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 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 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) 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: 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 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 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 Vaginal / Cervical Swabs 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)

OBGYN skills Interpretation of a smear result 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 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 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