair&distribution&is&ONLY&appropriate&if&relevant&to&HPC&and&
since&vaginal&examinations&aren’t&in&long&cases,&it&is&usually&unnecessary&to&
comment&and&may&lead&to&unpleasant&questioning&
Speculum&Exam&
• Prepare&by&washing&hands/put&on&gloves&and&unscrew&cap&for&thin&prep&jar&
• Using&the&left&hand,&separate&the&labia&to&visualize&introitus&
• Insert&the&speculum,&pressing&down&and&backwards&to&minimize&discomfort,&
handle&starts&off&to&one&side&(avoid&urethra),&rotate&handle&upwards&then&
separate&blades&of&speculum&to&visualize&the&cervix&
o Comment&on&cervical&os,&polyps,&ectropion&etc&
• Using&cytobrush,&take&sample&from&endocervix&by&placing&centre&of&brush&in&the&
os&and&turn&it&5b8&times&
• Dip&brush&into&thin&prep&jar&and&swish&around&to&ensure&adequate&sample&
• Slowly&withdraw&the&speculum,&closing&the&blades&slightly&for&comfort,&and&look&
at&the&vaginal&walls&–&comment&on&any&atrophy,&ulceration,&pigmented&lesions&if&
present&
Bimanual&Examination&
• Using&the&left&hand,&separate&the&labia&
• Insert&the&index&finger&and&middle&finger&of&the&right&hand&into&the&vagina,&feeling&
cervix.&Comment&on&consistency,&palpable&lesions&
• Using&the&left&hand&suprapubically,&ballot&the&uterus&and&comment&on&position,&
size,&mobility,&consistency&and&tenderness&(Normally&anteverted,&anteflexed,&
smooth,&nonbtender)&
• Repeat&maneuver&for&both&adenexae&feeling&for&masses&or&tenderness&
&
Ask&any&of&the&following&questions&
• Why&is&the&speculum&examination&and&smear&done&before&the&vaginal&exam?&
o To&get&an&accurate&smear&
• What&is&being&assessed&visually&on&speculum&examination?&
o Vaginal&wall&atrophy,&cervical&os,&any&lesions&
• What&is&the&purpose&of&performing&a&cervical&smear?&What&virus&are&you&worried&
about?&&
o Cervical&cancer&screening&
o HPV&(6&and&11&for&condylomata;&16&and&18&for&Cervical&Ca)&
• What&findings&would&you&expect&on&bimanual&examination&in&endometriosis?&
o Fixed&frozen&pelvis&with&a&retroverted&retroflexed&uterus,&and&cervical&
motion&tenderness&
)
Have&each&student&practice&summarizing&their&examination&findings&

& 2&
OBGYN&Tutorial&Notes&

• Eg:&on&inspection&the&vulva&appears&normal&with&no&visible&condylomata,&scars&or&
skin&changes.&Speculum&examination&revealed&a&normal&cervix&with&no&visible&
lesions.&On&bimanual&examination,&the&uterus&was&anteverted,&anteflexed,&mobile&
and&smooth&in&consistency.&There&were&no&palpable&uterine&or&adnexal&masses.&&
& &

& 3&
OBGYN&Tutorial&Notes&

Contraception)
&
This&station&will&be&a&Q&and&A&session&about&different&&methods&of&contraception,&their&
mechanisms&or&action&and&some&important&indications,&side&effects&or&contradications.&
Hand&samples&to&the&students&and&ask&the&following&relevant&questions.&&
&
Condom:&
Type&of&Contraception?&How&effective&is&it?&
Barrier&method&97%&effective&(99%&if&used&properly)&&
What&other&benefits&besides&contraception?&
Protection&against&STIs&–&Will&not&protect&against&syphilis,&HSV&and&pubic&
lice&
&
Diaphragm:&
& What&type&of&contraception?&&
Barrier&method&
How&does&it&work?&&
It&sits&across&the&cervix,&and&prevents&sperm&from&entering.&Can&be&used&
with&spermicidal&gel.&&
&
Combined&Oral&Contraceptive&Pill:&
What&type&of&contraception&is&this?&How&effective?&&
Hormonal&contraception,&containing&both&estrogen&and&a&progestin,&
approx.&99%&effective&(when&taken&properly)&–&must&be&taken&at&
approximately&the&same&time&each&day,&with&a&12&hour&window&for&
remembering&missed&pills&before&requiring&secondary&contraception&use.&&
What&is&its&mechanism&of&action?&& &
& Estrogen:&suppresses&ovulation&
Progestin:&thickening&cervical&mucus,&inhibit&implantation&(thinning&
endometrium&lining),&inhibit&ovum&transport&in&fallopian&tube&
What&are&the&nonbcontraceptive&benefits?&
Reduces&menorrhagia,&dysmenorrhea,&incidence&of&PID,&ovarian&cysts,&
endometriosis&
What&are&the&possible&side&effects?&
Nausea,&dizziness,&breast&tenderness,&vaginal&tenderness,&acne,&
depression,&loss&of&libido,&VTE&(!!)&
& What&are&the&contraindications&for&use&
Over&35&years&old,&smoker,&previous&VTE,&migrane&with&focal&neurological&
deficit,&estrogen&dependent&malignancy,&HTN,&impaired&liver&function,&
recent&trophoblastic&disease&(must&wait&6mo&after&betabHCG&is&
normalized),&undiagnosed&abnormal&vaginal&bleeding,&CVA,&coronary&
disease&
What&needs&to&be&regularly&monitored?&
& & Blood&pressure&
Progesterone&only&pill:&
& What&type&of&contraception?&
& & Hormonal&method,&containing&only&progesterone&
& What&type&of&patients&is&this&method&indicated&in?&
& & Patients&in&which&COCP&is&contraindicated,&breast&feeding&mothers&

& 4&
OBGYN&Tutorial&Notes&

& What&is&its&mechanism&of&action&
Thickens&cervical&mucus,&thinning&of&the&endometrium,&inhibiting&ovum&
transportation&in&fallopian&tube.&Suppressing&ovulation&is&inconsistent.&&
What&is&important&to&counsel&patients&about&with&regards&to&taking&this&method?&
There&is&no&pillbfree&interval,&take&continuously&or&have&pill&free&break&
every&3&months&for&menstruation.&This&pill&must&be&taken&within&3&hours&at&
the&same&time&each&day.&If&it&is&taken&beyond&the&3&hour&mark,&the&patient&
should&consider&it&to&be&a&“missed&pill”,&and&should&use&a&backbup&method&
for&the&following&week.&Can&cause&menstrual&irregularities.& &
&
Depobprovera:&
What&type&of&contraception&is&this?&
Injectable&progesteroneb&only&
How&often&is&it&administered?&
An&intramuscular&injection&given&every&3&months&
What&are&the&sidebeffects?&
Irregular&bleeding,&amenorrhea,&weight&gain,&decreased&bone&density&with&
long&term&use&
What&is&important&to&counsel&the&patient&about&
There&may&be&a&delayed&return&to&fertility&after&cessation&
&
Nuva&ring:&
& What&type&of&contraception?&
& & Combined&estrogen&and&progestogen&vaginal&ring&
& How&is&this&method&used&
Inserted&into&the&vagina,&worn&continuously&for&3&weeks,&removed&for&1&
week&
&
Implanon&
& What&type&of&contraception&is&this?&&
Hormonal&method,&implantable,&progesterone&only&
& How&is&this&method&used?&
& & Subdermal&implant&into&the&nonbdominant&arm&
& How&long&is&it&effective&for?&
The&implanon&can&remain&insitu&and&be&effective&as&contraception&for&3&
years&
&
Mirena&
& What&type&of&contraception&is&this?&
& & Hormonal&method,&progesterone&only,&intrauterine&contraceptive&device&
& How&long&is&it&effective&for&
& & 5&years&
& What&is&its&mechanism&of&action?&
Thickens&cervical&mucus,&thins&endometrium,&local&inflammatory&reaction,&
physical&barrier&
& What&are&its&nonbcontraceptive&benefits?&
& & Reduced&menorrhagia&
& What&are&the&absolute&contraindications&against&its&use?&
& & None&

& 5&
OBGYN&Tutorial&Notes&

&
Copper&IUD&
& What&type&of&contraception&is&this?&
& & Intrabuterine&device,&nonbhormonal&
& What&is&its&mechanism&of&action?&
& & Copper&has&toxic&effect&on&sperm&and&ova&
& How&long&is&it&effective&for?&
& & 10&years&
& Can&the&copper&IUD&be&used&as&emergency&contraception?&
& & Yes,&if&inserted&with&in&5&days&of&unproteted&intercourse&
& What&are&the&side&effects?&
& & Increased&menstrual&flow&
&
Sterilization&(tubal&ligation/vasectomy)&
& What&type&of&contraception&is&this?&
Permanent&method&of&sterilization&(1&in&200&chance&of&accidental&
pregnancy)&
& & Patietns&should&be&counseled&as&it&is&irreversible&
&
Emergency&Contraception&
& What&is&emergency&contraception?&
& & Hormonal&contraception&(levonorgestrelb&progesterone)&
& & Should&be&used&with&in&72&hours&of&unprotected&intercourse.&
& Also&can&consider&copper&IUD&
Note:&need&pregnancy&test&,&STI&screen&and&assessment&for&need&for&ongoing&
contraception&at&this&point.&"Quick&start"&contraception&refers&details&at&which&
point&each&type&of&longbterm&hormonal&contraception&can&be&commenced.&
&
) )

& 6&
OBGYN&Tutorial&Notes&

Miscarriage)Counseling)
&
Show&prompt&to&group.&You&should&act&as&the&patient.&Be&surprised,&insistent&that&there&
was&a&mistake&and&demand&another&ultrasound.&Ask&if&this&was&your&fault,&did&you&do&
something&to&cause&this.&Ask&what&this&means&for&future&pregnancies.&
&
Prompt:&
You&are&called&to&the&Early&Pregnancy&Assessment&Unit&to&speak&to&a&patient&regarding&
her&ultrasound&report.&The&report&is&below.&Please&counsel&the&patient&appropriately.&&
&
Ultrasound:&
LMPb&10&weeks&ago&
Ultrasound&shows&a&fetus&consistent&with&9&weeks&gestation.&&
No&fetal&cardiac&activity&is&detected.&
&
Signed:&Dr.&A.&Alloy,&Consultant&Radiologist&
&
Points&that&must&be&covered&by&the&student.&Prompt&if&necessary.&&
• Gently&break&the&news&to&the&patient&that&the&ultrasound&shows&no&cardiac&
activity&
• Explain&to&patient&that&this&means&she&has&had&a&miscarriage&
• Ask&if&she&has&had&any&symptoms&of&pain&or&bleeding.&&
• Explain&that&this&could&occur&in&10b20%&of&pregnancies.&&
• Discuss&management&at&this&point&
o Expectant&management&
! Spontaneous&completion,&repeat&ultrasound&scan&in&10b14&days&to&
ensure&complete.&
o Medical&management&
! Mifepristone&(antiprogestrone)&+/b&misoprostol&(prostaglandin&
analogue&induces&contraception&to&expel&RPOC).&Follow&betabHCG&
as&above.&
! Expectant&and&medical&management&only&if&patient&is&
hemodynamically&stable&and&has&24&hour&access&to&phone&advice&
and&emergency&admission&if&required&
o Surgical&management&
! ERPC&under&general&anesthetic&with&suction&curettage&
! Indications:&patient&preference,&heavy&PV&bleeding,&hemodynamic&
instability,&suspected&general&trophoblastic&disease,&evidence&of&
sepsis&
• Risk&factors&–&discuss&if&asked,&or&at&a&later&consultation,&may&not&be&appropriate&
for&initial&consultation&
o More&common:&
! genetically&abnormal&fetus/aneuploidy&
o Less&common:&
! Advanced&maternal&age,&alcohol&use,&chronic&maternal&illness,&
cigarettes,&cocaine,&IUD&
• Discuss&chance&of&recurrence&

& 7&
OBGYN&Tutorial&Notes&

o Same&risk&for&subsequent&miscarriage.&Risk&increases&if&three&successive&
miscarriages&and&may&require&investigation&for&a&cause&(eg&anti&PL&
syndrome)&
&
Tips&for&this&station/breaking&bad&news:&
• Be&empathetic&–&you&score&points&for&this&in&osce&exams&
• Allow&time&for&information&to&skin&in,&short&silences&are&fine&
• Allow&the&patient&to&ask&questions&
&
&
) )

& 8&
OBGYN&Tutorial&Notes&

PROLAPSE))
Definition:&prolapse&is&a&protrusion&of&an&organ&or&structure&beyond&its&normal&confines.&
Think&prolapse&=&protrusion!&
&
Classification:&based&on&the&location&of&the&prolapse&but&also&the&organ&contained&within&
it.&(ones&listed&in&bold&are&most&important)&
1. Urethrocele&–&when&the&urethra&bulges&into&the&lower&part&of&the&anterior&vaginal&
wall.&It&is&common&for&urethrocele&to&occur&with&a&cystocele.&
2. Cystocele&–&prolapse&of&bladder&into&the&anterior&vaginal&wall&forming&a&bulge.&
3. Uterine&–&3&degrees&of&increasing&severity&&
a. 1st&degree&=&slight&descent&of&the&uterus&i.e.&prolapse&of&the&cervix&into&the&
vagina&
b. 2nd&degree&=&cervix&protrudes&from&the&introitus&(vaginal&opening)&
c. 3rd&degree&=&complete&procidentia&i.e.&entire&uterus&outside&the&vagina&
4. Rectocele&–&prolapse&of&the&rectum&forming&a&bulge&in&the&middle&of&the&posterior&
vaginal&wall.&
5. Enterocele&–&prolapse&of&the&pouch&of&Douglas,&usually&containing&small&bowel.&
The&pouch&of&Douglas&is&located&just&posterior&to&the&posterior&vaginal&fornix.&
6. Vaginal&vault&prolapse&–&occurs&in&about&25%&women&postbhysterectomy.&&
&
Symptoms:&
• ‘Dragging&discomfort’&(not&commonly&pain)&
• Feeling&of&‘something&coming&down’&–&ask&if&she&needs&to&push&the&mass&back&up&
before&urinating/passing&bowel&motion&
• Backache&
• Urinary&symptoms&–&especially&with&cystocele&or&urethrocele.&&
o Prolapse)is)associated)with)but)not)a)cause)of)stress)incontinence)
o Frequency,&urgency,&nocturia&
o Haematuria,&dysuria&
o Incomplete&emptying&
• Bowel&symptoms&–&most&commonly&constipation&with&rectocele&
• Bleeding&–&caused&by&excoriation&on&clothes&if&coming&out&of&vaginal&introitus&
• Coital&difficulties&
&
Signs:&will&not&be&asked&to&perform&examination&but&still&need&to&know&what&you&would&
be&looking&for.&Examine&patient&in&the&left&lateral&position&using&a&Sims&speculum&
• Be&able&to&describe&how&to&demonstrate&a&prolapse&and&stress&incontinence&&
• Be&able&to&recognise&a&procidentia&
• Be&able&to&comment&of&presence&of&ulceration&(from&excoriation),&vaginal&atrophy&
(from&oestrogen&deficiency)&
&
Aetiology&of&Prolapse&–&must&ask&about&this&if&taking&a&history&(more&relevant&to&end&of&
year&exam):&
• Childbirth&history&–&specifically&ask&about&high&parity,&whether&babies&were&large,&
how&long&second&stage&of&labour&was,&and&the&method&of&delivery&(instrumental&
delivery&can&be&very&damaging).&&
• Has&patient&gone&through&the&menopause&–&lack&of&oestrogen&so&can&get&atrophy&
of&vaginal&tissue.&

& 9&
OBGYN&Tutorial&Notes&

• Raised&intrababdominal&pressure&–&chronic&cough/asthma,&chronic&constipation&
with&straining,&obesity.&&
&
Management:&
Conservative&"&optimization&of&modifiable&risk&factors:&
• Eliminate&chronic&cough.&
• Smoking&cessation&–&helps&with&cough&and&improves&vaginal&atrophy.&
• Avoid&heaving&lifting.&
• Pelvic&floor&exercises&–&most&important&pelvic&floor&muscles&are&the&levator&ani&
muscles&(pubococcygeus&and&ileococcygeus).&They&are&a&major&support&to&pelvic&
organs&–&support&mid&vagina,&urethra&and&rectum;&help&to&fix&the&perineal&body;&
assists&anal&and&vaginal&sphincters.&
• Bladder&retraining&–&may&be&helpful&if&associated&overactive&bladder.&
&
Conservative&"&pessaries&
• Not&curative&but&can&make&the&prolapse&less&problematic&in&a&select&group&of&
patients&e.g.&those&unfit&for&surgery&(age,&cobmorbidity),&patient&preference,&
pregnant&patient,&desire&for&future&pregnancies.&
• Ring&(doughnut,&gellhorn)&and&shelf&types&most&commonly&used.&Ring&often&best&
for&1st/2nd&degree&uterine&prolapse&or&cystocele,&whereas&shelf&can&help&for&3rd&
degree&prolapse.&
• Need&to&be&changed&every&6&months.&
&
Surgical&"&aim&is&cure&
• Vaginal&approach&–&&
o Anterior&colporrhaphy&–&for&cystocele&
o Posterior&colpoperineorrhaphy&–&for&rectocele&
o Vaginal&hysterectomy&&
o Mesh/tape&procedures&–&mostly&for&vaginal&vault&prolapse&procedures&
o Sacrospinous&ligament&fixation&–&vaginal&vault&prolapse&
o Manchester&(Fothergill)&repair&
• Abdominal&approach&–&
o Burch&colposuspension&
o Colposacropexy&–&vaginal&vault&prolapse&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&

& 10&
OBGYN&Tutorial&Notes&

Gellhorn&Pessary&

&
&
Ring&Pessary&

&
&
&
Urethrocele& & & & & Cystocele&

&
&

& 11&
OBGYN&Tutorial&Notes&

Uterine&prolapse&

&
&
Rectocele&

&
&
Enterocele& & & & & Vaginal&vault&prolapse&

&
)
) )

& 12&
OBGYN&Tutorial&Notes&

URINARY)INCONTINENCE)
In&order&to&understand&incontinence&need&to&be&able&to&understand&normal&bladder&
micturition&first.&&
Three&factors&act&to&ensure&continence&"&1)&intravesical&pressure&remains&low&because&
of&stretching&of&the&bladder&wall&and&stability&of&the&detrusor&muscle&which&does&not&
contract&involuntarily&2)&sphincter&mechanisms&of&the&bladder&neck&and&3)&pelvic&floor&
muscles&(particularly&levator&ani&muscles).&&

&
At&the&onset&of&voiding&the&sphincters&relax&due&to&decreased&SNS&activity&and&the&
detrusor&muscle&contracts&due&to&increased&PSNS&activity.&Overall&control&of&micturition&
is&by&higher&brain&centres&(cerebral&cortex&and&the&pons).&
&
Types&of&urinary&incontinence:&
1. Genuine)stress)incontinence)(GSI))–&most&common&cause)
2. Urge)incontinence)/)overactive)bladder)(OAB))–&second&most&common)
3. Urinary&retention&with&overflow&incontinence&
4. Fistula&–&vesicovaginal,&ureterovaginal&
5. Congenital&abnormalities&e.g.&ectopic&ureter&
6. Functional&incontinence&–&not&related&to&a&physiological&problem&
7. Can&get&a&mixed&picture&incontinence&e.g.&GSI&+&OAB&
&
Patient&will&present&with&the&symptoms&of&incontinence&and&you&must&tease&this&out.&
Important&to&determine&how&the&symptoms&are&affecting&her&quality&of&life!&
• Leaking&during&physical&activity,&coughing,&sneezing,&lifting?&GSI&>&OAB&
• Ability&to&reach&the&toilet&in&times,&following&an&urge&to&void?&OAB&will&not&
• Urgency&accompanies&incontinence?&GSI&seldom.&OAB&commonly&
• Waking&to&pass&urine&at&night&>2/night?&GSI&seldom.&OAB&commonly&
&
Tips&for&history&taking:&
• Onset,&frequency&of&leakage,&need&for&absorbent&pads&
• Precipitating&events&–&cough,&exercise,&meds,&childbirth,&surgery,&pelvic&oestrogen&
status&
• Lower&urinary&tract&symptoms&–&urgency,&frequency,&nocturia,&enuresis,&dysuria,&
haematuria,&pain,&pelvic&pressure,&vaginal&dryness,&dyspareunia&
• Daily&fluid&intake&"&a&voiding&diary&is&helpful&
• Ask&about&specific&medications&–&diuretics,&alphabblockers&
• Previous&treatments&and&effects&on&incontinence&
&
Tips&for&physical&exam:&

& 13&
OBGYN&Tutorial&Notes&

• Abdominal&mass&
• Pelvic&mass,&prolapse,&vaginal&atrophy,&voluntary&pelvic&floor&contraction&
• Rectal&mass,&tone,&voluntary&contraction&of&anal&sphincter,&faecal&impaction&
• Sacral&neurological&exam&–&sensation,&reflexes&(anal&wimk&S2bS5),&foot&
movements&
&
Investigations:&these&are&important.&Could&be&asked&to&describe&them&OSCE.&
• Urinalysis&–&bacteriuria,&haematuria,&pyuria,&glycosuria,&proteinuria&
• Other&basic&tests&–&&
o Postbvoid&residual&volume&b&determined&using&a&catheter&or&by&a&bladder&
USS&
o Stress/cough&test&–&objective&confirmation&for&stress&incontinence.&
Performed&with&a&full&bladder&in&the&standing&position.&Can&be&
embarrassing&for&the&patient.&
o Pad&test&–&aims&to&quantify&urine.&Not&commonly&used&
o Simple&cystometry&–&determines&bladder&capacity,&bladder&compliance,&
and&presence&of&detrusor&contractions.&(bladder&compliance&is&the&
relationship&between&change&in&bladder&volume&and&change&in&detrusor&
pressure)&
• Urodynamic&Assessment&–&looks&at&bladder&filling&and&bladder&voiding&phases&
o Filling)cystometrogram&–&the&bladder&is&filled&with&sterile&saline&via&a&
transurethral&catheter.&The&detrusor&pressure&is&measured.&&
o Note&that&actual&pressure&within&bladder&=&detrusor)pressure&+&intrab
abdominal&pressure.&i.e.&the&detrusor&pressure&is&measured&indirectly&by&
measuring&the&pressure&in&the&bladder&and&subtracting&the&intrab
abdominal&pressure,&which&is&measured&with&a&vaginal&or&rectal&catheter.&&
o Is&urodynamic&testing&carried&out&on&every&patient?&No,&only&in&women&
with&a&mixed&incontinence&presentation&(GSI&and&OAB),&or&in&any&patient&
who&has&failed&to&respond&to&medical&or&surgical&treatment.&&
o Results:&GSI&–&leaking&of&urine&in&the&presence&of&raised&intrababdominal&
pressure&and&the&absence&of&detrusor&activity.&The&total&bladder&pressure&
will&be&raised&at&the&moment&of&incontinence&but&the&detrusor&pressure&
remains&unchanged.&
o Results:&OAB&–&the&total&bladder&pressure&and&the&detrusor&pressure&will&
be&equally&elevated&at&the&time&of&incontinence.&
&
o Voiding)cystometrogram)–&this&time&the&assessment&is&carried&out&as&the&
bladder&is&emptying.&Measurements&include&total&volume&voided,&peak&
flow&or&urine&voided,&and&the&detrusor&activity&required&to&produce&the&
flow.&Also&demonstrates&residual&urine&remaining&in&bladder&postbvoid.&&
o Results:&GSI&–&leaking&of&urine&in&the&presence&of&raised&intrababdominal&
pressure&(coughing,&lifting)&and&the&absence&of&detrusor&activity.&Caused&
by&a&weakness&of&the&proximal&and&distal&urethral&sphincter&mechanism.&&
o Results:&OAB&–&involuntary&contraction&of&detrusor&muscle&is&what&causes&
the&incontinence.&Aetiology&usually&unknown.&&
&
Treatment&of&Stress&Incontinence:&
• Lifestyle&changes&b&weight&loss,&cough&and&constipation,&management&

& 14&
OBGYN&Tutorial&Notes&

• Behavioural&therapies&–&pelvic&floor&exercises,&vaginal&cones.&Alteration&of&fluid&
and&voiding&habits.&Pelvic&floor&muscle&training&is&most&helpful&in&mild&stress&
incontinence&with&cough&or&sneeze;&less&effective&for&exercisebinduced&
incontinence.&&
• Medications&–&duloxetine&(SNRI).&Mechanism&=&blocks&reuptake&of&serotonin&and&
noradrenaline&which&increased&pudendal&nerve&activity&the&acts&to&strengthen&the&
sphincter&contraction.&&
• Devices&–&intravaginal&support,&intraurethral&occlusion&(microparticulate&silicon)&
• Surgical&options&–&does&not&replace&the&physiological&mechanism&but&supports&the&
bladder&neck&and&proximal&urethra&and&prevents&incontinence&associated&with&
raised&intrababdominal&pressure.&&
o TVT&–&prolene&mesh&inserted&transvaginally&at&the&level&of&the&midb
urethra.&Need&to&know&complications&(vascular,&vessel&or&bowel&injury,&
voiding&difficulties,&erosion&of&tape&through&urethra,&tape&too&tight,&urge&
incontinence)&
o Burch&colposuspension&–&was&used&more&before&TVT&developed.&Nonb
absorbable&sutures&are&placed&retropubically&to&approximate&the&
paravaginal&tissues&to&the&ileopectineal&ligament.&Complication&of&voiding&
difficulties,&prolapse,&detrusor&over&activity.&
o Suburethral&slings&–&sling&placed&like&a&hammock&between&two&areas&of&the&
abdominal&wall.&Passed&from&the&abdominal&wall,&under&the&urethra&and&
back&to&the&abdominal&wall.&&
o Artificial&sphincters&–&for&severe&incontinence&in&specialised&centres.&
&
Treatment&of&Urge&Incontinence:&
• Behavioural&therapy&–&Bladder&retraining.&80%&success&rate&in&highly&motivated&
women.&Principles&of&method&=&education,&exclude&frequency&with&timed&voiding&
every&2&hrs,&extend&voiding&time&in&30min&increments.&
• Medication&–&can&be&used&to&augment&behavioural&therapy.&&
o Acetylcholine&is&the&neurotransmitter&that&causes&detrusor&contraction&–&
anticholinergic&agents&e.g.&oxybutynin,&tolteridine,&propiverine,&tropsium.&
Side&effects&of&dry&mouth,&blurred&vision,&constipation.&
o Local&oestrogen&therapy&–&can&be&used&in&postbmenopausal&women&with&
atrophy&of&local&tissues.&
• Surgery&–&not&the&firstline&therapy&and&not&as&commonly&used&as&in&stress&
incontinence&patients.&&
o Cystoscopy&and&intravesical&botox&
o Clam&ileocystoplasty&
o Urinary&diversion&procedures&
&
& &

& 15&
OBGYN&Tutorial&Notes&

AntebPartum&Haemorrhage&&
&
This)is)discussion)station.)Ask)each)student)in)sequence.)
&
A&patient&presents&with&painless&vaginal&bleeding&at&32&weeks&gestation.& &
Ultrasound&identifies&a&placenta&praevia.&She&is&Rh&positive.&Outline&your& &
approach&to&her&subsequent&care.& &
&
&
Start)by)asking)about)the)causes)of)APH)
• Placenta&Praeviab&30%&
• Placental&Aprutpionb20%&
• Local&causeb&5%&
• Unclassifiedb45%&
)
What)are)the)risks)of)placenta)praevia)(why)is)it)serious)?)
• Maternal&risks&
o Haemorrhage,&cobexistent&abruption,&placenta&accrete&(15%),&need&for&
hysterectomy,&death&
• Fetal&risks&
o Prebterm&birth,&IUGR&
&
Management)
• Immediate&management&(ir&p/w&active&PV&bleedingb&call&for&senior&help!&
o ABCs&
o 2x&14G&IV&lines,&start&fluids&
o FBC/&COAG/Crossbmatch&4&units&of&blood&(O&negative&STAT&if&necessary)&
o Notify&NICU&(if&immediate&delivery)&
• Decision&of&either&immediate&delivery&or&expectant&management&depends&on:&
o Did&the&bleeding&stop?&
o Was&it&mild&or&severe&blood&loss?&Was&it&a&life&threatening&bleed?&
o Is&the&CTG&nonbreassuring?&
o What&is&the&gestational&age?&
• Immediate&delivery&indications&
o Severe,&life&threatening&bleed&regardless&of&gestational&age&
o Nonbreassuring&CTG&regardless&of&gestational&age&
o Gestation&34b36&weeks&and&has&already&received&corticosteroids&
• If&minor&bleed,&not&recurrent,&steroids&not&administered,&wait&to&deliver&at&36b37&wks&&
• Expectant&Management&
o If&<&35&weeks,&give&2&doses&of&steroids&for&lung&maturity&
o Inpatient&admissionb&life&threatening&nature&with&chance&of&acute&severe&event&
o Keep&as&inpatient&from&viability&(24&weeks)&
o Repeat&US&scan&at&36&weeks&to&confirm&praevia&
o Aim&for&delivery&at&37&weeks&by&elective&LSCS&
&
Q:)What)role)is)there)for)AntiWD)in)this)case?))
A:&Noneb&she&is&Rh&positive&
Q:)What)test)would)determine)the)‘dose’)of)antiWD)required)if)it)was)necessary?)
A:&Kleihauer&test&

& 16&
OBGYN&Tutorial&Notes&

&
Comparison)of)Placental)Abruption)vs)Placenta)Previa)
Variable) Placenta)Abruption) Placenta)Praevia)
Pathophysiology& Premature&separation&of& Abnormal&placental&implantation&
normally&implanted&placenta&
Incidence& 1&in&150&deliveries& 1&in&20&at&24&weeks&
1&in&200&at&40&weeks&
Risk&Factors& Hypertension/&preeclampsia& Previous&LSCS&
Abdominal/pelvic&trauma& Previous&uterine&surgery&
Tobacco&or&cocaine&use& Grand&multiparity&
Previous&abruption& Advanced&maternal&age&
Prolonged&PROM/&chronic& Multiple&gestation&
chorioamnionitis& Prior&placenta&praevia&
High&parity& Smoking&
Previous&abruption&
Maternal&thrombophilia&
Symptoms& Abdominal&pain& Painless&vaginal&bleeding&that&
Backache& may&be&unprovoked&or&provoked&
±&vaginal&bleeding&& postbcoitus&&or&following&uterine&
& contraction&
& &
Fetal&distress&present& Usually&no&fetal&distress&
Physical&signs& Collapse&(from&shock)& Uterus&soft&and&non&tender&
Hard&“wood&like”&uterus& Fetal&heart&normal&
Fetal&parts&difficult&to&palpate& High&presenting&part&or&
±&fetal&heart&absent& malpresentaion&(fetal&head&
cannot&descend)&
Diagnosis& Primarily&clinical&diagnosis& TVUS&is&most&precise&(perform&
Confirmed&by&delivery&of& on&empty&bladder)&
retrobplacental&clot&
TVUS&to&rule&out&PP&
&
Management& bStabilize&patient& DO&NOT&perform&a&vaginal&exam&
bContinuous&CTG& in&a&patient&with&APH&(No&PV&
bIf&fetus&is&alive,&deliver&by& before&PP)&
emergency&LSCS& &
bIf&fetus&is&dead,&aim&for& 1.&Immediate&delivery&by&LSCS&if:&
vaginal&delivery& bsevere&haemorrhage&
& bfetal&distress&
b34b46&weeks&+&steroids&given&
&
2.&Expectant&management&
bIf&minor&bleed,&no&fetal&distress,&
and&fetal&lungs&immature,&plan&
for&delivery&at&37&weeks&by&LSCS&
Complications& Coagulopathy&(30%)"&DIC& Maternal=&haemorrhage,&cob
Hypovolaemic&Shock& existent&abruption,&placenta&
↑&risk&of&PPH&(at&LSCS&if& accrete,&hysterectomy,&death&
coagulopathy&present)& Fetal=&Preterm&birth,&IUGR,&death&

& 17&
OBGYN&Tutorial&Notes&

PostbPartum&Haemorrhage&
&
This)is)a)discussion)station.)Ask)each)student)in)sequence.)

You&are&the&SHO&on&call.&You&are&called&urgently&to&the&postnatal&ward&to&review&a&32&
year&old&woman&para&4&who&is&6&hours&post&vaginal&delivery&with&heavy&vaginal&
bleeding.&Her&BP&is&90/50,&pulse&110&bpm&and&she&is&pale.&Outline&your&management&
plan&

&
Show)the)students)the)prompt.)Ash)whether)this)is)1°)or)2°)PPH)and)then)move)on)
to)management.)
1°&PPH=&within&24&hours&of&delivery&
2°&PPH=&greater&than&24&hours&of&delivery&
&
Management)
• Call&for&helpb&senior&midwife,&senior&obstetrician,&anaesthetist&to&assist&with&IV&lines&
• Resuscitationb&ABCs&
o Lay&patient&plat,&O2&via&face&mask&
o IV&access,&2&14G&(large&bore)&IV&cannulas&
! Send&blood&for&FBC/&COAG/&Xbmatch&(±&4&units&O&neg&blood&STAT)&
o Fluid&resuscitation,&give&blood&products&when&available&
o Monitor&vitals&and&urine&output&(catheterization)&
• Identify&cause&
o Consider&4&Ts:&Tone&(atonic&uterus),&Trauma&(vaginal/cervical),&Tissue&
(retained&placenta),&Thrombin&(history&of&coagulopathy)&
! Is&the&uterus&soft&and&high?&Was&there&uterine&or&vaginal&trauma?&Are&
the&placenta&and&membranes&complete?&
o In&this&case,&given&the&patient’s&risk&factors&(para&4),&her&cause&is&likely&due&to&
atony,&which&is&the&most&common&cause&of&PPH&
• To&manage&atony&
o Ensure&uterus&is&well&contracted&
! Rub&up&contraction&
• Abdominal&hand&massages/compresses&uterus&
• Other&hand&expels&clots&from&the&cervix&and&vagina&
o Clots&stuck&in&cervix&are&easily&addressed&cause&of&
uterine&atony&
! Bimanual&compression&&
• Intravaginal&hand&and&abdominal&hand&compress&uterus)&
! Uterotonic&drugs&
• Oxytocin&(syntocin):&bolus&5b10&units&IV&or&IM<&then&infusion&of&
40&units&in&500&mL&Hartmann’s&over&4&hours&
• Ergometrine:&500&mcg&IM&
o C/I&if&hypertensive&
• Misoprostol:&800b1000&mcg&PR&
o Prostaglandin&E1&analog&
• Carboprost&(hemabate):&250&mcg&IM&every&20&minutes&
(maximum&8&doses,&20g)&

& 18&
OBGYN&Tutorial&Notes&

o Prostaglandin&F2&analog&
o C/I&in&asthma&
o Uterine&tamponade&
! Bakri&balloonb&inflated&inside&uterus&to&apply&even&pressure&
o Interventional&radiology&
! Uterine&artery&embolization&(rarely&available)&
o Laparotomy&
! Bblynch&sutureb&applies&external&pressure&to&uterus&
! Uterine&or&internal&iliac&artery&ligation&
! Hysterectomyb&absolute&last&resort&

& 19&