ONG Rubrics

Histories.
pdf
Antepartum Hemmorage History.jpg
Counselling for Hysterectomy.jpg
Counselling for Oral Contraceptive Pill.jpg
Counselling.pdf
Examination of Pelvis.jpg
Gynecological Exam.jpg
History Taking.jpg
Obstetrics OSCE.pdf
OSCE Counselling.pdf
PCOS.jpg
Pyleonephritis History.jpg
History taking - Abdominal pain
Introduction: Good morning I am Chris Bretherton a 4th yr medical student, can I check your
name – and date of birth. I would like to have a chat with you regarding your abdominal pain,
and answer any questions you may have, is that all right with you?
Site
Onset
Character
Radiation
Assocaited factors – nausea, vomiting, distension, sweating, SOB
Timing – Diurnal variation? Relation to food? Exercise?
Exacerbating/ relieveing factors – r getting better or worse now?
Severtity
Bowels – change? Diarhoea or constipation, pain etc
Urine – change? Frequency, pain etc
Appetite, weight loss?
Discharge or Bleeding?
Every had any of these before?
Menstrual history:
LMP, Cycle, Cervial Smear, Contraceptives?
Could you be pregnant?
Menopause/ HRT
Obs Hx:
Past Pregnancies – delivery, weight, complications (miscarriages, ectopics, stillbirths)
Medical history: h/o acid peptic disease, angina, appendicectomy, STD, PID, IUCD,
ectopics.
Gynae surgery?
Family history of bowel diseases or Carcinoma?

Drug history? + Allergies?
Smoking and alcohol?
Need vaginal exam and swabs

Need urine sample
Need pregnancy test (possibly mention ectopic risk)
Ask about further questions/ anxieties
History taking -- Ectopic pregnancy.
name – and date of birth. I would like to have chat with you about why you’re here today
and answer any questions you might have, is that all right with you?
When did the bleeding start?

How much do you bleed? Colour? Consistency?
S Bleeding?
O When
C How much
R – shoulder tip? Colour
A Consistency
T
E Bleeding or Pain first?
S
Ever had anything like this before?
Menstrual history:
LMP, Cycle, Cervial Smear, Contraceptives?
Sexually Active/ Could you be pregnant?
Obs Hx:
Medical history: STD, PID, IUCD, ectopics. appendicectomy
Gynae surgery?
Family history of bowel diseases or Carcinoma?

Explain need for investigation –

Need Urine & Pregnancy test
May need some scans
Any questions or concerns?
History taking - Infertility.
name – and date of birth. I understand you have some concerns regarding your fertility and
I’d like to get a bit more information from you and answer any questions you have, Is that all
right with you?
HER:
Menstrual history: LMP, Cycle, Cervial Smear, Contraceptives?
Obs Hx
Ever been pregnant?
Sex – type, how often, when in cycle/ aware?
PMH
Diabetes?
Thyroid problem?
Hyperprolactinamiia – Galactorrhea, Brain Tumour?
PCOS? Hairy, Acne etc
Stress
Exercise
Weight Changes
PID, STI
Pelvic Surgery ?
Family history of infertility + above conditions/ Genetic disorders

HIM:
Have you fathered a child before?
Occupational history? – exposure to chemicals etc?
Sex – type, how often, when in cycle/ aware?
PMH
Mumps?
UTI?
DM, STD?
Family history of Infertility / Genetic disorders
History taking: Post coital bleeding.
name – and date of birth. I understand you have some concerns about some bleeding I’d
like to talk to you to get some more information and answer any questions you have, is that
all right with you?
When did the bleeding start?

How much do you bleed?
Colour, Consistency
Is it only after sex?
Is the intercourse painful?
Discharge? – type, smell?
Urine: dysuria?
Weight Loss?
Every had anything like this before?
Smoking, alcohol and drugs?

Major illnesses like DM and HTN?
Menstrual history:
LMP, Cycle,
When was your first period?
Cervial Smear, Contraceptives?
Menopause/ HRT
Obs Hx:
Medical history: Diabetes, Hypertension, STD, PID, IUCD
Gynae surgery?
Family history of Cancer/ similar problem?


Need urine sample
Need pregnancy test (possibly mention ectopic risk)
History taking - Post menopausal bleeding.
name – and date of birth. I understand you have some concerns about some bleeding I’d
like to talk to you to get some more information and answer any questions you have, is that
all right with you?
How old are you?

When did the bleed start? For how long?
Have you noticed bleeding after sex?
Did you pass clots or have you noticed only spotting?
Have you got any abdominal pain?
Vaginal discharge? type?
Weight loss?
Other symptoms
Menstrual history:
LMP, Cycle,
When did you attain menopause
Hot flushes, night sweats and dry vagina?
Cervial Smear?
Obs Hx:
Medical history:
Gynae surgery?
Family history of Cancer/ similar problem?

Drug history? HRT + Allergies?

Need urine sample
History taking -- Amenorrhoea.
name – and date of birth. I would like to have chat with you about why you’re here today
and answer any questions you might have, is that all right with you?
Menstrual history:
LMP, Cycle,
Cervial Smear, Contraceptives?
Obs Hx
Ever been pregnant?
Primary:
What is your age? Have you ever had periods?
Do you have any sisters? When did she start her periods?
When did you mother have her first period?
Have you developed axillary hair? When? Breast development?
Do you get lower tummy pain?
Is there any chance, that you could be pregnant? Do you use any contraceptives?
Secondary
H/o withdrawal bleeding?, H/o vaginal discharge?
PMH
Diabetes?
Thyroid problem?
Hyperprolactinamiia – Galactorrhea, Brain Tumour?
PCOS? Hairy, Acne etc
Stress
Exercise
Weight Changes
PID, STI
Cancer
Gynae Surgery – D& C ?
Family history similar problem?

Drug history? Allergies?
Need urine sample
Suggest Further Investigations – blood tests etc
Counselling: Sterilisation
Introduction: Good morning I am Chris Bretherton a 4th yr medical student, can I check your name –
and date of birth. I understand that you wish to have a sterilization operation. I want to talk with you
about the options available and answer any questions you might have, is that all right with you?
Ok, well I’m going to talk to you about the different sorts of long term contraception available – but first
can I ask:
have you completed your family?

How many children have you got?
What is the age of the last child?
Have you considered other methods of contraception?
Have you discussed this with your partner?
First, sterilisation:
• It involves a small operation on your tubes. The tubes will
be blocked so that the egg cannot travel down the tube. However you will still continue to have your
periods.
• Usually it’s done via key-hole surgery, make a few small cuts in your tummy and then apply the
clips to your tubes
Advantages
• It’s a permanent procedure.
• Its a day case procedure so you should be able to go home the next day
•
Risk/ Disadvantages
• It will be done under general anaesthetic, so there are some small risks associated with that.
• Other risks with any surgery include bleeding an infection. There’s a small possibility that there
could be some damage to other structures around where we are doing the operation, if that does
happen or there is difficulty applying the clips, we may have to do a laparotomy- which means
making a bigger cut in your tummy and doing the operation that way.
• There’s a small chance you could still get pregnant – about a 1 in 200 risk.
• Overall you will continue to have periods and your sexual activity should not be effected.
Vasectomy
• Vasectomy is essentially irreversible. It involves a small operation on the tubes that carry sperm
from the testicles to where they are mixed with the semen. These tubes will be cut or blocked. This
doesn't effect your sexual function. You will still produce semen, but with no sperm in it.
•
Advantages are that it is a simpler operation and can be done under local or general
anaesthetic. It also has a better success rate- only 1:2000 people will subsequently
become pregnant.
Disadvantages/ Risks
• A small cut is made on both sides of the scrotum. The tubes are then tied and cut. You can go
home the same day. There shouldn't be any complications. You might be having some bruising or
pain, which will resolve in a few days time.
• You'll need to use some form of contraception for 2-3 months after the operation, because you will
still be producing sperms. We will do a semen analysis and let you know when you are sterile. It is
important that you understand that this procedure is permanent and irreversible.
Mirena coil
• Small device inserted into the womb. Secretes the hormone progestogen, which works as a
contraceptive.
• Failure similar rate to laparoscopic sterilisation, about 1 in 200
• Not permanent – lasts for 5 years
• Simple insertion, doesn’t need anaesthetic/ done as an outpatient procedure
• Common side effect is some slight spotting of blood for the 1st few months, then often stops periods
all together, which some often like and can be especially helpful if heavy periods are a problem
So I’ve told you a bit about some of the long term – methods of contraception available to you and
hopefully helped you see the pro’s and con’s of each, do you feel you understand things a bit?
Anything else that you want to ask?
Abnormal smear
Introduction: Good morning I am Chris Bretherton a 4th yr medical student, can I
check your name – and date of birth. Ok , so I understand you came for a smear
test recently and the results have come back with dyskariosis, ok I just wanmt ot
explain to you what that means and where we go from here aswell as answer any
questions you might have, is that ok?
Ok, so what do you understand about mild dyskariosis?
• Ok well the first thing I want to reassure you about is that this is NOT
CANCER. what mild dyskarosis means is that some of the cells around the
entrance to your cervix are abnormal. That means that when we had a look
at them down the microscope they looked a bit different to the health cells we
usually see. However, as you have MILD dyskariosis – your cells only look a
bit different to normal.
• As for what causes this, studies have shown that the majority of abnormal
cells are caused by “human papilloma virus”, this is virus which around 80%
of sexually active adults are exposed to in their lifetime, and because its so
common we don’t tend to screen for it. It’s the starting agent that induces
cell changes, and why some people gets these abnormal changes and other’s
don’t is not fully understood, but we do know that smoking may also be a risk
factor for progression
• So but to you; from what we know – these mildy dyskaryotic cells may be pre
– cancerous cells, and so have the possibility of progressing to cancer if we
left them for 10 years. However, as yours is mild – if we left it for 8-10 years
without treatment in 70-80% of cases would regress back to normal by
themselves. About 20-30% would just stay the same, however 1 in 100 cases
would progress to cancer.
• So in your case the risk of cancer is low, but it does mean we need to keep an
eye on you and give you more regular smears to check things aren’t
progressing. I’ll discuss it with my seniors and this could be one option, we
will just keep an extra eye on you.
• Another likely option is that we will offer you colposcoy, do you know what
that is?
• Its similar to having a smear, exepct we will lay you on the cough and pass a
speculum into your vagina, then we use a small telescope to look at the
cervix and magniy it and usually the magnified image will be shown on a
screen next to. Then what we do is use some special dye’s to stain the cervix
at look for abnormal cells. If there is anything that looks slightly abnormal
we may take a small biopsy of 1-2mm. Importantly – this procedure
generally doesn’t hurt and is similar or only a bit more uncomfortable that
having a smear taken.
• We’ll then wait a couple of weeks for the biopsy results and discuss them with
you. As yours is only mild, it is unlikely they will come back very abnormal,
however there is a chance that the normal looking cells we see aren’t so
normal when we test them in the lab.
• If you have a high grade of abnomrailty – 8-12% of cases will progrees to
cancer over 8-10 years, so If that’s the case then we can offer you treatment.
That usually involves loop excision of the abnormal area – which means we
will scrape off the layer of abnormal cells. We advise you abstain from
intercourse for 4 weeks to allow for healing and you may experience a small
amount of discharge in that time. The procedure also has a 5% risk of either
bleeding, infection or incomplete removal of abnormal (in which case you may
need a repeat). However in 95% of cases all the abnormal cells are removed
and we can just follow you with regular smears from then onwards to make
sure it does’nt come back.
• Some people say that even if they have just mild changes that they want this
excision procedure, however, in a young women of your age we prefer to
manage you conservatively and keep a good eye on you, as there is some
evidence that suggests the procedure can increase the risk of premature
labour in future pregnancies, though for just one procedure its only a small
risk.
• O.k so in summary I’ve told you about your result and said that its NOT
CANCER, but there is small chance you may need to undergoe further
treatment to stop it progressing, but that more likely you just need to make
sure you are aware of the need for regular follow-up.
How does that all sound to you? Are there any other questions or concerns you have?
VBAC
name – and date of birth. I understand you had a previous C-section and want to now what
your delivery options are for this pregnancy? I just want to ask you a few questions and give
you some information and answer any questions you may have, is that all right with you?
Can I ask
How long was your labour?
Why did you have C/S?
How heavy was the baby at birth?
Did you have any medical problems?
Do you know how far dilated you were before u went to C-section
What do you already know about VBAC?
• Ok, well if the reason you had a C/S last time was because of individual, non recurring reasons
(breech presentation, pre-eclampsia, placenta praevia, or an emergency section for fetal
distress) or ones which were just due to “bad luck on the day”, we find that vaginal delivery
next time is successful in 70-80% of cases. We worry a bit more if you had CPD – which
means that the baby’s head was too big to pass through your pelvis – and that’s either
because the babies head was especially big (often in babies of diabetic mothers), or because
your pelvis is too small! In those cases the chance of a success delivery after C/S is around
50% - however it doesn’t sound like that was a problem for you. Also the fact that you were
over 6cm dilated before you went for C/S is an encouraging sign.
• So the information that you need to know to help you make the decision is the comparative
risks of Vaginal Delivery and C/S
• Vaginal: have you heard of the risk of “uterine rupture”? What do you know about it? Yes there
is of around 0.5% of uterine rupture, whereas the risk of uterine rupture from C/S is around
0.1%. That could cause some severe bleeding and possibly require a hysterectomy, though as
I say the risk is small.
• Another risk is that you may need a C/S anyway – again if you have “bad luck on the day” and
have a similar problem as last time.
• So the risks and benefits of C-Section are (see risks of C/S answer)
• So there are risks and benefits of each and the decision is ultimately up to you. However I can
tell you that if do decide to go for a vaginal delivery we will need but a Intravenous line in from
the beginning in case you run into complications, and we will also be monitoring baby carefully
with an electronic heart monitor.
Do you feel you understand the implications of both types of delivery at bit better now?
Ok. Good – So like I say as long as everything continues to go well, there are no contraindications for
you trying either method of delivery, its up to you. So I’ll leave you to have a think about it and you can
have your review at 36 weeks and give us your final decision then.
Anything else you want to know?

CVS/ Amniocentesis
name – and date of birth. I understand you are considering having amniocentesis/ Cvs for
diagnosis of … I want to have a chat with you and give you some information aswell
answer any questions you may have, is that all right with you?
What do you know about amniocentesis and CVS?

Yes that's right, it’s done because it certain patients and in yourself screening has identified an
increased risk of abnormalities occurring in the fetus. It allows us to diagnose certain chromosomal
abnormalities, including Down’s syndrome, as well as other structural abnormalities.
Ok fisrt I’ll tell you about amniocentesis:
• It’s usually carried out around 15 weeks gestation. We’ll book you a time with one of the
doctors and ask you to come into hospital, just like you would for your normal scans. The
whole process takes about half an hour, most of this time is just using ultrasound to scan your
tummy and baby. It only takes about 30 seconds to obtain the sample – antiseptic solution will
be applied to your tummy and then a thin needle is passed into your tummy under ultrasound
guidance and a small amount of amniotic fluid around baby will be removed and sent to the lab.
We’ll then show you babies heart beat on screen just to reassure and then you’ll sit back in the
waiting room for 5 or 10 and the be allowed to go home.
• How does that sound ok?
• Ok well there is a small risk the procedure could cause a miscarriage – there’s about a 1%
chance of that happening. There’s also a small risk of bleeding and infection. There’s a risk
there could be a leakage of fluid from around baby which can cause lung problems later, but
again the risk of this is minimal. also leakage of babies blood into your circulation, which if you
were rh-ve, you would need some anti-D immunoglobulin, but luckily you’re not so you don’t
need to worry about that
• AS for the results: we can usually give you a preliminary answer about the risk of down
syndrome within a couple of days, though it takes 2 weeks to get a certain answer which also
tells you about the risks of other chromosomal or structural abnormalities. If anything abnormal
is found we will tell you as soon as you can and discuss with you and your partner what you
want to do.
Anything else you wanted to know about amniocentesis?
• Chorionic Villus Sampling (CVS) can be done from 10 weeks onward and is a similar procedure.
We bring you in, scan you and pass a needle into your tummy as for amniocentesis, however
with CVS we take a small sample from the placenta so we get a more direct representation of
the fetus. We get the preliminary result in 48hours (which is 99% accurate) and then we get
the result of cell culture back in 1-2 weeks which is even more accurate.
• Again there are similar risks as amniocentesis, with miscarriage occurring in 1% of cases. If it’s
done too early there is an increased risk that it could cause limb deformity or cleft lip and palate,
but this risk minimises later on and it’s why we usually like to wait till at least 11wks before we
do the test.
Just to reiterate, it's a simple and quick procedure that shouldn’t be too uncomfortable. The reason
we do it is to diagnose certain abnormalities in the fetus, its relatively safe, though there are some
risks its important you’re aware of.
How does that all sound to you, do you feel you have a better understanding now?
Do you have any more questions?
1) COUNSELING/ CONSENT – Cesarean Section (Total 20 marks)
You are the intern assigned to the maternity ward and you are asked to see A 32
year old woman G3 P2+0. She is to be admitted for an elective C-‐section on the
next available operating day. She has had 2 Previous Caesarean Sections and has
had an uneventful antenatal period thus far. She says that she did an ultrasound
and the baby is fine. Please obtain Informed consent and provide information
about her options for contraception.

Introduction (total 5 marks)
Name, age, LMP 1mark

q
Calculate EDD and ask # of fetuses, location of placenta as provided by
q
Ultrasound & calculates Gestational age (38wks) 1mark
q Assess indication for Previous C-‐sections (CPD)
Indication for current C-‐section (central placenta Previa & Breech)
Any previous surgeries (appendectomy) 1mark
q Asks What she Knows About the procedure & if she knows why it is being done
q Mentions Alternatives to C-‐section and states clearly why these options are not
beneficial/safe 1mark

Preoperative Measures (total 5 marks)
q Need for admission day prior 1mark

q Will Require an Intravenous Access 1mark
Blood will be taken for CBC GXM Urea electrolytes & Possibility Of Blood
Transfusion
q Urinary Catheter to monitor urine Output 1mark
q Kept N.P.O after midnight 1mark
q Medications: Ranitidine, Metoclopramide 1mark

Details of procedure (2 marks total)
q Epidural or GA with endotracheal tube placed to ventilate lungs 1mark
q Skin Cleaned & Draped with antiseptic Solutions
q Lower abdomen cut, bladder retracted, uterus cut open, membranes ruptured,
baby delivered, umbilical cord clamped and cut and baby handed over to
Paediatrician.
q Placenta Removed.
q Uterus closed in layers with sutures.
q Belly closed in Layers with sutures.

Complications – intra-‐op, post-‐op, long term, foetal, prevention (5marks total)

Intraoperative 1mark

q Haemorrhage
q Possibility Of emergency hysterectomy
q Difficulty identifying structures if adhesions Present
q Damage to bladder (urology referral)
q Damage to one or both ureters (stenting)
q Damage to bowel (Surgery referral /colostomy)

Post Operative 1mark
q Anesthetic: Aspiration pneumonitis, atelectasis

q Bleeding after the procedure, Secondary Haemorrhage & possibility for another
Surgery & possible need For Blood Transfusion
q Wound Complications: Infection, Dehiscence
q DVT/PE (clot in the leg)
q Post Op Fever
q Pain/discomfort
q Urinary Tract Infection, Respiratory Tract Infection, IV site
q Paralytic Ileus
Long term 1 mark

q Menstrual irregularities/ Back pain
q Possibility Of incisional Hernia
q Intestinal Obstruction Due to adhesions
q Risk Of Placenta Previa
q Risk Of uterine rupture
q Need for C-‐section in subsequent pregnancies
Fetal complications 1mark

Iatrogenic Prematurity (developmental issues, RDS)
Prevention of complications 1mark

Hydration
Blood Transfusion & screening for Infections (prevent anemia/infection)
Monitoring of Vitals/serial Examinations: watch out for PPH,
Analgesics to prevent pain
Prophylactic antibiotics
Removal Of urinary-‐catheter on day 2
Ambulation prevent clot formation
Heparin

Appropriate Contraceptive Method: 1mark
q Tubal Ligation (patients choice)
q IUCD copper 10, or Hormonal 5 years
q Condoms
Builds Rapport 1mark

Ask if Patient Understands 1mark

2) COUNSELING/ CONSENT – Myomectomy
Introduction
Introduces Self ask Patients Name Age & Parity 1mark
Do you know the Procedure & what they understand 1mark
Explains Procedure
You will need to be admitted to the ward,
You will require An IV Access in the Hand -‐
& blood will be taken for GXM, Complete Blood count, U& E’s 1mark
Pass a urinary catheter to empty the bladder 1mark
Major operation that will Require Anesthesia/complications 1mark
Shave, Clean Abdomen, prevent infection 1mark
Vertical Cut or transverse cut abdomen opened in layers 1mark
gauze packs to move the bowel and protect from damage 1mark
retract the bladder –protect bladder
Identify fibroids , make cut into uterus, inspect for other pathology and remove the
Fibroids, & gauze packs, give intercede
suction blood and suture uterus and abdomen in layers.

Complications & Prevention
Intra-‐op
Damage/ problems during intubation, aspirate drug reaction. 1mark
Risk of damage to bladder, bowel ureters, tubes and ovaries 1mark
Risk of haemorrhage during & after the procedure. 1mark
You May need blood after or during the operation
(risk of contracting infections HIV & hepatitis, allergic reaction) 1mark
Risk of Hysterectomy 2 Marks
If a hysterectomy is done -‐ infertility 1mark
Post-‐op
Clot/dvt/PE-‐ Will try to ambulate and get heparin 1mark
Infection at the operation Site,
Pneumonia (lungs), Urinary tract infection, 1mark
Scar dehiscence either uterine or abdomen 1mark
Intestinal obstruction 1mark
May need to reoperate 1mark

There is a 30 % risk that fibroids may recur in 5 years 2marks
May need a C-‐section for next pregnancy Placenta Previa 1mark
Ask Patient if she understands/ periodically stops patient 1mark
Thanks the patient & maintains rapport 1mark

2) COUNSELING/ CONSENT -‐ Bilateral Tubal Ligation.
Introduction-‐ Name, age, LMP, Parity
Why she wants the procedure? Is it possible she is pregnant currently?, Sure she
doesn’t want more?
Describe Proceedure
Same day surgery, Asked to fast from 6hrs before.
Surgery under GA (risks-‐ allergic rxn, aspiration), small incision bilaterally etc
Complications-‐ infection, pain, damage to structures, PERMANENT,
FAILURE rate – 1:200 (if get preg risk of ectopic increased)
Alternatives-‐ vasectomy (safer, failure rate 1:2000), Mirena
Close-‐ written consent signed, give date for procedure.
3) COUNSELING/ CONSENT -‐Post Dates/IOL
A 30 year old woman G 2 P1+0 presents to clinic at 40 weeks gestation her due
date was 2 days ago and she is concerned. Please counsel her.

Introduce self ask name age
Explains the difference between post dates and post term
Ask about delivery of previous child , uterine inscion, type of C-‐section
Induction of labour at 41 weeks and why
Affects of being post term -‐ Skin changes , Macrosomia, Developmental issues,
nuerological damage

Risk of induction of labour
1. Prematurity
2. Hyperstimulation syndrome
3. Acute fetal distress
4. Uterine rupture
5. Chorioamnionitis
6. Failed induction (emergency Caesarean section required)
7. Water intoxication
8. Neonatal jaundice
Contraindications to IOL
1. Cephalo-pelvic disproportion
2. Placenta praevia
3. Other contra-indications to vaginal delivery
4. Breech
5. Previous uterine scar
6. Cardiac disease in pregnancy

4) COUNSELING FOR CONTRACEPTION
You are asked to take a history and counsel a 21 year old female UWI student
who had Dilatation & curettage 2 weeks ago.
Introduce self & ask patients name 1mark
Ask Parity 1mark
Previous miscarriages 1mark
Reason for D&C 1mark
Any Bleeding, fever or Pain 1mark
Fertility wishes / Social embarrassment 1mark
Post Op orders
Past medical History -‐ DM HTN, DVT,
-‐breast ca, endometrial/cervical ca
-‐Migraine, gallbladder/Liver disease
-‐Sexually transmitted Infection/ treatment 1mark
Number of sexual Partners
Pap Smear/ Vaccine For HPV 1mark
Oral contraceptive Pill/IUCD/DepoProvera use 1mark
Are you willing to take injections every 3 months 1mark
Patient is motivated to take the Pill
What Precautions should she take 1mark

5) MEDICAL EMERGENCY (Total 20 marks)
You are the intern assigned to the Labour ward duties and the nurse calls you to assess a
patients fitness for a subsequent dose of MgSO4, the patient has already received 1
loading dose IV (4g) and 2 subsequent doses 5g IM in each buttock. Please examine this
Patient accordingly.

Examination (Total 10 marks)
Introduces self & role, Ask the patients name, age & Parity 1mark
Reports On patients general Appearance/Inspection 1mark
Reports Patients respiratory rate 1mark
Examines Patients Pulse Rate 1mark
Examines Deep Tendon Reflexes for hypo-‐reflexia & clonus 1mark
Examines Blood Pressure 1mark
Leopolds manouvres and say why you wont do leopolds 3rd manouver 1mark
Examines Fetal Heart 1mark
Reports Urine collection Bag / Urine Output 1mark
Makes diagnosis of Normal Patient Ready to accept subsequent dose 1mark

What features would you expect if she had Severe Pre-‐eclampsia? 4mark
q Impending eclampsia (seizures)
q Abdominal Tenderness/ Epigastric Tenderness
q BP >160/100
q Headache, visual disturbances
q HELLP syndrome Hemolysis, Elevated LFTs, Low Platelets
What are the complications of severe Pre-‐eclampsia 4marks
q Liver tenderness/ rupture/ haematoma
q Hyper reflexia, clonus
q Seizures
q HELLP
q IUGR,
q IUD

Thanks Patient 1mark

6) GYNE HISTORY TAKING
-‐Fibroids
Age: 42 P2+o
No chronic illness hypothyroidism no coagulation disorders
Menarche 12 regular no IUCD, periods last 5 days 2 pads per day no flooding
Well until 5/12 ago began menorrhagia last 5 days , clotting soaked pads, 4-‐5 pads per
day bright red asso. Dysmenorrheal day before and first day rel. analgesia, suprapubic
Symptoms of anemia: pallor palpitation fatigue headache loss of consciousness. No
intermenstrual spotting, post coital bleeding dyspareunia
No haematemeisis easy bruising.
No urinary symptoms/ compressive symptoms. Frequency retention, constipation leg
swelling varicosities haemorrhoids
Increase in abdominal girth, no wt loss fever nightsweats malaise

-‐Abdominal Pain/pelvic Pain
Case : a 27 year old Woman presents to Accident and emergency department with a
complaint of mild lower abdominal Pain. Her BP 120/70 Pulse 80. Her Urine Pregnancy
Test was Positive Please take a focused History.
1) Introduction
2) Time onset nature radiation of pain aggravating and relieving factors
3) LMP, sexual history
4) Contraceptive Use
5) Relationship to sexual intercourse & menses
6) Vaginal discharge ,Blood, clots , flooding, symptoms of anemia
7) H/o Fever
8) Intermenstrual /postcoital bleed
9) Pressure symptoms
10) At 7 mins What are your differentials? PID, ectopic Pregnancy, Miscarriage
-‐Vaginal Bleeding/ Post menopausal PV Bleed

1) Duration of the complaint
2) Cyclicity
3) Intermenstrual bleeding
4) Post coital bleeding
5) Is the bleeding regular
6) Thyroid disease
7) Clotting disorders
8) Medications such as warfarin
9) Contraceptive needs/intention for having children
10) Investigations: CBC,TSH,Plt,PT,PTT, endometrial sampling, pelvic US,
Hysteroscopy

-‐Amenorrhea/PCOS
-‐Vaginal Discharge
-‐Ectopic vs Miscarriage
STATION 1
You are the intern assigned to the maternity ward and you are asked to see A 32 year old
woman G3 P2+0. She is to be admitted for an elective C-‐section on the next available
operating day. She has had 2 Previous Caesarean Sections and has had an uneventful
antenatal period thus far. She says that she did an ultrasound and the baby is fine. Please
obtain Informed consent and provide information about her options for contraception. (2013
Group E)
General Questions to be Asked
q Introduces himself/herself and asks patient her name and age

1 Mark
q Asks What she Knows About the procedure & if she knows why it is being done
q Assess indication for Previous C-‐sections (CPD)/surgeries appendectomy & current C-‐
section (central placenta Previa & Breech)
1mark
q Ask about EDD, # of fetuses, location of placenta as provided by Ultrasound & calculates
Gestational age (38wks) to prevent iatrogenic Prematurity 1mark
q Mentions Alternatives to C-‐section and states clearly why these options are not
beneficial/safe 1mark

q Informs patient as to the Contraindication for elective C-‐section if Any

q Preoperative Measures ( total 5 marks)
q Need for admission day prior 1mark
q Will Require an Intravenous Access 1mark
Blood will be taken for CBC GXM Urea electrolytes & Possibility Of Blood Transfusion
q Urinary Catheter to monitor urine Output 1mark
q Kept N.P.O after midnight 1mark
q Medications: Ranitidine, Metoclopramide 1mark

q Explores Details of procedure: 2 marks total
q Anesthesia & Endotracheal tube placed to ventilate lungs 1mark
q Skin Cleaned & Draped with antiseptic Solutions
q Transverse incision (pfannenstiel) or vertical
q Abdomen cut in layers & Packs Placed in Abdomen
Obstetrics & Gynaecology

q Peritoneum on Uterus cut, Bladder retracted,Uterus cut opened ,Secure hemostasis,
Membranes ruptured
q Fetus delivered Umbilical cord Clamped and cut
q Handed to Paediatrician/ Neonatologist
q Placenta Removed
q Uterus Closed in layers with sutures
q Abdomen (Belly) closed in Layers
Intraoperative Complications &Measures to Prevent/correct
1mark
q Haemorrhage
q Possibility Of emergency hysterectomy
q Difficulty identifying structures if adhesions Present
q Damage to bladder (urology referral)
q Damage to bowel (Surgery referral /colostomy)
q Damage to one or both ureters (stenting)

q Post Operative Complications 1mark
q Bleeding after the procedure, Secondary Haemorrhage & possibility for another Surgery
q Wound Complications: Infection Dehiscence
q DVT/PE (clot in the leg)
q Post Op Fever
q Pain/discomfort
q Anesthetic: Aspiration Pneumonitis, atelectasis
q Urinary Tract Infection, Respiratory Tract Infection, IV site
q Need For Blood Transfusion
q Possibility for infection/ transfusion reaction
q Paralytic Ileus
Long term (1 mark)
q Menstrual irregularities/ Back pain

q Possibility Of insiscional Hernia
q Intestinal Obstruction Due to adhesions
q Difficulty with subsequent surgeries
q Risk Of Placenta Previa
q Risk Of uterine rupture

q Need for C-‐section in subsequent pregnancies
q Fetal complications: Iatrogenic Prematurity (developmental issues, RDS) 1mark
Prevention Of complications 1mark
Hydration
Blood Transfusion & screening for Infections (prevent anemia/infection)
Monitoring of Vitals/serial Examinations: watch out for PPH,
Analgesics to prevent pain
Prophylactic antibiotics
Removal Of urinary-‐catheter on day 2
Ambulation prevent clot formation
Heparin
Appropriate Contraceptive Method: 1mark
q Tubal Ligation (patients choice)

q IUCD copper 10, or Hormonal 5 years
q Condoms
Ask if Patient Understands 1mark
Total 20 marks
Station 1 B You are asked to consent a G3P 2 woman

who has had 2 C sections previously and would like to
have a 3rd along with Bilateral Tubal Ligation. Please
consent her for both procedures (2014 Group B)

Station 2
You are the intern assigned to the Labour ward duties and the nurse calls you to assess a
patients fitness for a subsequent dose of MgSO4, the patient has already received 1 loading
dose IV (4g) and 2 subsequent doses 5g IM in each buttock. Please examine this Patient
accordingly.
Introduces self & role, Ask the patients name, age & Parity 1mark
Reports On patients general Appearance/Inspection 1mark
Reports Patients respiratory rate 1mark
Examines Patients Pulse Rate 1mark
Examines Deep Tendon Reflexes for hypo-‐reflexia & clonus 1mark
Examines Blood Pressure 1mark
Leopolds manouvres and say why you wont do leopolds 3rd manouver
1mark
Examines Fetal Heart 1mark
Reports Urine collection Bag / urine Output 1mark
Makes diagnosis of Normal Patient Ready to accept subsequent dose 1mark
What features would you expect if she had Severe Pre-‐eclampsia? 4mark
q Impending eclampsia (seizures)

q Abdominal Tenderness/ Epigastric Tenderness
q BP >160/100
q Headache, visual disturbances
q HELLP syndrome Hemolysis, Elevated LFTs, Low Platelets
What are the complications of severe Pre-‐eclampsia 4marks

q Liver tenderness/ rupture/ q Seizures
haematoma q HELLP
q Hyper reflexia, clonus q IUGR, IUD
Thanks Patient 1mark
Total 20 marks
2B You are the intern on the labour ward and you are asked
to see a patient who is supposed to receive her next dosage of
Mg SO4 Her BP is 160/110, and she has started to complain of
flashing lights dizziness and headache. The midwife also
things that the Baby may be Breech and small for gestational
age. Please verify.
Station 3
You are the intern on call and a 27 y.o patient G3P1+1 booked at 12 weeks presents to
hospital with a booking complaint of Vaginal bleeding. Recently She is worried about the
advice her doctor gave her about previous pregnancies. She has normal Intrauterine gestation
with a closed cervix. Please take a focused history from this patient
q Introduce self, Ask name

q Ask Rhesus status
q Did She receive rhogam/ Anti-‐D Immunoglobulin
q Asks What advice her Dr gave her
q How / when She had a miscarriage
q Predisposing factors to Miscarriage
q Ask about Ultrasound, what gestational age she did it and location of placenta and if
there were any fibroids
q Ask about other causes of bleed
q Differential Diagnosis


Station 4:
A 29 yr. old G2P+0 presents to clinic for a Routine Antenatal visit at 18 weeks gestation please
examine her appropriately and address any concerns she may have.
Introduces self ask patient her name 1mark
Adequately exposes patient 1mark
General Inspection of the patient 1mark
Examines Mucus Membranes 1mark
Ask for Patients weight 1mark
Urinalysis results 1mark
Measures Blood Pressure 1mark
Symphysiofundal Height 1mark
Leopolds Maneuvres (1,2 & 4) 1mark
Listens for fetal Heart 1mark


Urine reveals 2+ proteins, leucocytes what is your clinical assessment
1mark
How would you manage this patient? 1mark
Builds rapport 1mark
Thanks & covers the patient 1mark

Station 5 History for contraception
You are asked to take a history and counsel a 21 year old female UWI student who had
Dilatation & curettage 2 weeks ago.
Introduce self & ask patients name 1mark
Ask Parity, 1mark
Reason for D&C 1mark
Any Bleeding, fever or Pain 1mark
Previous miscarriages 1mark
Fertility wishes / Social embarrassment 1mark
Post Op orders
Ask about Past medical History/ Oral contraceptive Pill
History of DM HTN, DVT, 1mark
History of breast Cancer, endometrial/cervical


Migraine, gallbladder/Liver disease
IUCD
Number of sexual Partners 1mark
History Of Sexually transmitted Infection/ treatment
DepoProvera
Are you willing to take injections every 3 months 1mark
Pap Smear/ Vaccine For HPV 1mark
Patient is motivated to take the Pill
What Precautions should she take 1mark
Station 6
Patient with history of DVT @ 32 weeks on heparin for C-‐section tomorrow
What are your Pre Operative Orders?
PT,PTT 1mark
Group & Cross Match 1mark
What will You need in case of Heparin Overdose?
Protamine sulphate 1mark
Stop the heparin Before the operation 1mark
What Predisposing factors lead to her developing a Deep Vein thrombosis?
Virchows triad – Gravid Uterus, Post Surgery, endothelial injury, Pregnant state, immobility
1mark


Station 7
32 year old woman G6P5 who is Post C-‐section
What are your Post Opeartive orders?
IV fluids 2.5L/4hrs 1mark
NPO for at least 6-‐8 hrs 1mark
Analgesics 1mark
Heparin 1mark
Oxytocin 1mark
Remove Urinary Catheter 1mark
Antibiotics 1mark
Monitor the vitals 1mark
Post surgery day 1
May allow to Eat drink once passing flatus


Respiratory examination
Remove Urinary catheter
Early ambulation
Station 8
35 year old woman presents to gynaecology clinic with 25 week size fibroids on ultrasound
and a history of menorrhagia, & dysmenorrhea. She is Christian and a virgin and wants a
Myomectomy . You are asked to fully consent her for the procedure
Introduces Self ask Patients Name Age & Parity 1mark
Do you know the Procedure & what they understand 1mark
Explains Procedure :
Major operation that will Require Anesthesia with associated complications 1mark
Before the operation. You will need to be admitted to the ward, You will require An IV Access
in the Hand & blood will be taken for GXM, Complete Blood count, U& E’s 1mark
You May need blood after or during the operation, and there is a risk of contracting
infections HIV & hepatitis and allergic reaction. But we try our best to screen for these1mark
We may need to Alter or stop medications
During the Procedure
Put to sleep, visited by anesthetist who will determine General or Spinal,

Damage/ problems during intubation, aspirate drug reaction. (Rare) 1mark
Shave, Clean Abdomen, Surgeons scrub and gown & gloves to prevent infection 1mark
Pass a urinary catheter to empty the bladder-‐ protect the bladder 1mark
Vertical Cut or transverse cut abdomen opened in layers 1mark
Put gauze packs to move the bowel and protect them from being damaged 1mark
Identify fibroids , make cut into uterus, inspect for other pathology and retract the bladder –
protect bladder 1mark
Risk of damage to bladder, bowel ureters, tubes and ovaries 1mark
Risk of haemorrhage during & after the procedure Use clamps, pitrussin, tourniquet to
prevent blood loss if we cannot control the blood loss you may need 1mark
Hysterectomy 2 Marks
Remove the Fibroids, &gauze packs, give intercede
suction blood and suture uterus and abdomen in layers

2mark
After the procedure there is a risk of
Clot/dvt/PE-‐ Will try to ambulate and get heparin 1mark
Infection at the operation Site, Pneumonia (lungs), Urinary tract infection, 1mark
You will be given Analgesics, Antibiotics, IV fluids, Heparin, may require blood or repeat
operation 1mark
Scar dehiscence either uterine or abdomen 1mark
Intestinal obstruction 1mark
May need to reoperate 1mark
If a hysterectomy is done You won’t have any more periods or chances of becoming
pregnant/ infertility
1mark
There is a 30 % risk that fibroids may recur in 5 years 2marks

May need a C-‐section for next pregnancy 1mark
There is increased risk of complications/ adhsions if you require a c-‐section or abdominal
operation, Placenta Previa 1mark
Ask Patient if she understands/ periodically stops patient 1mark
Thanks the patient & maintains rapport 1mark
Total 30 marks

Station 9 Counsel On grand-‐multiparity
• pap smear
• advice contraception long term
• sterilization iucd or jadel
• not condom, or depo
• supplementation breast feeding
• Complications
• Antepartum:
• Malpresentation, transverse lie, twins, anemia & malnutrition, thyroid issues , HTN DM,
std’s, cervical cancer, Increased miscarriages, APH, Rhesus varicosities & haemorrhoids,
fetal macrosomia
• Intrapartum: uterine inertia, precipitous labour, obstructed labour if macrosomic , C-‐
section , Preterm labour CPD Prolapse of cord Uterine rupture
• PostPartum : Uterine atony PPH


Station 10 What is the above picture showing and which disease is it associated with?:
Perihepatitis-‐ violin strings-‐ Fitz hugh Curtis Syndrome, Pelvic Inflammatory disease
What organism causes it?
• Chlamydial and or / Gonorrhea Infection


What 3 other symptoms may occur
• Right upper quadrant Pain,

• Jaundice,
• Vaginal Discharge
What are the long term sequale of this Disease?
• Infertility
• Adhessions
• Chronic Pelvic Pain
• Ectopic Pregnancy
What must you inform the Patient about before doing a Laparoscopy?
• May need to convert to open procedure

• Risk of Bowel Injury, Bladder Injury
Station 11 Post Date Counseling
A 30 year old woman G 2 P1+0 presents to clinic at 40 weeks gestation her due date was 2
days ago and she is concerned. Please counsel her
Introduce self ask name age
Explains the difference between post dates and post term
Ask about delivery of previous child , uterine inscion, type of C-‐section
Induction of labour at 41 weeks and why
Affects of being post term
Skin changes , Macrosomia, Developmental issues, nuerological damage
Risk of induction of labour
1. Prematurity
2. Hyperstimulation syndrome
3. Acute fetal distress
4. Uterine rupture
5. Chorioamnionitis
6. Failed induction (emergency Caesarean section required)

7. Water intoxication
8. Neonatal jaundice

Contraindications
1. Cephalo-pelvic disproportion
2. Placenta praevia
3. Other contra-indications to vaginal delivery
4. Breech
5. Previous uterine scar
6. Cardiac disease in pregnancy

Station 12 Cardiotocograph station
What pattern does the above cardiotograph show
What is it indicative of?


What pattern does the above cardiotograph show
What is it indicative of? Late decelerations are associated with decreased uterine blood flow and can occur as a
result of:
Hypoxia
Placental abruption
Cord compression / prolapse
Excessive uterine activity
Maternal hypotension / hypovolaemia
station13 Post Partum Pyrexia
endometritis (retained products)

(ii) chorioamnionitis
(iii) broken-down episiotomy
(iv) retained swab in vagina
(v) cystitis/pyelonephritis
(vi) Caesarean section – wound sepsis
(vii) thrombophlebitis
(viii) thrombosis (VTE)
(ix) pneumonitis/pneumonia
(x) mastitis
1. (i) CBC (leucocytosis)
(ii) blood culture
(iii) abdominal/ pelvic ultrasound
(iv) culture and sensitivity:
a) wound swab
b) HVS
c) sputum
d) milk
e) MSU
(v) chest X-ray


Fibroid history
Age: 42 P2+o
No chronic illness hypothyroidism no coagulation disorders
Menarche 12 regular no IUCD, periods last 5 days 2 pads per day no flooding
Well until 5/12 ago began menorrhagia last 5 days , clotting soaked pads, 4-‐5 pads per day
bright red asso. Dysmenorrheal day before and first day rel. analgesia, suprapubic
Symptoms of anemia: pallor palpitation fatigue headache loss of consciousness. No
intermenstrual spotting, post coital bleeding dyspareunia
No haematemeisis easy bruising.
No urinary symptoms/ compressive symptoms. Frequency retention, constipation leg swelling

varicosities haemorrhoids
Increase in abdominal girth, no wgt loss fever nightsweats malaise

Station 7
Abdominal Pain/pelvic Pain
Case : a 27 year old Woman presents to Accident and emergency department with a
complaint of mild lower abdominal Pain. Her BP 120/70 Pulse 80. Her Urine Pregnancy Test
was Positive Please take a focused History.
I. Introduction
II. Time onset nature radiation of pain aggravating and relieving factors
III. LMP, sexual history
IV. Contraceptive Use
V. Relationship to sexual intercourse & menses
VI. Vaginal discharge ,Blood, clots , flooding, symptoms of anemia
VII. H/o Fever
VIII. Intermenstrual /postcoital bleed
IX. Pressure symptoms
At 7 mins What are your differentials? PID, ectopic Pregnancy, Miscarriage
Station 20

Plot data on the partgram above
When would be your next vaginal examination


Station 8 Abnormal Pap smear


Station 9 Vaginal Bleeding
• Duration of the complaint

• Cyclicity
• Intermenstrual bleeding
• Post coital bleeding
• Is the bleeding regular
• Thyroid disease
• Clotting disorders
• Medications such as warfarin
• Contraceptive needs/intention for having children
• Investigations:
• CBC,TSH,Plt,PT,PTT, endometrial sampling, pelvic US
• Hysteroscopy


Station 10 Dysmenorrhea
• Age
• Parity
• Constitutional make up
• Socioeconomic status
• Ocp
• Cigarette smoking/alcohol
• Cold exposure


Station 11 Post menopausal vaginal Bleed


Station 14Amenorrhea



What is this
1. Bartholins Cyst
Clinical Presentation
1. Excruciating pain
2. Discharge
3. Erythema
4. Superficial Dyspareunia
Differential diagnosis
1. Vaginal wall cyst/ abscess

2. Sebaceous Cyst of vulva
3. Ischiorectal abscess
Treatment options
1. Incision & Drainage

2. Marsupialization
3. Antibiotics amox + Doxy
4. Word Catheter Placement
5. Analgesics Warm saline soaks







Obs and Gynae OSCE Stations
Twin Pregnancy: (40yo mother)
• Introduction and consent

• Explain findings of scan-confirmed age of foetuses (1.5% all pregnancies)
• Explain if same sac or different sacs (mono/di-chorionic) and 1 or 2 placentas
• What does she know about twin pregnancies?????
Complications, management
• Complications: Increased chance unpleasant symptoms-e.g. nausea, tiredness,

heartburn, backache, anaemia etc.
• 40yo so 1/55 chance of downs if dizygotic, 1/110 if monozygotic-but both would
be (offer nuchal translucency)
• Offer detailed USS at 18-20 weeks, increased chance NT defects, cardiac, bowel
atresia in twins (explain risk of selective termination in shared placenta)
• 5x risk of early labour (average 37 weeks, so half are preterm)-not VE normally
• Antenatal Care: Recommend shared care due to increased risk in twins

• After 20 weeks scan recommend growth scan every 2 weeks for discordant
growth and TTTS, also for BP and urinalysis
• Wouldn’t discuss labour in great detail, but recommend hospital delivery NOT
home-increased risk c-section due to one breach, also greater risk PPH etc.
• Any questions?
• Give leaflets/contact details of TAMBA (Twin and Multiple Birth
Association)
• Thank patient
• If monoamniotic increased risk cord entanglement and IUGR, alos risk conjoined
Oral Contraceptive: (COCP vs. POP)
• Name and age of patient
• Reasons for contraception-any preferred method, any previous/current

contraceptive use
• What does she know about oral contraceptives?
• 2 types of oral contraceptive-will compare them and give her positives and
negatives of both
• COCP: Oestrogen (ethinyloestradiol) and Progestogen
• Inhibits ovulation, makes cervical mucous less favourable and endometrium

atrophic
• 3 weeks on, 1 week off-withdrawal bleed, so regular, planned bleeding
• If missed pill (12 hours), vomit or diarrhoea or antibiotics, 2 20Mg missed or 3

30Mg missed use barrier method for 7 days
• Missed pill in week 3, omit pill free week
• Positives-Relieves endometriosis, menorrhagia, dysmen., reduces EM and ovarian

Ca.
• Negatives-Small increased risk MI, stroke (both), breast/cervical Ca., venous

thromboembolism.
• SE-nausea, weight gain, spotting, reduced libido
• Contraindications-Smokers, >35, breast feeding, some conditions
• POP-Progestogen only, endometrium unfavourable, cervical mucous thickened,

variable effect on ovulation (cerazette)
• Everyday pill-no breaks
• Few CIs, useful for women unsuitable for COCP
• Missed pill >3 hours (12 for cerazette) take straightaway additional method for 2
days
• Positives-menorrhagia, PMS, endometriosis, dysmen.
• Negatives-irregular cycle, amenorrhea sometimes, weight change, hirsutism,

acne, venous thrombosis and stroke-stop immediately if severe headache, visual
change, neurological change
• Low failure rate for both-0.27-2.7 COCP, 0.9-4.3 POP
• Do not protect against STIs and STDs
• Give leaflets, let patient decide in her own time, checkups in 3 months
after starting OCP
• Any questions? Thank patient

Mirena(IUS):
• Patient name and age
• Reason for wanting contraception-previous/current methods
• What she knows about IUS?
• Plastic core with progestogen (levonorgestrel) reservoir
• Lasts 5 years
• Renders EM unfavourable, thickens cervical mucous, may stop ovulation
• Failure <1/100 (if 100 women used it for 5 years, 1 would fall pregnant)
• Positives-Effective, time, reduced menstrual blood loss by 90% (65% @1 year

no/light bleeding), reversible, no effect on lactation, low risk extopic/PID
• Negatives-Can increase bleeding in first 6-12 weeks, IM pain up to 12 months in

some,
• Some have standard progestogen SEs-headaches, mood change, acne, breast

tenderness, bloating
• Risk of infection and perforation when putting in
• CIs-Pregnancy, current STI or high risk, undiagnosed uterine bleeding, uterine

abnormality/distortion, liver disease, current breast Ca
• Any questions?
• Give leaflets, arrange follow up appointment if wanted
• Thank patient
Breech Presentation:
• Intro and consent
• Woman’s name and age-brief prev. obs history
• What does she know?
• Scans show breech presentation-“bottom down” in uterus
• Which type-complete, incomplete (highest risk cord prolapsed and feto-pelvic

disproportion), frank (lowest risk...) (and explain what her fetus is)
• Potential problems-Raised perinatal mortality and morbidity due to increased

risk intrapartum trauma or asphyxia
• Management: Various methods; ECV-should be offered to all uncomplicated

women at term, reduced risk cord prolapsed, perinatal mortality and C-section
rates, but small risk haemorrhage and fetal complications
• CIs-Placenta praevia, Multiple preg., ruptured membranes, prev. classical section

or >1LSCS
• VD-Ideally if fully extended or flexed, no evidence head hyperextension,

EFW<3.8kg, no evidence of feto-pelvic disproportion
• Elective Section-Reduced ST risks than VD, no difference in long term,

increased maternal morbidity, risk of birth injuries, consequences for future
pregnancies
• Questions?
• Give mother information and opportunity to discuss in future
• Things can change, majority of foetuses turn by 36 weeks, 96% by term
• Do USS nearer term and at term to confirm diagnosis and choose management
plan
• Thank patient
Miscarriage:
• Intro and consent
• Name and age of patient
• Brief previous Obs history (if relevant) previous miscarriages and removal?
• Check the patient is aware that the decision has been made (hopefully with the
patient) to remove the pregnancy due to fetal death
• 2 possible methods-medical or surgical, will discuss both with the patient and
help her reach a decision, but the decision is hers
• Medical: Initial use of progesterone antag. Mifepristone,makes the uterus more

responsive to prostaglandins.
• Mother admitted to hospital 2-3 days later, receives oral or vaginal PGs-leads to
active contractions and provokes miscarriage within 12-18 hours.Pain relief by
opiates-patient controlled
• More “natural”, no surgery or anaesthetic, less frightening
• Surgical: Hazards increase with gestational age (due to increased cervical

dilatation required)
• Cervix prepared with misoprostol (PG) PV pre-op
• Oxytocin given after surgery to ensure uterus contracts
• Routine prophylactic antibiotics to all women
• Pre/post-op refer for counselling
• Availability of appointments with consultant in future to discuss the case or future

pregnancies
• Any questions?
• Information leaflets and advice/counselling details
• Thank the patient

Urogynae counselling
1. Stress incontinence
• Introduction
• Consent
• Name/age (child bearing? Post-menopausal?)
• Establish diagnosis/current knowledge
• Brief history
- Prolapse present?
- Social issues/job/pads per day
- Occur during >abdo pressure?
- Want treatment?
- Parity
- Surgical Hx
- CVA?
• Treatment options
1. Physiotherapy – supervised with ‘homework’. Daily for 3-6

months. 60-70% of pts improve.
2. Tension free Vaginal Tape TVT – local or GA, day-case, 2 small
incisions pubic area, small cut in vagina, tape left in place. Few
risks (B+I, bladder perf)
3. Colposuspension – GA, hospital stay. Permanent, very
successful. Few risks (B+I, damage to other structures)
4. Repair of prolapse if present.
5. Avoid Caffeine!
Emergency contraception
• Introduction
• Consent
• Confirm age/name
• Brief history
-LMP, menarche
-When did intercourse occur?
-How many times?
-Partner(s)?
-Current contraception
-Drug history (enzyme inducers may necessitate larger dose)
• <72 hours – Levonorgestrel, one tablet. Next period may be early/late. Use
contraception until next period. Take again if vomits <2 hours.
• Up to 120 hours/5 days post ovulation – Copper IUCD. “coil”. Can be fitted
immediately with antibiotic cover. Lasts 5 years. Risk of PID/perforation/bleeding.
Uncomfortable to fit. Copper allery?!
• Offer swabs/screen for STI’s
• Follow up 3/4 weeks
• Return if abdo pain/period >7 days late
• Future contraception – discuss COCP etc if doesn’t opt for IUCD
HRT
• Introduction
• Consent
• Confirm age/name
• Confirm reason for referral ie starting HRT
• Brief History
- LMP
- Menarche
- Hysterectomy?
- Symptoms (hot flushes/atrophic vag etc)
- CANCER? Breast/endometrial
- VTE/PE
- Liver disease
- Focal migraine
- FH of osteoporsis
- Hypertension?
- DH – Thyroxine?
- Contraception!
• HRT replaces some hormones, aims to reduce the symptoms.
• Options are:
1. NO UTERUS – Osetrogen only, oral/transdermal patch/subcutaneous
implant.
2. UTERUS – Cyclical combined HRT – monthly withdrawal bleed. Continuous
combined – no menstruation but may have initial spotting. Tibolone if
reduced libido.
• Side effects – Breast tenderness, weight/appetite increase, calf cramps,

headache. Only for 3 months.
• Risks – Breast/overian/endometrial cancer. VTE/CVA.
• Benefit – Reduce osteoporosis.
• Follow up – Recommend treatment for 3 years, no longer than 5 years. Keep
up to date with mammograms, self examine regularly. BP annually.
ECV
• Introduction
• Consent
• Confirm name/age
• Confirm reason for referral, breech? Suggest confirming presentation with
ultrasound. Does she understand what breech is? Bum/feet first.
• Brief history – Singleton pregnancy?!
- Any bleeding?
- Low lying placenta?
- Diabetes/big baby?
• Prefer baby to come out head first as there are risks associated with breech (cord
compression, head entrapment)
• Offer ECV
- 50% success rate
- Involves manually turning baby, like somersault.
- May be uncomfortable
- 0.5% risk of emergency CS
- May distress baby, therefore CTG required.
- Need to check rhesus status/give anti-D if rh-ve.
• If declines ECV
- Need to establish plan
- Term breech trial = slightly better outcome for baby if CS
- Maternal risk of CS > vaginal delivery – not significantly
- Hospital stay etc, elective, @ 39 weeks
- Can opt for vaginal delivery if wishes.

Previous C Section
• Introduction
• Consent
• Confirm name/age
• Confirm reason for referral (previous section)
• Brief History
-G? P?
-Previous modes of delivery,
-At what gestation, length of labour, weight of babies
-Complications,
-How is baby now?
-How many C sections?
-Reason for sections?
-Gestational diabetes?
-US scan, position of placenta? (accrete/percreta)
• If 2 or more previous sections, has to be section this time, elective @ 39

weeks.
• If one previous section, reason for section?
• If fetal distress/PET ie non-recurring reasons then offer VBAC (discuss risk of
scar rupture, 70-80% success rate)
• If cephalopelvic disproportion there is increased risk of failure to progress
• Placenta praevia – section.
Chlamydia:
Possible scenario: Miss S had vaginal examination 2 weeks ago with triple swabs, came
back +ve for Chlamydia. You have been asked to see her and explain the findings.
Good morning my name is Richard and I’m a 4th year medical student. I’ve been asked
to have a talk to you today about Chlamydia, is that alright with you?
What do you know about Chlamydia?
Chlamydia is the most common bacterial Sexually Transmitted Infection which can affect
both males and females.
The infection tends to occur the neck of your womb, at the top of the vagina.
It may be asymptomatic, or cause a variety of symptoms the most common being

irregular inter-menstrual bleeding and increased discharge and lower back ache.
It is detected by taking swabs during a vagina examination from the neck of the womb
like you had or from just inside the vagina by yourself.
The test detects whether there is a current infection, however if Chlamydia has been
contracted within the past two weeks then it may not detect this.
Chlamydia is easily treated by taking four tablets here today. Azithromycin.
It is good that we have picked this up, and treatment is very important because
Chlamydia can cause a number of more serious problems.
If the infection were to spread further up towards your tubes and eggs, it can cause a
more serious condition called Pelvic Inflammatory Disease.
PID would cause you to have abdominal pain on both sides, a tender stomach, a fever
and be generally unwell.
(if S. was pregnant, inc risk of choriomanionitis)
Because of all the inflammation, everything may not go back to the way it was before
and scarring can damage the tubes, blocking them and making it harder for you to get
pregnant naturally. This happens in 8% of women after first inflammatory spell.
It is because of this that you must use a condom when having sex even if you have
another form of contraception like the pill, an implant or a coil.
The tablets we will give you today will clear your infection but will not stop you from
getting another one so this advice is very important.
As it can remain asymptomatic, we don’t know how long, or from whom you contracted
this.
Do you currently have a partner? - they need to be tested and treated.
Anyone who you’ve had sex with unprotected w/i the last needs to be tested.
Do you have any questions?
Laparoscopy:
Scenario: Mrs O. is a 35 year old lady who came into clinic complaining of amenorrhea,
U/L lower abdominal pain which usually precedes the onset of vaginal bleeding. She has
an IUD but on blood tests but serum HCG has indicated that she is pregnant. It is
suspected that she has an ectopic pregnancy as USS shows no cenceptus in the uterus.
She is scheduled for a diagnostic laparoscopy and needs the details of the operation
explaining.
Good morning my name is Richard and I’m a 4th year medical student. I understand that
the doctors would like you to have an operation to look inside you stomach to see if we
can determine the cause of your pain. I’ve been asked to talk to you about the
operation, are you happy for me to do that?
Do you know what a ‘Laparoscopy’ is and why you’re having it?
Laparoscopy is performed to have a look inside of you using a small camera attached to
a video screen.
On the day of your operation you will come in early in the morning.
You cant have had anything to eat or drink from the night before.
You will be seen by a number of doctors: the surgeon performing the operation and
because we need to put you to sleep for this procedure, his anaesthetist.
The surgeon will talk to you about the operation and make sure you understand what is
involved.
Once you have been taken through to the operating room the anaesthetist will you to
sleep, and this will only be for about 20 minutes as this is a simple and quick procedure.
The surgeon will perform the operation by first blowing gas into your stomach, through a
small cut, to make it bigger making it easier to see inside, then making a small cut to
allow the camera inside.
After the operation the gas will be let out, the camera removed and the cutes sewn up.
You will be bought round from the anaesthetic in a recovery room and stay in hospital
until the late afternoon. If you are feeling well then someone may come to pick you up
and take you home.
You must not drive for 24 hours and you must not be left alone at home overnight.
As with any operation there are a number of risks but these are minimised.
The main risks are: infection, clots and damage to surrounding structures.
Infection is minimised by using sterile instruments, hand washing and gloves.
Clots occur due to immobility but as the operation is short there is a low risk of this. You
will be given some special stockings to help prevent this anyway.
It is very unlikely but damage to surrounding structures may occur such as bowel and
bladder but these would be repaired during the operation but he surgeon, although a
separate incision may be required to do this properly.
The aim of this operation is to diagnose the cause of the pain you are having and this
benefit outweighs the risks involved.
Any questions?
HPV Vaccine
Scenario: Miss W a 13 year old girl has been brought by her mother to the GPs saying
she has heard about the vaccine and wants to know more about it before her daughter
has it. Explain.
to talk to you about the HPV for your daughter, would you be happy with this?
Name, age check.
What do you know about HPV vaccine?
HPV is a sexually transmitted infection which can predispose to cancer of the cervix.
It can be carried by both males and females and passed between them.
Lots of subtypes of HPV.
50-79% women exposed to a form of virus at some point in their lives and most clear
without problems.
Peak prevelance 16-25years.
Some cause genital warts, and some can cause the cells to gradually change into cancer
cells.
HPV vaccine helps protect against the two most high risk for cancer subtypes 16,18.
Over 70% of cancers in this area of genital tract due to these two subtypes.
Vaccine doesn’t guarantee protection as doesn’t cover subtypes responsible for other
30%.
No cure for virus once contracted.
Regular smears later in life used to detect virus in women but no test for men.
Part of Uk government vaccination programme for all young women.
Mum has missed out because it’s a new initiative to vaccinate.
Ask mum to go out the room?
Need to ask W. if she is sexually active.
Highlight that condoms still need to be worn, for HPV protection and from other
STIs.
Other risk factors include multiple partners, smoking, sex from younger age.
Any questions?
Downs Screening
to talk to you about the screening for downs syndrome that we offer; would you be
happy with this?
Name, age.
How many weeks pregnant?
Down syndrome is a condition found in 1/1000
Increases to 1/300 in mothers over 30.
Caused by a problem on chromosome 21
Characterised by a floppy baby at birth, protruding tongue, heard defects, intestinal

defects, and develop learning difficulties later in life along with a higher incidence of
cataracts and dementia.
Can do a number of tests to see if there are indicators of the disease, biochemical and
US tests.
11-14 weeks: Nuchal translucency, HCG and PAPP.
A thick fluid layer at the back of the head on USS indicates greater risk.
HCG is raised, PAPP (pregnancy associated plasma protein) low
Between 15-20 weeks, quadruple test involving:
HCG –raised, Inhibin-raised, Oestridol-decreased, AFP-decreased.
Approximately 70% downs cases detected, with 20% women over 35 in high risk
category.
If high risk, can offer more definitive tests: amniocentesis between 15-17 weeks.
Fluid taken from around the baby using a needle through stomach under uss guidance
Tested for DNA with results w/I 3 weeks.
Risk of causing miscarriage from this is 0.5-1% which is similar for the chance of an over
35 having downs syndrome child.
If these tests indicate downs, have a choice to terminate pregnancy, but more
information will be discussed regarding that in such an event.
Induction of Labour:
Scenario: 41 weeks, no onset of labour, healthy fetus, discuss induction:
to talk to you about the details of inducing labour, would you be happy with this?
Name, age,
How many weeks pregnant?
Multiple Preg?
Do you know why we indue labour in some women?
Induce labour if risk to mother of child greater than letting pregnancy continue.
Indications =
pre eclampsia,
prolonged labour >42 weeks / 294days,
placental insufficiency,
APH +/- Rh neg,
Diabetes,
Pernatal mortality increase by double after 42 weeks and trebles after 43.
Bring woman in, assess baby with abdo exam, USS, CTG, liquor volume- induce if
distress or maternal wish for discomfort.
Cervical assessment by pelvic exam, determines whether ripening agents required.
Scoring system, if <5/6 use oral tablet or pessary of prostaglandin E to soften cervix.
Cervix soft and 2cm dilated, head engaged.
Rupture of amniotic fluid under sterile conditions.
Fetal membranes separated from lower segment of uterus to allow membranes to bulge.
Release fluid slowly not to cause cord prolapse.
Start syntocinin infusion gradually increasing the dose until established contractions at
3-4 minute lasting a minute.
Continual monitoring of baby throughout labour using CTG to assess for distress.
Risks:
If cause hyperstimulation where contractions >2 in 10, will stop infusion.
A prolonged labour is at more risk of ascending infection. If the liquor becomes

offensive and mother develops fever, abandon induction and deliver my c section.
If prolonged second stage or fetal distress may require instrumental delivery.
Chance that may have to abandon induction and perform c section if risk greater mother
or fetus develops

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Histories.

Family history of bowel diseases or Carcinoma?

Need vaginal exam and swabs

When did the bleeding start?

Ever had anything like this before?

Family history of bowel diseases or Carcinoma?

Explain need for investigation –

Sex – type, how often, when in cycle/ aware?

Family history of infertility + above conditions/ Genetic disorders

When did the bleeding start?

Smoking, alcohol and drugs?

Family history of Cancer/ similar problem?

Need vaginal exam and swabs

How old are you?

Family history of Cancer/ similar problem?

Need vaginal exam and swabs

Family history similar problem?

have you completed your family?

Ok, so what do you understand about mild dyskariosis?

Anything else you want to know?

What do you know about amniocentesis and CVS?

Name, age, LMP 1mark

q Need for admission day prior 1mark

q Anesthetic: Aspiration pneumonitis, atelectasis

Long term 1 mark

Fetal complications 1mark

Prevention of complications 1mark

Builds Rapport 1mark

Builds Rapport 1mark

-­‐Vaginal Bleeding/ Post menopausal PV Bleed

General Questions to be Asked

q Introduces himself/herself and asks patient her name and age

Intraoperative Complications &Measures to Prevent/correct

Long term (1 mark)

q Menstrual irregularities/ Back pain

Prevention Of complications 1mark

Blood Transfusion & screening for Infections (prevent anemia/infection)

Monitoring of Vitals/serial Examinations: watch out for PPH,

Analgesics to prevent pain

Removal Of urinary-­‐catheter on day 2

Ambulation prevent clot formation

Appropriate Contraceptive Method: 1mark

q Tubal Ligation (patients choice)

Builds Rapport 1mark

Ask if Patient Understands 1mark

Total 20 marks

Station 1 B You are asked to consent a G3P 2 woman

Reports On patients general Appearance/Inspection 1mark

Reports Patients respiratory rate 1mark

Examines Patients Pulse Rate 1mark

Examines Deep Tendon Reflexes for hypo-­‐reflexia & clonus 1mark

Examines Blood Pressure 1mark

Examines Fetal Heart 1mark

Reports Urine collection Bag / urine Output 1mark

q Impending eclampsia (seizures)

What are the complications of severe Pre-­‐eclampsia 4marks

Thanks Patient 1mark

Total 20 marks

q Introduce self, Ask name

Introduces self ask patient her name 1mark

Adequately exposes patient 1mark

General Inspection of the patient 1mark

Examines Mucus Membranes 1mark

Ask for Patients weight 1mark

-‐Vaginal Bleeding/ Post menopausal PV Bleed

Removal Of urinary-‐catheter on day 2

Examines Deep Tendon Reflexes for hypo-‐reflexia & clonus 1mark

What are the complications of severe Pre-‐eclampsia 4marks

32 year old woman G6P5 who is Post C-‐section

NPO for at least 6-‐8 hrs 1mark

Clot/dvt/PE-‐ Will try to ambulate and get heparin 1mark

Station 9 Counsel On grand-‐multiparity