Shifa Students Corner



OSCE – OBS/GYN Obstetrics: Obstetric Examination: IntroductionConsent & explanation Ask about empty bladderEnsure privacy, proper exposure & supine positionMake sure patient is comfortable throughout*** Say: need weight, height, blood pressure, urine dipstickINSPECTION OF ABDOMEN: start from foot-end of bedAbdominal distension and symmetryLinea nigra, striae gravidarum, scarsPALPATION OF ABDOMEN: facing motherSuperficial palpation for tendernessMeasure Symphyseal-fundal height (SFH): in CENTIMETERSPlace measuring tape at pubic symphisis with centimeters facing downPlace in between 2 fingers and stretch until palpation of highest pointpubic symphisis ~12wks; umbilicus ~22wks; 1 finger width ~2weeksLeopold’s Maneuvers:5080444500Fundal grip: number of poles & presentation Lateral grip “ballotment”: check liquor & liePawlik grip: confirm presenting partPelvic grip: (use 2 hands) engagementFace mother’s FEETScar tenderness (previous c section)AUSCULTATION: Fetal heart sounds Use pinard stethoscope (fetoscope) Place below umbilicus if cephalic presentation and above umbilicus if breechFace mother’s face & simultaneously check her pulse Hold fetoscope against ear and abdomen no hands on itNormal Labor: Definition: process by which regular painful contractions cause effacement/ dilatation of cervix & descent of presenting part leading to expulsion of fetus & placenta“Passage” Female Pelvis: Pelvic inlet: Boundaries: symphysis pubis, pubic bone margins, ileopectineal line, sacrum ala & promontoryTransverse (13.5) wider than AP (11) diameter ; normal angle = 60’Pelvic mid: Boundaries: middle symphysis pubis, pubic bones, obturator fascia, ischial bone & spine, 2nd-3rd sacrum junctionTransverse (12) equal to AP (12) diameter ** ischial spine: palpable vaginally; used to determine station & landmark for pudendal nerve block(pudendal nerve is below and behind ischial spine)Pelvic outlet: Boundaries: lower symphysis pubis, desc. ramus of pubic bone, ischial tuberosity, sacrotuberous ligament, end of sacrumAP (13.5) wider than transverse (11) diameter - Pelvic measurements widen during labor due to ligament laxityTypes of pelvis & their risks: Android: deep transverse arrestAnthropoid: occiput-posterior positionPlatypelloid: obstructed laborPelvic floor: Two levator ani muscles (pubococcygeus, ileococcygeus, puborectalis) & fascia musculofascial gutter (2nd stage)Perineum: perineal body (condensed fibrous, muscular tissue); 2nd degree tears & episiotomy“Passenger”Fetal Skull: - Sutures of face & skull base are firmly united- Sutures of vault are soft, unossified membranes: sagittal, frontal, coronal, lambdoid- Anterior fontanelle (bregma): sagittal, frontal, coronal suture junction -> diamond- Posterior fontanelle: sagittal, lambdoid suture junction -> triangleAttitude: degree of flexion of fetal skull at neck determines diameter of fetal skull presenting to pelvisVertexBrowFace9.5 cm10 cm11cm139.5 cmSub-occipito-bregmaticSub-occipito- frontalOccipito-frontalMento-vertical /occipitomentalSub-mento- bregmaticWell-flexedExtendedHyper-extendedMost common; normal deliveryCannot be delivered C-sectionMento-anterior can be delivered vaginally but not mento-posterior c-sectionLie: orientation of long axis of fetus to long axis of uterus (longitudinal, transverse, oblique)Presentation: portion of fetus overlying pelvic inlet (cephalic, breech, shoulder, compound)Position: relationship of fetal denominator (definite fetal part) to maternal bony pelvis (occiput, sacrum, mento, scapula anterior, posterior, left, rightStation: descent of fetal presenting part through the birth canal in relation to the maternal ischial spineCardinal Movement of Labor: Engagement: head in transverse position (longer diameter)Descent: due to contractions of labor in first stage and maternal pushing in second stageFlexion: in mid-cavity to decrease the presenting diameter; still transverseInternal Rotation: 90’ from transverse occipito-anterior going into pelvic outlet [shoulders enter pelvic inlet in transverse diameter]Extension: uses pubis as symphysis to extend leads to crowning [shoulders enter mid-cavity obliquely] delivery of head Restitution: slight 1/8th (45’) rotation of head to align itself with the shoulders (oblique)External rotation: 1/8th (45’) more rotation of head as shoulders rotate to AP diameter of outletBreech DeliveryPrerequisites: Frank breechPatient willingWeight < 3.5-3.8 kgAdequate pelvic assessmentNone of following contraindications: “star-gazing sign”: hyperextended necklow lying placentaprimigravidaGDM, HTNProcedure: Left lateral, O2, no active pushing; Dilation and descent is naturalWhen buttocks is visible prepare for delivery take to OTGive oxytocin for good contractions neededAnterior buttock is delivered anus seen “winking” give episiotomyLegs:If legs are flexed deliver on its ownIf legs extended PINARDs maneuver:Pressure on back of knee Flex at knee and extend at hip hook finger and deliver each leg** loosen umbilical cord “hands off” with fetal back ANTERIOR until scapulaShoulders: Originally entered pelvic inlet in transverse after legs are delivered the shoulders rotate to enter the pelvic outlet in AP diameter see scapula LOVSET’s maneuver: Hook finger and sweep anterior arm for deliveryRotate body 180’ so posterior shoulder comes anteriorlyDeliver posterior arm in same way (hook and sweep)Head: Burn Marshall: downward traction, backward somersault, baby on mother’s stomachMauriceau Smellie Veit: baby on dr’s arm, finger above lip and 2 fingers on maxillaPiper’s forceps: assistant holds baby’s legs and body UP and forceps placed on head to deliverShoulder Dystocia*Anterior shoulder struck behind pubic symphisis- read risk factors and complications from pg 126 Kaplan* “turtle sign” Call for help & NOTE THE TIME (5 minutes total only)Stop oxytocin, stop contractingBring mother to edge of tableMcRobert’s maneuver: maternal thigh flexion to chest sacral curvatureEpisiotomy extensionSuprapubic pressure: down & medial Wood corkscrew maneuver: clockwise rotation of shouldersReverse corkscrew maneuver: anti-clockwiseAll-fours position and repeat all maneuversDestructive proceduresSymphysiotomyCleidotomy – clavicle fractureZavenelli maneuver: cephalic replacement and go for Emergency LSCSInstrumental delivery pg 136-137 kaplan (advantages and disadvantages of each) Indications: Fetal distress (CTG)Prolonged second stageMalposition (deep transverse arrest)Shortening 2nd stage in maternal cardio diseasePoor maternal effortPrerequisites:Adequate pelvic dimensionsFully dilated cervixRuptured membranesAt least station +1 (engaged)Empty bladderEpisiotomy, pudendal block Contraindications for vacuum: < 34 weeksface presentationany fetal blood loss (scalp sample)Cesarean section indications:Elective: - Previous 2 scarsEmergency: fetal distresscord prolapsebreech footlingplacenta previadeep transverse arrestplacental abruptiontransverse liecephalopelvic disproportion** Know pre-op preparation, procedure and instrumentsInduction of Labor= planned initiation of labor prior to spontaneous onsetBishop’s score calculation: MEMORIZEIndications: Post-dates: 12 days beyond EDD [MC]Prolonged PROM (if >24-72 hrs) Pre-eclampsia or other hypertensive disordersDM: insulin control--38 wks, diet control--40 wksUnexplained APHFetal growth restrictionPlacental insufficiency (eg. oligohydramnios)Twin pregnancy > 38 wksRhesus isoimmunization Deteriorating maternal illnessDraw Partogram (graphical representation of active labor)- start plotting after 3cm dilation (active phase of 1st stage) ie. at 4 cm- Contractions: minor = <35 sec, moderate = 35-45 sec, severe = > 45 secInterpret partogram & give management of: pg. 124-126 kaplanProlonged latent phase: too long analgesics, mobilization, reassurancePrimary arrest: non-progress (usually at 2-3cm) Primary dysfunctional labor: (<1cm/hour dilation): due to inefficient uterine contractionsSecondary arrest (@7cm): malposition, malpresentations, CPDMx: ARM + oxytocin infusion (if poor contractions or malposition)Careful! In multiparous uterine rupture; thus only do ARM & wait* if oxytocin given & progress fails to occur over next 4-6 hours cesarean section Interpret CTG, give causes, management planDecelerations: Type 1 (Early): head compression left lateral, O2, hydrate, stop oxytocin; continue watching!Type 2 (late): fetal hypoxia (uteroplacental insufficiency) as above & ARM; if does not resolve LSCSVariable (type 3): cord compression (around neck or liquor) Emergency cesarean sectionEDD & gestational age calculation; Neigle’s ruleBooking/antenatal investigations: Interpret Urine R/E & treatment in pregnancyDefine high risk pregnancy & give high risk factorsInterpret types of anemia & treatment & further investigationsInterpret lab reports RFTs, LFTs (hypertensive disease)Management of massive obstetric hemorrhage:- Aim: Assessment & management simultaneouslyCall for help: senior obstetrician & anesthetistMonitor pulse! ABCNotify blood bank; cross match at least 6 units of blood2x 14 gauge IV lines plasma expander (ringer’s lactate rapid infusion)Draw blood samples:Blood group, Rh factorCBCClotting profile: APTT, PTSerum fibrinogenRFTs LFTsOxygen by mask initiallyFoley catheter into the bladder & fluid balance chart (at least 30ml/hr)Listen to FHR with fetoscope for full minuteTransfuse blood ASAPUncrossmatched same group as mother In extreme circumstances: O negative bloodWhen stable do CTGTake short history to find out causeExtra from 10 teachers:Central venous pressure & arterial linesMay need FFP, platelets, cryoprecipitate (consult heme)Eliminate the cause: deliver the baby & placentaManage postpartum hemorrhageManage a woman with threatened preterm labor:Threatened preterm labor: Palpable uterine contractions with closed cervical osManagement: Admit patient Counsel couple: discuss NICU issuesInvestigate underlying cause: antenatal profile, HVSUltrasound: check fetal well being & cervical length, coning & funnelingTreat vaginal discharge / infection if foundsedate (campex phergen), hydrate, Dexamethasone coverage for lung maturityTocolysisIf pain/ PUCs settle down (ie threatened), no tocolysis requiredIf pain continues and , give tocolysis Adalat (Nifedipine) Management & complications of PPROM / PROM: pg 75 kaplan Management protocol of eclampsia: ABC resuscitation – protect mother’s airway & tongue2 large bore cannulasMgSO4 IV bolus 5gm; maintenance infusion of 2g/hourIV Hydralazine / labetalol: Lower blood pressure (diastolic to 90-100mmHg)Avoid fluid overloadControl coagulopathy After pt is stabilized: Aggressive prompt delivery at any gestaional ageIf very stable attempt vaginal delivery with IV oxytocin infusion BUTMost likely cesarean section required in most casesIndications for urgent delivery in hypertensive disease:Persistent BP >/=160/110 mmHg + significant proteinuria LFTs PlateletsEclamptic fitAnuriaSignificant fetal distressGynecologyGynecological Examination: IntroductionConsent & explanation Short history of pain, discharge, infectionAsk about empty bladderAbdominal examination would also be usefulEnsure adequate light, privacyCheck instruments & put on glovesLithotomy / dorsal position & proper exposure with sheetMake sure patient is comfortable throughoutInspection:Hair distribution, blood, discharge, growth, swelling, pelvic varicositiesSeparates labia with thumb and index of left hand: inspect for anatomyAll structures: labia majora, minora, urethra, clitoris, check rectum for hemorrhoidsPalpate bartholin glandsPer speculum:Aim: to visualize & inspect cervixChoose correct size cusco speculum, warm, lubricate itWhile separating labia, insert speculum straight explaining to take deep breathsOpen speculum blades to retract anterior & posterior vaginal wallsVisualize cervix & tighten screws & Inspect: shape (regular/irregular)size (hypertropic), blood, dischargeIUCD threadMass: fibroid, polypPap smear if necessaryHVS if necessaryClose blades & remove speculum carefully (do not have any skin caught)Per vaginal/ bimanualLubricate & insert index + middle fingers of right hand; push cervix upwardsleft hand pressing down suprapubicly to feel lower fingersPalpate vaginal walls & fornices Cervix: Os: dilationLengthConsistency PositionTenderness Uterus: Size (weeks)Position: ante/retrovertedShapeMobilityTextureTendernessAdnexa: right & left sides; (ovaries are not normally palpable)Inspect internal fingers for any blood or dischargeCover up & thank patientDocumentation of findings or samplesProcedures:High Vaginal Swab: Perform if discharge is found on per speculumTake from posterior fornix & do not touch any other surfacePap smear: screening test for cervical cancer / dysplasiaContraindications: Active infection gives inflammatory reactionBleeding obscures cells Consent & explanation of test Steps of per speculum as aboveThen Insert ayer’s spatula into cervix / transformation zoneTurn spatula 360’Remove without touching sidesSmear each side (brush & spatula) on one slideUse fixative Place in container with label DocumentationExplain followup to patient & thank patientPipelle biopsy:Indications: MenorrhagiaPostmenopausal bleedingRule out endometrial cancerAdvantages: OPD procedureEasier, cheaper, convenientNo anesthesia, no dilation requiredIntroduction, explain procedure/pain, consentCheck instruments (pipelle works, formalin solution etc)Lithotomy position & drape; lightingInsert pipelle and apply suction (rotate cannula)Keep pipelle in uterus as suction is applied and move it around the wallContinue suction aspiration until confidentRemove pipelle and place tissue in formalinDocumentation: forms, notesThank patient & tell patient to follow up with reportInterpret HVS & treatmentsAmsel's Diagnostic Criteria for Bacterial Vaginosis- Three of four criteria must be metHomogeneous vaginal discharge (color and amount may vary)Amine (fishy) odor when potassium hydroxide solution is added to vaginal secretions (commonly called the "whiff test")Presence of clue cells (greater than 20%) on microscopy*Vaginal pH greater than 4.5Cervical cancer vaccinationsScreening protocol for pap smear at different age groupsDilation & Curettage:Indications: Same as pipelle Better in older postmenopausal women due to painIf endometrial polyp is seen on USG it is better to do hysteroscopy & DNCDiagnostic indications:Abnormal or heavy bleedingsevere menstrual paindifficulty becoming pregnantabnormal cervical cellsTherapeutic indications:excessive bleeding after birthcervical or uterine polypsfibroid tumorsincomplete miscarriageComplications: Immediate: Trauma to cervix, vagina, uterus; Hemorrhage; Rupture of uterusLate: infectionConsentAnesthetize – general anesthesiaLithotomy positionScrub, clean & drapeSet instrument trolley: metallic catheter, sims speculum, valsalem/tenaculum/sponge holding, uterine sound, hagar’s dilators, uterine curette, formalin solutionEmpty bladder, if not use metallic urinary catheterBimanual pelvic exam: uterus anteverted or retrovertedSims speculum: retract posterior vaginal wall (ask assistant)Hold anterior lip of cervix with either:Valsalem forceps: curved, hold in AP position; nongravid (*don’t confuse with Alice’s)Tenaculum: hold in transverse position; nongravid, (preferred due to one tooth)Sponge-holding forceps: gravid uterusUterine sound: measure uterocervical canal length (normal =6-7 cm) according to ante/retrovertedHagar’s dilators: dilate internal os; start from 2-3 size and wait for dilation to occur, then move on to next size and wait, etc until it is dilated at size 8Uterine curette: all walls of uterus; 3 freshnar? Samples: ________, fundus, _________Use sharp side for non-gravid uterus to do diagnostic endometrial samplingUse blunt /smooth side for RPOC / gravid uterusFormalin solution – labelingDocumentation: appropriate histopath forms & notesInstruments: identify, indication, contraindication, complicationImages: Identify: MRI: fibroid uterus (Hypoechoic areas)Fibroid typesPedunculated submucosal: bleeding Uterine fibroid + pregnancy: USG fibroid is BLACKTVS USG: white line shows endometrial liningcaput: edema accumulation under scalp skinmoulding: overlapping of fetal skull bonescaput succedaneum?Cephalic hematomaIntracranial hematoma Specimens: Gestational trophoblastic disease (molar)Cut Cross section of fibroidCounseling:Always start with: Your introductionAsk patient’s name, age, parity, educationTake short history of imp. pointsDo you know why you’re here today?Permission: I will be talking to you about sensitive issues today, ok? Has anyone come with you today? Husband? Mother? Would you like them to call them in?Always end with: Thanking the patientDo you have any questions? Early pregnancy loss: Breaking bad newsInvestigationsFertilityRecurrent miscarriages: 3 or more consecutive miscarriages75% no cause is found; counsel depending on cause60-70% chance that workup is normal -> normal pregnancy & babyInvestigations: Examination: uterine abnormalityUSG: uterine structural anomaly, cervical lengthParental & fetal karyotype to exclude translocation Glucose tests: RBS/ FBSThyroid: TSH, T4Antiphospholipid / anticardiolipin antibodiesLupus anticoagulantHVS: bacterial vaginosis3 months of contraception with daily folic acidregular checkups in pregnancyreassuranceEctopic pregnancy: Breaking bad news Confirmation of Diagnosis: BHCG > 1500, no intrauterine preg on TVSManagement options: Ruptured ectopic immediate laparotomy to stop bleedingIf no intrauterine pregnancy + < 1500 BHCG Possible ectopic repeat BHCG + TVS every 2-3 days until BHCG >1500 or shows appropriate doubling of BHCGUnruptured confirmed ectopic: BHCG <1000 conservativeBHCG 1000-3000 methotrexate 50mg/m2Criteria for methotrexate: Hemodynamically stable patient (no shock)Pregnancy mass < 3 cm (3.5cm)BHCG < 3000mIUNo fetal heart motionCounseling of methotrexate complications:May require second dose 15%May progress to ruptured ectopic 7%Follow up with serial bHCG levels day 4 & 7 (importance!)Bedrest, hydration, no sexual activityRh- given RhoGamTeratogenic; must use contraception for 3-6 months afterwards BHCG >3000 surgical: laparoscopySalpingostomy; segmental resection fertility maintainedSalpingectomy: if ruptured; no fertilityRh- RhoGamBHCG levels weeklyFollow-up/ fertitlityChances of recurrence (10-15%)Use contraception for at least 3-6 months after methotrexate use (teratogenic)Regular checkups if planning pregnancy; fertility Breech presentationInfertility: (blocked tubes)Contraception counseling: Family Planning = “mansooba bandi”What do you know about it? How long would you like contraception for?Short history of co morbiditiesExplain all types: IUCD = “challa”I think this is what is best for your situation because…..Advantages, disadvantagesComplications, contraindicationsWhat are your concerns? Ovarian cancer screeningShort history (pain, swelling, GI or urinary complaints), family historyP/V bimanual examination if marriedInvestigations: ultrasound, CT scan tumor markers: epithelial: CA-125, CEA; germ cell: LDH, hCG, AFP; stromal: estrogen, testosteroneGenetic screening (family hx): BRCA1, BRCA2If positive: recommend pt completes family early, watch for symptoms of ovarian, colon & breast cancer, screening at intervals, interval pelvic scansCounsel: Self breast examYearly / 3 yearly screening – mammography, pap smears etcOvarian cancer suspected & counsel for laparotomyCervical cytology report:Breaking bad newsPrognosisManagement: Gestational trophoblastic disease: Breaking bad news of diagnosis: ultrasound “snowstorm” & no fetal heart tonesPrognosis: malignancy progression: complete mole 20%, incomplete mole 10%Treatment: baseline BHCGsuction D&C: “safai” under general anesthesia; risk of excessive bleeding so arrange for bloodspecimen will be sent to histopath labchest xray to rule out lung metastasisFollow up: stress it’s importanceMust come weekly to do serial BHCG titers until negativeThen monthly BHCG for 1 -2 yearsContraception: MUST use careful contraception – barrier methodsdo not use IUCD – may cause metastasis may start using OCPs only after BHCG is negative Future fertility issues: If BHCG levels are fine & it’s benign GTN pt can conceive after 2 years ................
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