Guide for gynaecology & obstetric internship

Guide for gynaecology & obstetric internship- Yapa Wijeratne
Guide for gynaecology & obstetric internship
By Yapa Wijeratne
History taking
6 questions to filter the diagnosis
1. Abdominal pain?
a. ↑ frequency & duration, colicky
2. Back pain?
3. PV bleeding?
a. Mucoid, brownish, scanty amount → show
4. Dribbling?
a. Watery, clear, copious amount which wets bed sheets/ garments →true dribbling
b. False dribbling: DD: 1. Show 2. Candidiasis 3. Urine 4. Hind water rupture
5. Fetal movements?
6. PET symptoms?
a. Headache, epigastric pain, visual disturbances
Mx
1. CTG-stat & daily
2. FHS-tds
3. KCC
4. USS
5. FBC
6. PPBS
7. UFR
8. Continue haematinics
9. On any suspicion of going for a LSCS- fill DT 1Θ
PCM 1g 6hrly or Panadine 1g 6 hrly (outside chit)
If already on any drugs you need to add here
e.g. metformin 500mg tds
if < 37 wk & having a possibility of early delivery give IM dexa 6 mg 12 hrs apart 4 doses or 12 mg 2
doses. Dexa can be given IV if needed immediate action.
Dribbling
1. HVS
2. Bed rest
3. Erythromycin 250mg 6hrly 10 days or 500mg 6hrly
4. Sterile pads
5. QHT
6. Better check FHS frequently ( ¼ hrly if possible, like in labor room as there is a risk of cord
prolapse)
7. Inform PMO (Paediatric Medical Officer) for PBU care if preterm or any risk of PBU/SBU care
Preterm labor
1. Lung maturity → IM dexamethasone 12mg 12 hrly 2 doses or 6mg 4 doses in 48 hours
a. Dexamethasone action lasts for 7 days. But within a month no need to repeat.
b. Need to monitor CBS if GDM before giving dexamethasone

2. Tocolytic → Nifidipine 20mg 6 hrly x 48 hrs
PIH
1. PET screening
a. BU
b. S.cr
c. SGPT/SGOT
d. SE
e. PT/ INR
2. Urine albumin stat & chart
3. BP tds
4. Nifidipine 20mg bd
Need same day FBC if going for EM-LSCS
Look for PLT, PCV (there will be haemo-concentration)
Placenta previa
Ready 3Θ DT always in the ward
Bed rest
GDM
Insulin 10 U mane
Metformin 500mg tds
BSS
1. FBS
2. BS-post BF
3. Pre lunch BS
4. Post lunch BS- urgent chit
5. Pre dinner BS- urgent chit
6. Post dinner BS- urgent chit
OGTT
FBS : 92 mg/dl
1st
hr : 180 mg/dl
2nd
hr : 153 mg/dl
IUGR
CTG daily/ bd
2 weekly growth scan- tabulate them clearly
Every 3rd
day / EOD doppler
Pruritus
Risk of IUD: reason not clear
If bad obs history but still not willing early delivery, always document everything
Total bilirubin with fractions
PET screen
Mx
Piriton 4 mg tds
1% hydrocortisone cream

Aqueos cream local application
Routine growth scan- sample
TAS- Dr.----- (Reg)
SLF, CP
BPD 33+2
HC 33+5 33 +5
AC 34
FL 33+ 6
Placenta- fundal/ anterior/ posterior
Liquor average or AFI 8cm
Doppler good diastolic flow. RI 0.7 PI 0.9
EFW (estimated fetal weight)
In early USS, (1st
trimester & early trimester scans) , USS EDD is important
In twin pregnancy, EFW of both twins important- twin to twin transfusion
In IUGR, →EFW, Doppler diastolic flow, RI PI values
1st
scans → CRL (in extended position)
In early scans till about 13-15 weeks, BPD & HC alone is enough.
Routine clerking
P1C0
38+1
P/C
No complains
FM+
Plan:-
Foley insertion
VE
Os has to be less than 1.5cm
Cuscos speculum & visualize Os.
Foley inserted & catheter balloon was filled with 60 or 70 ml of N/S.
Traction is applied till the balloon get stuck at Os.
Keep NBM till CTG in ½ hr
Inform when the folley is fallen.
Then do a VE & assess the cervix
PG insertion
Primi 2mg → 1mg → 1mg (can insert 4mg 6 hrly)
Multi 1mg → 1mg → 1mg (can insert 3mg 6 hrly)
PGE2 inserted.
Keep NBM.

CTG in ½ hr, 2hr, 6hr (It is always better to take a CTG prior PGE2 insertion, as fetus may already in
distress & PGE2 can worsen)
ARM (Artificial rupture of membranes)
1. ARM done under aseptic conditions.
2. Liquor- clear/ thin to moderate / thick meconium.
3. No hand or cord prolapse.
4. VE
a. Os-1cm
b. Effacement- 30%
c. Station- (-1)
5. Mx
a. Start IV syntocinon 5U (primi)/ 2U (multi) in 1Θ N/S.
i. Drop rate 10/min → maximum 60/min.
b. CTG in ½ hr.
c. FHS ¼ hourly
d. Pain relief
i. IM pethidine 75mg (1mg/kg) stat
ii. IV maxalone 10 mg or IM phenagan 25 mg (here giving phenagan is beneficial as
its sedative effect can reduce the labor pain)
iii. Entonox SOS
e. R/v in 3 hrs.
f. In PIH patients- BP ½ hourly
g. In GDM patients- RBS with CBS 4 hourly
Episiotomy
1. Episiotomy sutured under aseptic conditions.
2. No active bleeding.
3. Swabs & clots removed.
4. Per rectal examination-PRE done.
5. Placenta & membrane examination-PME done.
6. KUO for bleeding.
7. If bleeding occurs
a. Start 20 units of IV syntocinon in 1Θ N/S.
b. Inform HO stat.
8. If no bleeding within 2 hrs, send the pt to ward ----.
LSCS premedication
IV ranitidine 50 mg mane
IV maxalone 10 mg mane
Or
Omeprazole/Famotidine 20 mg nocte/mane
O. maxalone 10 mg nocte/mane
Gynecology
Vomiting

How many episodes? – to assess the severity
Blood stained? –– to assess the severity
Content? – partially digested foods?
Can tolerate oral? → if yes oral antiemetics (domperidone 10mg stat & tds or oral maxalone 10mg) to
control the vomiting & then without cannulating the patient, you may be able to manage the vomiting.
Abdominal pain?
Urinary symptoms? UTI also can cause vomiting
Hyperemesis Gravidarum
Oral metochlopramide 10mg tds
IV ondansetron 4mg tds
UFR & urine for ketone bodies- ward test
SE (can be done if you suspect severe dehydration)
RBS stat with CBS (expensive, but less painful & you get quick results)
1 vial of polybion in 1Θ N/S
IV ranitidine 50 mg stat & bd
IV maxalone 10mg stat tds
N/S 6Θ – 24hrs
Hartmann 3Θ
Some patients develop reactions for polybion / ranitidine. Try managing with IV hydrocortisone 200mg
stat
(Here you may request FBC to exclude other causes of vomiting, but hyperemesis gravidarum is
common. Common things are common. )
If ketone bodies positive
1l → 0.5 hr
1l → 1 hr
1l → 2 hr
1l → 4 hr
Threatened Miscarriage
Do TVS
If FHB seen then
IM Prolutan 1 vial stat & weekly or
Vageston 200mg daily x 2/52 till 13 weeks
PV bleeding – in non- preganant
Norethisteron 5mg tds (10mg tds) for 21 days
Tranexamic acid 500mg tds during bleeding
Mefanamic acid 500mg tds during bleeding
FeSO4 1 or 2 tab daily
Vit C 1 tab daily
If pale, DT 1 or 2 pints
Before ANY blood transfusion, take blood for blood picture

Surgery
Pre-op investigations
FBC
UFR
FBS
CBS stat
SE
S.Cr
>40 years
ECG
CXR
2D ECHO
HIV 1 & 2 antibody
HepBsAg
Clean enema- just to empty the feces from sigmoid colon/ rectum
if past surgeries- need to give Klean prep
Diclofenac sup 100mg- for post op pain relief
Postnatal
LSCS
D0
Active PV bleeding
Abdo soft
Uterus hard
Pallor
Pulse Volume
D1
Complains?
Active pv bleeding?
UOP → >1000 ml → OK. Remove catheter
Pallor
Pulse rate, volume
Abdomen soft?
Uterus hard
Mobilize
Diclofenac 50 mg tds
Famotidine 20 mg bd
PCM 1g tds
D2
Fever

Bowel open
Urine output
FBC
PPBS
D3
Wound inspection → bath
VE→ No clots. No swabs
→ Discharge
PIH
D1
Check BP
Normal > stop drugs
> 150/90 & PET symptoms: urine albumin & continue drugs
NO diclo sup. Give Tramadol 50 mg tds
BP is highest in D3-D6. So need to measure that BP.
Nifidipine 20 mg bd → if not controlled + HCT 25 mg mane
Admit if > 150/100mmHg
R/v in 2/52 or 6/52 for BP
GDM
RBS stat
D1: stop metformin & insulin
D2: PPBS → (Normal 7.1) → Discharge
On discharge
No fever
Haemodynamically stable
Abdomen soft
Wound healthy
Plan on discharge
Calcium lactate 1 tab daily for 6 months
Family planning advices given
R/v at MOH clinic in 6/52 for family planning advices
If anemic→ (8-10g/dl) FeSO4 tab daily x 1/12
If GDM→ R/v at ward in 2/52 with PPBS
R/v at ward in 6/52 with OGTT Dr.Janaka
Post partum fever
Episiotomy?
LSCS wound?
3 undiagnosed
Neck stiffness for meningitis (LSCS patients- spinal anesthesia- risk of infection → may be misdiagnose as
pp psychosis
Calf tenderness for DVT

Saturation for atypical pneumonia
Clinic
If Rh (-)→ unexplained antibody level
UFR Pus cells >10
U culture → cephalexin 500mg 8H x 5 days → repeat UFR
Referral letters
Gyn/ Medical clinic
[ ] hospital
DMO/MO/RMO
[ ] hospital
Dear Doctor,
Ref: Mrs. ………………………..
Could you kindly arrange the follow up of this patient with ……………………….
[e.g. T2DM] at your institution.
We shall review the patient, if the necessity arises/ in one year.
Thank you.
………………..
VOG/ MO
Follow up plans
Gyn/ Medical clinic
Follow up plan
1. Review in ……………… weeks/ months
o Red number-
o Blue number
2. Referred to local hospital/ other clinic
3. Review SOS
Some useful tips
Past section patient suddenly collapse-think of “Uterine rupture”
Patient collapsed following “precipitated labor”- para vaginal hematoma. Needs to open & ligate
internal iliac.
Patient complains continuously of pain- may be meconium. Keep nill by mouth (cz she may need LSCS).
Do ARM & see liquor.
IUGR patient- document to compare two weekly growth scan.
Chronic pelvic pain- Meloxicam 15 mg mane. Amytriptiline 20 mg nocte

Infected LSCS wound- Iodosorb
Dysmenorrhea- Etovax 120mg 5 tab monthly during menstruation
CTS- keep hand over 2 pillows when sleeping
Candidiasis- Gynoperyl vaginal pessary for 3 days
Primapore plaster- non allergy plaster cheaper than “Tegaderm (LSCS size 25 x 10 cm)
Metformin- Panfor SR daily for 3/12
GDM mother delivers baby:
Check cleft palate & anus
Mx
Early assisted breast feeding
RBS in 2 hrs & 4 hrly for 24 hrs
Diane-35 tablet contains cyproterone acetate 2 mg + ethinyl estradiol 0.035 mg.
Yasmin (drospirenone and ethinyl estradiol)
Primolut N (norethisterone)
Ovidac 5000 iu/ml (Freeze Dried Powdered HCG Injection)

Op notes
These are sample diagnosis cards that you may write.
MINOR SURGERIES
EUA + DIALATATION AND CURRETAGE
By Dr (SHO)
Under GA By Dr. (MOA)
On 0/0/2016
Indication-
Heavy menstrual bleeding
P4 C3
EUA:
Cervix firm and healthy
Uterus anteverted. 8wks sized
Curettage done:
Curettings ++ and sent for histology
TVS by Dr (SHO)
Endometrial thickness 6.8mm
R/S ovary- dominant follicle seen
L/S ovary polycystic
No products
Investigations
Hb: 13.3 g/dl
Plt: 2267,000
UFR : normal
FBS : 6.4 mmol/L
Discharge plan
Review in Gyn clinic with histology report In 4 weeks
( on 00/00/2016)
B/L LRT + ERPC
By Dr (Reg)
On 05/0/2016
Indication-
T1 - Missed miscarriage
P4 C3
Skin incision supra pubic

B/L ligation and resection of tubes done
Skin sutured with subcuticular vicryl
TVS by Reg
Gestational sac diameter 26.3mm
Foetal pole seen. Diameter 8mm
No foetal heart beat seen
Management
Misoprostol 600micg inserted PV.
TVS on discharge
No products
Investigations
Hb: 13.2 g/dl
Plt: 250,000
UFR : normal
FBS : 5.4 mmol/L
Discharge plan
Review SOS
T1 INCOMPLETE MISCARRIAGE
P3 C2
POA: 9wk + 5d
TVS by Reg
Retained products of conception seen
Endometrial thickness 19mm
Management
Misoprostol 800micg inserted PV
TVS on discharge
Uterine cavity empty
Investigations
Hb: 11.8 g/dl
Plt: 244,000
UFR : normal
RBS : 5.2 mmol/L
Discharge plan
Folic acid 1 tab daily
Ferrup 1 cap daily
R/V sos

MAJOR SURGERIES
EM/EL LOWER SEGMENT CAESAREAN SECTION
On -
Done under SA GA
Done By :…Dr
Assisted by :…Dr
INDICATION:
Procedure:
Pfannenstiel incision made
Peritoneal cavity opened in to.
Routine LSCS done.
Liquor : clear/ meconium
Single live non asphyxiated baby delivered.
Placenta and membranes delivered completely.
Uterus sutured in two layers.
B/L tubes and ovaries appeared normal.
Complete haemostasis achieved.
Routine closure done.
Skin sutured with S/C vicryl
Post op
1. NBM 6 hrs
2. QHT
3. IP/OP chart
4. Monitor BP, PR, RR
a. ¼ hrly x 2hrs
b. ½ hrly x 2hrs
c. 1 hrly x 2hrs
5. Pain relief
a. IM pethidine 50mg SOS
b. IV metochlopramide 10mg SOS
c. Diclofenac sodium 100mg sup stat
d. Diclofenac sodium 50mg bd
e. Omeprazole 20mg bd
f. PCM 1g SOS
6. IV fluids
a. IV NS 80cc/hr
b. IV NS 2Θ
c. IV hartmann 2Θ 24hr
d. IV 5% dextrose 1Θ
7. Antibiotics
a. IV Cefuroxime 750mg tds x 24hrs

IV Metronidazole 500mg tds x 24hrs
O. Cefuroxime 500mg bd x 3d
KUO for bleeding
[PIH → urine albumin stat & tds- chart]
In GDM monitor RBS
LAPAROSCOPIC CYSTECTOMY
By Dr. (VOG), Dr (SR), Dr (Reg)
Indication- Left side ovarian cyst
Procedure –
Loyd Davis position
Closed verrus needle technique. Pneumo-peritonium acheived.
4 port entry into peritoneal cavity
Findings –
Large Left side ovarian cyst found.
Endometrioma. Size 8x 8 cm.
POD adhesions present, Grade 4 Endometriosis
Large bowel adhered to ovarian cyst.
Adhesions separated.
Cystectomy done. Part of cyst wall sent for histology.
Extensive surgery not done as POD adhesions were severe
Skin –subcuticular-vicryl
Discharge plan
1. Needs GnRH analogues – not affordable
2. DMPA started monthly for 6 months
3. May need second laparoscopic surgery
EXPLORATORY LAPAROTOMY +TUMOUR DEBULKING
Indication- Right sided ovarian tumour
Procedure –
Midline paramedian incision made.
Findings –
1. Moderate amount of ascetic fluid present in the peritoneal cavity. Straw in colour
2. R/S multilocular 6*8cm sized ovarian tumour found adhered to bowel loops.
3. L/S ovary and the uterus densely adhered to the rectum and lateral pelvic wall.
4. No macroscopic tumour deposits observed on the omental surface or under surface of the liver.
Procedure:
Peritoneal fluid sent for cytology. Tumour debulking done.
L/S Oophorectomy done along with the tumour.

L/S ovary and uterus were not dissected due to dense adhesions found with the sigmoid colon and
the rectum.
Omental biopsy taken.
Skin –interrupted nylon.
In any case of ovarian tumor/ suspicious cyst or suspicion of malignancy document about omentum,
bowel, rectum, liver, undersurface of diaphragm, ascetic fluid (if present) as that information is essential
for staging of tumor if histology came as malignant.
Total Abdominal Hysterectomy + Bilateral Salphingo-oophorectomy
On 03-10-2016
Indication: Heavy menstrual bleeding not responding to medical treatment/ multiple fibroid uterus
Procedure:
Pfannenstiel / midline incision made. Peritoneal cavity opened into.
Findings:
B/L ovaries and tubes appeared normal.
Three pedicles identified, ligated and resected.
Routine TAH + BSO done. Uterus- Multiple fibroids.
Complete haemostasis achieved
Vaginal vault and Rectus sheath sutured with vicryl.
Skin sutured with Vicryl subcutucular.
Specimen sent for histology.
Investigations:
Hb: 12.8 g/dl
WBC: 10.0 x 103/ul
Plt count: 350 x 103/ul
BU: 3.5 mg/dl
SE: Na 145mmol/L K 4.5 mmol/L
FBS: 5.9 mmol/L
CXR: NAD
ECG: SR
2D Echo: Good LV function. EF >60%. No RWMA. Mild MR
HIV I, II Ab:
Hep B sAg:
Post Op:
Recovery uneventful.
IV Cefuroxime 750mg 8 hourly
IV Metronidazole 500mg 8 hourly
Post op Hb
Management and follow-up:

O. Cefuroxime 500mg bd x 5 days
O. Metronidazole 400mg 8 hourly x 5 days
Review in Gyn clinic with histology report in 4 weeks ( on 00/00/2016)
ANTERIOR REPAIR
Done Under SA
INDICATION: Cystocele
Procedure:
Patient in lithotomy position.
Bladder emptied.
Vertical incision made.
Bladder separated from vaginal wall.
Buttress suture applied.
Anterior repair done.
Complete haemostasis achieved.
LAPAROSCOPIC + DYE TEST+ OVARIAN DRILLING under GA
INDICATION: Primary Sub fertility
Findings –
Uterus Normal Size and Anteverted,
B/L Ovaries polycystic. B/L Ovarian Drilling Done
POD Normal.
No evidence of PID or Endometriosis
Bilateral Fallopian tubes appeared normal
Sub mucus Fibroid (2*2cm) in posterior aspect.
Dye test - both tubes patent.
Discharge plan
- Wait for menstruation
- Ovulation induction with clomephine citrate 100mg daily from D2-D6
-Metformin 500mg nocte
-D12 TVS for follicular tracking (at ward at 8:30 am)
EXPLORATORY LAPAROSCOPY + Rt-SALPHINGECTOMY DONE under GA
Findings –
Haemoperitoneum noted (approximately 50ml of blood)
Right sided TUBAL ECTOPIC
Left tube appears normal
BL ovaries looks normal
Uterus Normal looking
No adhesions, cysts or masses
Rt- Salphingectomy done – Sample sent for histology

MANCHESTER REPAIR Done Under SA
Procedure:
Patient in Lithotomy position.
Bladder emptied.
Tear drop shaped incision made.
Bladder was separated from the vaginal wall.
Partial amputation of the cervix done.
Utero-sacral ligaments were cut and anchored tightly to the anterior aspect of the cervical stump
Amputated part of the cervix sent for histology.
Anterior repair done.
Haemostasis achieved.
Vaginal wall sutured with vicryl .

Guide for gynaecology & obstetric internship

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