This IMG2UK and WPMN teaching session is the perfect resource for medical professionals to gain an insight into clinical practice in the UK. Led by experienced staff, the session will cover essential topics in Obstetrics and Gynecology and management approaches in the UK's NHS. Take advantage of this exclusive learning opportunity today to help get up-to-date with UK clinical practice and prepare for exams.
IMG2UK - Obstetrics and Gynaecology
Summary
This IMGT UK webinar will focus on important concepts within obstetrics and gynecology to help medical professionals prepare for the Plav exams and UK Clinical Practice. Hosted by Widening Participation Medics Network, the session will be led by Dr Renea Mohammed, a clinical fellow at Ashford and Saint Peter's Hospital NHS Foundation Trust. During the session, Dr Mohammed will provide two clinical case scenarios for each of obstetrics and gynecology, which will be focused on the A-B-C-D approach and on how to posess a focused clinical history. There will be an opportunity to ask questions throughout and feedback forms will be sent at the end. This webinar is essential for anyone preparing for the Plav exams or working in the UK medical workforce.
Description
Learning objectives
Learning Objectives:
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Understand the common differential diagnoses when a pregnant patient presents with headache and blurred vision.
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Be able to differentiate between mild and severe preeclampsia.
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Identify the importance of a focused history and examination of pregnant patients.
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Explain the medications needed and the investigations required in order to safely manage a pregnant woman with pre eclampsia.
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Be aware of the primary objective when managing a pregnant woman with severe pre eclampsia.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
I want to say hi, everyone. Thank you again for joining this IMGT UK webinar uh where we're going to be focusing on some important concepts within obstetrics and gynecology to help you prepare for the Plav exams as well as for UK Clinical Practice. This series is hosted by the Widening Participation Medics Network or W PM N which is a national charitable organization that aims to make the medical workforce of the UK more representative of the population that we serve today. We have Doctor Renea Mohammed. Uh she's a clinical fellow at the Obstetrics uh in Obstetrics and Gynecology at Ashford and Saint Peter's Hospital NHS Foundation Trust. Um She has been working here in the UK for almost three years now. Uh and I'm sure she is going to bless us with her obstetrics and gynecology knowledge. Now, um before we get started, as usual, I'd like to remind anyone, everyone that if you have any questions at any point, please feel free to ask them in the chat. Um And then I'll try and highlight them to Renee as uh we go on alternatively, uh uh we will most likely save them for the end depending on how the clinical scenarios are going. Um And also at the end of today's session, we'll send out some feedback forms for um our teacher today and we'll appreciate if you complete these cause not only does it help out the person who's teaching but also helps us to cater future sessions to figuring out what exactly you guys would like as part of the teaching. Uh And so without further ado, I'll leave you guys in the capable hands of uh Doctor Rene Mohamed. Thank you. Thank you b um Hello everyone. Um I know this is a Saturday afternoon and hopefully this um webinar is not going to be too boring for you guys. Um Like vi introduced me, I've been working in Ashford and Saint Peter's Hospital for the last three years after I did my training in Gyne from India. Um I don't know how many of you guys are planning to come where the pla route or already working in the UK. I did do my plas um in 2017 and that's how I joined um as an F two initially before becoming a registrar. So um I will try and presentation which is um kind of favorable in terms of um how to approach a pla to exam at the same time um as an F two or, and show how it's um applicable when you're dealing with patients um in S and Gyne. So, um a brief introduction. So today is going to be um clinical case scenarios only. Um I'm trying to make it a bit concise. So there'll be two cases from obstetrics, uh two cases from gynecology and this would be um purely how to approach them and how to present them in your exam as well as um in real life as well. Um So, um just uh uh a small, um you know, a small um table on how to approach them or what to keep in your mind when you're seeing a patient with Ops and Gyne, um is that always in, in, in exam as well or in real life, try to be taking a focused clinical history. Um We can easily um you know, go into elaborate details when talking to a patient, so be very focused on what you ask the patient, especially when your time is limited. Um That is very important then going on to examination diagnosis and management. Obviously, we go through each one as it comes. Um I hope my slides are visible to everyone. Please let us know if there's any problems with listening or seeing the slides. Um So my first case scenario is going to be a very common one, hypertensive disorders in pregnancy. Um This is something which I got in my pla two exam as well. Um So we had um this is just to give you a rough idea of what we would be seeing, which is a 41 year old Primi Gravida with twins at 38 weeks of gestation, she presented um to maternity, triage with headache and blurring of vision uh for those of you who don't know. So triage is like an A&E but only for maternity. So as an S or an F two, we are the first points of contact with these patients after the midwife um examines her. Um she will be handed over to us to um examine and then manage as appropriate. So, um looking at this patient presenting to you in your case summary, you've got a pregnant lady term with headache and blurring of vision. So immediately you should have some differential diagnosis which comes up in your mind. Ok. And that will be um what do you think a pregnant lady with headache and blurring of vision? I know in medicine, we'll have a lot of differentials. But when in maternity, um we always try to rule out the maternity related things first, which is preeclampsia or you know, impending eclampsia, then you do go to the other uncommon ones which could be a migraine. It could be um you know, a clot in the brain which we call a cortical venous thrombosis. It could be rare medical problems, it could be a stroke, it could be even a tension headache, it could be anything, you know, out of the ordinary. But always when you are thinking of differentials, that is when you have to think what do I include in my history taking. So I keep stressing on focused history because in exam, you will find that this is the one that takes up a lot of your time. So ABC D approach is more for your examination. Um I think this is useful, not just S and Gyne for a medical case or for a surgical case, even you don't have to have a patient collapse to do the A CD approach. You can just go by, you know, the patient, I can see that the patient is conscious. She's speaking to me in, you know, then you think about respiration, your pulse, blood pressure in exams, these will be given to you by the examiner, the findings. If they are relevant. If they keep quiet, you carry on with the rest of the examination. Ok. So um ok, when you ask for examination findings, so you ask to focus history in history with preeclampsia, you would ask the nature of the pain. Where is the headache? How does the headache come on? What are the associated symptoms? So any vomiting, you know, blurring of vision, any seizures, any fever with rashes, you know, rule out meningitis. Um Also you ask about pregnancy as well. Is the baby moving? Ok. Is there any pain in your tummy? Are you leaking or bleeding? So these are the common things you kind of include in your first history. Um And then these things which I have shown in my slide are sometimes given to you straight away as the exam question for Bleb two. So they will say her BP is 1 61 10. Um She has got um pain in her upper right abdomen. She has got pedal edema and her jerks are exaggerated and she's got a three plus of protein, which kind of sums up what you are looking at. So your history can be again a bit more streamlined if you're given this beforehand, if not, they will give this to you. When you are saying after history, I would like to examine her pulse, her BP, her urine depth and her abdomen. An interesting thing I had in my exam was um when I was going through the history, my patient was quite anxious and um in the middle of the history taking, she was very agitated. She said uh you keep asking maybe about headaches and baby, I think something is wrong with me. Am I going to die? Is my baby going to be ok? So, um you do know that in exams in pla two, these are trained actors. So they will try and sort of, you know, derail you off your track. So um I know exams can be stressful. We want to uh you know, we want you guys to keep a very clear mind. So if you think, oh, she's not letting me finish my history, which they would do. Sometimes you always address the patient's concerns then that carries the most marks which I have personally experienced. That is why I'm really confident in telling you as well. So if you think the patient is not letting you complete address her concerns before going on, um because naturally all of us will think, oh, I've got this many minutes left of to complete this and then go on to this. Why is she not letting me complete? And that is a normal thing to feel. But you just have to sort of think in real life, if your patient was crying in between your conversation, you obviously would not be talking, you know, medical stuff, then you will stop, you will pause and you will listen to her. So imagine that that is just the case. And sometimes if they see you are addressing their problems, they will stop and let you complete. And that doesn't mean you need to go through the whole thing, even if you're halfway through, you get really good marks. This is not always a usual thing. So we know here what would be your diagnosis? So your diagnosis is severe preeclampsia because she's got a BP, 1 61 10, she's got a headache, she's got, you know, deep tendon reflexes exaggerated. So you, you tell your diagnosis in an exam or if it's real life, you think, ok, this is severe preeclampsia. How would you manage the patient? No, this is going to be very concise as an F two or sh they don't expect you to know too much, you know, you know, very high grade stuff. All you need to say is, are you a safe doctor or not? That's all what they check for in GMC. So would you admit this patient or would you escalate? So that is the first line you have to say for every patient I would admit her in H so HD is high dependency unit. It depends um in different hospitals, it'll have different names. So even if you say I will admit to her for, you know, closed observations and high dependency unit, that is correct. Or if you say, you know, in labor or that's also correct and you escalate your senior, you wouldn't manage her yourself, you always escalate. So that would be either a registrar or a consultant. And then what is your primary objective with a severe preeclampsia? You do not let her have a seizure, you do not let her have a fit then. So you give her antihypertensive and magnesium sulfate. These two are the most important. So explain to the patient because you know, explain to the um examiner. So I will give you a medication as IV to reduce your chances of BP going up, you having a seizure or a stroke. And also it's important that we bring your BP down because otherwise it will affect you and your organs as well as baby So how to make sure the baby is ok. You also will ask the midwife to do a CT G and then you will say to the patient, I will send some blood investigations which are important to look for your kidney function, your liver function and your uh blood clotting and you know blood routine. Um after the initial management, then along with your registrar or otherwise, you will make sure the baby is grown normally because normally preeclampsia is associated with placental insufficiency and the babies are usually smaller. So you address that. And then, so in between again, like I said, most of the time when you are explaining the diagnosis, that's when the patient gets really tense. So you tell her this is something which is due to pregnancy and now we'll be managing this and we will be making a plan regarding your delivery and me along with my seniors, we will um most likely be um you know, once we settle your BP, we would like to think, talk about delivery because she's 38 weeks, preeclampsia, the treatment for severe preeclampsia is delivery because the cost is pregnancy. So we would talk about delivery and then that will be, you know, you don't have to go into details. You just, you know, touch that bit that you do think about delivery as well. So it's very important you talk about um baby, how you're going to manage that. So magnesium sulfate anti intensive CTG blood investigations. Um, you know, as an s show, these are the things we have to be sure we have thought about and we have verbalize it sometimes you will think of it. But, you know, in that stressful scenario, it's very normal to forget. So you just localize when it comes in a very non medical way because you are actually speaking to a patient there in an exam, even in real life, you have to explain to the patient here that you keep gonna give medications, you're gonna, you know, help you get through this, we're going to settle this all of that. And um um different countries from, you know, I know many of you are from different parts of the world. We have different ways of um you know how the medicine works, how the system works. But in the UK, um the patient is very, very informed of each and everything we do to her. So even if it's a cannula, you explain and take the consent, that's very important at every step after history, before examination, you take the consent when talking to her, you talk to her in her own terms as in, in words that she understands. So these are very important, think this is the sense of how you manage a severe preeclampsia scenario. And even if you do not medically do really well, in that scenario, if you address the patient's concerns really well, you get really good brownie points for it. Ok. I think that is the end of the first scenario. Now, second one, I hope I'm, I'm ok. At this point. If I'm going to fast, please feel free to let me know. Ok. Um, the next patient we have um an F two in A and um I've got a 24 year old who presented with sudden right, lower abdominal pain, you talk to patient, take history, do relevant examination, discuss initial management or address her consents. And this is how they will usually give an, you know, an exam question to you. Otherwise this is how you would get a referral when you're in a set in of some gyne so sudden, right, lower abdominal pain, 24 year old. So there are a few things you have to think about. Obviously, when she is 24 she is young, she's in the reproductive age group. You always rule out what is a pregnancy. So pregnancy is something you should always keep in the back of your mind. Now, um in your history, all you know is that she's got abdominal pain. So you explore the pain. So you know, any synonyms that work for you Socrates, which is sight onset character, radiation associated symptoms, any exacerbating relieving factors. Um you know, when did that start? How bad is the pain, things like that and also associated symptoms, you know, in a young female, you're worried about, you know, pregnancy. So you ask for vomiting. You ask, she, she also have other intraabdominal organs which may be, you know, causing the problem. Now, an appendix gallbladder, a gallstone, anything. So you ask about fever dysuria, um any discharge for vagina, you can also ask about dyspareunia, um which is sometimes an associated symptom for pelvic inflammatory disease. So, um your history should sum up pain and associated symptoms. Always ask in your history about periods that is very important in a young female. So um this slide is really, really important because I go by this for any obstetric or gynecology patient, for any patient. I come, this is a flow chart that comes to my mind when I'm asking the question. So menstrual history. So imagine the patient is a small girl and you know, you imagine how she's growing through years. So she starts with having menarche. You ask menstrual history and when is her last menstrual period? Then you go on to sexual history, partner history, which is very important when she comes with abdominal pain because it could be a pid, it could be um you know, an sti so you ask if she's got a stable partner, um does she, you know, have unprotected intercourse? Any contraceptives, she's using all of that, then obstetric history, if she has had pregnancies in the past, any ectopic pregnancies in the past? Why? Because they have a tendency to recur um obstetric history is important. If not, she's an ali Paris um woman, that's how your history should go. Then you go on to when she becomes an adult medical surgical allergic histories. Ask in a very short way and then personal history, mainly smoking, drinking drugs um is what we have to include. So this is the sense of a normal history taking in, in pregnancy. Otherwise, in gynecology as well, this will really help you not forget the important points. Um on examination. Um like in exam, you will say I would like to take her verbal consent, offer her chaperone, then examine her observations, abdomen, speculum and a by manual examination because you wouldn't be doing that. You will be just verbalizing, you would do it with consent. So usually the examiner will give you the findings and then they will say there's a copper coil in situ and she has got a right adnexal tenderness and a cervical excitation for those of you who can understand it essentially means that when you move the cervix, she feels tenderness and you know, the fornix on the right side is tender and abdomen also has a bit of tenderness. Um Initial investigations you can ask for, I would like to get a CRP a full blood count and a urine dips along with a urine pregnancy test, which is a very, very important in a young female. Please do not forget to mention that in an exam. So you have done the examination, you have found this is the scenario. She has got excitation, she has got adnexal tenderness. So, what is your diagnosis? Anyone wants to contribute? Ok. Um, so she has got pelvic inflammatory disease, which is, you know, essentially an infection of the womb or the tubes or the ovaries. And that can be caused usually by bugs which are ascending from the genital tract. Um, so this is your diagnosis and sometimes if the patient doesn't run a few, she'll ask you, what does that mean? Doctor? What is that a cancer? Is that something which is going to, you know, cost me my life. So you explain to her, this is a treatable condition. This is an infection of your womb, your tubes, your ovaries. And in PAP two, you have to talk like that, you would not be just using medical terms. Um So you have to say it's an infection and this is how you would treat it. So, in your management before your management, how would you treat her? So, based on your examination, you will understand if she's stable or if she's unstable because in Pid, you've got three types, mild, moderate and severe, mild and moderate, you can manage them as an outpatient, severe, you have to manage them as an inpatient. So if in your examination findings, the examiner gives you, she has got a temperature of 39 °C, she's got a pulse of 120. Her BP is 100 and 60 would you send her home? No. So because she's ideally in sepsis. Now, so you have to manage a septic, you know, septic screen septics bundle all of that. So you always admit her. So like I mentioned in your management, your first management should be, would you treat her as an outpatient or an inpatient? Then before giving her pid regimen, you have to talk about triple swabs, which is essentially the genital swabs you would send. So you take an endocervical swab, a high vaginal and a low vaginal swab essentially to look for the common um organisms that cause this infection. And you would do a blood test, which you mentioned before, you can always say that again. And then if you think she really has got a mass sometimes in the examination findings. If they say there's a mass, when you're examining, you talk about a transvaginal ultrasound. Because does she have a tube ovarian abscess or something? You have to treat, you know, as an inpatient. So you always mention this. Um if you have talked about the initial examination and investigations, you also advise the patient. So imagine you are the doctor, you're talking to the patient, you will say I will give you antibiotics which will be taken for a period of 14 days. Um after an injection, which I'll give you as a stat dose. Now depends on the severity of pid. Of course, it's the protocol. And then during this time I would advise you not to have intercourse because that would exacerbate your already, you know, ongoing problem. And um also in a very nonjudgmental way you have to ask about the partner because um it is really important that we treat the partner as well. Um And if the patient is not keen to divulge that information, then obviously, we have to follow protocol through partner initiation program and get in touch. And um there is a test of cure we would do after treating you. And then once that says that you're cleared, then obviously, this would be um that is the end point of your treatment. But if the patient asks you, will this affect my fertility? Will this affect my pregnancy in the future? You say um at the moment because we have just started, you know, treating you, we would treat you and see but some bugs like chlamydia, for example, do have a tendency to affect the tubes and can cause ectopic pregnancies in the future. So that is something we time will only tell. But some bugs do produce a risk for affected fertility and can lead to abnormal pregnancies like ectopics. So you mentioned that to the patient but tell her this is all treatable and it is good that she came at the right time and that she's seeking the right help. You have to reinforce the positives in your clinical review. Um These are some of the things which in pla two they would look for for markings, the partner initiation program, you have to mention it, test of cure safety netting. What safety netting would you think about she's having pid? So she has a focus of infection which can always flare up. So, sepsis is something you look out for. So really unwell high grade temperature, not getting better in the next 48 to 72 hours. You are, you know, having no urine, you know, sepsis, severe sepsis, kidney problems, anything different, you ask her to come back in straight away. Um We can also bring her back as an outpatient appointment to review her in 48 to 72 hours. And then say in the future, safe intercourse is the best way always because barrier methods can prevent S ST S and can prevent bids from happening. Um Also say during treatment, this is something we would advise against. And in between you pause, you ask them for patient concerns and see if she's understanding, especially if she is young, she would be understandably more worried about her parents coming to know um what will happen to her future is this the end, that kind of thing. So you pause, you address that before you go over to finish the rest of your station in real life. Obviously, we won't be time restrained. We can easily talk about this, you know, in detail when you're in A&E or when you are seeing the patient elsewhere. But in an exam, you have to be mindful of the time. So address the concerns but don't be too slow either. Just address reinforce reassure, go on with your history. Um This is usually very straightforward the station, it will be more or less them seeing how you manage the interpersonal skills. Um So that would be something you have to really keep an eye on. Um So that brings us to the end of the second case. We've got two more to go. Um I hope I am clear so far. So we have talked about a case of preeclampsia which is obstetrics, a case of um pid which is gynecology. Um Now my third case scenario, yes, a girl who is 18 years old comes to A&E with six weeks Amenia, sudden onset lower abdominal pain distension and spotting for vagina. On the exam. Question it or on your referral. It just mentioned over the counter or she did at home. She said the pregnancy test is positive. So, you know, you've got a first trimester pregnancy whose come with pain distention and bleeding. So what is it that you're immediately worried about? So when you're being a safe doctor, when you're in A&E all they want to know as an F two and S is, are you looking for lifethreatening conditions? Are you looking for things that can prevent life-threatening conditions from happening before you go on to manage to common things? So this lady could very well have a UTI and she's just pregnant, you know, it's going side by side. So it's not that it won't be a problem if you miss a UTI I and pick it up the next day. But it will be a problem if you miss something which can grossly affect or, you know, cause her imminent life risk, which is ectopic. So things like that is something you have to bear in the back of your mind, especially if in the question, they say over the counter pregnancy test is positive. Um again, bear in mind she is a young girl. So again, interpersonal skills would be very, very crucial and that's something they would look for in the exam. So in your history, like I mentioned before, um I'll just go through it again. You ask about presenting complaint and history of presenting complaint. So that is first. So she's come with pain and spotting. So and a menor so you can cover your menstrual history in that as well. When is your last menstrual period? You calculate the period of gestation. When did the pain start? When did the bleeding start? Do you have any pain in your lower back? Did you pass any blood clot? Did you think you saw, you know, anything different when passing the clots? Because some people, if they're having a miscarriage, they would see pregnancy tissue as well. So you asked for all of that and then you go on to the other history quickly. So what I mentioned was obstetric or past obstetric history, um partner history, um medical history, surgical history, personal history. But even if you don't complete at least ask the relevant history, sti is very important. I I just highlighted the relevant history here. Sti is why because if there is a previous history of chlamydia, gonorrhea, she is a high risk for ectopic pregnancies. And why is that? Um because these bugs, they affect the tubes. Philippine tubes and they are said to affect the motility of the Celia in the tubes. So, um they are highly prone to develop tubal ectopics rather than anything else. And even if none of s sts has happened, you always ask if she has had a previous ectopic or a previous surgery because that puts her at higher risk to get another ectopic. Why have I mentioned contraceptive history? We do know that you know a cup of coil. Um um um a patch a pill, everything is contraception but a copper coil, if a patient has a coil in situ and comes with pregnancy, it is an ectopic unless otherwise proved because they, they are very good at avoiding intrauterine pregnancies, but they are not so good at avoiding tubal pregnancies. So if they do say they have got a coil in situ that should make your mind think more in line of an ectopic, previous obstetric history like I mentioned before. Um then you talk. Ok. Now, after your history, I would like to examine my patient with verbal consent and offering chaperone. I would like to do an abdominal examination. I mean observations very important. A abdominal examination, speculum examination, bimanual pelvic examination. Uh Please do not forget to mention. So anything else that you would like to add to the examination or what you would want to do before you come to a diagnosis? You have to mention that I would like to do a urine dipstick and a urine pregnancy test. This is very important because on the question, it mentions over the counter, the pregnancy test is positive. You have not physically seen evidence of pregnancy test being positive. So you have to always confirm, you need objective evidence before you go about diagnosis. So you say observations, what is relevant with ectopic pregnancy and observation. Um If you're thinking that will be a rapid pulse rate, hypotension, is she bleeding inside her tummy as she had a ruptured ectopic again, speculum in bimanual pelvic, you will see some spotting and bleeding. But other than that, they usually do not have any positive signs. Sometimes they will say abdomen is distended. She has signs of guarding peronism which confirms ectopic pregnancy. So that is your diagnosis. So you clearly mentioned, I think you may be having or I think the patient has got an ectopic pregnancy. Now, your management, normally, when you've got positive findings say peronism distended abdomen, what are you worried about the patient going into shock or decompensating? So you have to say I will admit the patient, I will escalate and then I will send a blood investigation after putting an IV cannula. So you explain to the patient, there are blood tests we would do to check your blood pregnancy hormone levels. And um progesterone is something we add to in real life in an A E. We see a patient, we always check the progesterone as well. And then we would like to organize a transvaginal ultrasound is urgent um with early pregnancy unit. Um The three most common differential diagnosis for first trimester bleeding is one is ectopic. The other one is a miscarriage which can be a threatened miscarriage or an incomplete miscarriage. And third is a molar pregnancy. So you, it's very important that you do a serum HCG, even though you know she is pregnant, you need to know the levels of HCG and the progesterone and please do not. So if say you're examining the patient, she's crying out in pain. You do not go about to explaining your diagnosis and your management straight away, you have to pause and offer her pain relief because um in real life, you would not be talking to a patient who is screaming out in pain. You would want to calm her down before you talk to her, make sure she understands. So you offer her analgesia if she's in pain and if she refuses admission, you again reiterate the high risk involved. So if you've got a tubal pregnancy and if we think that it can be ruptured, it is very risky to your life. It can um if we do not manage it straight away, it can cause even death. And then mention to her and if she's more worried about parents knowing her about this, explain to her, we are worried about her health and her safety, we'll make sure she is ok. She is stable before because she's 18, she's an adult. Actually, if we do not have a, she is not giving us consent to explain to parents, we can't divulge the parents straight away without her approval. So we talk to her about her safety and it's vital that she stays in hospital while we evaluate her and um you know, decide on further management. And if it's an ectopic and if it's ruptured, she will ask what next, what would you do to me? Then you talk to her and tell um you know, if it's a rupture op, my, my registrar, my consultant will um discuss about possible laparoscopy as an emergency where we would have to um look at your um tube and the pregnancy and very likely you may need a salpingectomy, which means taking out one of the tubes. Um at this point, sometimes she might think, oh, this is going to affect the fact I can't have any more kids in the future, then tell them about, you have another tube and it's perfectly, you know, perfectly ok. You can still fall pregnant. This is something which is important because if we leave the tube and just drain the blood out, you are highly at risk to develop another ectopic really soon. So, um, you know, be calm pause and then explain to her if she declines admission because this is very, very important for her safety. And despite the fact that you have explained and she doesn't understand that is ok, at least you have explained. And then, you know, depending on that situation you handle it, do escalate straight away. If she's threatening to self discharge, you may need to escalate to bring in your seniors to help talk to the patient. Um Otherwise, if she's going to go straight away, she needs to sign a self discharge form because that's essentially her own informed decision. So we should respect that. Um As long as she has the mental capacity to process what you have explained to her. So that was my third case scenario. This, these are very, very common when you start working in the UK because um when you are starting off as an F two or an S, um you might sometimes feel really out of your zone um in A&E because that is you are the first point of contact for these patients, not the um not anybody else in maternity. So when you see the patient when you think that you are not understanding what's actually going on, feel free to ask um your seniors in, I'm talking about when you start working because sometimes you will really, really feel out of your element there, but that's completely normal to feel that way and you might feel you making very crucial decisions. And sometimes if it's a stable patient with some spotting and pain has settled, there are occasions which we would send them home and bring them back the next day to scan, get scanned in early pregnancy unit. So do not worry that all the ectopics are going to, you know, rupture. But in your exam, the things would be a bit more clear, most likely be an ectopic in a lot of pain, possible rupture where you will always admit. But in real life, you would also see stable patients who would go home. So that is something you always think about and keep in mind. Ok, coming to my last um case discussion for today's webinar, which is um you are in f two, an Antenatal clinic. You have got a 35 week pregnant patient who is a multigravida. Uh She has had three vaginal deliveries in the past, do an examination and discuss management. So um this very likely would be a mannequin station in plaque two because it would be to assess how you are examining the obstetric uh patient. Um How would you go about it. Sorry. So that would be um um you would, you know if it's a real life patient, that would be mostly just history and ex explanation. But otherwise this would be just essentially your approach to this case as well. A short focus history, any complications, antenatal and previous obstetric history and um past medical surgical history. Now, when you've got a mannequin, even though we know we there's no patient. You, you say you um introduce yourself to the patient, then you stand on the right hand side of the patient. You usually have a mannequin STMS exposed to explain to the patient, offer her chaperone and then say, I'm gonna be exposing you your tummy uh from the ce sternum. Ideally any of an examination, it should be up to the mid thigh. But in obstetrics, we just go up to the pubic and physis mm and make sure she's comfortable before you start examining her. And then on the mannequin, you verbalize as you're examining. Um you can go in any order. I've just mentioned things which I would look for and I was taught back then. That was a fundal group. So you feel the fundus of the um uterus. And then you explain on the fundus, I can feel a hard round compact blot, you know, mass very likely that is the baby's head and then on the umbilical grip. So you feel on one side, then you feel on the other side at the level of the umbilicus, you always keep one hand fixed when you're moving the other hand. And then what do you feel on one side? I can feel a uniform resistance. Very likely the baby's spine or back. And then on one side, I can feel um irregular nodules, very likely baby's limbs or fetal limbs. And then first pelvic grip is you hold like that at the, at the, just about the pubic symphysis and you try to feel the presenting part. I can feel a round, um broad, soft, um non belo belo, you know, mass and it's very likely it is the baby's breech or buttocks and second pelvic grip. Um I'm not sure if you still do that. So you start from the umbilicus and you go with both the hands. So it confirms your first pelvic grip, confirms the presentation. Uh You can also understand if the baby has descended into the pelvis or not. And then you always listen to the fetal heart sounds um with the fetoscope which is a funnel like instrument which would be kept there. And uh you listen with um so it should be hands off and then you um concentrate on the spinal umbilical line. And usually if it's a breech baby, you will hear better about the level of the umbilicus. If it's a cephalic baby, you will hear it better below the level of the umbilicus. There is a reason why I mentioned Multigravida 35 weeks in this patient because, you know, breech pregnancies, they are more common when on a multigravida because the uterus and the abdomen will be a bit more lax. So the babies will easily move around and also she is preterm. So, um preterm is again a risk factor for malpresentation which is breach. So, and then you would, you would, this is just a, a quick idea of how you are, you know what you are feeling when you're examining a baby. Um This is called a complete breech, which is the fetal position, flexed, knees, flexed hands, and you will feel either the buttocks or the legs um in a vaginal examination as well. So on the abdomen, you feel the head, this is your fundal grip. You can see my cursor. Um this is your first pelvic grip on the umbilical grip. You will feel the back one side and the limbs on the other side. And when you listen to the baby's heart, you listen somewhere here, you usually feel it. And um this is called a Frank breech or an extended breach where it's like, you know, a folding knife position, the legs are extended, but they are the, the head is usually splendid in between the legs and you'll feel the bump and you'll feel the head. Um they're usually not bearable even the head because if they are fixed in between the legs in, in clap two, it'll be really, really clear. I'm just saying in real life, if you see such a mom, it would be sometimes a bit hard to identify. This is a foot length Bree where it's, it's a half complete breach. So one leg is hanging, one leg is flexed. That's it. Transverse lie. You will find an empty lower pole. You don't usually get that in exam, but it's just helpful. You will not find any fetal parts in your first pelvic grip and it will be really confusing and the abdomen will be transversely distended rather than longitudinally distended. And I know in your diagnosis, you have to mention the lie, the presentation of the fetal heart sounds. So you always say this mom has got a singleton baby in breech presentation, longitudinal lie um with a echo or not. So you have to mention if you feel a like or and then say fetal heart sounds are so and so heard in the spinal umbilical line or you know, or above the spinal umbilical line on the right or left side. Um This brings me ideally to the end of my case scenario presentation. Um In clap two, all I would like to stress is they are usually off and gyne scenarios are very straightforward. You, the moment you go into the room, read the question, you would understand what you're going in for. So in your mind, be prepared um immediately before you go into the room, you get a few minutes to think about what to say. So just think about only the salient points. Don't think about everything, all the order just like that. Just think about what you would not miss um in your, you know, diagnosis, management and your examination and you will be sometimes caught off guard when they change the story inside, they may stop talking to you, they may get angry, they may get sad upset, then you pause, they expect you um to address that rather than go on to complete the station. Um The reason why I'm stressing on this so many times is I've had colleagues who have done really well in their stations because they were so um happy coming out that they finished the entire station in the scheduled time, they covered all the points, everything, but still they did not get a good score in those stations because they did not identify or address the patients. Concern. You pause, you ask if they understand you address, if they are sad or if they're anxious, you do not go on to complete whatever you have learned. So that is very important. Again, Mannequin stations are very straightforward. The other common one is a speculum examination. How do you demonstrate it to a medical student? Which is again, very straightforward, I think practice was really make it easier um breach in management. Again, you mentioned all these three which I'm sure you guys already know. So um what is the management So she is 35 weeks. This patient, what would you offer her? Tell her your preterm? It's very common for you to have malpresentation at this time. So after your term, we can check if the baby is still in breech position. In that case, we can offer you something called this external cephalic version where we try to move the baby. This image is something to guide you to see how we move it. And we see if the baby goes back. Sometimes due to some other reasons like a low placenta or a fibroid in the uterus, the babies are breached because they don't have enough space otherwise. So they will go back to the original position. In that case, we have to talk about the other two options, which is an elective cesarean section, um which would be always done after 39 weeks. Um And or a vaginal breech delivery in the UK, vaginal breach deliveries are considered very, very, very high risk is not usually recommended to patients. We always talk about the other two, but some patients are very keen to have a vaginal delivery. Then it has to be an informed decision. It has to be a consultant led delivery in a tertiary care center because there is high risk of fetal entrapment at multiple positions, can be a head entrapment, shoulders getting stuck. So it's a very high risk delivery. But that is again, you offer all the options to the patient. When you talk about management, an E CV elective section or a vaginal breech delivery and say the pros and cons of each. The reason I'm not going too much into medicine is because I'm sure all of you must be well worth with all of this already. It's just the, the way you present it and how you talk about it is more important in exam and when you're working as well, that brings me to the end of my presentation. Thank you so much for listening. I'll be happy to answer any questions. If you guys have any, anything you want me to talk about. Hello. So I want to say thank you to Rena. That was such a good uh a good talk. I uh I actually learned a lot so I was very happy to done that. Um And having also done the pla exams quite recently, I wrote mine in um 2022. So I, I remember all these things and having to um you know, especially your point stressing the pa the fact that you have to address the patient concerns before anything else was, was very, very vitally important. Uh Like, like you said, because I had, I also had a lot of colleagues who, who definitely knew the medicine, but because they didn't put the patient first, they ended up uh not doing so well as they thought on those, on those uh cases. Um uh I'm going to ask anyone who does have a question from who's attended today uh to please put it in the chat and, and we'll wait for that. In the meantime, I've just sent out a feedback form. So if you guys can please fill out that feedback form, that will be really, really appreciated. Uh One because um it helps us figure out what you guys want for future talks and also what worked and what didn't. But also it's really helpful for, for us to be able to put into our portfolios um which you guys will soon come into as soon as you guys come into UK Clinical Practice as well. So um if no one has any questions, um we'll wait a couple more minutes and then