●
You and your partner are not keen on a further pregnancy.
●
You have noticed over that past 3–6 months that you have had some intermenstrual bleeding but no postcoital bleeding. Your periods are otherwise regular every 28 days, bleeding for 4–5 days. You are otherwise well and asymptomatic. No previous history of note except for some degree of irrita-ble bowel syndrome.
●
You also want to explore with the doctor some other form of contraception.
You are unsure of your last smear test – both the result and when it was performed.
96
INTERMENSTRUAL BLEEDING
Mark sheet
History-taking
●
Length IMB occurs in cycle
●
Any postcoital bleeding
●
Ellicits history of epilepsy
●
Carbamazepine
●
Wants to consider other contraception
●
Pregnancy history and not wanting further children 0
1
2
3
4
5
6
Investigations
●
Do another pelvic examination to do a cervical smear
●
Arrange a USS
0
1
2
3
Management
●
Discusses fact that OCP may not be high enough dose with carbamazepine which interferes with absorption
0
1
2
●
Discuss either:
– increasing the dose of OCP
– IUCD
– mirena
– depoprovera
– sterilization
0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
97
This page intentionally left blank
Circuit B
Circuit B, Station 1
Labour ward prioritization
Candidate’s instructions
You are the registrar on call for the delivery unit. You have arrived for the handover at 08.30 h. Attached you will find a brief résumé of the 10 women on the delivery suite as shown on the board.
The staff who are available today are as follows:
●
a second-year O&G SHO
●
a second-year anaesthetic registrar
●
the on-call consultant, who has been asked to deal with a problem in main theatres
●
six midwives:
– SW is in charge
– SW, CK and MC can suture episiotomies
– DB, SW and PL can insert i.v. lines.
Read the board carefully. You will have 15 minutes preparation for this station and will discuss it with the examiner at the next station.
MARKS WILL BE AWARDED FOR:
●
Detailing tasks to be done
●
Prioritizing the cases
●
Allocating staff to each task
100
RM
NAME
PARA
GEST
LIQUOR
EPID
SYNT
COMMENTS
MW
1
SMITH
0+1
32
C
N
N
SROM 4 days ago. Dexamethasone given
SW
Contracting 1 in 3 since 0300hrs
2
JONES
2
41
–
–
–
Delivered 0600 hrs. N.V.D.
SW
Bleeding
3
HOWARD
1+0
39
C
N
N
Breech in spontaneous labour
VM
6 cm at 0600 hrs
4
GREEN
0+1
40
C
Y
Y
Fully dilated at 0600 hrs
CK
CTG non re-assuring
5
SPENCER
2+0
38
–
–
–
Delivered, awaiting suturing
CK
6
BAKER
2
34
I
–
–
Abdo pain & vomiting. CTG normal
DB
Doctor to see
7
NGOSA
3
37
I
N
N
Due for elective CS at 39/52
DB
Admitted contracting & scar tenderness
8
COLGATE
0+0
36
I
N
N
Twins contracting regularly
MC
4 cm dilated Ceph/Breech
9
McMILLAN
1
39
MEC
Y
N
ARM 0300 hrs – CTG suspicious
PL
pH at 07–30 was pH 7.23 – 6cm
10
DAVIS
2
41
C
N
N
Spontaneous labour 6cm at 0500 hrs
Comm
Domino
MW
CIRCUIT B
Examiner’s instructions
Candidates have 15 minutes to explain to you the following:
●
the tasks that need doing on the delivery suite
●
the order in which they would do them
●
the staff they will allocate to each.
These instructions may not be exclusive.
Tasks required
●
Room 1 – TPR, needs assessment; paediatricians need to be informed, can SCBU cope with the baby
●
Room 2 – needs assessment, TPR, i.v. line, bloods, fluids, catheter. Assess amount of blood loss, placenta complete? May need EUA, clot expulsion, the four Ts: tissue, tone, trauma and thrombin
●
Room 3 – needs reassessment, for vaginal delivery, CTG status, may need epidural
●
Room 4 – needs assessment, ?delivery or FBS. Has she been pushing, or unde-livered because epidural v. effective?
●
Room 5 – midwife to suture
●
Room 6 – assess, needs more history, MSU/dipstick, examination, previous obs history, possible non-obstetric cause for pain, e.g. appendix
●
Room 7 – needs assessment, bloods and consent, will need CS. Is the CTG
normal?
●
Room 8 – needs epidural, monitoring both twins, bloods, routine observations
●
Room 9 – needs assessment, repeat FBS
●
Room 10 – no action.
Priority of tasks
There may not be total agreement with these suggestions. As long as there is consistency and safety, one can score according to how confident one is of the candidate’s priority setting:
●
Urgent review: rooms 2, 3 and 4
●
Semi-urgent review: rooms 7 and 9
●
Routine review: rooms 1, 5, 6, 8 and 10.
102
LABOUR WARD PRIORITIZATION
Personnel
Room 1 – SHO
Room 2 – reg
Room 3 – reg
Room 4 – reg
Room 5 – midwife
Room 6 – SHO
Room 7 – SHO/reg
Room 8 – SHO
Room 9 – SHO/reg
Room 10 – midwife
103
CIRCUIT B
Mark sheet
Room 1
0
1
2
3
4
Room 2
0
1
2
3
4
Room 3
0
1
2
3
4
Room 4
0
1
2
3
4
Room 5
0
1
2
3
4
Room 6
0
1
2
3
4
Room 7
0
1
2
3
4
Room 8
0
1
2
3
4
Room 9
0
1
2
3
4
Room 10
0
1
2
3
4
Mark
/40 → divide by 2
Final mark
/20
104
Circuit B, Station 2
Abdominal pain – premature labour
Candidate’s instructions
The patient you are about to see has just been admitted to your maternity unit. The midwife is concerned about her and no other doctor is available to see her at present.