1. Overview of OBGYN December 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 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)

17. 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

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