PACES Revision Obstetrics and Gynaecology

1. PACES RevisionObstetrics and Gynaecology 27/04/2012 Amrita banerjee & OLA MARKIEWICZ Kindly sponsored by:

2. Plan for the morning 9-10.30 - Lecture + demonstration station 10.30-11.00 - Break 11.00-12.30 - Mock PACES stations (x4) 12.30-13.00 – Lunch

3. Outline of Talk • Obs & Gynae • History • Examination • Clinical Skills • Investigations • Management • Red Flags • Ethics and Law • Common PACES Stations • Demonstration Station • Tips and Advice • Further Resources

4. HISTORY

5. The History The main part of all PACES stations!! Do not compromise on this. PC HPC Gynae history Obstetric History PMH DH FH SH Systems review

6. The Gynaecological History • Periods • Dysmenorrhoea • Oligomenorrhoea • Amenorrhoea • Menorrhagia • Mittelschmerz • Discharge • Smell • Colour • Consistency

7. The Gynaecological History • Think about sex: • Contraception • HPV vaccine • Have sex: • Dyspareunia • Post-coital bleeding • After sex catch: • STI’s • HPV – smears! • Babies

8. The Gynaecological History • Boys • Regular • Protection – pregnancy and STI’s • GUM clinic visits • Peer pressure • Legal

9. The Gynaecological History • Obstetric History – don’t forget TOPs! • Consequences of childbirth • Sphincter dysfunction • Rectal/vaginal prolapse

10. The Gynaecological History • Menopause • Symptoms • HRT • Post menopausal bleeding! • Vaginal atrophy • Sex life • Quality of life

11. Obstetric History PC HPC Current Pregnancy Was this a planned pregnancy? EDD - scan or dates (LMP, Menstrual cycle) Complications Investigations so far Gravidity – number of times a woman has been pregnant, regardless of outcome Parity = (any live or still birth after 24 weeks) Specific Symptoms... Nausea / Vomiting - if severe known as hyperemesisgravidarum Urinary frequency – pressure on the bladder causes this – rule out UTI Tiredness Fetal Movements - usually felt at around 18-20 weeks gestation, earlier in multips Ideas, Concerns & Expectations…

12. Obstetric History Details of each pregnancy: • Date / Year • Place of birth • Gestation • Mode of delivery • Baby – sex, weight, current health • Problems during antenatal, labour & postnatal • Same Partner? Consanguinity? Miscarriages & Terminations Previous difficulty conceiving/ assisted conception Plans for future pregnancies

13. Obstetric History • Maternal: DEATH P • Diabetes • pre-Eclampsia • Anaemia • Thrombus • Hypertension • Pain • Bleeding • Infection • For each pregnancy, including the current one if pregnant, ask about complications: • Fetal • Movements • Scans/tests • Hospital admissions

14. Obstetric History Cont. Past Gynaecological History Contraceptive use? Last Cervical Smear – was the result normal? Any gynae surgery: - Loop excision of transitional zone (LETZ) -↑ risk of cervical incompetence- Previous myomectomy - ↑ risk of uterine rupture / placenta accreta /adhesions Gynae investigations & treatment for: - Infertility- Ectopic – ↑ risk of future ectopics- PID - chlamydia is most common cause – ↑ risk of ectopic

15. The rest of the history Past Medical History and Past Surgical History Drug History Pregnancy medication -folates, iron, anti-emetics, antacids Teratogenic drugs – avoid at all costs -ACEi, Retinoids, Sodium Valproate, Methotrexate OTC Drugs - make sure to ask patient about these, to ensure nothing unsafe ALLERGIES Family History Medical conditions - gestational diabetes Inherited genetic conditions – CF Pregnancy Loss - recurrent miscarriages in mother & sisters  Pre-eclampsia - in mother or sister? – increased risk Social history Smoking, Alcohol, Drug use Living Situation, Relationship Status Occupation  Systems review

16. Other Important Questions How do her symptoms affect her life What support does she have at home – do not assume she is married! Is there anything else that you are worrying about? Is there anything else that you’d like to ask me?

17. EXAMINATION

18. The Physical Examination • Examination • Abdomen: • Gravid • Non-pregnant • Pelvic examination • Speculum • Swabs • Smear • To complete my examination • Blood pressure • Pregnancy test

19. The Pelvic Examination • Brief abdominal examination • Inspect vulva • Inspect cervix using Cusco’s speculum • Take smears and swabs if required • Withdraw speculum • Bimanual examination • Cervix • Uterus • Adnexae • Inspect fingers for blood or discharge

20. What is this?

21. The Obstetric Examination • Inspection “There is an abdominal mass consistent with pregnancy” • Linea nigra • Striae • Scars • Fetal movements • Measure symphysio-fundal height • Palpate – use ballottement • Assess amniotic fluid volume • Fetal lie • Presentation • Engagement (fifths palpable)

23. The Obstetric Examination cont. Fetal heart sounds BP and urinalysis Antenatal notes

24. CLINICAL SKILLS

25. Clinical Skills • Blood Pressure • Urine dipstick • Pregnancy test Gynae: • Vaginal swabs • Cervical smears Obstetrics: • CTG

26. Blood Pressure Make sure you know how to use a sphyngomanometer Roughly determine systolic BP using the radial pulse Start 20mmHg above this and measure BP Korotkoff sounds

27. Urine Dip Use gloves Expiry date Remove a strip, then close the bottle Dip the strip into the urine and wipe any excess urine on the side of the bottle • Compare the strip to the bottle label

28. Pregnancy test Perform in almost every woman of childbearing age Detects βhCG Dipsticks vs pipette urine Control line Test line Confirm result with another member of staff

29. Vaginal Swabs

30. Cervical screening programme • Aim: identification of CIN and initiating early treatment before the development of cervical carcinoma NOT a test for cancer! • Age range: • 25-49 every 3 years • 50-64 5 yearly • 60+ if not screened since 50 or recent abnormal results • Technique: Rotate brush in the external os to pick up loose cells over the TZ for liquid based cytology

31. Cervical screening programme Counselling and explaining the process/results/follow up!

33. Cardiotocography DR – Define Risk C – Contractions BRA – Baseline Rate – mean rate over 5 – 10 mins. Normal = 110 – 160 bpm V – Variability – should be >5 bpm A – Accelerations – rise in fetal heart rate by at least 15 bpm lasting at least 15 secs. D – Decelerations – fall in fetal heart rate by at least 15 bpm lasting at least 15 secs O – Overall

34. INVESTIGATIONS

35. Investigations General tips: Importance of observations and bedside tests Do not mention lists of investigations unless you are able to justify why you want them Hit the jackpot early (but don’t show off) Think outside the box – pregnant women get non-pregnant diseases

36. Investigations Gynae: Cervical smears Interpret hormone levels: FSH, LH,TFT’s Urodynamics Ultrasound: endometrial thickness Surgery: endometrial biopsy, laparoscopy, lap + dye Contraceptive methods: IUD Hysteroscopy

37. Investigations Obstetrics: Pregnancy test (in A+E) Glucose Tolerance Test Cardiotocographs Partogram Pelvic USS Screening tests Amniocentesis/chorionic villus sampling

38. MANAGEMENT

39. Management What everyone does worst on! Don’t forget: Resus+ CONSERVATIVE MEDICAL SURGICAL And VERY importantly ASK FOR HELP!

40. RED FLAGS

41. Red Flags - Obstetrics

42. Red Flags – Obstetrics cont.

43. Red Flags - Gynaecology

44. COUNSELLING

45. Counselling Shared decision making MDT Empathy Active listening Use of silence Avoid jargon Ideas, concerns, expectations

46. Counselling cont. Congenital abnormalities e.g. Downs, Turners syndrome Cervical smear results Ectopic pregnancy Miscarriage Contraception

47. LAW AND ETHICS

48. Law and Ethics • Everyone ignores but is very important! • Most sued specialty • Extremely sensitive issues: cultural, religious, personal Important principles: • Gillick competence • The Abortion Act • The Mental Capacity Act

49. Law and Ethics • Everyone ignores but is very important! • Most sued specialty • Extremely sensitive issues: cultural, religious, personal Important principles: • Gillick competence • The Abortion Act • The Mental Capacity Act

50. The Abortion Act • Permits termination of pregnancy by a registered practitioner subject to certain conditions. • Must be performed by registered medical practitioner in an NHS hospital or DoH approved location (e.g. British Pregnancy Advisory Service Clinics) • An abortion may be approved for the following reasons: