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Treat as though this were cancer
●
Type of incision – midline
●
Warns re: catheter, drains, bowel prep, possible NG tube, thromboprophylaxis, lower midline incision, the staging is done at laparotomy, length of stay 0
1
2
3
4
5
6
Discusses chemotherapy
●
General overview of adjuvant chemotherapy
●
Outlines number of courses and timing – 6 courses, 3 weeks apart at cancer centre
0
1
2
3
Global score
0
1
2
3
4
Totaclass="underline"
/20
151
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Circuit C, Station 4
Uterine perforation
Candidate’s instructions
The patient you are about to see is postoperative on the gynaecology ward. Kirsty Hadfield was admitted as an emergency last night with a history of 6 weeks’ bleeding following a normal delivery. Her Hb was 9.8 g%. An ultrasound scan was performed which suggested the presence of an echogenic area in the uterine cavity. It was decided that she needed an evacuation of the uterus.
She was taken to theatre and an evacuation was performed. Unfortunately, during this procedure the uterus was perforated and bowel was pulled through the cervix. This was when you were called to theatre. You undertook a laparoscopy, which showed a perforation and bleeding, so you proceeded to a laparotomy. You oversewed the perforation, which was adjacent to a few small fibroids, and you wondered whether there could have been some degeneration of one of them to make the uterus so soft and consequently more susceptible to perforation. The rest of the pelvis looks normal. The sigmoid looked all right and only required oversewing of the serosal surface.
You have come to explain the findings to the patient and their implications for the future.
YOU WILL BE AWARDED MARKS FOR:
●
Explaining the operative findings
●
Future implications and management
●
Dealing with her concerns
You have 14 minutes.
153
CIRCUIT C
Role-player’s instructions
You are Kirsty Hadfield, a 28-year-old woman who works as a legal secretary. You delivered 6 weeks ago and have continued to bleed vaginally ever since. You have been fobbed off a few times by your GP with courses of antibiotics but have finally been admitted.
You signed a consent form for evacuation of the uterus (D&C) but now have pain in your abdomen and have pressure dressing over a wound. There is a drain and urinary catheter in place. You are concerned that they have taken away the uterus.
Questions you may ask
●
‘What did you do, did you do a hysterectomy?’
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‘Why did this happen?’
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‘What happens if I try for another baby?’
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‘Did the fibroids have anything to do with it?’
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‘Why didn’t you remove the fibroids?’
●
‘Is this because people have fobbed me off with antibiotics?’
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‘I want to see the consultant’ – become increasingly bolshie about having been operated on by a junior member of the staff and this happening.
●
‘Why didn’t you wake me up and discuss it?’
154
UTERINE PERFORATION
Mark sheet
Explains the operative findings and procedures performed
●
Explains laparoscopy bleeding
●
Explains concerns at evacuation of uterus
●
Discusses the possibility of uterine perforation being due to infection or degeneration of the fibroids
●
Allows questions along the way
●
Tries to be open and non-defensive
●
Deals with bowel injury
0
1
2
3
4
5
6
Discusses future fertility
●
Rest of pelvis normal
●
Would need to consider mode of delivery at 37 weeks
●
More than likely normal delivery
●
Discusses future types of contraception
0
1
2
3
4
5
Other concerns
●
Discusses the management of the fibroids – risks of removing them at that time may have caused unnecessary bleeding
●
May disappear – could scan in 2–3 months’ time
●
Favours conservative approach unless they become symptomatic
●
Will need antibiotics
●
Uterus was well emptied at end of procedure
0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
155
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Circuit C, Station 5
Postpartum haemorrhage – collapse
Candidate’s instructions
Delivery unit emergency calclass="underline" ‘Doctor, please come to Room 6 immediately, Mrs Abbott, gravida 3, para 2, under the care of an independent midwife delivered 2
hours ago and has suddenly collapsed.’
You are the registrar called to see this patient. You need to discuss with the examiner how you would proceed.
YOU WILL BE MARKED ON YOUR ABILITY TO DESCRIBE HOW YOU
WOULD DEAL WITH THIS EMERGENCY
You have 14 minutes.
157
CIRCUIT C
Examiner’s instructions
Familiarize yourself with the candidate’s instructions. Say to 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
●
Recent (2 weeks ago) Hb 11.8 g, blood group O (Rh-+ve)
●
Normal vaginal delivery, baby weighed 3.5 kg, physiological third stage and placenta appeared complete
●
Observations stable throughout the labour and no analgesia was required
●
Patient suddenly felt faint, and passed out
●
Patient looks pale, pulse rate 110 bpm, BP 90/60
●
Small pv blood loss
What candidate should do
●
Introduce self to midwife/patient and partner if appropriate
●
Examine abdomen to check fundus and rub up contraction if necessary
●
Briefly ask about the history of the pregnancy and labour
●
Ask about placenta completeness
●
Ensure i.v. line(s) inserted and take bloods for FBC, X-match clotting baseline
●
May run in haemacel
●
May want to check pulse and BP him/herself
●
Vaginal examination expels clot, insert catheter
●
Ensure input and output well documented
●
Discuss the use of syntocinon and ergometrine, including infusion
●
Involve the anaesthetist, may need CVP
●
Inform senior staff and take to theatre for EUA
●
Discuss the 4 Ts: tone, trauma, tissue, thrombin (clotting)
●
Use of Hemabate and its contraindications
●
B-Lynch suture tying off blood vessels
●
Hysterectomy – if not, risks for future pregnancy
●
Postoperative ITU
●
Mention Sheehan’s syndrome
●
Debriefing the patient important
●
Overall competency
158
POSTPARTUM HAEMORRHAGE – COLLAPSE