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Obstetrics Clinical Diagnosis

Obtain a full history from a pregnant woman Demonstrate sensitive communication with female patients Ability to distinguish relevant aspects of history Ability to take an accurate menstrual history Ability to assign risk status to a particular pregnancy Demonstrate knowledge of health promotion issues during pregnancy

HPI Establish pregnancy if unknown status delayed menstruation (up to a week, on a background of previous normal cycles), date of the last period, evidence of morning sickness, if a home pregnancy test has been used, has it been confirmed by ultrasound? Other symptoms include breast pain and presence of foetal movement. History of present pregnancy: o Mothers age o Date of last menstrual period o Weeks gestation o Expected delivery date o Planned? o Symptoms / complications during pregnancy (of importance is: pelvic/abdo pain vaginal bleeding cramping suspicion of ectopic or abortions. Vaginal discharge (infection) fluid leakage (ruptured membranes) also important Some routine problems of pregnancy include back pain constipation dehydration oedema urinary frequency Foetal movement (usually by 16-20 weeks) Blurred vision, headache, rapid weight gain Any prenatal care received up until now? Menstrual history: Date of last menstrual period Age of menarche Regularity Abnormal bleeding (amenorrhea, dysmenorrhea, etc) Heavy bleeding / spotting / breakthrough bleeding

Prior use of the OCP

Past History Obstetrics history of prior pregnancies o Date o Outcome o mode of delivery o length of time in labour o birthweight o any complications. Sexual history STDs, dyspareunia. Other relevant past medical / surgical history. Medications prior to and during pregnancy. Allergies Family History Congenital problems (mother & fathers family) Other relevant family history (hypertension, IHD, DM) Social History Tobacco / EtOH history Recreational drugs Occupation of both parents Examination of a pregnant woman Ability to palpate pregnant abdomen and interpret findings (Would you like me to examine the patients vital signs? HR, RR, temp) Blood pressure + weight (again, ask examiner if this should be measured) Abdominal palpation: o Abdominal inspection (scars, abnormal distension, etc.) o Foetal movement o Uterine tenderness o Fundal height (from the top of symphysis pubis. At 12 weeks, fundal height should be at the pubic symphysis. At 16 weeks, it should be midway between symphysis & umbilicus. At 20 weeks, at the umbilicus. At 20-32 weeks, fundal height in centimeters above symphysis should equal gestational age in weeks. Use a measuring tape Check for foetal position (>32 weeks): vertex, breech or transverse. Foetal heart tones listen with bell of stethoscope (normal range is 120-160 bpm. Present usually after 20 weeks). Deep tendon reflexes

Oedema Dipstick urine protein (ask examiner)

Foetal Heart Sounds Area of the mothers abdomen where foetal heart sounds best heard depends on position of foetus & degree of descent into pelvis. - Cephalic presentations, foetal heart best heard below umbilicus - I. Occipito anterior near midline - II . Occipito transverse further towards mothers side - III. Occipito posterior in the flank (towards mothers back) - Breech presentation: at or above level of umbilicus

Examination of a woman in labour Knowledge of parameters of assessing progression of labour Ability to communicate effectively with birth partners Demonstrate strategies to soothe an anxious patient Foetal lie whether infant is longtitudinal or transverse. Palpate bimanually the fundus, either side of the uterus, and the presenting part above the pubic symphysis (Leopold maneuvers). Foetal presentation vertex or breech. Using same technique, however this is more difficult and may require ultrasound to confirm. [ Suspected membrane rupture speculum exam with pool, nitrazine and fern tests (to diagnose amniotic fluid) ] Cervical exam: o 1 Dilation (fingers to assess how open cervix is at level of internal os: 10 cm is full dilation) o 2 Effacement (subjective measurement of how much length is left of the cervix) o 3 Station (distance from level of ischial spines of the most descended aspect of the presenting part. If at level of spines, station = 0) o 4 Consistency (cervix firm/medium/soft?) o 5 Position (cervix posterior/mid/anterior?) Foetal presentation & position: o Presentation can be palpated during cervical exam (eg. hair/sutures vs gluteal cleft/anus) o Position: In the vertex presentation, can be done by palpation of the sutures. Distinguish between occiput & posterior fontanelle vs posterior fontanelle, and describe accordingly (pg. 23, blueprints book). Stages of labour: o 1 Onset of labour until complete dilation of cervix. o 2 Full dilation until delivery of infant

o 3 After delivery of infant until delivery of placenta Cardinal movements of labour: o Engagement: foetal presenting part enters pelvis o Flexion: of head, to allow the smallest diameter to present to pelvis o Descent: of vertex with passage of head down into pelvis o Internal rotation: following descent into midpelvis o Extension: as vertex passes beneath and beyond pubic symphysis. o External rotation: after the head delivers.

Assessment of fetal well-being Demonstrate ability to use Pinard stethoscope Pinard stethoscope is used to monitor foetal heartbeat every 15-30 min during Stage 1 of labour, and following every contraction during Stage 2. More common nowadays to use handheld ultrasound (SonicAid). Demonstrate ability to take CTG readings using: o External pads o Scalp electrode ** Main use for the CTG is information regarding variations in foetal heart rate, measuring the frequency of contractions, and comparing contractions with the foetal heart rate tracing to determine the type of decelerations occurring. Foetal heart rate tracing: o Determine baseline is within normal range (between 110-160 bpm). o Above 160 bpm, foetal distress secondary to infection, hypoxia or anaemia is of concern. o A flat tracing is also non-reassuring (hypoxia, various drugs) o As is increased sinusoidal variability (foetal asphyxia, foetal anaemia) o Beat-to-beat variation is normally 2-3 bpm o Long term variability (over 15 secs) = 10-15 bpm o Should be at least 3-5 cycles/min around baseline o Tracing considered formally reactive if there are 2 accelerations above baseline which last for at least 15 secs within 20 mins. Decelerations: o Early: Begin and end ~ at the same time as contractions. Result from increased vagal tone due to head compression during contraction. o Variable: Can occur at any time

Result from umbilical cord compression. Repetitive variables seen when cord wrapped around neck or within shoulder (and compressed with each contraction).

o Late: Begin at peak of contraction and slowly returns to baseline after contraction result of uteroplacental insufficiency. Mnemonic for assessing foetal well-being: DR C BRAVADO o Determine Risk - Assess prenatal and intrapartum risk factors and labor progress o Contractions - Adequate? Hypertonic? o Baseline RAte - Should be 110-160 BPM, requires 10min monitoring to establish; bradycardia = < 110; severe bradycardia = < 100; tachycardia = > 160, severe tachycardia = > 200 (note; the latter can be from fetal congenital heart disease) o Variability: Normal = 10-15BPM around baseline More accurately assessed w/FSE Best predictor of good fetal outcome (better than accels); Decreased with sleep, hypoxia, acidosis, prematurity, CNS anomalies, and drugs including narcotics o Accelerations: Requires > 15BPM over baseline x > 15sec; presence is reassuring o Decelerations--Must correlate with timing of contractions to classify o Overall assessment Foetal scalp electrode: o Used in the case of repetitive decels or if foetus difficult to trace externally with doppler. Small electrode attached to foetal scalp. Tracing is more sensitive in beat-beat variability and in no danger of being lost during contractions (where the foetal heart position may change). Foetal scalp pH: o if tracing nonreassuring, this can be used to directly assess foetal hypoxia and acidemia. o Reassuring if pH > 7.25 o Indeterminate between 7.20-7.25 o Non-reassuring if < 7.20.

Obstetrics Investigations
Pregnancy testing Ability to carry out a urinary pregnancy test Many home pregnancy tests have a high sensitivity and will be positive around the time of missed menstruation (as early as 8-9 days after ovulation).

These test for beta-hCG, produced by the placenta shortly after implantation into the uterus, peaking by 10 weeks of gestation. When using a urinary pregnancy test, patient will either need to urinate in a cup (with midstream urine) and then place a small amount of urine, using a dropper, into the testing well (or urinate directly on a testing stick). Most of the tests have two windows o one that tells if the test has been performed correctly (control) o one that gives the positive or negative result. o In the result window, the tests usually give a line or a plus. For the line tests, any colored line, no matter how faint, in the result window during the alotted time is a positive result, meaning the urine contains hCG. Demonstrate knowledge of quantitative HCG assessment Another alternative is a quantitative beta-hCG blood test, measuring amount of hCG in the blood (compared with a qualitative test which determines the presence or absence of hCG).

Ante natal investigations Ability to take an adequate blood pressure pregnancy induced hypertension preeclampsia eclampsia Routine urinalysis Preeclampsia Eclampsia renal compromise UTI. Ability to undertake and explain routine screening investigations

Routine screening investigations: 1st trimester: o FBC (+Haematocrit) o Blood type (including Rh & antibody screen) o Rubella antibody screen o HBV surface antigen, urinalysis + culture

o Pap smear o VDRL (syphilis) o cervical gonorrhoea & chlamydia. o Glucose test o HIV if indicated. 2nd trimester: maternal serum AFP ultrasound (18-20 weeks) o number of foetuses in uterus o foetal age o physical development o placental position o amniotic fluid around foetus 3rd trimester: o Haematocrit o glucose loading test. o Group B strep culture (36 weeks)

Screening for congenital/genetic abnormalities: CVS: 11-13 weeks (0.5% risk of miscarriage) Amniocentesis: 15-18 weeks (0.25% risk of miscarriage) Nuchal translucency + blood test (free-beta-hCG, PAPP-A): o 12 weeks, Down Syndrome. CF carrier test: DNA from buccal cell sample (mouth swab) CTG criteria & normal vs abnormal CTG traces: refer to above (foetal well-being) . Ultrasound investigations Demonstrate a systematic approach to looking at ultrasound photographs Ability to check name and date and tell orientation of US Demonstrate ability to determine foetal position and presence of fetal heart Check name of patient, date of US, gestational age (if known) Assess regional coverage: do the images cover the region required? Assess exposure: are all of the tissues to be imaged sufficiently bright for diagnosis? Assess patient positioning: have the images been obtained in the correct plane? Examination of the image in detail: o foetal position Demonstrate knowledge of appropriate use of ultrasound techniques Demonstrate knowledge of normal CTG criteria Ability to distinguish normal from abnormal CTG traces

o foetal lie o placental location o foetal anatomical survey. Ultrasound is the only frequently performed imaging technique in obstetrics. o Indications (in general) Diagnosis of early pregnancy 5/40 gestational sac 6/40 fetal heart Bleeding in early pregnancy (threatened abortion, ectopic) Determination of gestational age/foetal size/foetal number Placental location Identification of foetal malformations Abnormal size for dates (polyhydramnios & oligohydramnios) Diagnosis of foetal death Assessment of foetal well-being Confirmation of presentation (eg. vertex vs breech) o Indications (specifically): Early pregnancy: Confirmation of pregnancy: gestational sac containing embryo (with heartbeat by 5 wks) Investigating pain or bleeding associated with suspected abortion or ectopic. Middle pregnancy: Anatomical surveys to rule out congenital malformations Placental location Foetal age Prior to CVS, amniocentesis, nuchal translucency screening. Late pregnancy: Assessment of suspected IUGR & foetal distress. Malpresentation Review of foetal anamoly Demonstrate knowledge of the limitations of ultrasound investigation Relatively free of hazards. Whilst some artefacts can occur, the do not usually detract from the quality of the image obtained. Image detail significantly reduced by obesity and abdominal scars. High quality detail may not be present with older scanning equipment.

Obstetrics Management and Communication

Conduct appropriate ante natal care Identify normal progression of pregnancy see previous sections B-HCG o produced by the placenta o Doubles every 2/7 o Urinary pregnancy test often +ve by time of 1st missed menstrual period o 5/40: 1,500-2000 (U/S: gestational sac) o 6/40: 5000-6000 (U/S: fetal heart) o 10/40: Peaks at 100,000 mlU/mL o Drops to 25,000 by about 15-20 weeks and plateaus there. CV system: (most increases in 1st trimester, max at 20-24 weeks) o HR inc 10-15bpm, increased SV, CO o Decreased: BP 10/15 by 24 weeks, returns by delivery RESPIRTORY: o Increase: TV (30%), RR o Decreased: other lung volumes, PaCO2 (30mmHg by 20/40) GASTROINTESTINAL o 70% nausea and vomiting (should resolve by 14-16/40) o reflux, ptyalism (spitting), constipation (dec. motility bowel) RENAL o Increased GFR (50%) o Decreased BUN and Creatinine (25%) o Urinary frequency can increase (consider UTI) HAEMATOLOGICAL o Increased: Plasma volume (50%), RBC volume (25%), WCC (6-16) o Decreased: Haematocrit, platelets o Hypercoagulable state: Increased fibrinogen and clotting factors VII-X o Haemorrhoids, varicose veins common ENDOCRINE: o Hyperestrogenic state (mainly from placenta): increases TBG (though reduced free T3 and T4 in pregnancy leave patient Euthyroid) o Progesterone: from CL early, then placenta; causes SMM relaxation o HPL: (HCS) from placenta; causes lypolysis and antagonizes insulin, causing increased ffa, insulin and protein synthesis. (diabetogenic) MUSCULOSKELETAL + DERMATOLOGICAL o LBP secondary forward shift in center of gravity o Carpal tunnel o Ankle oedema o Spiderangingiomata and palmar erythema (estrogen)

o Hyperpimentation (nipples, umbilicus, linea nigra, face (melasma, chloasma), perineum) (alpha-MSH) Initial Pre-natal visit: screening and date verification Much of screening for genetic and congenital abnormalities is done in 2nd trimester (or on border of) At each visit: o BP o weight gain o fundal growth o fetal heart rate o symptoms (including contractions) o vaginal bleeding/discharge,

Know how to assign risk to a pregnancy

PREGNANCY RISKS: Features pertaining to the mother: o Pre-existing disease o Increased maternal age (>35) o Height (<154cm) o Extreme obesity, social deprivation o 5th pregnancy and greater o Infection +ve serology (HbsAg, HIV, TORCHES) STI Features pertaining to previous pregnancies: o Preterm (<37wks) or small (<2.5kg) o Deformity, stillbirth, neonatal death o C/S or hysterectomy o Retained placenta; abruption o Pelivc floor damage +/- repair o Instrumental deliveries o PPH Features of this pregnancy: o Cardiac or thyroid disease o Multiple gestation o Rh ve with antibodies o Poor fetal growth or wellbeing o Diabetes, increased BP, anaemia o Malpresentations after 34 wks o Raised alpha-FP o Placenta previa

o ROM o Renal probs o Clotting abnormalities

Identify abnormal signs or symptoms and act appropriately

COMPLICATIONS: Ectopic pregnancy: (1%, most tubal) o Unilateral pain, bleeding o Dx: Ultrasound o Rx: Ruptured: Remove, stabilize Unruptured: Methotrexate Spontaneous abortion: o 1st trimester: Rule out ectopic, complete with D+E (or expectant Mx) up to 3/40: incomplete, missed, inevitable, Rho-GAM to Rh-ve mums. nd o 2 trimester: secondary to uterine/cervical abnormalities, trauma, systemic disease or infection Rx: D+E, prostaglandins or oxytocic agents to assist completion if needed. Incompetent cervix (painless dilation): o Risk factors: Surgery, cone biopsy, lacerations in previous vaginal delivery, uterine anomalies, DES exposure o Can cause: infection, PPROM, Preterm labour o Previable fetus: expectant Mx, elctive termination, or immediate cerclage o Previous Hx: elective cerclage offered at 12-14 weeks Recurrent abortions Antepartum haemorrhage (see lec) Fetal vessel rupture Pre term labor: o Rx: tocolytics, (Mg, Ca blockers, NSAIDS), Betamethasone PPROM: o Continue as long as possible up to ?36 weeks with close monitoring of fetus. o Rx: corticosteroids and ampicillin (+- erythromycin); Delivery if signs of infection (chorioamnionitis) C/S Indications o Maternal/fetal: Cephalopelvic disproportion Failed induction of labor o Maternal

Severe pre-eclampsia / eclampsia Cervical cancer ?Prior uterine surgery Obstruciotn (fibroids, tumor) o Fetal: Non-reassuring testing Scalp pH < 7.2 Cord prolapse Malpresentation (breech, transverse lie, brow) Multiple gestation (non vertex 1st twin, >2 babies) Fetal anomalies (hydrocephalus, osteogenesis imperfecta) o Placental: Placenta previa Abruptio placentae

Conduct normal labour Demonstrate ability to monitor well-being of mother and baby CTG Fetal scalp electrode Intrauterine pressure catheter Fetal scalp pH Vital signs of mother Stage of labour, presentation etc

Demonstrate knowledge of pain relief in labour Epidural (bolus, more can be infused) o L3/4 region (anaesthatises T11-S5 pain fibres) o Setup IV line + give 500ml IV Hartmans 1st to prevent BP drop o Check PR, BP, Resps, contractions, fetal hr every 15mins o Requires 2 hourly top ups o Helpful for: OP position, breech, multiple gestation, preterm delivery, pre-eclampsia, forceps, inco-ordinated uterine contractions. o Problems: Slows active phase of labor Postural hypotension Urinary retention Paralysis Post delivery: urinary retention + headache o Can be bolused if need to go to C/S

Spinal (one off dose) o More common for C/S Nitrous oxide o +ve: use throughout labour patient initiated/administered o C/I: pneumothorax Pethidine o Useful to relax 1st stage o Cross placenta so shouldnt be used within 2-3hrs of delivery (though can use naloxone to reverse so long as mum is not narcotic dependant!) o Analgesia onset in 20 min with duration 2-3 hours o Low doses may produce vomiting without pain relief (give enough!) o Other S/E: disorientation, decreased gastric emptying, neonatal respiratory depression o C/I: mum on MAO-Is Local o For episiotomy General o For C/S, esp emergent Pudendal block o Injected at: point where pudendal nerve travels just posterior to the ischial spine at its juncture with the sacrospinal ligament. Or: 1cm beyond a point just below and medial to the ischial spine on each side. o Commonly used with forceps or vacuum delivery. Demonstrate ability to administer nitrous oxide o SSSSSShhhhhhhhhhhhhhhhhhhhhhh. Ability to summarise the salient points of a case at handover o Um err, um err, um err, mumble, fidget, Im not sure Doc. What do you reckon?

Normal delivery Understand principles of making and repairing an episiotomy Incision in perineum to facilitate delivery Indications: o To hasten delivery o Impending/ongoing shoulder dystocia C/I:

o Assessment that there will be a large perineal laceration Two types: o Median (more common) o Mediolateral (5 or 7 oclock) Support it once made, to prevent spread to anal area Repairs: (p147 oxford) o Swab the vulva towards perineum, infiltrate with 1% lignocaine o Place wrapped tampon? in vagina; insert 1st suture above apex of vaginal cut o Bring together vaginal edges with continual sutures1cm apart. Knot introitus under the skin. Appose divided levator ani muscles with 2 or 3 interrupted sutures o Close perineal skin o Remove tampon, check vagina to ensure all swabs removed o PR to check that apical sutures have not penetrated rectum (Nick this is your job!) Tears: o Labial: common, uncomfortable, heal quickly, suturing not necessary o 1st degree: (superficial, dont involve muscle) suture only of excess blood loss o 2nd degree: (involve perineal muscle o 3rd degree: extends to anal mucosa; repair under general or epidural. Demonstrate knowledge of appropriate use of local anaesthetic in the perineal area

See above. Demonstrate ability to handle a neonate, Demonstrate ability to clamp and cut cord With care, with a clamp and with scissors!

Understand reasons for giving and administration methods for vitamin K Given IM (possibly with plasma IV if a bleeding diathesis has developed). Formula contains it. Given for Haemorrhagic disease of the newborn which occurs days 2-7. Baby is well and develops unexplained bleeding and bruising PT and APPT are prolonged, Platelets are normal.

Demonstrate knowledge of oxytocic drugs and their administration Syntocinin, given according to protocol to induce labor, with increasing rate up to a max infusion, unless labor already progressing adequately. o Induction agents can also be:

Prostaglandin gel or tablets to ripen cervix to a bishop score > 5 before induction Syngometrine (ergometrine maleate 500 microgram IM and oxytocin 5U IM) can be given in the 2nd stage after delivery of the anterior shoulder: o Has reduced 3rd stage time to 5 mins o Reduces PPH

Normal post natal care Ability to assess lochia Peurperium= 6 weeks after delivery. o Uterus: involutes from 1kg at delivery to 100g at 6 weeks felt at umbilicus at delivery, is a pelvic organ by 10/7 afterpains are felt (especially whilst suckling) as it contracts o Cervix becomes firm over 3 days: Internal os closes by 3/7 External os closes by 3/52 o LOCHIA: Endometrial slough, RBC and WBC Is passed PV Red (lochia rubra) for 1st 3 days Becomes yellow (lochia serosa) and then white (lochia alba) by 10 days until 6 weeks. Ability to advise on appropriate contraception Natural methods: o Periodic abstinence (55-80% effective) o Coitus interruptus (withdrawal) 15-25% failure rate o Lactation amenorrhea Suppression of ovulation whilst breast feeding 2% failure rate in 1st 6 months 50% still ovulate between 6-12 months; therefore 15-55% failure rate in this time. Barrier methods: o Male condom 98% effective occasional hypersensitivity (rubber, lubricant, spermicide) prevent STD spread o Female condoms 15-20% failure rate (however ST studies only)

protect against STDs o Diaphragm (+spermicide) Apply before, till 6-8hrs after intercourse Add further spermicide for additional sessions! 94% theoretical effectiveness (80-85% reality!) S/E: bladder irritation, cystitis, toxic shock syndrome +ves: cheap (can reuse for up to 5yrs or until 5kg weight change), can put in a couple of hours before sex.gives woman more control. IUDs: o Good for: patients where OCP is C/I monogamous multigravid women. o C/I: Absolute: Current pregnancy Undiagnosed abnormal vaginal bleeding Suspected gynaecological malignancy Acute cervical, uterine or salpingeal infection History of PID Relative: Nulliparity or desire for future childbearing Prior ectopic pregnancy Hx of STIs Multiple sexual partners Moderate or severe dysmenorrhea Congenital malformations of the uterus o Method of action ? foreign body reaction to sperm augmented by progesterone (thickens cervical mucus and atrophies endometrium) copper addition (?hamper sperm motility and capitation) do not affect ovulation, nor act as abortifacients o 3% failure rate in 1st year, 2% per year therafter o uncommon S/E: pelvic infections (rarely after 1st 20 days of insertion) prevent with doxycycline or azithromycin at time of insertion) pain + bleeding expulsion (5%) perforation (1/500) insertion related salpingo-oophoritis o benefits: added protection against ectopics (not as low as decrease with OCP) Hormonal: o OCP Monophasic (fixed combination pills)

Combination pill for 1st 21 days of cycle Last 7 days placebo or no pill Bleeding within 3-5 days of starting placebo pill Multiphasic (dose varying) Provide a lower level of estrogen overall but are still highly effective Progestin-Only (minpill) Not as effective (3-6% failure rate) Small dose taken each day Associated with o irregular ovulatory cycles o breakthrough bleeding o ectopic pregnancy Benefit: ideal for nursing mother whom estrogen is C/I OCP effectiveness: 1% theoretical, 3 % actual non-compliance due to: o nausea, breakthrough bleeding and daily taking medications that reduce the effectiveness of the OCP: o Sulphonamides o Tetracyclines o Rifampin o Ibuprophen o Phenytoin o Barbituates o Penicillins OCP reduces the effectiveness of: o Folates o Insulin o TCAs o Phenothiazines o Hypoglycaemics o Anticoagulants o Methyldopa OCP Benefits: Reduced life threatening problems: o PID o Ectopic pregnancy o Endometrial cancer o Ovarian cancer Alleviates q.o.l problems: o Benign breast disease o Iron deficiency anaemia o Dysmenorrhoea o Functional ovarian cysts

o Osteoporosis OCP complications: Cardiovascular (mainly in smokers): o Thromboembolism o PE o CVA o MI o HT Other: o Benign hepatic tumors o Increased gall bladder disease o 2-5% weight gain (increased breast and hip) C/Is: Absolute: o Venous thrombosis o PE o CVA o Breast/endometrial Ca o Melanoma o Hepatic tumor o Abnormal liver function o Focal migraines: Severe headaches (especially vascular) Relative: o Renal disease o Uterine fibroids o Lactation o DM o Sickle cell disease o HT o Age 35+ and smoking o Age 40+ and high CV risk o An/oligo-ovulation o Depression o Hyperlipidaemia o Acne o Severe varicose veins o Implanon: to 1/10 of progestin levels of OCPs sustained progestin release up to 5 yrs contraception 0.09-.2% failure rate no serious S/E (as no estrogen) some bothersome S/E of sustained progestin release: irregular vaginal bleeding headaches

weight change mood changes NO significant delay in restoration of fertility Cheap long term, but one off cost may be prohibitive Has to be inserted by GP o Depo-Provera IM injection of slow release progestin (over 3 months) 0.3% first year failure rate S/E: Irregular menstrual bleeding o >70% experience spotting and irregular menses in 1st year Depression Weight gain Breast tenderness On ceasing some women experience significant delay in return to normal ovulation (independent of no. of doses) Fertility returns to normal within 18 months Abortion: o RU-486 o Morning after pill: High dose estrogen Must be given within 72 hours Sterilization: o Tubal occlusion o Vasectomy Abortion

Assess advise on healing perineum ice packs, salt baths and hair dryer to perineum for comfort

Abnormal labour and delivery Ability to discuss the common causes of abnormal labour Dystocia: difficulty in labour: Causes: o Abnormal pelvis: Flat brim (platypoid) <5% of women > 152cm, 30% <152cm Spinal stenosis, kyphosis, sacralizations of L5, spondylolithesis, pelvic fractures o Abnormal presentation:

Extended head (more flexed is more favourable) Transverse Brow o Uterine dysfunction (Poor uterine contraction; normally 3 per 10 min, up to 75sec) Hypotonic Normotonic but Infrequent o Cervical dystocia Failure of dilation Ability to describe the different types of instrumental deliveries Normal: Forceps: Vacuum: C/S: Ability to identify the equipment used for operative vaginal deliveries Demonstrate understanding of surgical principles of caesarian section Types: o Lower uterine segment incision: Most common Less uterine rupture in subsequent pregnancies Better puerperal healing Reduced infection as wound is extraperitoneal Lower post-op complication rates o Classical: midline incision (rarely used) Indications: Transverse lie, with ROM and liquor draining Structural abnormalities preventing other incision Constriction ring present Some fibroids Some anterior placenta previa (lower segment abnormally vascular) Mother dead and rapid birth needed Very premature, lower segment poorly formed Ability to counsel in a crisis situation

Gynaecology Clinical Diagnosis

Obtain a gynaecological history Ability to discuss intimate details without awkwardness Ability to take an accurate menstrual history Ability to identify key signs and symptoms

Gynaecological examination Ability to perform an adequate pelvic examination including speculum examination without causing the patient undue discomfort. Demonstrate sensitivity to the intimate nature of a vaginal examination Demonstrate ability to identify common cervical Ability to assess the need for a chaperoned examination ** Ability to identify significantly enlarged adnexal mass per vaginam

Gynaecology Investigations
Assessment of Infection Ability to take appropriate swabs Ability to label tubes correctly Ability to ensure transport to lab in good condition Ability to carry out speculum examination Ability to take adequate Pap smear and to label correctly Ability to fix slide Ability to explain results to patient Understanding of screening program for cervical cancer and ability to carry out appropriate action according to result of cervical smear

Ability to assess infection Ability to take appropriate swabs for bacteriological or viral tests Ability to interpret results Interpret and discuss ultra sound examination of the female genital tract Demonstrate a systematic approach including checking name and date Demonstrate ability to point out normal female anatomy on scan Demonstrate knowledge of the limits of ultrasound

Gynaecology Management and Communication


Demonstrate knowledge of the pharmacology of drugs commonly used in the treatment of gynaecological conditions Demonstrate knowledge of side effects Demonstrate ability to communicate necessary information about drug therapy to patients

Management of vaginal bleeding Ability to assess blood loss Ability to resuscitate a haemodynamically compromised patient Ability to institute drip therapy: and to assess fluid replacement needs both quantitatively and qualitatively

Assessment and treatment of infections Ability to discuss feminine hygiene and sexual behaviour in order to prevent or reduce recurrence Ability to explain proper use of pessaries Ability to explain drug regimen to patient Demonstrate appreciation of the importance of considering sexual partner

Incontinence and prolapse Competence in the vaginal examination in the older woman Indications: o Menstrual abnormalities o Unexplained abdominal pain o Vaginal discharge o Prescription of contraceptives o Bacteriological and cytological studies o Patient desire o Rape Preparation: o Chaperone for man o Try to make patient relaxed o Explain anatomy and reason for exam first o Show the patient the speculum and other equipment and allow her to handle them during your explanation o Avoid hurting them in 1st encounter especially.be as gentle as possible.

o Ask the patient to empty the bladder o Patient positioning: Position the drape appropriately (covering mid abdomen to knees depress it in the middle to allow patient and Dr to see each other) Assist feet onto stirrups (or get nurse to!) Ask her to move to the end of the bed until the buttocks are slightly beyond edge Alternately without stirrups: o Feet together on bed, open knees, rest outside one against Dr. Thighs flexed, abducted and externally rotated Elevating patients head and shoulders slightly (pillow) Arms by side or crossed on chest (not behind head as tightens Abs) o Offer a mirror if possible to allow the patient to see o Explain each step o Warm your hands and the speculum (check speculum on patients leg) o Watch the patients face when possible Equipment: o Light o Speculum Pedersen= narrow type (plastic or metal) Graves= wider end (metal) o Lubricant o Cytobrush and other smear brush o Slides o Fixating spray Abdominal examination o Scars o Organomegaly o Masses Inspect External Genitalia: o Inspect: Mons pubis Hair/ sexual maturity Labia Perineum o Part labia majora and inspect: Labia minora Clitoris Urethral meatus Vaginal opening or introitus Note: Inflammation Ulceration

Swelling Nodules Lesions: palpate these Bartholins gland (if a history of labial swelling) o Place index finger in up to DIP at 5 or 7 oclock and palpate with thumb outside the posterior part of the labium maloris o Note tenderness, swelling or discharge. Urethra (if urethritis or paraurethral gland inflammation suspected) o Place index finger in vagina at 12 oclock up to DIP and part labia minora gently with other hand index finger and thumb. o Milk gland and watch for discharge..culture if present.

Internal examination o Locate the cervix: Insert index finger and identify the firm rounded surface of the cervix Use water only for lubricant if doing it before smears to locate cervix and check speculum size needed o Assess vaginal wall support: Labia separated (index and middle finger) Ask patient to strain Note any bulging of the vaginal walls o Insert the speculum: Part labia with left hand Point down and back (hold handle down in right hand) Gentle external pressure at the base of the extroitus will widen it. Open the speculum and adjust it till it cups the cervix To find the cervix drawing back may help and repositioning the slope Wipe excess discharge away with a large cotton swab Inspect the cervix and os: Colour, position, surface characteristics, ulcerations, nodules, masses, bleeding or discharge. Tighten screw to maintain the open speculum o Obtain smears: PAP smears: Endoervix (cytobrush) Ectocervix (cervical brush / broom) Endocervical swab o Inspect vagina: Withdraw speculum slowly allowing it to close slowly once clear of the cervix and opening slightly at the end. o Perform a bimanual examination: Palpate adnexae for masses Palpate uterus (hand midway between symph and umbilicus and elevate cervix with other hand) Feel shape, consistency, mobility, identify tenderness or masses. o Assess pelvic muscles:

2 fingers drawn out clear of cervix and spread. Patient should be able to contract them together for 3 seconds. o Rectovaginal examination: Index in vagina, ring in rectum Allows palpation of retroverted uterus Knowledge of the methods of investigation of urinary incontinence ** Urinalysis and urine culture: o To rule out infection Neurological examination: o Perineal sensation o Pelvic floor contraction o Reflexes: deep tendon anal bulbocavernosal Standing stress test: o Patient (full bladder) stands over a towel or sheet with feet a shoulder width apart. o Patient coughs o Dr observes for leakage o Can be done in lithotomy position as an alternative o Low sensitivity and specificity Cotton swab test o To Dx a hypermobile bladder neck with genuine stress incontinence o Insert lubricated swab into urethra to the angle of the urethrovesical junction (UVJ) o Patient strains as if urinating: UVJ descends and the swab moves o Normal angle is < 30 degrees from horizontal o 30-60 degrees associated with a hypermobile bladder neck. Cystometrogram: o Distinguishes b/w genuine stress incontinence and detrusor instability o Pressure sensors used to determine bladder and sphincter tone as bladder is filled o Observations made about: Bladder filling capacity Presence/absence of a detrusor reflex Patients ability to control or inhibit the strong desire to void Uroflowmetry o Measures rate of flow through urethra o Patient asked to spontaneously void whilst sitting on a chair

o Particularly useful in patients complaining of: Hesitancy Incomplete bladder emptying Poor stream Urinary retention Urethroscopy/Urethrocystometry Ability to fit a ring pessary Vaginal pessaries: o Mechanical support for lost structural integrity of pelvis o Indicated if surgery is C/I o Placed in the vagina, positioned like a diaphragm o Need regular follow up to avoid trauma and necrosis o No sex whilst in position

Common Gynaecological cancers Ability to relate to the patient with cancer See Greg Gards lecture (Monday wk 5) for facts Be sensitive, listen to the patient, tell them about the problem, options etc. (touchy, feely!)

Explanation of further investigation Ability to explain techniques and principles of: o Infertility investigation 90 % of young couples conceive within 1 yr Infertility Causes (some couples have multiple causes): o Anovulation: 20% o Male factors: 25-40% Endocrine: Hypothalamic dysfunction, pituitary failure, hyperprolactinaemia, exogenous androgens, thyroid disease, adrenal hyperplasia Abnormal Spermatogenesis: Mumps orchitis, chemical/radiation/heat, varicocele, cryptorchidism) Abnormal motility: Varicocele, antisperm antibodies, kartageners syndrome, idiopathic Sexual dysfunction: Retrograde ejaculation, Impotence, decreased libido

o Uterine-tubal factors: (30%) Uterine abnormalities Congenital, submucosal leiomyoma, intrauterine synechiae Tubal occlusion PID, Tubal ligation, endometriosis o Peritoneal factors: (40%) Endometriosis, pelvic adhesions o Cervix abnormalities (10%) DES exposure, stenosis, surgery, cervitis, hostile mucus, mulleriuan duct abnormality History: o Male

Puberty Previous pregnancies fathered Environmental exposures Illness: STIs Mumps orchitis Surgery: Hernia repair, orchidopexy, bladder neck surgery, prostate Trauma to genitals Occupation: is he home when ovulation occurs o Female: Menstrual history Endometriosis: (Maybe Pain, Dyspareunia, Abnormal bleeding) Adhesions: (maybe pain) STIs Contraception Previous pregnancies Pelvic infections Abdominal surgery o Both: Technique, frequency, timing Feelings about infertility Previous investigation Physical Examination o Male: Endocrine signs Signs of testosterone deficiency Varicocele Identify urethral meatus / penile abnormalities Testicular size (Normal = 3.5-5.5 x 2.1-3.2) o Female: General health

Hirsuitism Endocrine Sexual development Abdominal/pelvic exam Investigations: o Ovulation: Track menstrual cycle Measure basal body temperature (rise mid cycle) Cervical mucus: raw egg white at mid cycle Midluteal surge serum progesterone (day 21 rise, 7 days pre menstruation) LH surge (at ovulation, midcycle) US: visulaise follicle development or change to secretory endometrium Endometrial biopsy: adequate gland and stromal development Premenopausal/ovulatory symptoms Progestin challenge: o 5-10/7 progestin administration, then stopped: should bleed o demonstrates endometriums response to progesterone Endocrine evaluation: o FSH, LH, prolactin, TFTs, thyroid antibodies o Cushings: Serum testosterone, DHEAS, 17hydroxyprogesterone, 24hr urinary cortisol, overnight dexamethasone suppression test o Intracranial pathology: MRI or CT o Male: Semen analysis: Volume (mean 2.75ml) Count (>20 million) Morphology (>60% normal) Motility (>40%) Ph WCC Antibodies Infection If abnormal: o Endocrine evaluation: TFTs, serum testosterone, prolactin, FSH Post coital test Less common Normal= large no. sperm seen in thin acellular mucus. o Uterine-tubal Pelvic ultrasound Hysterosapingogram Sonohystogram Hysteroscopy

Laparoscopy o Peritoneal causes: Laparoscopy o Cervical causes: Post coital test o Cancer treatments Vulval: o Leukoplakia Topical corticosteroids S/E: mucosal thinning, absorption PUVA, methotrexate, cyclosporin o VIN seen with 5% acetic acid (6% go onto cancer, linked with HPV) Wide local excision or laser ablation o Carcinoma (95% are squamous, rare, occur in elderly mainly) Stage 1 and 2 (<2cm, no nodes) triple incision or radical vulvectomy + wide excision + inguinal nodes may need skin grafts Cervical: o Regular Pap smears (2 yearly if normal) o Abnormal pap smear: 3 types: ASCUS: Atypical squamous cells of undetermined significance) o Follow up pap smear in 6 months Squamous intraepithelial lesions Squamous cell carcinoma If suggestive of CIN 1 (inflammatory cells, or mild atypia) Repeat pap smear in 6 months Or Colposcopy if 2nd repeat +ve If suggestive on CIN 2/3 or cancer Colposcopy o Abnormal tissue has characteristic blood vessels and stains white with acetic acid o Punch biopsies taken for histology o Doesnt detect adenocarcinoma o CIN 1 (mild dysplasia) Repeat pap smear 6 months 50% return to normal serial pap smears (6 monthly), colposcopy if continue to be abnormal. Takes 7 years on average to progress to cancer o CIN 2/3 (moderate dysplasia) (98% curable) Small lesions confined to exocervix: Cryotherapy

Laser Electrocautery (requires laser) Repeat colposcopy, papsmears Endocervix Surgical excision of the transformation zone o Cone biopsy o Loop (LEEP) Electrosurgical Excision procedure o Smear taken of tissue deep to that of biopsy and margins checked o INVASIVE DISEASE 95% SCC, 5% adenocarcinoma Stage 1 (tumors confined to cervix) (80% 5 yr survival) Consider cone biopsy to maintain fertility for microinvasive disease 1A1- simple hysterectomy 1A2 and 1B - radical hysterectomy Stage 2 (local invasion beyond cervix but not beyond pelvic wall, involves vagina but not lower third) TAH (60%- 5 yr survival) Stage 3 (Spread to pelvic wall and lower 1/3 of vagina) Extensive radiotherapy and chemotherapy TAH (up to 50% survival?) Stage 4 Palliation Endometrial cancer o Surgical staging o TAH o BSO o Peritoneal washing o Pelvic aortic node sampling o Local or regional radiation o (stage 3 and 4 also: hormonal therapy and chemotherapy) Ovarian o 90% are epithelial tumors: TAHBSO, omentectomy, debulking procedures, taxol and cisplatin based chemotherapy o Germ cell tumors Removal of affected ovary, combination chemotherapy o Colposcopy See above.

Neonatology Clinical Diagnosis

Assessment of baby at birth Demonstrate ability to assign APGAR score Demonstrate ability to decide speedily whether resuscitation is required

Examination of newborn Ability to handle neonate confidently and competently Ability to efficiently examine all systems without distressing baby or mother

Assessment of respiratory distress Ability to recognise respiratory distress Ability to assess severity of RDS Identify likely underlying cause in term and pre-term infants Assessment of baby with neonatal abstinence syndrome Recognise baby with signs of Assess severity of NAS

Neonatology Investigations
Anthropometric parameters Weigh baby Measure length accurately Measure Occipito-frontal circumference properly Enter findings into "The Blue Book"

Blood tests Ability to perform heel stab for neonatal screening tests Take sample for bilirubin measurement Ability to interpret blood tests results Bacteriology Ability to carry out an infection screen Demonstrate knowledge of appropriate samples to take, correct labeling and how to transport to laboratory Ability to interpret results of bacteriological investigation

Neonatology Management and Communication

Supporting Breast feeding Encouragement of mother Demonstrate knowledge of the physiology of breast feeding Knowledge of correct feeding position for both mother and baby Knowledge of common breast feeding problems and how to advise

Cord care Manage cord care till separation

Baby in SCBU Ability to handle baby in incubator Ability to inform parents of progress Ability to help parents bond with SCBU baby

Resuscitation Ability to prepare resuscitation equipment Ability to evaluate an infant for resuscitation Ability to use a mucus extractor Ability to apply bag and mask ventilation Ability to perform cardiac massage on a neonate

Assessment of neonate Filling in meconium/urine chart Ability to diagnose jaundice and manage appropriately Knowledge of phototherapy units and precautions to take with their use

STATIONS + MEQ: PPH Antenatal checkups IUGR Pre-eclampsia Irregular bleeding/abdo pain

Infertility Polycystic ovary Pap smear CIN2 * Neonatal resus * Respiratory distress Neonatal hypoglycaemia Post partum fever Morning after pill * - high dose estrogen up to 72 hours HRT Skin conditions Breast feeding Jaundice Guthrie test