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OSCE SERIES THE OBSTETRICS ST A TION SHRAYA ANDYA PROUDLY IN COLLABORATION WITH1 OBSTETRIC Hx 2 EXAMPLE SCENARIOS CONTENTS 3 COUNSELLING ATIONS 4 PREGNANT ABDOMEN EXAMOBSTETRIC HISTORIES + EXAMPLE SCENARIOSHistory of Presenting Complaint - O&G Menstrual History M • LMP • Cycle (length + duration) • Age of Menarche (+ Menopause) • Associated symptoms (e.g character): pain, amount, flooding Obstetric History • Gravida and Para O • Previous pregnancies including TOP, Miscarriages etc. • Form of delivery for each pregnancy: Vaginal, Assisted, C-Section • Children: ages, birth weights, pregnancy + delivery complications Sexual History S • Current or previous partners • Intercourse: protected vs unprotected • Subfertility C Contraception History C Cervical Smear History History of Presenting Complaint - Obstetrics PV Discharge 4Ps PV Bleeding Pain Pregnancy st Pregnancy 1 day of LMP / Duration of gestation + positive pregnancy test Antenatal appointments attended + Scan results Investigations (including Rhesus status & Down Syndrome risk) Hydration status Fetal movements (over 16 weeks) Contractions GMCF Obstetric History • Gravida and Para • Miscarriages, Ectopics and Terminations • Children: ages, birth weights, pregnancy + delivery complications • Form of delivery for each pregnancy: Vaginal, Assisted, C-SectionSystems Review Pain - SOCRATES General Fever Sweats Fetal movements Pregnancy Contractions PV Loss Pre-eclampsia: Headache, Dizziness, Gynaecological PV discharge PV bleeding Storage: frequency, volume, urgency and nocturia Urological Infection: dysuria, haematuria, odour Weight change Gastrointestinal Appetite Nausea and Vomiting Indigestion Bowel Habit ChangePast Medical History • Do you have any conditions you see a doctor for? • Any hospitalizations recently? • Any previous surgeries? Drug History • What medications do you take currently? Any changes recently? • Any Herbal remedies? • Any over-the-counter medications? • Do you have any drug allergies? Family History • Is there anyone in the family who has any medical conditions? Social History • Do you smoke? Or Have you ever smoked? If so, how many cigarettes per day and for how long? • Do you drink? • Where do you work? • Who is with you at home? • Do you feel well supported/safe at home? ICE • Ideas • Concerns • Expectations OBSTETRIC INVESTIGATIONS TESTS A-E Baseline Vitals/Observations BEDSIDE Examination Urinalysis Swabs 12-lead ECG Full blood count (FBC) Liver function test (LFT) Urea and Electrolytes (U&Es) BLOODS CRP Clotting Screen Group & Save Crossmatch IMAGING Ultrasound (Abdo/TV) SPECIAL TESTS CTG or Doppler OBSTETRIC MANAGEMENT A-E + Senior Support Oxygen INITIAL: MOTHER IV Fluids Anti-D (if Rhesus negative) Monitor Observations ONGOING: MOTHER Syntocinon post delivery Corticosteroids INITIAL: BABY Magnesium Sulphate Monitor Observations ONGOING: BABY Paediatric Review Role Foundation Year 1 (FY1) Doctor Setting General Practice Patient Anita Johnson, a 40 year-old woman has presented STUDENT to the practice for her booking visit. INSTRUCTIONS Student task Please take a history from the patient. At 7 minutes, the examiner will stop you, and will require you to state if this patient is high or low risk.BOOKING VISIT History • Obstetric History • Past Medical History • Diet History • Alcohol History • Smoking History • Folic Acid consumption • Vitamin D consumption • Antenatal Classes - interested or booked in? Checks • Blood Pressure • Urine Dipstick • Check BMI Booking • FBC Tests • Blood group + Rhesus Status • Hepatitis B, HIV and Syphilis screen • Urine culture (asymptomatic bacteriuria) Summarising the history Patient details, occupation visit for their first pregnancy.son, a 40-year-old man who presented for their first booking first & key presenting complaint Today, Anita has presented to the clinic following a positive at-home pregnancy test. Her last History of presenting complaint menstrual period was 10 week ago. She has no history of previous pregnancies including miscarriages, termination of pregnancies or ectopic pregnancy. Relevant negatives She does not currently have a history of diabetes or hypertension. Relevant PMH/PSH/SH/DH PMH is significant for psoriasis, which is well controlled with topical vitamin D analogues. NKDA! She is a non- lives with her husband and is well supported at home.itive pregnancy test result. She is a lawyer and currently Ideas, concerns & expectations She is worried about age related complications of her pregnancy. So far, Anita is presenting with an uncomplicated pregnancy of dating approximately between 8- Conclusion 10weeks I would like to request a blood pressure measurement, urine dipstick and culture, check her BMI status, as Further Tests well as requesting bloods including FBC and blood group status. Role Foundation Year 1 (FY1) Doctor Setting Emergency Department Patient Joanna Smith, a 35 year-old woman is a 32 week pregnant woman, who attends with complaints of STUDENT PV Bleeding. INSTRUCTIONS Student task Take a history from the patient. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. History of Presenting Complaint & Obstetric History • 32 weeks into my first pregnancy. I have had a history of two previous miscarriages in the last 8 years. • I have been particularly stressed at work recently and noticed a cup full of fresh blood in the toilet bowl. • Since then, I have soaked through 3 pads already and have started to get mild cramping. • I previously had light spotting at 11 weeks however this had resolved. At my previous earlier scans, they noted a low-lying placenta Question Given this history, apart from examining the A MRI patient, what is the first line imaging you would order? B Abdominal Ultrasound C CTG D CT Abdo E Transvaginal Ultrasound Question Given this history, apart from examining the A MRI patient, what is the first line imaging you would order? B Abdominal Ultrasound C CTG D CT Abdo E Transvaginal UltrasoundANTEPARTUM HAEMORRHAGE Placenta praevia Differentials Ectropion Vasa praevia Miscarriage/Stillbirth Adenomyosis Placental Abruption Investigations Bedside: Vitals, Urine Dip, Blood Glucose Bloods: FBC, U&Es, LFTs, CRP, TFTs, G&S, Crossmatch, Coagulation Studies Imaging: Abdominal USS Special: CTG A-E + Senior Support 2222 + Major Haemorrhage Protocol Management Anti-D (Rheusus neg) Steroids <37weeks Emergency C-Section if unstable or home with elective planned at 37 weeks Summarising the history Patient details, occupation with abdominal cramps and pV bleeding.35-year-old woman who is G3P0 at 32 weeks, presenting & key presenting complaint Today, whist at work, Joanna experienced PV bleeding whereby an initial cup full of fresh blood History of presenting complaint was present on the toilet bowel. There was no discharge or mucus present. Subsequently, she has continued to bleed and has soaked through 3 pads. On her way to the emergency department, she has experienced light abdominal cramping which she has rated a 3/10. Relevant negatives During this pregnancy, she has presented with light PV bleeding at 11 weeks which had resolved. Her previous antenatal Relevant PMH/PSH/SH/DH scans have also shown she has a low-lying placenta. She has no previous or family history of any coagulation disorders. She is currently on iron supplementation and was previously on folic acid during the first trimester. Ideas, concerns & expectations She is worried about the health of her baby. My top differential is Placenta Praevia. Top differential & why Other differentials that I would like to rule out placental accrete, vasa praevia and placental Other differentials abruption. Role Foundation Year 1 (FY1) Doctor Setting Emergency Department Patient Jayna Patel, a 29 year-old, is a 37 week pregnant woman, who attends with complaints of generally STUDENT feeling unwell and a severe headache today. INSTRUCTIONS Student task Please take a focussed history from the patient. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis, as well as formulate a management plan. History of Presenting Complaint & Obstetric History • 37 weeks into my second pregnancy. I previously had an uncomplicated vaginal delivery 2 years ago. • Since this morning, I have started to get a headache, which has made me vomit once so far. For the last two days, I have also been feeling quite tired. • My husband also mentioned that my face has started to look a bit swollen and more ‘puffy’. Question Given this history, what is your most likely A Tension Headache differential diagnosis? B Eclampsia C Pre-Eclampsia D Gestational Diabetes E HELLP Syndrome Question Given this history, what is your most likely A Tension Headache differential diagnosis? B Eclampsia C Pre-Eclampsia D Gestational Diabetes E HELLP SyndromePRE-ECLAMPSIA Pre-eclampsia Differentials Eclampsia HELLP syndrome Gestational Diabetes Migraine Tension Headache Investigations Bedside: Vitals, Examinations (opthalm, neuro, abdo, PV), Urine Dip Bloods: FBC, U&Es, LFTs, CRP, Coagulation Studies Imaging: Abdominal/TV USS Special: CTG A-E + Senior Support Management IV Labetalol/ MgSO4 Fluid Restrict Steroids <37weeks Emergency C-Section Blood pressure education/management (next pregnancy - aspirin 75mg) Paediatric ReviewECLAMPSIA: Mx • A-E + Senior Support • IV MgSO4 • IV Labetalol • Continuous CTG • Emergency C-Section HELLP Syndrome • Haemolysis • Elevated Liver Enzymes • Platelets (Low) Summarising the history Patient details, occupation I took a history from Jayna Patel, a 29-year-old woman who is G2P1 at 37 weeks, presenting with & key presenting complaint headaches and lethargy. History of presenting complaint Since this morning, Jayna has presented with a headache, which has subsequently led to 1 episode of vomiting. She has also made comment on marked lethargy for the past 2 days, and her husband also notes her face has become more swollen. She is not presenting with photophobia, fever, neck stiffness or seizures. Relevant negatives Her previous antenatal scans have been normal. She has had a previous vaginal delivery with no Relevant PMH/PSH/SH/DH complications. Her mother also has a history of pre-eclampsia. She is not currently on any anti-hypertensive medication and has NKDA. She smokes 3 cigarettes a day. Ideas, concerns & expectations She is worried about the health of her baby. Top differential & why My top differential is Pre-Eclampsia Other differentials that I would like to rule out are eclampsia and HELPP Syndrome. Other differentials Role Foundation Year 1 (FY1) Doctor Setting Emergency Department Patient Annie Taylor, a 23 year-old woman who has just recently delivered her child 30 minutes ago. She has STUDENT asked to see you as she is complaining of PV bleeding. INSTRUCTIONS Student task Please take a focussed history from the patient. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis, as well as formulate a management plan. History of Presenting Complaint & Obstetric History • This is my third pregnancy. I have just given birth to two healthy twins 30 minutes ago via vaginal delivery. • I have noticed some bleeding from below and I am now starting to feel a bit lightheaded. • I have previously had a miscarriage at 12 weeks 2 years ago and another healthy vaginal delivery 4 years ago.POSTPARTUM HAEMORRHAGE Secondary to: Differentials • 4Ts: Tone, Tissue, Trauma, Thrombin Other Causes: • Malignancy • Ectropion • Polyps • Inflammatory vaginitis Risk Factors Previous PPH Antepartum Haemorrhage Bleeding Disorder Age Management A-E + Senior Support (SBAR) 2222 + Major Haemorrhage/Obstetric Protocol 15L O2 via NRB 2x wide bore cannula Resuscitation fluids + blood products Question What is the definition of a primary and A Primary: <24hrs + Secondary: Up to 3 secondary PPH? weeks Primary: <24hrs + Secondary: Up to 6 B weeks Primary: <24hrs + Secondary: Up to 12 C weeks D Primary: <12hrs + Secondary: Up to 6 weeks Primary: <12hrs + Secondary: Up to 12 E weeks Question What is the definition of a primary and A Primary: <24hrs + Secondary: Up to 3 secondary PPH? weeks Primary: <24hrs + Secondary: Up to 6 B weeks Primary: <24hrs + Secondary: Up to 12 C weeks D Primary: <12hrs + Secondary: Up to 6 weeks Primary: <12hrs + Secondary: Up to 12 E weeks Summarising the history Patient details, occupation I have presented to assess, Annie Taylor, 23-year-old woman who has just delivered twins via & key presenting complaint vaginal delivery 30 minutes ago. History of presenting complaint She has complained of PV bleeding since the delivery and has started to feel lightheaded. She has delivered her twins 30 minutes ago and has also passed placenta. She is not presenting with any fever, pain, discharge or mucous. Relevant negatives Her previous antenatal scans have been normal prior to delivery. She has had a previous vaginal delivery with Relevant PMH/PSH/SH/DH no complications. NKDA. Ideas, concerns & expectations She is worried the bleeding will continue. Top differential & why My top differential is Post-partum haemorrhage, secondary to uterine atony. I would like to find out the cause of the haemorrhage, and I am considering placental or bleeding Other differentials disorders as other likely causes, alongside malignancy and vaginitis.COUNSELLING STATIONSGeneral Principles Brief History Obstetric History + Risk Assessment Past Medical History Drug & Allergy History Social History Understanding Check understanding of current pregnancy status Concerns Any worries about the current pregnancy - ICE! Explanation Based on Risk Assessment - Location & Mode of Delivery Summarise Chunk and Check! Ask them to repeat backBirthing Options Risks from Previous Pregnancies Risk Assessment • Number of children • Post-partum haemorrhage history • Previous C-Section Risks for Current Baby • Position of baby - Breech/Transverse/Footling • Growth of baby - IUGR/Macrosomia • Multiple pregnancy vs Singleton pregnancy • Placenta praevia Risks of Mother • Gestational Diabetes • Pre-Eclampsia • Obesity (BMI >35) • Age >40 • AnaemiaBirthing Options Locations Hospital Labour Ward • High risk pregnancies - obstetrician/paediatrician led • Epidural anaesthesia Midwife Led Centre • Low risk pregnancies • Familiar midwife relationship • Environment - more personal/intimate compared to hospital • No epidural anaesthesia • Water v Hypno Birth • Complications need to be addressed in hospital Home • Familiar midwife relationship • Familiar environment - personal touch • Privacy • Water v Hypno Birth • Complications need to be addressed in hospitalBirthing Options Vaginal Delivery Assisted • Ventouse or Forceps C-Section • Grades: • I: Immediate (within 30 minutes) • II: Urgent (within 75 minutes) • III: Scheduled • IV: Elective • Elective: multiple pregnancy, placenta praevia/accrete, previous C-Sections, breech/transverse presentation, severe hypertension/pre-eclampsia • Vaginal Birth After C-Section • Cephalic + Singleton pregnancy at 37 weeks • Contraindicated in those with previous uterine rupture or classical scar • Continuous Fetal MonitoringC-Section Perioperative + Anaesthetic Concerns Before • Full Blood Count • Group & Save • Anti-emetics • Thrombo-phylaxis • Prophylactic Antibiotics • Indwelling catheter • Spinal/Epidural Anaethesia + Side Effects Incision Type - Classic vs Lower Uterine Segment Incision During Team involved - obstetrics, anaesthetists, and possibly paediatrics Intraoperative complications: haemorrhage, bowel/bladder lacerations, uretheral injury Post-operative Recovery and Complications After • Taken to recovery • Pain relief • Infection risk • VTE risk • Hospital stay longer compared to vaginal deliveryPREGNANT ABDOMEN EXAMINA TION General Inspection Abdominal Inspection • Striae albicans • Excoriations • Pulse rate • Distention • Head + Neck: jaundiced • Distended Superficial • Scars sclera, pall, oedema • Fetal movements Veins • Legs: Swelling, oedema • Umbilical Eversion • Linea Nigra and varicose veins • Striae gravidarum • Cough (hernias) Completion Fetal Auscultation Abdominal Palpation • Blood pressure • Use of Pinard or • Fundal Height • Urinalysis Doppler • Lie • History • Presentation • Liquor Volume Role Foundation Year 1 (FY1) Doctor Setting Emergency Department Patient Lizzie Smith is a 37 year-old woman of 26 weeks gestation who has presented for her next antenatal STUDENT check. INSTRUCTIONS Student task Please take a focussed history from the patient. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis, as well as formulate a management plan.• On examination, patient is comfortable at rest. • Fetal lie is longitudinal, no engagement present. • Symphysis-Fundal height is 33cm. • Fetal HR 138.MACROSOMIA Gestational Diabetes Differentials Polyhydramnios Twin-twin transfusion syndrome Congenital anomaly Bedside: Vitals, Urine Dip, OGTT Investigations Bloods: FBC, U&Es, LFTs, CRP, HbA1C Imaging: Abdominal/TV USS Special: CTG Management Conservative: • CBG • USS Medical: • Diet and exercise • Metformin + Insulin Surgical: • IoL/C-section at 37 weeks • Hourly glucose measurements Spot Diagnosis A 24-year-old female who is 32 weeks pregnant presents with painful PB bleeding following a Placental Abruption road traffic accident. A 34-year-old woman who is 33 weeks pregnant Premature rupture of membranes presents with 1 quick episode of PV discharge (gush). Spot Diagnosis A 16-week pregnant lady presents with PV Miscarriage bleeding. Upon ultrasound investigation, there is no presence of foetal contents. A 26-year-old woman who is 37 weeks pregnant presents with headache and a swollen face. Her HELLP Syndrome blood results revel, low red blood cells and platelets and elevated liver enzymes. References https://geekymedics.com/caesarean-section/PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO THE REST OF OUR OSCE SERIES