TOP 5 OBSTETRICS AND GYNAECOLOGY Facinganobstetricorgynaecologycaseinthefinalclinicalexaminationscanbea challengeforeventhemostconscientiousandconfidentofmedicalstudents.Comparedto medicineandsurgery,afractionoftheundergraduatecurriculumisdedicatedtoO&Gand studentsoftenfeelunderpreparedanduncomfortable.IntheirshortO&Gblockinthelast yearortwoofmedicalschool,studentstrytobecomeaccomplishedathistoryand examination,whilstfacingunfamiliarclinicalpresentationsanddifferentialdiagnosis.This can understandably seem overwhelming.This guide is not intended, and could never be, a substitute for a sound understanding of the applied basic sciences in obstetrics and gynaecology.Nor could it be an alternative to spendingtimewithpatients,takinghistories,clinicalexaminationandpresentingcasesto seniorcolleagues.TheTOP5approachprovidesausefulframeworkfororganisingones learninginpreparationforclinicalexaminations.Ihopethattheselistswillmakelearning easier,andprovideawaytocategoriseandunderstandsomeoftheclinicalscenariosyou have encountered. Theobstetricspartofthisguideisdividedintofoursections.Thefirstoutlinesan examplemarkingschemeforobstetricexamination,includingadescriptionofexamination technique and possible findings. The second deals with normal pregnancy.Thethird looks atproblemsonthelabourward.Lastly,thefourthsectionlistscommonpresentationsin maternity assessment or in the ante-natal clinic. Thegynaecologysectionisstructuredinasimilarway.Thefirstsectionoutlinesa potential marking system for examination of a patient with a gynaecological complaint.The secondlooksatcommonpresentingcomplaints,andtheircauses,encounteredinthe gynaecology clinic.The third section deals with emergency gynaecology presentations.The last section includes miscellaneous lists, such as tumour markers. On a final note, I have written this guide some years after graduation, with experience asatraineeinO&G.However,Icaneasilyrecallthedauntingprospectofmedicalschool finals.The memory of my obstetric OSCE station, during which I fumbled my way through consent for external cephalic version, still feels very uncomfortable.I trust that you will feel more prepared than I did, and I hope you consider the following approach to be useful. Good luck SECTION ONE: HISTORY AND EXAMINATION FINALS OBSTETRIC EXAMINATION/18 Introduces self/obtains consent1 General examination General inspection 1 Weight, height and BMI 1 Blood pressure1 HR, RR, and temperature 1 Abdominal examinationInspection Note the distension of abdomen1 Comment on any scars1 Comment on any cutaneous signs of pregnancy 1 PalpationMeasure the fundo-symphyseal height (cm)1 Determine number of fetuses1 Lie 1 Presentation 1 Engagement1 Comment on any tenderness, or guarding1 Comment on any palpable uterine contractions1 AuscultationAuscultation of the fetal heart 1 Urinalysis 1 Summary 1 Proposed plan of management1 Generalinspectionshouldbebrief.Commentonwhetherthepatientlookswellor unwell,showsanysignsofanaemia,andiflookscomfortableatrest.BMIisusually calculatedandrecordedatbooking,butitisimportanttoshowthatyouknowitformsan importantpartoftheexamination.Bloodpressureisanessentialpartoftheobstetric examination and is recorded at each antenatal visit.If it is an unscheduled antenatal review, for instance, at maternity assessment, then all observations would be taken. Ageneralstatementsuchastheabdomenisdistendedinkeepingwithpregnancyof estimated gestation.Anyabdominalscarsshouldbenotedandcorrelatedwiththeclinicalhistory.They mightincludesuprapubictransverseforpreviousCaesareansection,appedicectomy,ora midline laparotomy scar. Cutaeneous signs of pregnancy include linea nigrans, abdominal striae and distended superficial veins. Inordertocalculatethefundo-symphysealheight,palpatethehighestpointofthe uterus.Usetheulnaraspectofyourlefthandtomovedownfromxiphisternumuntilthe fundus is located.Measure from here to the upperborder of the bony symphysis.From 20 weeksgestation, thedistancein cm is equivalenttogestationalage(i.e.20cm=20weeks) until 36 weeks.Thenumberoffetusisdeterminedbypalpatingthethefetalpoles,andassessingif there is more than one fetal back. Thelieofthefetusdescribesitsrelationshipbetweenitslongitudinal accessandthe longitudinal access of the mother.It may be described as longitudinal, transverse or oblique. The presentation of the fetus describes the part of the fetus that is the presenting part to the mothers pelvis.If the lie is longitudinal, the presentation may be cephalic (head first) or breech (bottom, or foot first).If the lie is transverse or oblique, there may be no presenting part, or it may be shoulder, arm or umbilical cord.With transverse or oblique lies, a vaginal deliveryisnotpossibleunlessthefetusspontaneouslychanges,oristurnedbyexternal cephalic version, to longitudinal lie, preferably with a cephalic presentation.Uterineactivityisassessedbypalpation.BraxtonHickscontractionsarepainless tightenings which come and go.This is a normal finding in latesecond and third trimester.Uterinecontractionsassociatedwithlabourarepainfultighteningswhichcomeandgo.A vaginal examination is then required, if not contra indicated, to diagnose and assess stage of labour.Atense,tenderuterusisabnormalandsignalsseriouspathology,suchasplacental abruption or uterine rupture. Auscultation of the fetal heart can be done with pinard stethoscope or doptone.This is best heard by palpating for and listening over the anterior fetal shoulder.A normal rate is 120-160. Urinalysisisdoneateveryantenatalvisit,routineorunscheduled.Itmaysuggest urinary tract infection, or show significant proteinuria indicative of pre-eclampsia. Asummaryshouldincludethepertinentdetailsofthehistoryandexamination, includingage,parity,gestation,pertinentpointsfromthehistory,andasummaryofthe positive and any important negative examination findings. Youshouldbeabletopresentaplanforyourpatient.Thiswillvaryhugely, dependingontheproblem.Itmaybethat thewomanhasnopresentingcomplaint assuch, and is completely well in a normal pregnancy.An appropriate plan in that situation would be toschedulearoutinereviewattheantenatalclinic.Aplanforawomanwithantepartum haemorrhage at 35 weeks might be CTG, admission, IV access, FBC and group & save, USS for placental site and speculum examination once placenta praevia is excluded. SECTION TWO: NORMAL PREGNANCY and LABOUR Top 5 physiological changes in normal pregnancy 1.Cardiac a.Increase Stroke Volume and slight increase HR b.Therefore, increased CO (HRxSV =CO) 2.Respiratory a.RR unchanged b.Tidal volume increases 3.Endocrine a.Increased thyroxine demand b.Impaired glucose tolerance4.Haematologicala.Increased clotting factors b.Increased iron consumption, and increased plasma, therefore iron deficiency anaemia common 5.GI a.Delayed gastric emptying b.Reduced peristalsis causing constipation Top 5 components of the 12 week booking appointment* 1.Full PMH 2.Past obstetric history (POH) 3.Offer of screening blood tests a.FBC b.Group and savec.Syphilis d.Rubella e.HIV 4.Dating scan to confirm ongoing pregnancy and estimated date of delivery (EDD)** 5.Offer of screening tests and discussion of diagnostic tests a.Some hospitals are able to offer nuchal translucency scans withb.Other hospitals just offer serum screening in isolation.Blood test done at 15+5 20 weeks is called the AFP/HCG test to give low risk or high risk for spina bifida and Downs syndrome c.Fetal anomaly scan doen at 20 weeks to look for fetal structural anomalies * usually at 12 weeks but can often range from 11-16 weeks **note any women with a dating scan after 24weeks is known as a late booker and EDD is not reliable.The dating scan may also show multiple pregnancy, or problems like anencephaly Top 5 components of each return appointment Primigravida women should have 10 antenatal checks at 16, 25, 28*, 31, 34*, 36, 38, 40 and also at 41 weeks if undelivered. Parous women should have 7 antenatal checks at 16, 28*, 34*, 36, 38 and 41 weeks. 1.Ask about general well being/oedema/awareness of fetal movement 2.BP 3.Urinalysis4.Palpation of fundal height, fetal lie, presentation and assessment of liquor 5.Ausculation of the fetal heart using Pinnards stethoscope or doptone *FBC and antibodies are repeated outinely at 28 and 34 weeks.If patient is rhesus negative, routine anti-D prophylaxis is given as IM injection at 28 weeks Top 5 common complaints in normal pregnancy 1.GIa.Nausea and vomiting b.Heartburn c.Constipation d.Haemorrhoids 2.Urinarya.Frequency b.Urinary tract infection3.General a.Weight gain b.Fatigue c.Peripheral oedema4.Musculoskeletala.Backpain b.Symphysis pubis dysfunction 5.Breast tenderness 3 pathways of antenatal care 1.GREEN low risk2.AMBERmoderate risk 3.REDhigh riskThere are only three! Top 5 High risk factors identified at time of screening 1.Co existing maternal co morbiditiesa.Obesity b.Renalc.Cardiac d.Respiratory e.Previous DVT/PE f.Psychiatric g.Inflammatory bowel disease h.Previous extensive abdominal surgery i.Endocrine (Diabetes, thyroid disease, Addisons) j.Infections2.Previous antenatal complication a.Pre eclampsia b.Gestational Diabetes c.Ante partum haemorrhage3.Previous intra partum or post natal complicationa.Previous caesarean section b.Previous pre term labour orpre term ruptured membranesc.Previous third degree tear d.Previous severe post partum haemorrhage e.Previous intra uterine death or neonatal death4.Social problems a.Domestic/drug/alcohol abuse b.Asylum seeker5.Family history of fetal anomaly or genetic disorder Top 5 signs of normal labour Labouristheprocessbywhichthecontentsoftheuterinecavityareexpelledafter24 completedweeks(stageofviability).Itisdefinedasregular,painfuluterinecontractions withprogressivecervicaldilatationandeffacement(shorteningandretractionofcervix).This is described as at term if it occurs after 37 completed weeks. 1.Persistent backpain2.Painful, regular uterine contractions 3.PV Show 4.Spontaneousruptureofmembranes(onlyifinassociationwithcervical dilatation) 5.Nausea/vomiting/diarrhoea Three Stages of labour 1.First stage The first stage commences with the onset of labour and ends when the cervix has reached full dilatation. 2.Second stage The second stage begins at full cervical dilatation and ends with delivery of the baby. 3.Third stage The third stage begins with the delivery of the baby and ends with the expulsion of the placenta. There are only three stages. 5 stages of normal vaginal delivery 1.Descent and flexion of fetal head 2.Internal rotation3.Extension and delivery of fetal head4.Restitution5.External rotation and delivery of shoulders Top 5 analgesics in labour 1.Non pharmaceutical (bath, birthing pool, relaxation techniques, TENS) 2.Entonox (50/50 mixture of nitrous oxide and oxygen) 3.Diamorphine IM4.Epidural5.Pudendal and perineal infiltration SECTION THREE: PROBLEMS ON THE LABOUR WARD Top 5 Maternal labour ward emergencies 1.Ante partum haemorrhage (APH) 2.Post partum haemorrhage (PPH) 3.Eclampsia4.Maternal collapse 5.Uterine inversionTop 5 Fetal labour ward emergencies 1.Shoulder dystocia2.Cord prolapsed 3.Fetal distress (hypoxia/acidosis) 4.Malpresentation5.Failed operative delivery Top 5 causes of APH The definition of APH is bleeding from the vaginal tract after 24 weeks pregnancy until completion of second stage of labour. 1.Uteroplacental causesa.Placental abruption b.Placental praevia* c.Uterine rupture 2.Cervical lesionsa.Cervical erosion b.Cervicitis c.Cervical polyp d.Cervical cancer3.Vaginal infections 4.Vasa praevia** 5.Unexplained *Note, a digital vaginal examination is contraindicated in women with APH until placenta praevia is excluded.If a previous scan at around at least 20 weeks gestation showed the placenta is not low lying, the placenta will not then become low after this. **Fetal bleeding Top 5 causes of PPH Primary bleeding from vaginal tract in excess of 500ml after second stage of labour, until 24 hours of delivery Secondary excessive vaginal blood loss in puerperium after 24 hours until 6 weeks after delivery 1.ATony a.Failure of the uterus to contract well after delivery 2.Trauma a.Perineal/vaginal wall tear b.Cervical tear c.Extension of uterine incision and broad ligament tear can occur at time of caesarean section3.Tissue a.Retained Placenta b.Retained pieces of placenta or membrane4.Thrombin a.Clotting factor deficiencies can precede PPH or be due to severe PPH 5.UTerine inversion a.Prolapse of uterus though vagina causes severe maternal shock and is mercifully rare. Top 5 risk factors for PPH 1.Uterine distension a.Big baby b. Multiple pregnancy c.Polyhydramnios 2.Prolonged labour and/or operative delivery3.Fibroids4.Grand multiparity 5.APH Top 5 principles of PPH management 1.Call for help2.ABC a.Oxygenb.Large bore IV access x 2 c. FBC, coag, XM 4 units d.Urinarycatheter 3.Identify cause(s) of PPH4.Control bleeding 5.Replace the blood loss 5 stages in PPH management algorithm 1.Ensure 3rd stage complete if not MROP 2.Rub uterine fundus to stimulate contraction +/- bimanual compression if required to stop uterine bleeding 3.Assess for cervical/vaginal wall/perineal tears if present, repair 4.Medical management of atony with oxytocic medicines a.Syntocinonb.Ergometrine c.Carboprost d.Misprostol 5.Surgical managementa.Intra uterine balloon device b.B lynch suture if at Caesarean sectionc.Uterine artery embolisation/ligationd.Hysterectomy Top 5 complications of 3rd stage of labour 1.Retained placenta 2.Post partum haemorrhage 3.Uterine inversion 4.Third/fourth degree tear5.Amniotic fluid embolisation Top 5 reasons for Elective Lower Uterine Segment Caesarean Section (El LUSCS) 1.Previous LUSCS 2.Breech presentation or abnormal lie 3.Multiple pregnancy with non cephalic presentation of first twin 4.Previous traumatic delivery and/or maternal request 5.Placenta praevia Top 5 indications for emergency LUSCS (Em. LUSCS)These can be divided into Fetal and Maternal indications, although clearly there can be considerable overlap. Fetal1.Fetal distress in first stage of labour 2.Fetal distress in second stage of labour and any contra indication to instrumental delivery 3.Malpresentation a.Breech b.Shoulder c.Armd.Brow e.Face 4.Cord prolapse 5.Prolonged second stage and any contra indication to instrumental deliveryMaternal 1.APH 2.Maternal morbidity during labour e.g sepsis3.Maternal cardiac arrest4.Absolute/relative cephalopelvic disproportion 5.Uterine rupture Top 5 LUSCS complications 1.Haemorrhage +/- blood products2.Infection3.DVT/PE 4.Damage to bladder/bowel/ureter/vessel5.Injury to baby Top 5 indications for instrumental delivery 1.Prolonged second stage2.Fetal distress in second stage3.To prevent undue maternal effort in women with cardiac or respiratory conditions4.Malposition of the fetal head (occipito-trasnverse or occipito-posterior) 5.After coming head in breech delivery or delivery of head at caesarean section Top 5 pre requisites for instrumental delivery 1.Full dilatation of cervix 2.Cephalic presentation 3.Vertex at least at level of ischial spines 4.No more than 1/5th palpable abdominally 5.Adequate analgesiaTop 5 risk factors for shoulder dystocia* 1.Suspected big baby or post dates pregnancy2.Gestational diabetes 3.Previous shoulder dystocia 4.Prolonged labour+/-instrumental delivery5.Maternal short stature *Note most cases of shoulder dystocia are unpredicted Top 5 Maternal complications of shoulder dystocia1.PPH 2.Third/fourth degree perineal tear 3.Uterine rupture 4.Rectovaginal fistula 5.Symphyseal separation and associated neuropathy Top 5 Fetal complications of shoulder dystocia1.Fetal hypoxia 2.Fetal death 3.Brachial plexus injury 4.Fracture of clavicle 5.Fracture of humerus Top 5 shoulder dystocia management**CALL FOR HELP**1.Evaluate for episiotomy and put patient into McRoberts position (knee-chest position) 2.Suprapubic pressure behind impacted shouldera)Continuous initially b)Then rocking movement like CPR 3.Internal rotationa)Tries to release impaction of anterior shoulder, by rotating to oblique plane4.Remove posterior arm5.Turn over onto all fours and repeat Top 5 principals of management in eclampsia1.Call for help and place in left lateral positionif still antenatal (reduces vena cava compression) 2.ABC resuscitation a.Oxygen b.BP, HR, RR, O2sats, temp, BM c.Large bore IV access d.FBC, Coag, U&Es, LFTs, Urate, Group and save3.Control seizure a.Magnesium sulphate 4grams (8mls) as loading dose then maintenance infusion4.Control Blood pressure a.Labetalol loading dose IV then maintenance infusion5.Control Fluid balance a.Urinary catheter b.Fluid restrict to maximum 85 mls/hour c.Patient high risk of developing pulmonary oedema if overloaded SECTION FOUR: In MATERNITY ASSESSMENT (A&E for pregnancy!) Top 5 common presentations to Materbaity Assessment1.?Labour/preterm labour 2.?Spontaneous rupture of membranes/preterm pre labour rupture of membranes3.Reduced fetal movement 4.Abdominal pain5.Ante partum haemorrhageTop 5 causes of pre term labour (PTL)1.Cervical incompetence2.Infection3.Obstetric complication a.Polyhydramnios b.Placental abruption 4.Multiple pregnancy 5.Maternal morbidity a.Intra abdominal surgery e.g. appendicectomyb.UTI Top 5 principals of PTL management 1.Assess maternal and fetal well being (immediate delivery may be required if either compromised) 2.IM steroids to promote fetal lung maturity, if delivery not imminent 3.IV Antibiotics to protect fetus against Group B streptococcus4.Tocolysis (if less than 34 weeks gestation, and no contraindication) 5.Ensure neonatal staff aware of patient and cot available in special care baby unit Top 5 risk factors for preterm pre labour rupture of membranes (PPROM) 1.Polyhydramnios2.Previous history of PPROM 3.Bicornuate uterus 4.Infection (bacterial vaginosis) 5.Fetal anomaly Top 5 principals of PPROM management1.Assess maternal and fetal well beinga.Confirm PPROM with speculum examination to assess if liquor clear b.Determine if delivery imminent c.CTG d.Maternal observations, FBC, CRP, G&S 2.Steroids IM if delivery not imminent3.PO Erithromycin4.Fetal surveillance with weekly USS for growth, liquor volume and umbilical cord dopplers 5.Maternal review with daily temperature and twice weekly FBC and CRP Top 5 causes for large for dates 1.Macrosonia 2.Polyhydramnious 3.Increased maternal BMI 4.Multiple pregnancy 5.Increased weight gain in pregnancy Top 5 causes of small for dates 1.Constitutionally small 2.Intrauterine growth restriction3.Fetal anomaly 4.Smoking/drug abuse 5.Pre eclampsiaTop 5 risk factors for pre eclampsia 1.Essential hypertension (Hypertension before pregnancy or diagnosed before twenty weeks) or pre existing diabetes or renal disease 2.Primigravida 3.Age < 20 years or >35 years4.Previous history in previous pregnancy, or family history in first degree relative5.Fetal hydrops Top 5 clinical manifestations of pre eclampsia*1.Asymptomatic (on routine antenatal screening with BP measurement and urinalysis) 2.Headache 3.Visual disturbance4.Epigastric pain5.Irritabilitiy and decreased consciousness*there is a wide clinical spectrum in pre eccampsia, with varying hypertension, proterinuria, oedema and complications.Mild to moderate pre eclampsia may be characterised by BP >140/90 and 125, with > ++ proteinuria. Top 5 maternal complications of pre eclampsia1.Eclampsia 2.Cerebral vascular damage3.Renal and liver failure 4.HELLP (haemolysis, elevated liver enzymes, low platelets) 5.DIC (disseminated intravascular coagulation) Top 5 fetal complications of pre eclampsia 1.IUGR 2.Intra uterine death3.Iatrogenic pre term delivery 4.Hypoglycaemia in neonatal period if mother treated with labetalol5.Thrombocytopenia if mother affected HELLP Top 5 investigation and management of pre-eclampsia See also management of eclampsia in LW section1.24 hour urinary protein collection2.FBC, U&Es, LFTs, urate (and coagulation if indicated)3.Anti hypertensive medication if required 4.Maternal observationa.Regular BP measurement b.Check reflexes and presence of clonus (hyper reflexia ++ in severe pre eclampsia) c.Fundoscopy if headache/visual disturbance d.IM steroidse.Consider induction/delivery if indication5.Fetal surveillance a.CTG b.USS for growth, liquor volume and umbilical cord doppler Top 5 indications for induction of labour 1.Post estimated date of delivery (after Term+10 days) 2.Suspected uteroplacental insufficiency a.Reduced fetal movements at term b.Oligohydramnious c. Intr uterine growth restriction3.Previous intra uterine death/neonatal death at term4.Multiple pregnancy5.Maternal complicationa.Gestational diabetesb.Essential hypertension/Pregnancy induced hypertension/pre eclampsia/HELLP syndrome c.Obstetric cholestasisTop 5 points in consent for external cephalic version (ECV) ECV is a procedure which is done to try to turn a fetus, by applying abdominal pressure, to a cephalic presentation.It can be attempted for breech presentations, and also to correct a transverse or oblique lie. 1.50 % chance success 2.May revert to breech/unstable lie 3.Uncomfortable during procedure 4.Can avoid need of LUSCS and associated risk 5.Fetal monitoring with CTG before and 1/2 hour after to ensure no fetal distress suspected. Top 5 contraindications to ECV 1.Planned or previous c/s 2.Multiple pregnancy 3.Placenta praevia or history of APH 4.Fetal anomaly 5.Oligohydramnios Top 5 causes of post natal pyrexia1.UTI 2.Endometritis3.Retained products of conception4.Wound infection (Caesarean/perineal) 5.Mastitis