Obstetric Gynaecology Jan 11

8/13/2019 Obstetric Gynaecology Jan 11

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Practical issues, History taking & Clinicalexamination in O&G

Hervinder Kaur

Consultant Obstetrician & Gynaecologist, UHCWObstetric & Gynaecology Lead for Warwick

Medical School


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LEARNING OBJECTIVES

To develop the basic clinical skills of history taking, clinicalexamination and case presentation in O & G.

To obtain knowledge of the common clinical problems in O & G.

ANC : Booking visit: History taking Investigations ( booking bloods & scan) Downs syndrome screening

Health promotion advice- smoking, alcohol, drug abuse& diet Management plan High/Low risk pregnancy?


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LEARNING OBJECTIVES CONT.

Examination of pregnant women

Pre eclampsia, IUGR, Large for dates , polyhydramnios,breech/ transverse lie, twins , previous caesarean, grandmultiparous , Obesity & placenta previa

Medical disorder- Diabetes , thyroid problems, essentialHTN, Cardiac, renal, drug misuse, Hepatitis/HIV.

Pre-operative counselling for C-section

Emergency Obstetric Admissions

Abdominal pain

Preterm labour/ SROM

Ante/postpartum bleeding

Pre eclampsia/ Eclampsia


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Obstetric Day Assessment Unit

Antenatal fetal assessment- CTG, USS (growth/liquor/doppler)

Maternal assessment-BP/urine, blood test (PET, GTT)

Labour Ward

Induction of labour

Management/Complications of labourNormal deliveries

Fetal Monitoring in labour

Pain relief in labour

Instrumental deliveries & Caesarean section-elective/emergency

Twins

Preterm labour

HDU care- PPH, Severe pre eclampsia/eclampsia


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EPAU

Early pregnancy scan

Miscarriage

Ectopic pregnancy

Molar pregnancy

GOPD

History taking

Gynaecological examination-abdomen, pelvis (speculum,

digital bimanual)Investigation & management of menstural abnormalities

Investigation & management of pelvic pain/endometriosis


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Diagnosis & management of menopause

Urogynae clinic-Management of prolapse

& incontinenceInfertility clinic- Management of male & female infertility

OncologyManagement/follow-up of gynae cancer

& management of abnormal smear (colposcopy clinic)

GUM clinic

Obtain sexual lifestyle history

Understand relevance of confidentiality and

being non-judgmental.Genital examination and swabs from couple

STD- diagnosis & treatment

Pre/post test counselling for HIV


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Community

Home visits - Postnatal examination

(caesarean scar, perineal tears)

Pre eclapmsia surveillance

Community midwife ANC


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PORTFOLIO CASES

Obstetrics:

1. A normal pregnancy delivery and puerperium

2. Antepartum/postpartum haemorrhage

3. An abnormality of fetal growth and development

4. Pre-eclampsia

5. Medical disease complicating pregnancy

6. Multiple pregnancy

7. Abnormal labour

8. A third stage abnormality


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Gynaecology

1. Menstural disorder

2. Endometriosis3. Prolapse

4. Incontinence

5. Infertility

6. Postmenopausal bleeding

7. Early pregnancy complication


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Obstetric History

Age

Gravidity

Parity- (Preg>24 wks)+(Preg< 24wks)

LMP; menstural cycle; conceived on pill; EDD

History of this pregnacy :

- Presenting complaints- when did they occur &how long they lasted, any investigation ortreatment already ?

- Low/high risk pregnancy?

- Any problems in antenatal care so far ?

- Fetal movements


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Obstetric History

Previous pregnancy:- Previous miscarriages

- Gestation & mode of delivery

- Length of labour & complications

- Third stage complications- Postnatal problems

Medical & surgical history

Drug history & allergies

Family history- hereditary disorders, HTN,DM, twins orcongenital malformation

Social history- smoking, alcohol, drug misuse,occupation, housing & marital status


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Examination

Consent, explanation & beware ofsupine hypotension

General examination-Colour

-Hand, eyes & mouth

-Presence of oedema

-BP & Urine

-CVS & Respiratory systemexamination


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Abdominal Examination

Inspection: abdominal scars

striae gravidarumlinea nigra

oedema


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Abdominal palpation

alpation of pregnant abdomen:1. Examination of uterine

fundus

Symphysio- fundal

height(cm)

2. Fetal back

3. Presenting part e.g

vertex, breech

4. Engagement of

presenting part

Four maneuvers

of leopold

P


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Lie of Fetus

Longitudinal lie

Transverse lie

Lie: relationship of long.axis of fetus to long.axis

of uterus e.g longitudinal,

transverse, oblique


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Presentation of fetus

Presentation:

presenting part of fetus

occupying the lower pole

of uterus i.e ceph(vertex),

breech,face,brow or

shoulder


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Female bony pelvis

Pelvic diameters:

Anterio-posterior

Transverse

Oblique

Right

Side

Left

side


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Position: Relationof denominator(occiput/ sacrum) of

presenting part tothe quadrants ofpelvis e.g

LOA,LOP

1. Left Occipito- anterior

2. Left Occipito- posterior


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Amniotic fluid

Auscultation:FETAL HEART

G

Engagement: Widestdiameter of head below thepelvic brim.

No. of 5th head palpableabove the pelvic brim e.g4/5th , 3/5th


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Fetal skull

s

Bregma


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Parts of fetal skull:

a) Occipital boneb) Posterior fontanella

c) Saggital suture

d) Frontal bone

e) Anterior fontanelle

f) Parietal bone

Presenting diameters:

g) Face presentation

Submento-bregmatic

h) Deflexed OP

Occipito-frontal

i) Brow presentation

Occipito-mental

j) Normal vertexSub-occipito bregmatic

Bregma

Mentum

Occiput


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Vaginal Examination

Vulva & vagina

Cervix-dilatation ,effacement, position & consistency

Presenting part i.e Vertex

Station-cm in relation to the ischial spine

Caput-swelling on the scalp superficial to periosteum ofcranium ,as a result of venous congestion, on the part of

head most in advance

Moulding- Overriding of the bones of skull

Membranes & Liquor


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Vaginal Examination

Station -3

Station +3

s

Station- position of presenting part(PP) in cm in relation to the ischialspine


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Mechanism of labour

1. Free head

2. Descent &

engagement3. Descent & Flexion

4. Internal rotation

5. Extension

6. External rotation7. Restitution

8. Delivery of shoulder

LOA position:


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Useful website for medicaillustration

Nucleus Medical Media

Normal vaginal delivery anim002

Normal vaginal birth ANC00030

Delivery ANC00037

Birth station of presentation ANC00038

Change in cervix during pregnancy S15551477


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Gynaecological History

Age, Gravidity, Parity, LMP

Contraception

Last cervical smear

Presenting complaints: Nature & duration

Relation to menstrual cycle

Bowel symptoms

Urinary symptoms

Vaginal discharge

Vaginal bleeding


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Gynaecological History

Previous Gynaecological & Obstetric History:

PID/STI

EndometriosisPrevious miscarriages / preg24 wks & outcome


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History cont.

Medical

Surgical

Family history- Fibroids, endometriosis,cancers, DVT/PE

Medications

Allergies

Social History


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Examination General-Conjunctiva, pulse

Abdomen:

- Inspection- distension of abdomen

mass

previous scar

- Palpation- tenderness

mass( size, consistency)

ascites

lymph nodes- Percussion

- Auscultation


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Vaginal Examination

Vulva

Speculum (Cuscos & Sims)

- vagina (atrophy, mass, trauma, prolapse)

- cervix (ectropion, polyp, growth, contact bleeding,

- uterine prolapse

Bimanual pelvic exam.uterine/ adenexal massestenderness


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Competencies (Mandatory)

Examination of pregnant abdomen

Examination of non-pregnant abdomen

Speculum(Cuscos speculum)examination


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Demonstratio

n

Obstetric Gynaecology Jan 11

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