Download obs-and-gynae-revision-lecture

Overview of OBGYN
December 2016
Dr Alice Martha Schofield MD
OBGYN
University of Manchester
Outline
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Name, age, occupation, LMP
Presenting complaint
History of presenting complaint
Gynaecology history
Obstetric history
Medical history
Surgical history
Social history
Current medications
Allergies
Family history
History essentials
• Introduce / confirm identity / consent /
confidentiality
• Open and closed questions
• Active listening
• Be careful of sensitive areas eg TOP, pregnancy
loss, sexual history
Gynaecology history
Presenting complaint:
eg menstrual problems, pain, bleeding in early
pregnancy, vaginal discharge, postmenopausal
bleeding, prolpase, urinary problems, menopause,
contraception, routine smear
History of presenting complaint:
eg onset, duration, associated symptoms, weight loss
Past Gynae History – eg past gynae surgery
Gynaecology history
Further specific questions:
• Pelvic pain –
*dysmenorrhoea (onset/duration/nature of pain/severity),
*dyspareunia (superficial/deep)
*pain related/unrelated to menses, midcycle pain
* bowel symptoms, urinary symptoms, abdominal distension
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Infertility –
*duration
*previous pregnancies (both partners)
*Intercourse (timing/frequency/problems)
*h/o PID
*Contraceptive history
*Smoking/drug/alcohol
* age, occupation, medical history of partner
Gynaecology history
Further specific questions:
• Menopause
*last menstrual bleed, postmenopausal bleeding
*hot flushes, night sweats, sleep disturbance, vaginal dryness, dyspareunia, mood changes,
vaginal discharge,
*risk factors for osteoporosis (family history, smoking, alcohol, exercise, medical conditions,
drugs eg steroids),
*risk factors for IHD (smoking, family history, hypertension)
*contraindications / caution re estrogen treatment (breast cancer, endometrial cancer, liver
disease, DVT/PE)
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Urinary problems
*frequency (day & night),
*dysuria, urgency
*incontinence (stress, urgency, continuous)
*enuresis, stream, incomplete emptying,
*fluid intake, prolapse, drugs, medical history
Gynaecology history
Menstrual history:
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last menstrual period (first day) (LMP)
frequency of menses
duration of menses
amount of bleeding
intermenstrual bleeding
postcoital bleeding
dysmenorrhoea
premenstrual syndrome symptoms
menarche age
menopause age
Gynaecology history
Fertility (obstetric history):
- contraception
- coitarche / relationships
- vaginal discharge
- sexually transmitted diseases
- sexual difficulties
- smear history
Obstetric history
History of this pregnancy:
- LMP – sure/unsure, regularity of cycle, recent
contraceptive use, fertility treatment
- Date of first positive pregnancy test
- Date & result of first USS
- Results of routine blood tests
- Result of Down’s syndrome screening if done
- Result of 20/40 scan & other scans
- Admissions / problems eg bleeding in early
pregnancy, pain
Obstetric history
Current problem:
- pain: nature, site, duration, other symptoms eg
bleeding, discharge, evidence of ROM, urinary or
bowel symptoms
- bleeding: onset, amount, duration, recent events eg
intercourse, VE, pain, placental localisation on
previous scan
- reduced fetal movements – is the fetal heart
audible?
- hypertension: headache, visual disturbance,
epigastric pain, oedema
Obstetric history
History of previous pregnancies:
*Gestation at delivery
*Antenatal complications
*Labour complications and method of delivery eg
induced, length of labour, analgesia, use of
Syntocinon, indication for C/S or instrumental
delivery
*Postnatal complications eg PPH, retained placenta
- Baby: sex, birth weight, problems, current health
OBGYN Hx
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Past Medical History
Past Surgical History
Current Medication (Rx & OTC)
Allergies
Alcohol / Smoking / other drug use
Family History
OBGYN skills
Pregnancy
• General antenatal examination – anaemia / oedema / general well being
• Pregnant abdomen
Inspection
- distended abdomen / Linea nigra / caput medusa
- fetal movement
Palpation
- Fundal height (SPH – hide cm, fundus to symphysis)
- Lie
– Presenting part
– Position (back on right / left)
– Station (fifths of head palpable suprapubically)
– Feel fetal movements
Auscultation – fetal heart sounds: Pinard / Sonicaid
OBGYN Skills
Vaginal Examination
– always do abdominal examination prior to vaginal
examination
– Specific consent
– Chaperone unless declined by patient
– Respect privacy & dignity
– Have everything ready before you start
– Wash / gel hands, gloves!
OBGYN Skills
• Inspection
– Inspect external genitalia
• Anatomy, skin lesions, redness/ leukplakia, discharge,
obvious prolapse
– Speculum examination
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Cuscoe – insert AP then rotate, angle posteriorly
Inspect cervix – colour, lesions, open/closed
Inspect vagina – discharge, lesions, prolapse
Sims speculum in left lateral for prolapse (not routine)
OBGYN skills
• Cervical smear
– Visualise cervix, 360 degree X5 in clockwise direction using
‘broom’ (blue handle)
– Broom into container
– Complete Form (all details)
• Vaginal / Cervical Swabs
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Chlamydia – endocervical swab (small one) PCR
General MCS – larger swab in black transport medium
Label immediately at bedside
Complete form (all details)
OBGYN skills
Others
• Interpretation of partogram
– Look for the obvious
• Interpretation of scan report
– eg Obstetric growth chart
• Interpretation of microbiology report
– Read carefully – clue cells for BV, trichomonas seen on
microscopy
• Interpretation of a smear result
-- Counselling about colposcopy
• Interpretation of blood test results
– eg menopause FSH/LH, progesterone for ovulation
Emergency Contraception
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Copper IUD most effective
0-120h post UPSI or 5 days after ovulation
Uillipristal – 120h post UPSI
Levonelle – LNG – 1.5mg 72h post UPSI
Liver enyme inducers – Coil / 3mg LNG
Missed COCP
• Pointers
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Be careful re jargon / sensitive areas
Repeat / check understanding
Be aware of confidentiality issues
Pregnancy – antenatal screening / miscarriage / common
antenatal counselling situations eg breech, vaginal birth
after previous caesarean section / mechanism of delivery
– Gynae – contraception / HRT & menopause / heavy
menstrual bleeding treatment options