P.S.G.

HOSPITALS, COIMBATORE – 641 004

1

DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
HOSPITAL MANUAL 1. DEPARTMENT ORGANOGRAM

Head of the department

Support staffs

Unit chiefs

Secretary Staff nurses

Professors Counsellor Associate professors Nursing assistant Technicians Attenders Selection Grade Tutors

Assistant professors

Resident Doctors

CRRIs

2

2. ACADEMIC FUNCTIONS OF THE DEPARTMENT Teaching schedules are followed as per university regulation in both undergraduate & postgraduate The teaching consists for 1. Undergraduate 2. Postgraduate 3. CRRI Undergraduates: Teaching schedule preparation: A maser chart is prepared by the department registrar consists the details of all batches teaching schedule for a month in date wise manner. It consists the time, topics and the faculty name for every session. The chart is being displayed in the student’s notice board. The format of the chart is as below: Date Lecture topics Clinical teaching Batch / Time Topic Faculty Batch / Time / Topic Faculty Phase Phase Sessio n

Class conducting system: The students are expected to see their schedule earlier. Undergraduate’s timetable is divided as  Lecture classes  Tutorial session  Case presentation session  Symposium  Small group teaching

3

 Integrated teaching Lecture classes: This is a period of 1 hour and the topics are scheduled as per the list recommended by the university. Students are attending the Obstetric & Gynaec lecture class from 4th semester onwards. Every phase of students is having one lecture class in a week for this subject. Tutorial session: In final year clinical teaching, students are having tutorial session which is scheduled as each topic for a day from Monday to Friday. In Saturday they are having General clinical session. (Some Mondays are scheduled for internal assessment test) Case presentation session: All phase students except introductory phase is having case presentation session on everyday (Monday to Friday) of clinical postings. Every batch is divided in to subdivisions which may consists of 4 students and the each subdivision is responsible for case presentation on that particular day and they have to report to the faculty prior to 1 or 2 days. They will be given a case for presentation by the faculty. The student observes and takes notes of the history & presenting complaints of the case and they prepare for presentation. The diagnosis & management of the case is discussed on the case presentation session by the faculty & the students. Symposium: The scheduled symposium topics are prepared by the concern students group with the guidance of faculty and presented by the students. Each student gets a chance of symposium presentation in the final year phase.

4

Small group teaching: In final year clinical teaching, students are having small group teaching session which is scheduled as Monday 2.00 pm to 4.00 pm & Wednesday 3.00 pm to 4.00 pm. Internal assessment: Theory test are conducted on Mondays for III MBBS part B students in concern subjects by rotation. Test scheduled is prepared and display in the notice board at prior time, the test notice consists of the topics, date, time. Clinical tests are conducted at the last clinical posting day of that phase, and valuated mark details are sent to the Academic cell and displayed in the student’s notice board. Model exams are scheduled prior to the university exams and model exams are conducted in the university’s question & marks pattern in both theory and clinicals. Mark details are sent to the academic cell & students notice board. Final year student’s record note: Student’s has a faculty in-charge for record note book and they get correction and signed from that faculty by weekly in a regular manner. Friday 2.00-4.00 is the time schedule for record note correction. At the finishing of the final year posting they should get complete correction of the record note book and HOD’s signature, and then submitted to the department. The record marks are given by record in-charge faculty of the student. Record mark awarded in the format of Case record perfection Presentation Regularity Neatness - 8 marks - 4 marks - 4 marks - 4 marks

Total

- 20 marks

5

The computerized student’s attendance report of every month is verified by the head of the department and the checked statement is sent to academic cell and student’s notice board. MBBS students semester wise clinical posting details: II MBBS students are attending clinical posting for a period of 10 weeks
3RD SEMESTER 2 weeks Introduction to OG

The introductory posting topics are taught by the faculty
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8 DAY 9 DAY 10 DAY 11 DAY 12 DAY 13 DAY 14
4TH SEMESTER -

Introduction to Obstetrics . Fertilisation & Implantation Duration of pregnancy I + II + III trimesters. AN care. Few complication in pregnancy in I + II + III trimesters Outcome of pregnancy. Abortion, Labour :Preterm, Term & Post term Causation & Stages of labour Modes of delivery Complication in labour. Puerperium – duration, problems AN History taking, AN Case Introduction to Gynaecology Menarche, Normal menstrual cycle, Menopause Common problems in adolescence, reproductive age group and menopause Gynaec history taking, Gynaec cases Infertility Lucorrhoea Descending PV, Mass abdomen Post menopausal bleeding
4 weeks 3 weeks - AN history taking, Obs palpitation, Gyn. History taking , cases 4th week - Family Planning

Family planning Day 1 Day 2 Day 3 Day 4 - IUCD - OCP

- Natural family planning & Barrier methods

- Other hormonal contraceptives

Day 5 Day 6 Day 7

- Injectable - Female - Male sterilisation

6

5TH SEMESTER

-

4 weeks

-

Clinical assessment & Management in brief

III A MBBS students are attending clinical posting for a period of 6 weeks
6TH SEMESTER
6 weeks -

Clinical assessment
Peripheral centers postings

III MBBS Part A students:

In OPD 2 students are posted by rotation and they are

taught interesting OP cases by faculty.  In peripheral maternity centers 2 students are posted by rotation and for witness of deliveries The III B MBBS students are posted for a period of 8 weeks
8TH SEMESTER 8 weeks Clinical teaching P.S.G.Posting – LW Case discussion, Tutorials, SGT, IT

III MBBS Part B students postings:
o

Two students of III MBBS Part B are posted for Labourward by

rotation for witness of deliveries conducting in labourward and caesarean sections and other gynaecological procedures in Operation Theater. o One student of III MBBS Part B students is posted in OPD Ultrasound room The III MBBS Part B students are attending clinical classes from 9.00 am to 1.00 pm. Postgraduate teaching:

7 ⇒

Postgraduates are posted in OPD, Labourward, Antenatal ward, Gynaec ward & Postnatal ward, peripheral posting by rotation as per university regulations.

The postgraduate students are posted under a particular faculty in an unit by rotation. Attendance register is maintained and the monthly attendance report is sent to the academic cell. Postgraduates are mainly involved in examining patients, following up, management and progress of the patient. They are also involved in bed side teaching & OMP They see OP cases with a faculty presiding. Complicated cases are shown and discussed by the postgraduate with unit faculties. They are trained to perform minor procedures like D & C, puerperal sterilization, IUCD insertions assistance in all major and minor Obstetric and Gynaec procedures.



⇒ ⇒

⇒ ⇒

They perform caesarean section, hysterectomy and other gynaecological procedures with consultant assistance. A separate logbook is maintained by each postgraduate student for recording academic activities Classes scheduled by monthly and displayed in postgraduate’s notice board. The monthly teaching schedule consists of class topic, time and the faculty name.  A journal club is arranged monthly once

Perinatal care unit meeting is arranged to discuss the complicated & high risk pregnancy cases. Postgraduate discusses about the cases with the various specialty consultants like Newborn, Paediatrician, Paediatric surgeon, Pathologist.

8

 Every postgraduate student presents an interesting case by weekly ⇒ Each MD(OG) postgraduate student is guided by a faculty for their thesis work and scheduled for thesis work as follows
o After 6 months from the joining they will guided to do the

following before completion 1st year • Decide topic of thesis • Presentation of review of literature and methodology • Submit title of thesis • Presentation of questionnaire (Proforma) and finalization In 2nd year • •
o

Finish data collection Data analysis to be completed and presented 3rd year

Thesis book (hardcopy & softcopy) to be prepared To be submitted
o

Postgradautes are expected to attend CME

programmes and conferences (in a minimum of 3 programmes they should attend) and guided for paper presentations. CRRIs teaching: They are posted for a period of 3 months in the department of Obstetric & Gyanec. They are posted under a unit and guided by the corresponding unit’s faculty. Their postings is scheduled as follows 2 weeks - Labour ward 2 weeks - Newborn 2 weeks - Elective posting

The rest of period they do OPD, ward, Operation Theater and intensive care areas duty.

9

In OP posting CRRIs are taking history and doing preliminary examination for new cases. Subsequently the cases are followed up with the consultant. The case will be thoroughly examined by the consultant and disposed. They are attending the ward rounds taking by the unit chief and faculty and follow the chief consultant orders. Ward CRRIs monitor the ward patient’s progress and inform the patient’s status and reports to the consultant. They are expected to perform procedures like starting IV line, dressing, suturing, suture removal and intensive care monitoring. They are trained up in assisting and doing minor surgeries in Operation Theater. In labourward posting they conduct deliveries, perform episiotomy, assist for caesarean section & monitor patient in labour. 3. CLINICAL / PATIENTS RELATED FUNCTIONS OF THE DEPARTMENT The clinical work in the department of Obstetric & Gynaecology broadly divided under the following categories: 1. Antenatal care 2. Intra partum and post partum care 3. Operative and emergency Obstetrics 4. Gynaecological and operative Gynaecological care a. Screening for cervical cancer b. Basic and special investigations of Infertility 5. Urogynaecology 6. Family planning Antenatal care protocol:

1. Diagnosis of pregnancy 2. Monitoring of the health status of mother and fetus
a. Upto 6th month b. 7th month & 8th month

10

- monthly checkup - 15 days once

c. from 9th month onwards - weekly monitoring

3. Identification of risk factor 4. Detection of associated medical, surgical disorders 5. Screening for the woman for infections
a. Tamilnadu Aids Control Society project – PPTCT program for

counseling & educating the woman about HIV infection and preventing methods and screening. 6. Antenatal investigation includes the following a. Blood group b. Heamoglobin c. Urine routine d. VDRL e. GCT f. HIV g. HBsAg h. Ultrasound at early diagnosis of pregnancy to rule out intra uterine pregnancy and fetal viability
i. Ultrasound at 18-20 weeks to rule-out structural fetal anomalies

which can be detected by ultrasound.
j. Ultrasound at term to assess fetal growth & AFI

7. Educating the woman about the effect of health, nutrition, drugs etc., on pregnancy 8. Preparing the woman for labour, breast feeding. • Outpatient department

1.

At patient entry, they register at the Medical Record Department department

11

depending on the complaints is registered to the concerned
2.

Once the registration is made the OP file (medical record) of the patient is transferred to the outpatient department by the MRD attender. The OP file is checked weather the file is transferred to proper department or not and then received by the department secretary.

3.

The patients are called in the order of registration time and a token is placed for every attended patient’s file serially. If the called patient is not in the OP waiting hall, it will be informed to the MRD and checked up for proper registration.

4.

The called patients are checked for Height & Weight by the staff nurse. Patient is asked to wait till their turn comes. If the patient condition warrants immediate treatment, she will be consulted by a Gynaecologist immediately.

5.

6.

The patient’s history & presenting complaints will be entered in the file by the junior doctor. The patient history includes: 1. 2. 3. 4. 5. 6. 7. 8. Presenting complaints Menstrual history Marital history Obstetric history Previous gynaecological history Medical & Surgical history Family history Personal history

7.

A general examination is done by the junior doctor and recorded on the case sheet. The general examination includes the following: BP, Pulse, pallor, edema, CVS, RS and temperature.

8.

Then the patient will be consulted by a consultant Gynaecologist. provisional diagnosis arrived at. The examinations are: Abdominal examination Vaginal examination Speculum examination

12

9.

The patient is thoroughly examined by the consultant and a

10.

The

required

investigation

to

substantiate

the

diagnosis

is

recommended after counseling the patient & their attender.
11.

After the sample collected for the investigations the patient is advised about the probable time taking for investigation report and the report copy will be available on the patient’s file at all. The probable time taken for investigation report is 2-3 hrs from, some investigation report takes few days like culture takes 3 days, for histopathology 7 days, etc.

12. The patient is advised about the review date and if any medication.
13.

On report review, if any procedure is indicated by the investigation, patient & the attender is explained about procedure & its risks. Date is fixed for the procedure if the patient is willing to undergo the further procedure. If the condition warrants and immediate medical / surgical treatment, she is counseled regarding the treatment and admitted. The admission orders written by the Gynaecologist in the case sheet.

14. The admission patient is shifted from the outpatient area to the ward by the OPD attender with the OP file and the patient attender is informed for wait in the IP patient attender area. 15. Day care procedure which do not warrant admission and deal with in the OPD and the patient discharged on the same after when she is stable.

13

Inpatient department
1.

Following admission to the ward, the patient is assessed and if intensive care is necessitated the patient is admitted to the critical care units of ward & monitored intensively.

2.

If the patient is admitted for a major / minor procedure the required investigations which were ordered by the consulted Gynaecologist are sent results are collected by the ward staff. Pre-op protocol followed.

3.

If the patient is admitted for observation, the results of the investigations and the patient status are followed and informed by the concerned ward interns & resident doctor to the consultant.

4.

All nursing as well as medical work is supervised by the unit concerned in a standard manner which includes conventional ward rounds taken, thrice a day, in the morning, after noon and late evening

5.

If any complaints encounteded during the night is handled by consultant & resident on duty.

4. JOB SPECIFICATIONS Head of the department: The HOD will function as the administrative head of her/his department in addition to the professional responsibilities  To supervise punctuality and regularity in reporting To effectively administer his/her unit in all aspects To ensure smooth co-operation from his/her unit members To implement effectively the policies laid by the HOD To train the students and CRRIs posted under him/her To actively contribute to uplift the academic standard of unit Professors: 

  

as well as the department

14

To supervise the quality of work done by the Assistant Co-operate with the HOD in all aspects so as to maintain the To shoulder all the responsibilities of the HOD during his/her To supervise the work done by the other category staff in the Plan and implement protocols for clinical work as well as

professors and Residents  smooth functioning of the department  absence  maintenance of the professional zones of the institution  academic activities for junior staffs to update and keep alert of recent development in the field Associate professors:  To render adequate help and co-operation to the HOD and Professors in the smooth functioning of the department  To perform all the duties allotted by the institution administrative heads and the HOD regarding patient care and academic activity

To extend sufficient professional help to the Assistant Professors whenever required

Assistant Professor:    To carry out the work responsibilities allotted by the HOD To do stay in duties as per schedule To get actively trained in the respective specialties under the supervision of senior faculty member 

Gain teaching experience by vigorous participation in the academic activities To adequately guide the Residents and CRRIs and help them gather enough practical skill To pay attention to the maintenance of outpatient, inpatient zones and special areas

15

To maintain absolute harmony in the unit/department by full co-ordination with all members of the department To ensure a very smooth public relationship

5. LIST OF REGISTERS • List of registers maintained in Outpatient department
1. Daily OP Patient register 2. Papsmear & Biopsy specimen register

3. Colposcopy register 4. Ultrasound register 5. Scan appointment register 6. Cu-T insertion register 7. Family planning progamme – sterilization register 8. MTP register 9. OP Things stock account register 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. High risk cases register Interesting cases register Perinatal care unit meeting register Departmental library books register Department staffs & faculty leave register Letters & communication dispatch register Postgraduate attendace register Undergraduate attendance register CRRI – Intensive care areas attendance register OPD daily Statistics

All register’s format enclosed in separate sheets • List of registers maintained in Labourward • List of registers maintained in Daycare room

16

• List of registers maintained in OG ward

6. Format of work instruction (operational instruction) Out Patient department:
1. Patient registeration at MRD 2. File (Medical record) arrival to OP waiting area by MRD attender 3. Patient is called by the staff nurse and checked for patient presence

in OPD. If patient not present at OPD waiting area verification is done by OPD secretary.
4. Patient is checked for Height & Weight by the staff nurse 5. Patient is first seen by Resident doctor and the patient’s history with

presenting complaints is taken by the Resident doctor. 6. Subsequently the patient is consulted, examined and diagnosed by a Gynaecologist
7. Advised for the investigation required, proposed line of treatment.

8. Explained for probable charges and duration stay if any hospitalization required. 9. Procedures done in OPD: a. USG – Pelvis, Obstetrics i. Patient takes a prior appointment, pays the bill on that particular day & get USG done ii. It is done on the same day depends on the urgency iii. Explained consent obtained for obstetric scan b. IUCD insertion i. Patient is advised for IUCD ii. Patient purchases IUCD at pharmacy

iii. IUCD is inserted by the consultant and advised about medication and followup iv. The patient has to pay the insertion procedure charge and the miscellaneous charges

17

c. Colposcopy & cervical biopsy
i. Usually done by Papsmear result’s indication.

ii. Colposcopy directed biopsy is taken. If Colposcopy is normal, no need for cervical Biopsy
iii. After the procedure the patient is advised for medication

and report review (Histopathology report processing time - 7 days)
d. Cryo cautary: following the histopathology report, if indicated

patient is offered cryocautery in post menstrual phase.
10. Inpatient :


Admission requisition sent by the consulting doctor Patient & patient’s relation is accompanied by the According to the patient choice the ward / room is Patient & patient’s relation is accompanied by the The concern unit ward resident doctor and CRRI are

OP attender to the admission counter

allotted for the patient  admission counter attender to the allotted ward

informed by the ward staff nurse who is receiving the admission patient.  The consultant orders are followed by the ward, CRRI and the staff nurse

18

The ordered investigations requisition to the lab is Blood samples are collected by the ward staff and Routine blood & urine investigation processing Some special investigations like CT, Ultrasound, MRI

written by the ward Resident doctor  sent to the lab by the ward attender

takes 3 hrs for reporting  are done by a prior appointment. The appointments are made by the ward staff nurse.  In case of any emergency, urgent requisition can be made and the results can get ready within 2 hr as soon as possible. It is informed to the unit faculty by the CRRI immediately after the result obtained 

The results are collected by the ward attender The results are review in the next ward rounds by a Pre-procedure protocols are followed for the case Proper consent for all procedures and surgeries is

consultant and decided for further treatment.  who got admitted for certain procedures.  obtained by the Resident doctor & staff nurse
7. Protocols for Surgical procedures

• Pre-procedure:

The indication for the surgical procedure and its risks involved are explained to the patient & patient attender by the treating doctor.

• A written informed consent is obtained from the patient & patient attender.

19

• Patient will be investigated for fitness for the surgical procedure either as an outpatient or inpatient depending on the patient decision.

The patient is admitted 2 days prior to the surgical procedure if the patient wants to do all investigations and fitness opinion as an inpatient.

If high risk, patient will be admitted earlier depending on the risk. prior to the surgical procedure.

• General Physician opinion and Anaesthethic fitness will be sought • Instructions given pre-op includes 1. Preparation of the surgical site and site of locoregional anaesthesia by the ward staffs
2. Enema is given night prior to and the morning of the surgical

procedure by the ward staffs 3. Xylocaine and antibiotic test dose given on the morning of the surgery. 4. Patient is kept nil per-mouth from previous midnight and also pre-anaesthetic medication is administered 5. IV hydration is maintained.
6. The patient is shifted to pre-op room half an hour before the

surgical procedure 7. The patient attender is informed when the patient has shifted into the theater block. 8. During the process of shifting the _______ standards are adhered to Per-operative :
⇒ In the pre-op room the anaesthetist re-examines the patient to

ascertain the fitness for the surgical procedure.

20

⇒ Inside the operation theatre, the full dose of antibiotic is administered during induction of anaesthesia. ⇒ The patient is placed in the required position (dorsal/lithotomy) for the surgical procedure ⇒ The patient is intensely monitored during the surgical procedure. ⇒ Strict aseptic precautions are followed during the surgical procedure. ⇒ After the surgical procedure is completed the patient is shifted to the post-operative care ward for monitoring.
⇒ The patient attender is explained & informed about the patient

status and the procedure done by the surgeon. Post-operative instructions: ⇒ Patient is monitored for vitals half an hourly still stable, then two hourly for a minimum of 6 hours to 24 hours in the post-operative ward. ⇒ When the patient is stable, shifted to the ward and informed
⇒ The patient is monitored by team of intensives, interns and staff

nurses. ⇒ The patient who is presently on IV hydration will be started on oral hydration 4-6 hours after the surgical procedure. ⇒ Broad spectrum antibiotics are administered for minimum period of 48 hours ⇒ DVT prophylaxis started 6 hours following the surgical procedure for patient at risk for the same.
⇒ Post-op analgesia is maintained with parenteral or epidural opioids

⇒ Post-op physiotherapy and early ambulation is advised. ⇒ If there is deterioration of patient status, will be retained in the postop ward, treated further and then shifted to ward once stable. 8. Protocols for Day care procedures

21

• 1.
2.

List of day care procedure Fractional curettage 1st trimester MTP Medical abortion Vulval biopsy Cervical biopsy Suction evacuation • Pre-procedure instructions: a.
b.

3. 4. 5. 6.

The indication for the procedure and its risks involved are Patient is examined & investigated for fitness of the day care

explained to the patient & patient attender by the treating doctor. procedure. The routine investigations are as follows:       Haemoglobin Urine routine Blood grouping & typing HIV & HBsAg Blood sugar USG if required c. If the patient is fit for the procedure, a written informed consent is obtained from the patient & patient attender and the patient is shifted to the day care room by the OPD staffs d. 

The following orders will be instructed by the doctor

Preparation of parts Verify for NPO from the previous day night   • a. Xylocain test dose Inj. TT 1 dose Per-procedure instructions: For Fractional curettage & Suction evacuation:

22

IM sedation – Fortwin or Pethidine 1 amp with 12.5 mg Phenargan given by the day care room junior doctor After ½ hr from the IM sedation given the patient will be placed in the required position

 b.

For Vulval / Cervical biopsy no sedation required, only local infiltration of 1 % of xylocaine at biopsy site applied

c. For Medical termination of pregnancy / abortion 2 doses of

Cytotec of 400 micro gm 4 hours apart to kept in posterior fornix. In case of missed abortion Tab. Cytotec 400 micro gm kept vaginally followed by Suction evacuation after 4 hrs under IM sedation and paracervical block.
d. The procedure will be done by a Gynaecologist and a junior

doctor. Post-procedure instructions:
e. After the completion of procedure the patient will be monitored

for vitals & bleeding p/v by the team of day care room junior doctor & staffs.
f.

The Biopsy specimen / curettage specimen will be sent for Histopathology lab with requisition of doctor.

g. After 5 hrs from the procedure, if the patient is stable the

patient is shifted out from the day care procedure room and the patient attender is informed for the same. If the patient has any complaints or not stable, get admitted for observation and treated further.
h. The patient is advised for the review date in the outpatient

department, medication and the report follow up. 9. Test SOP (Standard operating procedure)