Obstetrics

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Obstetrics Gynaecology

• Hannah Thackray
• Amy Laycock

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Introduction

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

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General Inspection

• End of the bed

- ? comfortable - ? clues around the bed

• Distended abdomen consistent with
• pregnancy

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General Examination

• Hands
• - koilonychia/pale palmer creases
• - palmer erythema

• Pulse

• Blood pressure

• Chloasma

• JACCOL

• Heart sounds/lung bases

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Position

• Semi-recumbent

• Is she comfortable lying flat?

• Maintain modesty

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Abdominal Inspection

• Shape and symmetry

• Foetal movements

• Scars

• Striae gravidarum

• Striae albicans

• Linea nigra

• Umbilicus

• Superficial veins

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Quiz Time!!!!
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Linea Nigra
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Striae Albicans
Striae Gravidarum
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Pregnant Man!
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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

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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

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Small For Dates

• Wrong dates

• Constitutionally small

• Oligohydramnios

• Intrauterine growth restriction

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IUGR

• ? foetal growth potential

• ? foetal growth support

- TORCH
- maternal
- chromosomal abnormalities
- drugs/alcohol/smoking
- structural abnormalities
- malnutrition
- ? uteroplacental perfusion
- DM
- poor trophoblast invasion
- multiple gestation
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Oligohydramnios

• Not enough produced

- renal agenesis
- multicystic kidneys
- urinary tract obstruction
- IUGR
- maternal drugs (NSAIDs)

• Too much lost

- PPROM
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Large For Dates

• Wrong dates

• Constitutionally large

• Multiple gestation

• Maternal DM

• Polyhydramnios

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Polyhydramnios

• Maternal - DM

• Placental AV fistula

• Foetal

- multiple gestation
- oesophageal/duodenal atresia
- anencephaly
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Palpation of Foetal Poles

• Lie

• longitudinal
• oblique
• transverse

• Presenting part

• cephalic
• breech

• Engaged

- fifths palpable
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Auscultation

• Pinard stethoscope

• Hand held Doppler

• Feel mothers pulse

• Listen over anterior shoulder

• One minute

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Extras

• Urine dipstick ketones
• Blood pressure

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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

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• Obstetric Examination
• Video

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Gynaecology History Station
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Gynae History

• Take your time!!
• Read the information outside the station
• .. and breath!!

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Gynae History

• Introduce yourself
• Check patient name DOB
• Explain
• Consent . Is that OK?
• So what problem have you been having?

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Gynae History

• Presenting complaint
• Pts own words
• Identify most troublesome symptom

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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

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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

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Gynae History

• GH continued..
• PV discharge
• Pruritus
• Climacteric symptoms
• Hot flushes, vaginal dryness
• Contraception
• Urinary symptoms
• Bowel function

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Obstetric History

• OH
• No. of pregnancies
• Result of each pregnancy Gestation
• Miscarriage
• ToP
• Delivery
• Mode of delivery
• NVD
• LSCS
• Forceps/Suction

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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?

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Gynae History Continued

• MedH
• Taking any medications?
• Px or OTC?
• Allergies
• What happens when you take it?
• ? True allergy ? Or just sensitivity

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Gynae History Continued

• SH
• Smoking
• Alcohol
• Sexual partner/Married
• FH
• RoS If taken a comprehensive Hx shouldnt be any

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Summarise

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

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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!!!

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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

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Investigations

• Radiology
• USS (?transvaginal)
• X-ray hysterosalpingography (HSG)
• CT/MRI
• Extras
• HyCoSy
• Biopsy endometrial / cervical loop
• Surgical exploration

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Blind surgeon?
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Management

• 1 Conservative
• Lifestyle advice
• Physiotherapy
• 2 Medical
• Drug therapy
• 3 Surgical
• Least invasive where possible

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Gynae History

• Previous LOCAS
• Menorrhagia Dysmenorrhoea
• Endometriosis / Adenomyosis
• Fibroids
• Dysfunctional uterine bleeding
• PCOS
• Post-menopausal bleeding

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Gynae History

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

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Key Points!!

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

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Any Questions?