Management options
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Recommend weight loss and stopping smoking
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Refer for physiotherapy and pelvic floor exercises
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May benefit from HRT
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Treat UTI if still present
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May need to manage non-insulin-dependent diabetes if indicated by blood glucose levels
●
Reduce fluid intake, especially caffeine intake. Advice on timing of intake to reduce nocturia. May be useful to keep a fluid diary for a few days to get the message home
●
See in 3 months for review
0
1
2
3
4
5
6
Global score
0
1
2
3
4
Total
/20
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Circuit B, Station 4
Urinary incontinence viva
Candidate’s instructions
You are about to discuss the further management of the patient who you saw in the previous station. The examiner will ask you a number of questions relating to this further management
The plan of management should have been as follows:
●
Recommend weight loss and stop smoking
●
Refer for physiotherapy and pelvic floor exercises
●
May benefit from HRT
●
Treat UTI
●
Reduce fluid intake
●
See in 3 months for review.
She now attends 3 months later and there is no appreciable change in her symptoms. She feels that the lump in her vagina has been getting worse.
The results of her investigations are as follows:
●
MSU – negative
●
Blood sugar normal
●
Urodynamics showed a normal cystometric capacity, minimal residual volume, good flow rate. Stable bladder with genuine stress incontinence demonstrated.
The examiner will also ask you four specific questions relating to her further management during the next 14 minutes.
YOU WILL BE MARKED ON YOUR ABILITY TO ANSWER THE
QUESTIONS REGARDING SURGICAL MANAGEMENT
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CIRCUIT B
Examiner’s instructions
At this station, the candidate will have 14 minutes to discuss the further management of the patient seen earlier (in Station 3). Familiarize yourself with the candidate’s instructions. You should ask the candidates the following questions: What surgical operations are open to this patient and what are their basic differences?
●
Anterior repair ± hysterectomy
●
Transvaginal tape (TVT)
●
Colposuspension
●
Needle suspension Stamey/Raz
●
Sling procedures – not appropriate as first line
●
?Sacrocolpopexy
●
Injectable agents
Discusses the differences between the suprapubic approach, vaginal approach and procedures for failure of initial procedures.
0
1
2
3
4
What are the objective success rates of these surgical procedures?
●
Success would be continence or a substantial improvement
●
Anterior repair: 1 year < 70 per cent; 5 years < 40 per cent
●
TVT: 1 year 80+ per cent, long-term studies ongoing
●
Colposuspension: 1 year 90 per cent; 20 year up to 70 per cent
●
Stamey: 1 year 80–90 per cent; 5 years 60–70 per cent
●
Sling operation not appropriate as first operation in this case 0
1
2
3
4
What are the possible intraoperative and postoperative complications and how these problems would be managed?
●
Bleeding, pressure, diathermy or in a colposuspension continuing to tie the support sutures
●
Bladder damage, use of dye in the bladder
●
Infection – preoperative antibiotics
●
Retention of urine postoperatively, suprapubic catheter
●
Detrusor instability (10 per cent)
●
Enterocele 10–20 per cent
●
Sexual problems secondary to vaginal shortening and narrowing 0
1
2
3
4
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URINARY INCONTINENCE VIVA
Describe how you would perform a Burch colposuspension would be undertaken
●
Routine preoperative work-up
●
GA, TED stockings
●
Lloyd Davis position, prepping the skin and towel, urethral catheter,
?methylene blue in bladder
●
Suprapubic incision, specify the layers
●
Identify cave of Retzius/retropubic space
●
Identifying where sutures to be placed, and type (ethibond) and number, from paraurethral tissue to pectineal line
●
Closure and insertion of suprapubic catheter and drain
●
Writing notes
0
1
2
3
4
Global score
0
1
2
3
4
Total
/20
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Circuit B, Station 5
Operative – Caesarean section
Candidate’s instructions
You are the registrar coming on duty at the time of routine handover. Mrs Jones is in Room 6. She is a primip who has been in labour for 12 hours and over the past 6 hours has remained at 9 cm dilatation despite the use of syntocinon over the past 2 hours. There is one-fifth of the head palpable abdominally on bimanual examination with caput and moulding of the head. The CTG has remained normal throughout, despite a trace of meconium on the pad. A decision has already been made for the patient to have a Caesarean section and you will have to do it.
You are asked to describe in detaiclass="underline"
●
the steps required in relation to the decision for LSCS, discussion, consent preparation
●
the procedure itself
●
the patient’s postoperative care and the plan for future pregnancies.
The examiner will ask you a number of questions over the next 14 minutes.
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CIRCUIT B
Examiner’s instructions
Familiarize yourself with the candidate’s instructions. You should ask the candidate to describe in detail the steps required in relation to the decision for LSCS, discussion, consent preparation and the procedure itself, the patient’s postoperative care and the plan for future pregnancies.
You will need to cover aspects of the procedure that relate to Caesarean section in general and also the factors that relate to the specific case.
Do not prompt the candidate.
118
OPERATIVE – CAESAREAN SECTION
Mark sheet
Take me through what you would do.
Decision to undertake CS (good/bad)
0
1
2
Discussion with patient (most likely due to malpresentation, risks of attempt at vaginal delivery – maternal/fetal)
0
1
2
Anaesthesia: type and preparation (GA vs. spinal, antacids etc.) 0
1
2
Degree of urgency/supervision (within 30 minutes, experienced SpR) 0
1
Procedure – opening/findings (routine/oedematous lower segment with free fluid) 0
1
2
Procedure – delivery (deep head/rotation/forceps/pressure from below, risk of incision extension/CPD vs. malpresentation)
0
1
2
Procedure – closure (inspect for haemostasis)
0
1
Procedures and specific risks to the case (difficult head delivery, extension of incision, poor contractility of uterus and PPH) 0
1
2
Postoperative care/future pregnancy (thromboprophylaxis, ELP no use, decision re.
mode of subsequent delivery)
0
1
2
Global score
0
1
2
3
4
Total
/20
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Circuit B, Station 6
Abnormal smear
Candidate’s instructions
The general practitioner has referred the patient you are about to see to your colposcopy clinic. A copy of the referral letter is given below. Read the letter and obtain a relevant history from the patient. You should discuss any relevant investigations and treatment that you feel may be indicated.
The Surgery
High Rd
Buckhurst Hill
Dear Doctor
Re: Mrs Joan Starr (23.10.74)
I would be pleased if you could see this patient whose recent cervical smear result showed severe dyskaryosis with wart viral infection.
She is nulliparous and the rest of her medical history is unremarkable.
Yours sincerely
Dr S. White
MARKS WILL BE AWARDED FOR:
●
Relevant history-taking
●
Explaining result
●
Discussion of relevant treatment options
You have 14 minutes.
121
CIRCUIT B
Role-player’s instructions
You are Joan Sturr, a 30-year-old woman who works as a secretary. You have been completely freaked out by your abnormal smear result and have two things on your mind:
●
You think this result means that you have got cancer.
●
Your partner (husband) has been unfaithful and has given you the wart virus, and this is entirely his fault.
You are completely asymptomatic; you have never been pregnant and have never had any sexually transmitted diseases. You have only ever had three sexual partners and do not really like talking about sexual matters. You are, however, taking the pill but no other medication and have no other medical history of note. You smoke 20
cigarettes per day but this has recently increased since discovering the smear result.
You are anxious to know more about the procedure of colposcopy: will it hurt and how long will it take for the results? You want to know the treatment options and might consider alternative therapies because you are afraid of hospitals. Your mother died from breast cancer at the age of 54 years. You are also anxious about your fertility as you were planning to stop the pill to try for a pregnancy and only had the smear taken to check all was well before doing so. This is your first smear.
122
ABNORMAL SMEAR
Examiner’s instructions
At this station, the candidate will have 14 minutes to obtain a history relevant to the patient’s complaint. The candidate should also discuss with the patient what colposcopy entails and that a biopsy may be necessary.
The candidate needs to explain to the patient that cytology is looking for a premalignant lesion, and to sensibly explain what the term ‘wart virus infection’
means.
123
CIRCUIT B
Mark sheet
History
●
Symptoms IMB/PCB
●
Basic gynaecological history/contraception
●
Obstetric history
●
Genital tract infections
●
Family and social history, including smoking
●
Allergies, especially to iodine and peanut oil if sultrin cream to be used 0
1
2
3
4
5
6
Colposcopy counselling
●
Explains what happens – looking at the transformation zone and why
●
Biopsy needed
●
Usually gives a good idea of what is going on by the end of the procedure
●
Explains that the screening programme is looking for premalignant disease
●
This smear result is suggestive of precancer
●
More than likely needs treatment
●
Avoids blaming any particular partner
0
1
2
3
4
5
Treatment
●
Advises stopping smoking and why
●
Explains about LLTZ and that it could be done as an outpatient or GA
●
Could see and treat at this procedure but would depend on colposcopic findings
●
Need for follow-up after treatment
●
At some point explains that this should not affect her fertility 0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
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Circuit B, Station 7
CTG abnormality
You are called to see Mrs Dunne in Room 4. She is a 22-year-old primip who is now term + 7 days in an otherwise uneventful first pregnancy. She was booked for induction of labour in 4 days’ time. She has presented with some irregular contractions, decreased fetal movements and a show. The midwife is worried about the CTG which she shows you.
You are asked to counsel the patient and her partner about the management of the labour. Her vital signs are normal. The cervix is 2 cm dilated but fully effaced and the head is 2 cm above the spines.
MARKS WILL BE AWARDED FOR:
●
Discussing the CTG
●
Discussing further management of this labour
You have 14 minutes at this station.
125
CIRCUIT B
Role-player’s brief
You are 22 years old and you live with your partner who works for Greenpeace. You had initially wanted a home birth with as little intervention as possible. You have been well throughout the pregnancy and noticed some tightenings during the night with a show and slight decrease in the baby’s movements. You are convinced it is a girl and keep calling her Flora.
Your partner is devoted to you and you are constantly looking to him for support. You are reluctant to be monitored and do so grudgingly for Flora’s sake, but feel that the whole of the medical profession is male-dominated and wants to do Caesarean sections on everyone.
You are concerned about the welfare of your baby and want the registrar to be very explicit about why he is worried about the trace. If he does not pick up on the severity of the trace, you need to get him to explain why it doesn’t look like the one in your pregnancy book.
126