Introduction to Obstetrics and Gynaecology

1. Introduction to Obstetrics and Gynaecology Clare Tower MBChB PhD MRCOG Senior Registrar in Obstetrics and Gynaecology Subspecialty Trainee in Fetal and Maternal Medicine/ Clinical Lecturer St Mary’s Hospital, Manchester

2. Brief Overview • Student booklets – read it!! • There are 3 teams – red/ blue/ green (4 of you on each) • Timetable for each team on Medlea • In addition: ward rounds • On call sessions • Specialist clinics

3. What is expected • PBL booklet guides what you are expected to know • You will need to do some reading • Turn up – it’s the easiest thing to do • Minimum requirements: • 4 antenatal clinics • 4 labour ward rounds • 4 on-call sessions on labour ward • 4 gynae clinics • 4 gynae theatre lists • 2 consultant ward rounds

4. Obstetric wards: SM4, SM5, SM6 SM4 – blue team SM5 – red SM6 – green Registrars/ SHOs do ward rounds daily Consultants – varied See the patients! Gynae wards SM9, SM10 SM9 – long stay SM10 – day cases, closed sat /sun Registrars/SHOs do ward rounds daily Consultants - vary The wards

5. Obstetrics CDU = central delivery suite Triage Introduce yourself to coordinating midwives and the doctors Gynaecology GUR = gynae urgency room Sees gynae emergencies during the day until 5pm SM10 after 5pm Emergency work

6. Vaginal examinations • Valuable skill • You will be expected to look like you have done a speculum before in the OSCE • Gynae clinic is a good place to learn • Examinations under anaesthetic – need written consent and YOU have to get this before going to theatre • Also write in the patient notes

7. Specialist clinics • There are a limited number of these • You need to book them beforehand on Medlea • You still need to make contact with the person organising the clinic before – as specified in the student handbook • Swap clinics with other teams

8. Partograms and assessment of progress in labour

9. Overview • Definition of labour • Physiology – you can read this • Diagnosis and assessment • Partograms • Abnormal labour • Cardiotocographs

10. Definition of labour • Regular painful contractions resulting in cervical dilatation • 3 stages • First • Second • Third

11. Stages of labour • First Stage • Up to fully dilated • Two phases • Second Stage • Full dilatation until delivery of the baby • Third stage • Delivery of the placenta

12. Latent phase Slow Contractions irregular Cervix: shortens (effaces) Softens Moves Dilates up to 3-4 cm Active phase Regular painful contractions Progressive cervical dilatation greater than 4 cm First Stage of labour

13. Duration of labour

14. Bishop’s score

15. Assessments in labour • The partogram • Labour record • Useful overview if completed properly • Can be used to aid diagnosis in abnormal labours • Visual representation of progress

18. Assessment • History and review notes (handhelds) • Physical observations: temp, pulse, BP, urinalysis • Assess contractions: length, strength, frequency

19. Assessment • Abdominal palpation: • fundal height • lie • position • presentation • station • Vaginal loss • Show • Liquor • Blood loss

20. Assessment • Assessment of pain – need for pain relief • Fetal heart rate • Pinard or doppler • Listen for one minute after each contraction • Differentiate from maternal • Normal rate: 110-160 • Vaginal examination • If appears to be in labour • With consent

21. Normal labour

22. Length of second stage • Can allow a ‘passive’ second stage for the head to descend • Epidurals • Total second stage less than 4 hours (NICE) • Pushing limited to 30 mins (multip) to 60mins (primip)

23. Abnormal patterns of labour • Partogram can be used to identify abnormal progress in labour • Deep transverse arrest • Primary dysfunctional labour • ‘3Ps’ – passenger, passages, powers

24. Cardiotocograph CTG • Cardio = fetal heart rate • Toco = uterine activity: • Hence 2 monitors – • Abdominal pressure transducer • Doppler for fetal heart rate • Used to indicate fetal hypoxia • Poor!! – no reduction in the rate of intrapartum hypoxic injury/ Cerebral palsy since introduction in the 1980s • Increases rates of intervention • Even with the worse trace – 60% will be normoxic babies

25. CTG machine

26. Normal CTG Fetal heart rate Toco = uterine activity

27. Assessment of a CTG • DR C BRaVADO • DR = define risk • C= contractions • Timing and frequency • CTG cannot indicate strength • BRa = baseline rate • Normal 110-160 • beware changes in rate • Fetal heart increases in the presence of maternal tachycardia and increased temperature • Also increases with hypoxia and sepsis

28. DR C BRaVADO • V= Variability • Band width • Should be more than 5bpm • If reduced can indicate fetal sleep/ maternal opiate use • A= Accelerations • Increase in baseline of more than 15bpm for more than 15 seconds

29. DR C BRaVADO • D = Decelerations • = drops in fetal heart of more than 15bpm, lasting got more than 15 seconds • Time with contractions • Early – rare and benign • Late – pathological and indicate hypoxia • Variable – vary in timing and in pattern. Commonest and occur with cord compression • O = Overall • Make overall assessment taking into account all aspects

30. Variability = 20 bpm Baseline rate accelerations Contractions Irregular 1-2:10 Normal CTG No decelerations

31. Baseline rate = 170-180 Variability = 5 Late decelerations Abnormal CTG Contractions 4:10 No accelerations

32. Abnormal CTG

33. Abnormal CTG