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Circuit B, Station 10
Breech delivery
Candidate’s instructions
Delivery unit emergency call
Doctor, please come to Room 6 immediately, Mrs Pearson gravida 4, para 3 under the care of an independent midwife is in advanced labour with an undiagnosed breech presentation.
You are asked to discuss with the examiner how you would proceed and will then be asked a number of questions pertinent to the case. A doll and mannequin are available for you to take the examiner through a breech delivery.
YOU WILL BE AWARDED MARKS FOR:
●
Dealing appropriately with the situation
●
Conduct of the breech delivery
●
Subsequent examiner’s questions
You have 14 minutes.
137
CIRCUIT B
Examiner’s instructions
Ask the candidate: ‘Take me through what you would do?’
Prompt
‘Would you like any other information?’
Information available
●
Normal pregnancy
●
Normal obstetric history
– SVD: 3.4 kg
– SVD: 3.6 kg
– SVD: 3.6 kg
●
Term
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SRM 2 hours previously, no meconium
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Observations normal, FHR 150 bpm, intermittent auscultation
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VE – fully dilated
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Breech RSL distending introitus with contractions
●
Doll and pelvis present for the candidate to take examiner through breech delivery.
Once the candidate has finished the delivery, the following questions should be asked:
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‘What is the role of ECV in this case and generally?’
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‘What are the contraindications to ECV?’
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‘How would you have managed this patient had you seen her the week prior to delivery?’
138
BREECH DELIVERY
Mark sheet
Asks appropriate history:
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Weight of previous babies.
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Current gestation and any problems
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When did the membranes rupture
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The colour of liquor
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Has monitoring been normal so far
0
1
2
3
4
Examines abdomen to assess:
●
Size of baby
●
Descent of presenting part
●
Asks for vaginal findings and suggests that he/she confirm them 0
1
2
3
Conduct of Breech Delivery:
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Places thumbs and fingers appropriately on fetal spine and iliac crest
●
Avoids touching the baby’s abdomen
●
Does not use traction, but guides baby
●
Keeps sacrum and back anterior (uppermost), made need to hold baby to avoid rotation
●
Allows time for body to hang
●
Delivers head appropriately, either forceps to after coming head, or Mauriceau-Smellie-Veit manoeuvre. Avoids pulling on the jaw and understands the importance of keeping head flexed with malar pressure 0
1
2
3
4
5
6
Answers questions appropriately:
0
1
2
3
Global score
0
1
2
3
4
Total score
/20
139
Circuit C
Circuit C, Station 1
Vicar’s daughter – ethics
Candidate’s instructions
You are doing a regular session in the family planning clinic while taking some time off full-time employment to study for the MRCOG. Last month Jocelyn Broody, the local vicar’s only child, came to see you for some contraception advice. She wanted you to prescribe the pill for her, as her relationship with her boyfriend has become sexually intimate. Although you encourage her to use a barrier method, and by the end of the consultation you are happy to prescribe the pill for her, Jocelyn is 15
years old. She does not want her parents to know.
The next person on your list today is one of Jocelyn’s parents, who is the person in front of you. You suspect rightly that the reason for the appointment is that Jocelyn’s parent has found out and wishes to question the morality of your action and its legality.
MARKS WILL BE AWARDED FOR:
●
Dealing with a difficult situation
●
Explaining the ethical issues
You have 14 minutes.
141
CIRCUIT C
Role-player’s instructions
You have discovered that Jocelyn, just 15 years old, and your only child, is on the pill, which you found whilst tidying her bedroom in her absence. You know that she goes out with a group of her friends, but you were not aware that she was intimately involved with anyone in particular.
You are the local vicar’s wife and do not approve of extramarital relationships.
You think that whoever prescribed the pill was acting unlawfully in that:
●
you as her parent should have been consulted
●
given that it is a criminal offence to have sex with someone under 16 years, the doctor is an accessory to a crime.
You suspect rightly that this family planning doctor prescribed the pill for Jocelyn and you decide to confront the doctor with your findings and complain mainly about two issues:
●
why you weren’t consulted
●
the legality of what the doctor has done, as Jocelyn is only 15.
When the doctor talks about Jocelyn’s competency, you ask how she can be assessed as competent when she is only 15 years old. You close the scenario by saying that you have heard the advice/explanations given; that you want to share them with your husband and perhaps arrange to come again as a couple.
142
VICAR’S DAUGHTER – ETHICS
Examiner’s instructions
The purpose of this station is for the candidate to diffuse a potentially irate parent.
The doctor has acted within the law and has acted in the patient’s (the daughter’s) interest. There is a confidentiality issue in not disclosing information to the mother despite the daughter being under the age of consent.
Ethical issues covered
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Acting in the best interest of the child
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Not prepared to divulge contents of Jocelyn’s consultation
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Mother may want to consider TOP option if no contraception
●
Non-judgmental in attitudes and behaviour
●
Duty of care is to the patient and not to the relative
●
Need to be aware of Data Protection Act, which does not allow disclosure of patient information
0
1
2
3
4
5
Following ‘illegality prompt’
●
Not illegal to prescribe contraceptive to under-16s
●
Mention the House of Lords decision in Gillick case/Fraser guidelines 0
1
2
3
Assessment of Gillick competency/Fraser guidelines
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Should discuss this generally and avoid mentioning the daughter.
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Assesses the ability of a 15 year old girl to understand what is going on, the consequences and risks
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A girl in this situation is encouraged to inform her parents, and the reasons for not doing so are usually explored
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A girl is informed that her confidentiality would be respected
●
A doctor can consider that a girl, if competent, can consent to examination and treatment under 16 years of age
0
1