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OBGYN CHECKLIST FOR OSCE

Greet the patient


Interview
Position the patient
Dorsal lithotomy position. Explain how.
Drape the patient. Ask to wear hospital gown.
1.) Demonstrate clinical competence in performing the pelvic examination in a
female patient

I. 4 parts of a proper pelvic exam


Inspection
Discharge
Swelling
Discoloration
Mass/lesions
Cauliflower like lesions
Macule
Papule
Hair pattern
Symmetry
Speculum exam
Wear gloves
If not for pap smear, put lubricant on top and bottom of blades.
2 purposes
Pap smear
Performed without any lubricant
Dipped on warm water only
Done before touching the patient
Explain to the patient: May malamig po akong bagay na ipapasok.
Check cervix, vaginal wall
Discharge
Lesions - location, color, bleeding?, smooth?
One way is open up the labia or directly insert one finger press down on the perineum
(fourchette)
Then insert speculum diagonally and downwards
Then rotate. And open.

IE or bimanual examination
IE
Gloved hand
Palpate vaginal wall, cervix
Bimanual examination
2 hands
Palpate adnexa and uterus

Rectovaginal exam
Done in gyne should be smooth and thin
Explain: ipapasok ko lang po yung daliri ko sa pwetan ninyo para matignan kung may
bukol
Remove middle finger and insert in anus

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Then move fingers in horizontal pattern


2. Compute for the AOG using the LMP and earliest ultrasound.
Current Date: 03/06/15
LMP: 09/01/14
EDC computation(Naegeles Rule)
9

14

-3

+7

+1

EDC: 6

15 or June 6, 2015

AOG computation:
Sept

29

Oct

31

Nov

30

Dec

31

Jan

30

Feb

28

Mar

06
185/7= 26.4 or 26 weeks & 4 days

AOG by Ultrasonography
In the first trimester, gestational sac mean diameter and crown-rump length measurements
have become the primary means of evaluating gestational age. In the second and third
trimesters, fetal head, body, and extremity measurements have been commonly used to
assess gestational age. Those parameters most commonly measured include biparietal
diameter, head circumference, abdominal circumference, and femur length.

3. Demonstrate Adequate communication skill in explaining to an obstetric


patient about her AOG. Ang edad po ng inyong pagbubuntis ay 26 weeks and 4 days, ito
pa ay mahalaga para malaman natin kung ang paglaki ba ng bata sa inyong sinapupunan ay
naaayon o naakma sa dapat nyang maabot sa kasalukuyang edad.

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4. Diagnostic procedures for the first prenatal check up


First, ask for the history which includes A. Biographical - age, race, occupation, marital
status B. Obstetrical - gravidity, parity, prior labor/deliveries (vaginal, cesareans),
complications, infant status, brith weight C. Menstrual: LMP, menstrual irregularities D.
Contraceptive use: What type and when was. It last used? E. Medical: Asthma, diabetes,
HPN, Thyroid dse, Cardiac dse, seizures, rubella, previous surgeries, medications, smoking,
alcohol, recreational drugs F. Family hx: Multiple gestations, diabetes, HPN, bleeding d/o,
hereditary d/o, mental retardation, anesthetic problems
Physical Exam Vitals: BP, weight, height, temp, HR Head, neck, heart, lungs, back Pelvic:
External genitalia - Bartholin's gland, condyloma, herpes, other lesions Vagina - discharge,
inflammation Cervix - polyps, growths Uterus - masses, irregularities, size compared to
gestational age Adnexa - masses Clinical pelvimetry - following are dimensions of a gynecoid
pelvis shape: Pelvic inlet : Diagonal conjugate > 12.5 cm (distance bet the inf border of
symphysis pubis to sacral promontory Midpelvis: Ischial spines blunt > 10 cm Pelvic outlet:
Intertuberous diameter > 8 cm, pubic arch > 90 degrees
Labs:
Ultrasound Hct Hgb - to check for anemia or other blood disorders
Rh factor - Rhesus (Rh) factor is an inherited trait that refers to a specific protein found on
the surface of red blood cells. Your pregnancy needs special care if you're Rh negative and
your baby's father is Rh positive. (Mayo clinic) Accdg to the American Pregnancy Association,
if the mother is Rh negative she has to be rescreen on her 26-28th week of pregnancy,
complications could arise if the baby is Rh positive, RhoGram is administered to mothers
who would are Rh negative
Nuchal translucency tests and blood tests - at 11 and 13 weeks to screen for Down
syndrome and other chromosomal abnormalities.
Blood type
Antibody screen
Pap smear - Cervical CA screening
Gonorrhea and Chlamydia cultures
Urine analysis - protein (a sign of preeclampsia or UTI) , glucose (elevated levels maybe a
sign for gestational diabetes) , ketones
Urine culture - to check for any signs of bladder or urinary tract infection

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Infection screen - Rubella, syphillis, hep B, HIV, TB - important because of the congenital
malformations or deformities it can cause to the fetus
Cystic fibrosis screen Urine drug screen Hgb electrophoresis
5. Demonstrate adequate communication skill in explaining the diagnostics to an
obstetric patient
Good morning po mommy, so ngayon po kukunan lang po naming kayo ng dugo
at ihi, tapos po
6. Formulate 3 d/dx for a given case (bleeding first trimester) (From a Journal by
Bastiaan Jager) REMEMBER, BIBIGYAN TAYO NG CASE SO ETO MGA. POSSIBLE NA SAGOT
TANDAAN NYO PARA MARAMI KAYO PEDE PAGPILIAN DEPENDE SA CASE
Originating from uterus, tubes, amniotic sac with its contents or placenta:
Ectopic pregnancy (see Chapter 12)
Miscarriage (see Chapter 13)
Miscarriage with infection (see Chapter 13)
Molar pregnancy (see Chapter 27)
Subchorionic hemorrhage
Idiopathic bleeding in a viable pregnancy
Originating from cervix or vagina:
Infection (Chlamydia, etc.) (see Chapter 17)
Trauma (e.g. after intercourse, medical treatment)
Malignancies, especially cervix cancer (see Chapter 26)
Cervical abnormalities (e.g. excessive friability or polyps) (see Chapter 9)

Originating from anus, bladder or vulva:


Hemorrhoids
Lacerations of skin due to trauma, malignancy (rare) or infection

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UTI, schistosomiasis

9. PERFORM FUNDIC HEIGHTMEASUREMENT AND FETAL HEART TONE


DETERMINATION IN AN OB PT. IN THE 3RD TRIM
Fundal Height
As the fetus grows, the leading edge of the uterus, or the fundus grows superiorly in the
abdomen, toward the maternal head.
Fundal height (in centimeters) roughly corresponds to gestational age (in weeks).

Uterus at level of pubic symphysis: 12 weeks

Uterus between pubic symphysis and umbilicus: 16 weeks

Uterus at the level of umbilicus: 20 weeks

Uterine height correlates to weeks gestation: 2036 weeks

Fundal height (cm) should correlate to gestational age (weeks) 3. If not, consider
inaccurate dating (most common), multiple gestations, or molar pregnancy. Past
approximately 36 weeks gestation, the fundal height may not correspond to the gestational
age due to the fetal descent into the pelvis.

Non-stress Test (NST)


evaluates four components of the fetal heart rate (FHR) tracing:

Baseline: Normally 110160 beats/min.

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Variability: Beat-to-beat irregularity and waviness of the FHR. Presence of variability


refl ects an intact and mature brain stem and heart.

Periodic changes: Transient accelerations or decelerations:

Early deceleration: Vagally mediated, caused by head compression usually at


cervical dilation of 47 cm.

Variable deceleration: Caused by cord compression.

Late deceleration: Reflects hypoxemia.

Acceleration: At least two accelerations of at least 15 beats/min above baseline


for 15 sec in a 20-min period. Presence of accelerations = fetal well-being.
Reactive NST = two or more accelerations over 20 min.

Uterine contractions are also recorded to help interpret the NST.

Preterm fetuses are frequently nonreactive:

2428 weeks: Up to 50% nonreactive.

2832 weeks: 15% nonreactive.

An NST usually takes 2040 min to complete. If the NST is nonreactive, the baby may
be asleep. If this is suspected, ask the patient to eat or drink to make the baby active
if not reactive within 12 hours, then additional testing may need to be performed.

Function
Fetal Doppler machines have a small wand that is pressed onto your stomach. The wand
emits a form of ultrasound waves to convert the sound waves that are in your uterus into an
audible heartbeat. Most ultrasound machines in your doctors office have a Doppler function;
on these machines, the Doppler can also produce a visual representation of the blood cells
as they move through your babys blood vessels.
To measure the babys heartbeat, you simply count the number of these beats over a
minutes time; you can also count the number in 15 seconds and multiply that by 4.
Typically, a babys heartbeat is in the range of 120 to 160 beats per minute; if you get lower
than that, you may be hearing your heartbeat across the placenta and not the babys.

10. FORMULATE 3 D/DX FOR A GIVEN CASE (BLEEDING 2ND-3RD TRIM)

Placental abruption. Premature separation of placenta from uterine wall before the
delivery of baby
RISK FACTORS
o Trauma (usually shearing, such as a car accident).
o Previous history of abruption.

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o
o
o
o

Preeclampsia (and chronic HTN).


Smoking.
Cocaine abuse.
High parity.

Placenta previa. A condition in which the placenta is implanted in the immediate


vicinity of the cervical os. It can be classified into four types:
o Complete placenta previa: The placenta covers the entire internal cervical
os
o Partial placenta previa: The placenta partially covers the internal cervical
os.
o Marginal placenta previa: One edge of the placenta extends to the edge of
the internal cervical os.
o Low-lying placenta: Within 2 cm of the internal cervical os.

Vasa previa. A condition in which the unprotected fetal cord vessels pass over the
internal cervical os, making them susceptible to rupture when membranes are
ruptured.

Velamentous insertion. Fetal vessels insert in the membranes and travel unprotected
to the placenta. This leaves them susceptible to tearing when the amniotic sac
ruptures. The vessels are usually covered by Whartons jelly in the umbilical cord
until they insert into the placenta.

Uterine rupture. The disruption of the uterine musculature through all of its layers,
usually with part of the fetus protruding through the opening.

Circumvillate placenta.
Extrusion of cervical mucus (bloody show).

12. ENUMERATE

CTG ELEMENTS BASIC FEATURES

fetal heart rate pattern has 4 recognizable features


1. Baseline heart rate : 110-160
2. Baseline variability: 5-25
3. Acceleration
4. Deceleration
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BASELINE FHR: the mean level of FHR when this is stable, excluding
acceleration and deceleration. It is determined over a period of 5-10 minutes and
expressed in beats per minute (BPM)
BASELINE VARIABILITY: the minor fluctuation in baseline FHR occuring at 3-5
cycles per minute. It is measured by estimating the difference in beat per minutes
between highest peak and the lowest trough of fluctuation in one minute segment
of trace. It is considered reduced if less than 5
ACCELERATION: transient inc in FHR of 15 bpm or more and lasting 15 seconds
or more
DECELERATION: transient episodes of slowing FHR below the baseline level or
more than 15 bpm and lasting 15 sec or more
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TYPES OF DECELERATION
1. Early deceleration - uniform, repetitive, periodic slowing of FHR with onset
early in the contraction and return to baseline at the end of contraction
2. Late deceleration - uniform repetitive periodic slowing of FHR with onset mid to
end of contraction and nadir more than 20 second after the peak of contraction
and ending after the contraction
(Nadir: worst and lowest point something)
3. Variable deceleration: variable, intermittent periodic slowing of FHR with rapid
onset and recovery. Time relationships with contraction cycle are variable and
they may occur in isolation
4. Prolonged deceleration: an abrupt dec in FHR to level below baseline last
atleast 60-90 sec. These decelerations become pathological if they cross to
contraction: >3 mins
5. Atypical variable: variable deceleration with any of the following additional
deceleration component - loss of primary or secondary ruse in baseline rate slow return to baseline FHR after the end of contraction - prolonged secondary
rise in baseline - continuation of baseline rate at lower level

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6. Sinusoidal pattern:
a regular oscillation
of baseline long term
variability resembling
a sine wave. This
smooth, undulating
pattern lasting at
least 10 min and
amplitude of 5-15
CAUSES OF FHR
BRADYCARDIA bradycardia: <100
bpm
1. Fetal hypoxia - bradycardia is a late sign of fetal hypoxia (continual lack of
oxygen) - the heart rate slow in response to a depression of heart muscle
(myocardial) activity caused by this continued decrease in needed oxygen
2. Medication: narcotics
3. Epidural: causes vasodilation
4. Synthetic oxytocin / pitocin: bradycardia via hyperstimulation of the uterine
muscle
5. Maternal hypotension
CAUSES OF TACHYCARDIA -161-180 (suspicious) - >180 pathological
1. FETAL HYPOXIA: early sign of hypoxia 2. Medication: terbutaline

13. CTG INTERPRETATION

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IDENTIFY THE IE FINDINGS IN THE SIMULATION MODEL

1.

Inspect external genitalia


Warts
Rashes
Ulcers
Lumps

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Vesicles
Excoriation
2. Palpate vaginal walls
Mass
Cyst
3. Cervix
Dilatation how open the cervix (1-10cm)
Effacement how thin the cervix feels and measured in % (0% cervix long and
thick, 10% cervix is paper thin
Position leans towards the back (posterior) behind the baby's back
Station how far the baby's head has come down into the pelvis
Assess the fetal presentation (head, foot, buttocks)
BIMANUAL EXAMINATION

palpate the uterus by pressing it between your right middle and index fingers and your left hand
placed on the lower abdomen. Feel for any masses

You should also try to palpate each of the ovaries. This is done by placing your internal fingers in
the right fornix and trying to press the ovary between them and your left hand placed in the right
iliac fossa.

Do the same for the left ovary.

Note any tenderness or masses which you may feel

Rectovaginal examination

The rectovaginal exam is a diagnostic tool that helps doctors to more fully examine the internal
pelvic anatomy and check the vaginal and rectal areas for abnormalities.
feel for signs of tumors that might be located behind the uterus, on the lower walls of the vagina
or in the rectum.
evaluate the tissue between the uterus and vagina, the tone and alignment of the pelvic organs
(like the ovaries and fallopian tubes) and the ligaments that hold the uterus in place.

INTERPRET AN ABNORMAL PARTOGRAPH


1. The first stage starts with uterine contractions leading to complete cervical dilation
and is divided into latent and active phases. In the latent phase, irregular uterine
contractions occur with slow and gradual cervical effacement and dilation. The active
phase is demonstrated by an increased rate of cervical dilation and fetal descent. The
active phase usually starts at 3-4 cm cervical dilation and is subdivided into the
acceleration, maximum slope, and deceleration phases.
2. The second stage of labor is defined as complete dilation of the cervix to the delivery
of the infant.
3. The third stage of labor involves delivery of the placenta.

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Prolonged latent phase

failure to progress
20 hours or more for nulli and 14 hours or more for multi
There is a slow effacement of the cervix.

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Protracted active phase

slower than normal rate of cervical dilation

1.2 cm/hour for nulli and 1.5 cm/hour for multi

Protracted descent

delayed descent of the fetal head in the active phase


less than 1.0 cm/hour in nulli and less than 2.0 cm/hour for multi

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Prolonged deceleration phase

deceleration phase lasting more than 3 hours in nulliparas or more than 1 hour in
multiparas

Secondary arrest of dilatation

no progressive cervical dilatation in the active phase of labor for 2 hours or more

Arrest of descent

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descent failing to progress for 1 hour or more

Failure of descent

descent failing to occur during the deceleration phase of dilatation and during the
second stage.

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14. PELVIC LANDMARKS

Dystocia
1.) Call for HELP!!
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2.) Place patient in Mcroberts position


3.) Mazzanti Rubins
4.) Corckscrew
5.) Fracture clavicle
6.) Symphysiotomy
7.) Do all fours (doggy)
8.) Zavanelli
9.) CS
Artificial
1.) Female condom
2.) Male condom
3.) Diaphragm
4.) Cervical cap
5.) Spermicide
6.) Sponge
Hormonal agents
Combination pills - Progestin only pills - lactating women, women > 40, estrogen sensitive
tumors
Injectable
Medroxyprogesterone - SLE, migraines, HA, heavy bleeding
Implantable
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Levonorgestrel - oral contraceptives contraindication, smokers over 35, DM, HTN, CAD

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