Obstetrics & Gynaecology

Hannah Thackray
Amy Laycock

Introduction

Introduce yourself
Check patients identity
Explain your intention
Gain consent
Wash hands
Chaperone
Bladder emptied?

General Inspection
End of the bed

- ? comfortable
- ? clues around the bed
Distended abdomen consistent with
pregnancy

General Examination
Hands
- koilonychia/pale palmer creases
- palmer erythema

Pulse
Blood pressure
Chloasma
JACCOL
Heart sounds/lung bases

Position
Semi-recumbent

Is she comfortable lying flat?

Maintain modesty

Abdominal Inspection

Shape and symmetry

Foetal movements
Scars
Striae gravidarum
Striae albicans
Linea nigra
Umbilicus
Superficial veins

Quiz Time!!!!

Linea Nigra

Striae Albicans

Striae Gravidarum

Pregnant Man!

Palpation
Always ask if patient is in any pain
Ask patient to let you know if she
experiences any discomfort
Use palmer aspect of the fingers
One hand moving at a time for lie
Two hands for presenting part

Symphysis-Fundal Height
Feel for top of fundus
Feel for symphysis pubis - GENTLE

Place tape on symphysis pubis

Measure to top of fundus
cm down, then turn tape over
SFH (cm) = gestation (weeks) 2 weeks

Small For Dates

Wrong dates
Constitutionally small
Oligohydramnios
Intrauterine growth restriction

IUGR
foetal growth potential
- TORCH
- chromosomal abnormalities
- structural abnormalities

foetal growth support

- maternal
- drugs/alcohol/smoking
- malnutrition

- uteroplacental perfusion
- DM
- poor trophoblast invasion
- multiple gestation

Oligohydramnios
Not enough produced

- renal agenesis
- multicystic kidneys
- urinary tract obstruction
- IUGR
- maternal drugs (NSAIDs)
Too much lost
- PPROM

Large For Dates

Wrong dates
Constitutionally large
Multiple gestation
Maternal DM
Polyhydramnios

Polyhydramnios
Maternal - DM

Placental AV fistula
Foetal
- multiple gestation
- oesophageal/duodenal atresia
- anencephaly

Palpation of Foetal Poles

Lie

- longitudinal
- oblique
- transverse
Presenting part
- cephalic
- breech
Engaged
- fifths palpable

Auscultation

Pinard stethoscope
Hand held Doppler
Feel mothers pulse
Listen over anterior shoulder
One minute

Extras
Urine dipstick ketones
Blood pressure

Summary
This is a . year old lady who has
presented at . weeks gestation
It is a singleton/multiple pregnancy
The foetus is in a . position
It is a . presentation
The head is/is not engaged

Obstetric Examination
Video

Gynaecology History
Station

Gynae History
Take your time!!
Read the information outside the station

.. and breath!!

Gynae History

Introduce yourself
Check patient name & DOB
Explain
Consent . Is that OK?

So what problem have you been having?

Gynae History
Presenting complaint
Pts own words
Identify most troublesome symptom

History of Presenting Complaint

HPC
Complete story for each symptom
If pain:

Onset, duration, frequency

Nature & Severity
Site & Radiation
Aggravating / Relieving factors
+ relationship to menses/ micturition / defecation

Gynae History
GH tailor the Hx to the individual!
LNMP
No. days bleeding / Length of cycle
Age of Menarche / Menopause
Post menopausal bleeding
IMB / PCB
Dyspareunia

Gynae History
GH continued..
PV discharge
Pruritus
Climacteric symptoms
Hot flushes, vaginal dryness

Contraception
Urinary symptoms
Bowel function

Obstetric History
OH
No. of pregnancies
Result of each pregnancy + Gestation
Miscarriage
ToP
Delivery

Mode of delivery
NVD
LSCS
Forceps/Suction

Past Medical / Surgical

PMH
Any other health problems?
Anything your GP treats you for?
Ever been admitted to hospital?

PSH
Any previous operations?
Ever had an anaesthetic?

Gynae History Continued

MedH
Taking any medications?
Px or OTC?

Allergies
What happens when you take it?
? True allergy ? Or just sensitivity

Gynae History Continued

SH
Smoking
Alcohol
Sexual partner/Married

FH
RoS If taken a comprehensive Hx
shouldnt be any

Summarise
Thank the patient!!!
Turn to the examiner
Give a concise summary of relevant
information

Differential Diagnosis
Common things are common!!!!
Start with the commonest
Include the serious
~ 3 differentials is fine
If you cant justify it dont say it!!!

Investigations
1st I would like to examine the pt!!
Sensible - not excessive!
Blind Surgeons Retire Early !
Bloods
FBC, Ca125, beta-hCG

Secretions
urine, PV swabs, cervical smear

Investigations
Radiology
USS (?transvaginal)
X-ray hysterosalpingography (HSG)
CT/MRI

Extras
HyCoSy
Biopsy endometrial / cervical loop
Surgical exploration

Blind surgeon?

Management
1 Conservative
Lifestyle advice
Physiotherapy

2 Medical
Drug therapy

3 Surgical
Least invasive where possible

Gynae History
Previous LOCAS
Menorrhagia & Dysmenorrhoea
Endometriosis / Adenomyosis
Fibroids
Dysfunctional uterine bleeding

PCOS
Post-menopausal bleeding

Gynae History
Possible topics
Pelvic pain
Menorrhagia
Amenorrhoea/Oligomenorrhoea
Sub-fertility
PCB/IMB

Key Points!!
Take your time
Be nice to the patient!!
Common things are common
Blind Surgeons Retire Early
Practice!!!!!!!!!!!

Any Questions?