Introduction to Obstetrics and Gynaecology
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Introduction to Obstetrics and Gynaecology Clare Tower MBChB PhD MRCOG Senior Registrar in Obstetrics and Gynaecology Subspecialty Trainee in Fetal and Maternal Medicine/ Clinical Lecturer St Mary’s Hospital, Manchester Brief Overview Student booklets – read it!!

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Introduction to Obstetrics and Gynaecology

Clare Tower MBChB PhD MRCOG

Senior Registrar in Obstetrics and Gynaecology Subspecialty Trainee in Fetal and Maternal Medicine/ Clinical Lecturer

St Mary’s Hospital, Manchester


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Brief Overview

  • Student booklets – read it!!

  • There are 3 teams – red/ blue/ green (4 of you on each)

  • Timetable for each team on Medlea

  • In addition: ward rounds

  • On call sessions

  • Specialist clinics


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What is expected

  • PBL booklet guides what you are expected to know

  • You will need to do some reading

  • Turn up – it’s the easiest thing to do

  • Minimum requirements:

    • 4 antenatal clinics

    • 4 labour ward rounds

    • 4 on-call sessions on labour ward

    • 4 gynae clinics

    • 4 gynae theatre lists

    • 2 consultant ward rounds


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Obstetric wards:

SM4, SM5, SM6

SM4 – blue team

SM5 – red

SM6 – green

Registrars/ SHOs do ward rounds daily

Consultants – varied

See the patients!

Gynae wards

SM9, SM10

SM9 – long stay

SM10 – day cases, closed sat /sun

Registrars/SHOs do ward rounds daily

Consultants - vary

The wards


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Obstetrics

CDU = central delivery suite

Triage

Introduce yourself to coordinating midwives and the doctors

Gynaecology

GUR = gynae urgency room

Sees gynae emergencies during the day until 5pm

SM10 after 5pm

Emergency work


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Vaginal examinations

  • Valuable skill

  • You will be expected to look like you have done a speculum before in the OSCE

  • Gynae clinic is a good place to learn

  • Examinations under anaesthetic – need written consent and YOU have to get this before going to theatre

  • Also write in the patient notes


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Specialist clinics

  • There are a limited number of these

  • You need to book them beforehand on Medlea

  • You still need to make contact with the person organising the clinic before – as specified in the student handbook

  • Swap clinics with other teams



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Overview

  • Definition of labour

  • Physiology – you can read this

  • Diagnosis and assessment

  • Partograms

  • Abnormal labour

  • Cardiotocographs


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Definition of labour

  • Regular painful contractions resulting in cervical dilatation

  • 3 stages

    • First

    • Second

    • Third


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Stages of labour

  • First Stage

    • Up to fully dilated

    • Two phases

  • Second Stage

    • Full dilatation until

      delivery of the baby

  • Third stage

    • Delivery of the placenta


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Latent phase

Slow

Contractions irregular

Cervix:

shortens (effaces)

Softens

Moves

Dilates up to 3-4 cm

Active phase

Regular painful contractions

Progressive cervical dilatation greater than 4 cm

First Stage of labour




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Assessments in labour

  • The partogram

  • Labour record

  • Useful overview if completed properly

  • Can be used to aid diagnosis in abnormal labours

  • Visual representation of progress


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Assessment

  • History and review notes (handhelds)

  • Physical observations: temp, pulse, BP, urinalysis

  • Assess contractions: length, strength, frequency


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Assessment

  • Abdominal palpation:

    • fundal height

    • lie

    • position

    • presentation

    • station

  • Vaginal loss

    • Show

    • Liquor

    • Blood loss


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Assessment

  • Assessment of pain – need for pain relief

  • Fetal heart rate

    • Pinard or doppler

    • Listen for one minute after each contraction

    • Differentiate from maternal

    • Normal rate: 110-160

  • Vaginal examination

    • If appears to be in labour

    • With consent



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Length of second stage

  • Can allow a ‘passive’ second stage for the head to descend

  • Epidurals

  • Total second stage less than 4 hours (NICE)

  • Pushing limited to 30 mins (multip) to 60mins (primip)


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Abnormal patterns of labour

  • Partogram can be used to identify abnormal progress in labour

  • Deep transverse arrest

  • Primary dysfunctional labour

  • ‘3Ps’ – passenger, passages, powers


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Cardiotocograph CTG

  • Cardio = fetal heart rate

  • Toco = uterine activity:

  • Hence 2 monitors –

    • Abdominal pressure transducer

    • Doppler for fetal heart rate

  • Used to indicate fetal hypoxia

    • Poor!! – no reduction in the rate of intrapartum hypoxic injury/ Cerebral palsy since introduction in the 1980s

    • Increases rates of intervention

    • Even with the worse trace – 60% will be normoxic babies



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Normal CTG

Fetal heart rate

Toco = uterine activity


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Assessment of a CTG

  • DR C BRaVADO

  • DR = define risk

  • C= contractions

    • Timing and frequency

    • CTG cannot indicate strength

  • BRa = baseline rate

    • Normal 110-160

    • beware changes in rate

    • Fetal heart increases in the presence of maternal tachycardia and increased temperature

    • Also increases with hypoxia and sepsis


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DR C BRaVADO

  • V= Variability

    • Band width

    • Should be more than 5bpm

    • If reduced can indicate fetal sleep/ maternal opiate use

  • A= Accelerations

    • Increase in baseline of more than 15bpm for more than 15 seconds


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DR C BRaVADO

  • D = Decelerations

    • = drops in fetal heart of more than 15bpm, lasting got more than 15 seconds

    • Time with contractions

    • Early – rare and benign

    • Late – pathological and indicate hypoxia

    • Variable – vary in timing and in pattern. Commonest and occur with cord compression

  • O = Overall

    • Make overall assessment taking into account all aspects


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Variability = 20 bpm

Baseline rate

accelerations

Contractions

Irregular 1-2:10

Normal CTG

No decelerations


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Baseline rate = 170-180

Variability = 5

Late decelerations

Abnormal CTG

Contractions 4:10

No accelerations




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