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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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slide1

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

slide2

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
what is expected
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
the wards
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
emergency work
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
vaginal examinations
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
specialist clinics
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
overview
Overview
  • Definition of labour
  • Physiology – you can read this
  • Diagnosis and assessment
  • Partograms
  • Abnormal labour
  • Cardiotocographs
definition of labour
Definition of labour
  • Regular painful contractions resulting in cervical dilatation
  • 3 stages
    • First
    • Second
    • Third
stages of labour
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
first stage of labour
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
assessments in labour
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
assessment
Assessment
  • History and review notes (handhelds)
  • Physical observations: temp, pulse, BP, urinalysis
  • Assess contractions: length, strength, frequency
assessment19
Assessment
  • Abdominal palpation:
    • fundal height
    • lie
    • position
    • presentation
    • station
  • Vaginal loss
    • Show
    • Liquor
    • Blood loss
assessment20
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
length of second stage
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)
abnormal patterns of labour
Abnormal patterns of labour
  • Partogram can be used to identify abnormal progress in labour
  • Deep transverse arrest
  • Primary dysfunctional labour
  • ‘3Ps’ – passenger, passages, powers
cardiotocograph ctg
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
slide26

Normal CTG

Fetal heart rate

Toco = uterine activity

assessment of a ctg
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
dr c bravado
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
dr c bravado29
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
slide30

Variability = 20 bpm

Baseline rate

accelerations

Contractions

Irregular 1-2:10

Normal CTG

No decelerations

slide31

Baseline rate = 170-180

Variability = 5

Late decelerations

Abnormal CTG

Contractions 4:10

No accelerations