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Overview of OBGYN December 2016

Overview of OBGYN December 2016. Dr Alice Martha Schofield MD OBGYN University of Manchester. Outline. Name, age, occupation, LMP Presenting complaint History of presenting complaint Gynaecology history Obstetric history Medical history Surgical history Social history

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Overview of OBGYN December 2016

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  1. Overview of OBGYNDecember 2016 Dr Alice Martha Schofield MD OBGYN University of Manchester

  2. Outline • 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

  3. History essentials • Introduce / confirm identity / consent / confidentiality • Open and closed questions • Active listening • Be careful of sensitive areas eg TOP, pregnancy loss, sexual history

  4. 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

  5. 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 • Infertility – *duration *previous pregnancies (both partners) *Intercourse (timing/frequency/problems) *h/o PID *Contraceptive history *Smoking/drug/alcohol * age, occupation, medical history of partner

  6. 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) • Urinary problems *frequency (day & night), *dysuria, urgency *incontinence (stress, urgency, continuous) *enuresis, stream, incomplete emptying, *fluid intake, prolapse, drugs, medical history

  7. Gynaecology history Menstrual history: • 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

  8. Gynaecology history Fertility (obstetric history): - contraception - coitarche / relationships - vaginal discharge - sexually transmitted diseases - sexual difficulties - smear history

  9. 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

  10. 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

  11. 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

  12. OBGYN Hx • Past Medical History • Past Surgical History • Current Medication (Rx & OTC) • Allergies • Alcohol / Smoking / other drug use • Family History

  13. 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

  14. 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!

  15. OBGYN Skills • Inspection • Inspect external genitalia • Anatomy, skin lesions, redness/ leukplakia, discharge, obvious prolapse • Speculum examination • 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)

  16. 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 • Chlamydia – endocervical swab (small one) PCR • General MCS – larger swab in black transport medium • Label immediately at bedside • Complete form (all details)

  17. 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

  18. Emergency Contraception • 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

  19. Missed COCP

  20. Pointers • 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

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