GYNAECOLOGY/OBSTETRICS l/ll Paper XIX

Specific Objectives

 History taking and recording

Students will be able to

  • enquire about the reasons for which a woman has come to the clinic or hospital and record it properly;
  • enquire about the record, duration, magnitude of the problem and its relation to the environment, and treatment;
  • enquire about the menstrual pattern of a woman in the following order:
  • the age of onset of menstruation,
  • duration of menstrual period,
  • interval between the two periods (from the first day of bleeding of one period to the first day of bleeding of the next period)
  • the last bleeding and its duration,
  • pain in relation to the menstrual period,
  • enquire about the bleeding from the nose or rectum during the menstrual period in addition to vaginal bleeding, and whether there is pain or bleeding during defaecation or micturition;
  • enquire about the relationship of a married woman with the husband in terms of sexual desire, performance, pain during intercourse (dysparunia) and bleeding during defaecation or micturition;
  • enquire about the relationship of a married woman with the husband in terms of sexual desire, performance pain during intercourse (dysparunia) and bleeding during or after the intercourse;
  • enquire a bout pregnancies and record in the following order:
  • the number of pregnancies,
  • abortion occured before 28 weeks of pregnancy.
  • intra uterine death occured after 28th weeks of pregnancy (i.e. viable fetus ),
  • number of live births or stillbirths (if a stillbirth, whether it was fresh or macerated, and whether the woman felt movement of the fetus till or near the time of delivery or not),
  • the sex of the babies born and their ages (if some of the children are dead, the age at which they died, and if possible the reason);
  • enquire about any deformities or abnormalities in the children (living or dead);
  • enquire about previous deliveries (spontaneous, operative or assisted delivery); if delfivery was assisted, how it was done (forceps, indication of operative delivery after vacuum or caesarean section, (sometimes mothers carry a piece of paper or discharge slip from the hospital this should help the students to record the reason);
  • enquire whether the mother had excessive bleeding after delivery or blood transfusion done or any other reason;
  • enquire whether she had to be helped for the delivery of the placenta.

History taking from a pregnant women

Students will be able to

  • determine the date of the last menstrual period and calculate the expected date of delivery (which falls on the completion of the 40th weeks from date of last menstrual period);
  • record the presence of pain during present pregnancy, and note the type duration and location of the pain;
  • record the presence of pain during present pregnancy, and note the type, duration and location of the pain;
  • record the presence of any bleeding per vaginum during course of pregnancy, its colour, amount, duration and association with pain;
  • enquire whether the mother feels the movement of the fetus in the second trimester.

History taking regarding vaginal discharge

Students will be able to

  • ask how the vaginal discharge affects her, whether it is just a botheration that she has to change very often or if there is any other associated conditions like irritation and bad smell with itching associated with blood or not, type of discharge;
  • record choice of contraceptive.

History taking regarding other general health problems

Students will be able to

  • record the age, number of siblings and family history of hypertension, diabetes mellitus, multiple births, and physical deformities or blindness.

Clinical examination

Students will be able to

  • assess the height and proportionate growth of women;
  • detect pallor on the face to assess anaemia and note excessive hair growth on the face and limbs;
  • examine the breasts; see if there is any difference between two breasts, discharge from nipple and redness over breasts including colour of areola) and palpation (using whole of the palm and feel the smooth contour of breast; feel for any mass or tenderness in one or both breasts);
  • examine abdomen (shape and size, any localized mass specially in supra pubic region any scar on the abdomen), palpation (for any mass or tenderness, is it localized or generalised ? test for rebound tenderness; if there is mass, demonstrate shape, size mobility, consistency of the mass and tenderness over it; in pregnancy demonstrate the height of the uterus, fundus, and feel the fetal parts, the lie, presentation and position of the presenting part) (and auscultation (listening to the fetal heart sound).

Pelvic examination

Students will be able to

  • inspect distribution and development of pubic hair, swelling in the vulva, vaginal opening including presence of absence of hymen, signs of infection or scar, normal clitoris and urethral opening, vaginal discharge or bleeding, and any lesion around the anus;
  • palpate for any tenderness or swelling in the vulva, especially lower part of labia majora for Bartholin cyst;
  • list the equipment needed for clinical examination of female reproductive system (speculum, sims, duckbill or cusco’s; swab, sponge holding forceps and volsellum, cervical smear spatula, swab with sticks used for examination of discharge);
  • explain the whole procedure of speculum examination of a woman;
  • describe and demonstrate the comfortable and different positions of the patient for examination);
  • demonstrate awareness of need of securing patients confidence and cooperation, and the necessity of a female attendant during examination;
  • recall the antomical features of the external genitalia;
  • carry out bimanual examination (introduce one finger in the vagina through the introitus, then introducing both index and middle fingers);move the uterine cervix and stop it if this causes pain, rest the left hand over the suprapubic region, and with the two fingers in the vagina lying on either side of the cervix, the size, shape and mobility of the uterus between the two hands, (the tubes and ovaries are normally not palpable);
  • identify any abnormal mass in the pelvis and determine its size, shape, mobility and relation to the uterus; remove the fingers from the vagina and see if there is any blood or discharge in the examining finger;
  • introduce the speculum into the vaginal opening with its breadth anterioposteriorly; direct the length of the speculum blade downward, then forward and then finally upward; turn the speculum in such a way that the blade rests in the posterior vaginal wall; retract the anterior vaginal wall with retracter of sponge holding forceps;
  • inspect with the speculum, the shape, size and colour of the uterine cervix; visualise different fornices; note any growth /erosion/ inflammation / discharge;
  • remove the speculum in the same position as it was introduced;
  • recall normal shape, size and position and relations of vagina, cervix,uterus ovary and tubes;
  • recognize inflammation, swellings, congenital anomalies and trauma such as erineal tear and scars in external genitalia.
  • recognise normal and abnormal discharge per vagina and describe normal and abnormal bleeding per vagina;
  • describe and demonstrate proper technique of the examination of pelvic organ;
  • recognise and demonstrate differences in genital organs at different ages before puberty, reproductive and menopause;
  • recognise and differentiage between normal and abnormal shape, size and position of the genital organs;
  • recognise the presence of mass or tenderness or its presence in the surrounding structures such as bladder, rectum or lateral pelvic wall or pouch of Douglas;
  • describe and demonstrate lesion of cervix such as cervical erosion and polyp and growth on cervix.

Management of pregnancy and labour

Students will be able to

  • diagnose pregnancy;
  • determine the duration of pregnancy;
  • predict the likely outcome of pregnancy and delivery;
  • take the opportunity for health education, eg, family planning, nutrition, hygiene early pregnancy bleeding causes, diagnosis and management etc.
  • manage normal labour and delivery record a partograph during labor after managing normal labor.
  • recognise and understand the principles of treatment of delayed and obstructed labour, fetal distress;
  • recognise and manage postpartum haemorrhage and retained placenta;
  • manage normal puerperium; encourage successful breastfeeding and supervise infant care;
  • recognise and manage puerperal fever and haemorrhage;
  • assess the maternity needs of a community and organise optimal utilization of available resources;
  • recognise and understand the principles of management of neonatal disorders (including RH disease).

Management of women who do not wish for any more children

Students will be able to

  • recognize the problem even when the patient does not clearly state it;
  • advise on the alternatives open to them;
  • provide information about the available methods of contraception and their mode of action;
  • provide follow-up of temporary and permanent contraceptive acceptors;
  • assess the contraceptive needs of a community and organize maximum utilisation of all available resources.

Management of common obstetrical and gynaecological problems

Students will be able to

  • identify problems by history taking and physical examination;
  • find appropriate causes, and manage by planning appropriate treatment in women who in becoming pregnant,
  • difficulty in becoming pregnent
  • have irregular or absent menstruation, intermenstrual or postmenopausal bleeding,
  • excessively heavy or frequent menstruation, pain in association with menstruation,
  • vaginal discharge or vulval irritation,
  • discomfort related to genital prolapse,
  • urinary incontinance,
  • vulval or abdominal pelvic swelling,
  • acute or chronic vulval or abdominal pain.

Obstetrics

Students will be able to

  • describe the development of fetus, placenta and amniotic fluid;
  • describe the physiology of uterus and changes in mother during pregnancy;
  • describe the mechanisms of labour and delivery;
  • describe the mechanisms of the puerperium and lactation;
  • describe abnormal function, nature and consequences of abortion,
  • ectopic pregnancy,
  • molar pregnancy;
  • hypertension;
  • antepartum haemorrhage,
  • multiple pregnancy,
  • hydramnios,
  • oligohydramnios,
  • fetal malformation,
  • representations,
  • prematurity,
  • dystocia and third stage disorders,
  • tumors of genital tract,
  • endometriosis,
  • infections of genital tract, and genital tract trauma,
  • Rh isoimmunization,
  • induction of labour,
  • post dated pregnancy,
  • PET,
  • eclampsia
  • incoordinated uterine, action,
  • medical disorder in pregnancies, puerperum and IUD,
  • diabetes in pregnancy;
  • UTI in pregnancy ;
  • Safe-motherhood, reproductive health;
  • STD & HIV in pregnancy;
  • USG, CT , MRI in pregnancy ;
  • describe infertility and its management.
  • perform the induction of obstetric analgesia, including paracervical block
  • assist postpartum tubectomy;
  • insert an IUD;
  • carry out normal delivery including repair of eipsiotomy;
  • carry out induction of labour;
  • manually revove placenta;
  • perform blood transfusion and intravenous therapy;
  • carry out direct microscopy of vaginal discharge for monilia and trichomonas;
  • assist in forceps and vacuum delivery;
  • fit vaginal pessary for prolapse or urinary incontinence;
  • resuscitate newborn;
  • assist hysterosalpingography;
  • assist to drain an abscess of haematoma, MVA;
  • clinical demonstration class (mechanism of labour, breech, occipito posterior, forceps, vacuum, instruments);
  • perform 3 Norplant insertion and 2 IUCD insertion;
  • assist in one Vasectomy and two Minilap operations;

Gynaecology

Students will be able to

  • review the anatomy and physiology of female reproductive tract; and physiology of menstruation;
  • manage (under supervision) patients with:
  • amenorrhoea
  • congenital malformations of female genital tract
  • menopause,
  • endometriosis,
  • genital prolapse and trauma,
  • gynaecological cancer,
  • general perspectives and review of pathology,
  • carcinoma of cervix,
  • health education issues in Gynaecology,
  • uterine tumors,
  • fibroids,
  • endometrial carcinoma,
  • ovarian tumors,
  • gynaecological infections,
  • lower genital tract,
  • urinary incontinence,
  • temporary and permanent methods of contraception; interpret laboratory data;
  • explain subfertility I, and subfertility II.
  • enumerate steps of D and C, cervical biopsy, total abdominal hysterectomy, vaginal hysterectomy and myomectomy.

Obstetrics

Students will be able to

  • describe health education issues in obstetrics and give health education;
  • manage (under supervision) patients with delay in labour, fetal distress, breech presentation and delivery, forceps, vacuum, caesarean section;
  • prevent and manage obstetric trauma;
  • manage medical disorders in pregnancy and fetal malformations;
  • handle reproductive statistics and community activities;
  • describe high risk obstetrics.

Medical disorders in pregnancy

Students will be able to

  • state the various medical disorders associated with pregnancy, recognize the complications and manage accordingly.

Neonatalogy

The students should be able to manage prematurity and care for neonates.

Clinical experience

Students will work in indoor, labour room, operation theatre and maternal and child health care clinics for four weeks. The students will diagnose investigate and treat, under supervision, common gynaecological problems; diagnose, observe and assist normal delivery, share responsibility with consultants to provide service to pre, peri and postnatal cases including neonatal care with special emphasis on maternal and child health care. The students will keep complete record of at least 15 cases during the posting period.

Students will be able to

  • take history, record finding, investigate and assist to provide treatment to gynaecological and obstetric cases;
  • Assist residents or consultants to assess patient’s condition and provide supportive treatment when necessary;
  • assist in patient’s care before, during and after delivery including neonatal care;
  • evaluate patient before operation, assist during operative procedures and share responsibility during recovery and post operative period;
  • identify and use commonly used surgica! instruments; observe and explain common surgical procedures; institute minor surgical procedures under supervision;
  • describe the services provided for maternal and child health care in the clinic and assist the consultant or residents to provide these services;
  • assist consultants or residents to provide counselling for maternal and child care and explain to the patient the follow up procedures.
  • list the indications, contraindications, steps and postoperative complications of
  • LSCS and Hysterectom
  • observe the induction of obstetric analgesia, including pudendal block .
  • observe and assist postpartum tubectomy.
  • observe insertion of I.U.D.
  • observe and assist carrying out normal delivery including repair of episiotomy.
  • observe induction of ovulation.
  • observe and assist manual removal of placenta.
  • observe blood transfusion and intravenous therapy.
  • observe carrying out direct microscopy of vaginal discharge for monilia and trichomas.
  • observe and assist instrumental delivery.
  • observe and assist inserting vaginal ring pessary.
  • observe and assist resuscitation of newborn.
  • observe hysterosalpingograpy.
  • observe and assist drainage of abscess and haematoma.

Third and Fourth Year

During the period students learn about history taking of pregnant women, gynaecological problems, and clinical examination during pregnancy and at other times. Lectures are supplemented by clinical teaching about obstetrics and gynaecological problems. Ward attachments and participation in the conduct of normal delivery and observation of operative procedures enhance this clinical experience.

Fourth Year

For four weeks students are allocated cases, and under supervision, carry out their management, with the guidance from consultants and other members of their team. The students thus develop experience in the management of maternal and child health care.