Overview of Obs & Gynae

1. Overview of Obs & Gynae

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 and result of first USS - Results of routine blood tests - Result of Down’s syndrome screening if done - Result of 20/40 scan and 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 haemorrhage, retained placenta - Baby: sex, birth weight, problems, current health

12. Obs and gynae history • Past Medical History • Past Surgical History • Current Medication (prescribed and over-the-counter) • Allergies • Alcohol / Smoking / other drug use • Family History

13. Obs and Gynae 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. Obs & Gynae Skills Vaginal Examination • always do abdominal examination prior to vaginal examination • Specific consent • Chaperone unless declined by patient • Respect privacy and dignity • Have everything ready before you start • Wash / gel hands, gloves (2!)

15. Obs & Gynae 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. Obs and Gynae 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) • General MCS – larger swab in black transport medium • Label immediately at bedside • Complete form (all details)

17. Obs and Gynae 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 blood test results • eg menopause FSH/LH, progesterone for ovulation

18. 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 and menopause / heavy menstrual bleeding treatment options