Ten OBG Tips

Professor David Healy

1. Nothing is safe in medicine



e.g. milk IV is WRONG --> fat embolism
50 percent of current knowledge may not apply

2. Hx, Ex, DDX, then Ix if any, Mx



thought>info.

3. Every woman, from 13-53 yrs, is pregnant TPO



OCP failure rate is a DEFINITE EXAM QN (835 qns only in exam bank)

4. any diagnosed STD means all other STDs



e.g. HPV (RNA virus; test for Rx in EXAM)

5. 1st and 2nd labours are like chalk and cheese



onset of labour = ROM, 'the show'- cervical mucus, regular contractions
progress of labour = dilatation of cervix

6. Every pregnant woman is hypothyroid TPO




7. The empty contracted uterus will NOT bleed



fiboids extremely common

8. Practise IV access +++




9. The most important pap test is the first




10. for every woman, ask about Contraception and Pap-smear



OSCEs in general

General measurs: iron tablets/vitamin C tablets
Exercise/physiotherapy: not appropriate
Medical treatment:
- tablets:tranexamic acid, oral contraceptive pill, NSAIDs, progestagen
- injections: Depo Provera
- medicated devices: Mirena IUD

Surgical treatment:
- minor surgery: endometrial ablation/resection
- major surgery: hysterectomy


Gynae History and Examination
Patient name, age,
Presenting complaint: primary reason for visit today
Menstrual history:
- age at menarche/menopause
- how many days since last menstrual period?
- are cycles regular? how many days does she bleed? average length of cycles
are periods heavy? (if so, how long has it been present? Clots/flooding? How many pads used per day? Has she had any previous treatments? If so, how effective were they? Side effects?)
Are periods painful? (if so, when during cycle? how does it affect daily functioning- e.g. number of days off work? any treatments? effective? side effects?)
Any intermenstrual bleeding? Post-coital bleeding? Post-menopausal bleeding?
Sexually active at present? Any problems with intercourse? Dyspareunia? (If so, timecourse, and whether superifical or deep, or related to cycles)
Contraception- types tried, failures/unwanted pregnancies, side effects
Vaginal discharge (if present: colour, odour, itch, irritation?); past history; sexually transmitted diseases? (if so, treated? contact tracing? checked for other STDs?)
Last pap smear? does she have regular pap smears? (what frequency) normal? ever abnormal? (if so, what treatment)
Last mammogram/breast ultrasound?
Menopausal symptoms (if age-appropraite, or amenorrhoea)
Urinary incontinence/symptoms; prolapse/lump in vagina; bowel symptoms
Pelvic pain (not associated with menses or intercourse)
Past gynaecological history: past diagnoses (and basis for diagnosis), past operations
Past obstetric history (see obstetric history-taking for details)
Past medical history; past psychiatric history
Past surgical history
Family history (of cancers, or medical and genetic conditions)
Social history: home, relationships, work, financial/social stresses
Smoking history; alcohol intake; other recreational drugs
Medications; allergies

Examination
General appearance (colour, secondary sexual characteristics)
Vitals (temperature, blood pressure, pulse rate, respiratory rate); body mass index; full ward test (urine pregnancy test if appropriate) - remember: inspection, palpation, percussion, ascultation)
Thyroid, cardio-respiratory and breast examination
Abdominal examination
Inspection of external genitalia (lumps, skin conditions, ulcers, discolouration, atrophy), including urethral meatus
Bimanual examination: uterine size and shape, antevereted/retroverted; tenderness; mobility; adnexal masses
Joint vaginal and rectal examination (if appropriate- for Pouch fo Douglas nodules/tenderness)

Speculum examination
Bi-valve to inspect vaginal walls and cervix (take pap semars and high vaginal /cervical swabs if appropriate)
Sims speculum to examine for prolapse (systematically examine anterior and posterior vaginal wall then vault) and urinary incontinence (loss of urine with cough)


History/examination of the obstetric patient:
Antenatal history
patient name and age
Current pregnancy- spontaneous or assisted conception (IVF/ovulation induction; reason for infertility)
- planned pregnancy? wanted pregnancy?
- gestation: last menstrual period (gestation by dates); if by ultrasound, when performed and findings (nuchal translucency, singleton/twins, placenta, other findings, e.g. fibroid, ovarian cyst)
- on folate or multivitamins prior to conception? Rubella/parovirus/varicella checked prior to conception?
- Current pregnancy symptoms (ask appropriate to gestation: first trimester- hyperemesis, breast tenderness, urinary Sx; third trimester- backache, gastro-oesophageal reflux)
- any screening Ix performed to date? what results?
Past obstetric history- pregnancies in order with their outcomes
- early pregnancy losses: miscarriages (gestation, treatment, complications); terminations (gestation, mode of TOP, complications); ectopics (type, gestation, treatment)
- Pregnancies > 20/40 (gestation at delivery, medical complication of previous pregnancies; mode of delivery; delivery complications - post-partum haemorrhage, shoulder distocia, puerperal complications- infections, breast-feeding issues, postnantal depression)
- Gynaecological and general history as above, but with less comprehensive questioning of gynaecological history

Examination
general history as above for gynaecological history, until the candidate reaches the abdominal examination
N.B. check urine for protein and glucose no dipstick
abdominal and vaginal examination depending on gestation

first trimester
abdominal/vaginal ex: is uterus palpable abdominally? if not, what size uterus on vaginal examination? speculum for pap smear if due

second trimester/third trimester
Abdominal Ex: symphyseal-fundal height (SFH); lie and presentation of fetus; single or multiple pregnancy; doppler of fetal heart (present? rate?); miscellaneous findigns (fibroid, uterine tenderness)
Vaginal Ex (only if appropriate). Cervical length, dilatation, consistency, position, station of presenting part



Obstetric History and Examination
Patient name and age
Parity, single or multiple pregnancy
Mode of previous deliveries: prior delivery complications
Brief medical/surgical history
Medications (including syntocinon), allergies
Presenting complaint (often called by midwife/junior doctor)
Progress of labour (contractions, vaginal assessments)
Status of membranes, colour of liquor
Use of analgesia (pethidine? how long ago? epidural?)
Assessment of fetal wellbeing (fetal heart rate, CTG)

Examination
General: BP, full ward test of urine, pulse rate, temperature
Abdominal Ex: Lie, presentation, SFH, fetal heart, contractions
Vaginal Ex: Presentation, station, position, moulding, caput; cervix-dilatation, length, position, assessment of pelvis.

N.B. the obstetric encounter is more likely to be fast-paced, focusing on management of emergencies and the history needs to be abbreviated to focus on the crucial issues that pose a risk to the mother and fetus(es). E.g. make sure this is not a trial of scar, a placenta praevia, multiple pregnancy or a breech presentation. Check for gestational diabetes, hypertension, anaemia or concerns regarding IUGR. Exclude significant maternal illnesses such as T1DM, asthma, epilepsy, stroke or cardiac disease.