Review station 4
Surgical skills – placenta praevia
Candidate’s instructions
You have admitted a 32-year-old primigravida for an elective Caesarean section.
She has major placenta praevia and the presentation is breech. She is currently 38
weeks’ pregnant.
The examiner will ask you a series of five questions regarding aspects of this woman’s care following her admission, i.e. counselling, preparation, techniques, postoperative care and follow-up. You will need to highlight issues related to Caesarean section in general as well as those related to this specific case.
THIS IS A STRUCTURED VIVA. YOU WILL BE TESTED ON YOUR ABILITY
TO APPRECIATE PREOPERATIVE, INTRAOPERATIVE AND POSTOPERATIVE MANAGEMENT OF A MAJOR OBSTETRIC PROCEDURE
21
REVIEW STATIONS
Mark sheet
The candidate has been given the task of arranging an elective Caesarean section for major placenta praevia. Please ask the following questions:
‘Preoperatively what will you discuss with the patient?’
●
Site of placenta (anterior, posterior)
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Risks, benefits, consent
●
Warn about need for i.v. line, catheter, possible drain, possible blood transfusion
●
Type of anaesthesia
0
1
2
3
‘What other personnel will you liaise with?’
●
Anaesthetist, paediatrician, haematologist
●
ODA/midwife
●
Partner (warn of seriousness of operation)
0
1
2
3
‘Preoperatively what will your orders be?’
●
Nil by mouth for > 6 hours
●
Intravenous fluids, antibiotics, ranitidine, shaving, catheter, TED/Flowtron stockings
●
Blood available in theatre
0
1
2
3
‘Take me through your operative procedure and outline any concerns’
●
Consultant involvement
●
Incision – abdominal, uterine (classical vs. lower uterine), oxytocin, morbid adhesion of placenta, closure
●
Quick entry through placenta and clamp cord immediately
●
Be prepared for excessive blood loss
0
1
2
3
4
22
SURGICAL SKILLS – PLACENTA PRAEVIA
‘Postoperatively what would you do?’
●
Ensure adequate i.v. fluids
●
Check haemoglobin
●
Hourly urine output initially
●
TED stockings
●
Thromboprophylaxis
●
Early mobilization
●
Discuss future pregnancies
●
Contraception
0
1
2
3
Global score
0
1
2
3
4
Totaclass="underline"
/20
23
REVIEW STATIONS
Discussion
What is the station testing?
This woman is about to have a potentially life-threatening operation. The examiner wants to know what you would normally do before a Caesarean section as well as the extra precautions that you would take in this case. You must be thorough and go through your normal checklist, appreciating that with this type of case a lot of extra preparation is required so that the operation can be as safe as possible.
What are the pitfalls?
You must be aware of the seriousness of the case. No matter how experienced one is, this type of case can bleed excessively and be very frightening for all concerned.
It is easy to miss out obvious precautions and concentrate on the more dramatic features, thus failing to carry out routine preparation.
Preparation
Design difficult scenarios and ask your colleague to play the examiner. When a difficult surgical case occurs in your clinical practice, go back to the beginning and see if you could have been better prepared so that the case was easier.
24
Review station 5
Communication skills – ectopic
pregnancy
Candidate’s instructions
The patient, Flora Burton, you are about to see has returned to the emergency gynaecology unit for follow-up after an operation for an ectopic pregnancy 14 days ago. She had a salpingostomy and the ultrasound today has shown a live ectopic on the left side.
Please explain the results of the ultrasound scan to her, suggest management and answer her questions.
MARKS WILL BE AWARDED FOR TAKING A RELEVANT HISTORY, DISCUSSING A MANAGEMENT PLAN AND ADDRESSING HER
CONCERNS
25
REVIEW STATIONS
Role-player’s instructions
You are Flora Burton, a 35-year-old woman who had your last menstrual period 9
weeks ago. This pregnancy has not been straightforward: from 6 weeks onwards you had some vaginal bleeding and at 7 weeks you presented to the early pregnancy unit and were told that you had an ectopic pregnancy. You had a laparoscopy and the tube was opened up and the ectopic was removed. You were told to return the following week to check that the pregnancy levels had gone down but you didn’t do this and you have continued to have some bleeding. Now you have some pain on the left side. When you presented today to the early pregnancy unit, they performed another scan and did another blood test. You do not know the results of the scan or the blood test but you are just about to see a doctor who will explain the ultrasound scan to you and suggest further management.
You will be told that the ectopic still remains in the left tube when you thought the operation had removed it. You are clearly very cross about this as your previous obstetric history has not been straightforward. You want to know why the pregnancy was not removed 2 weeks ago and you are now terrified that the hospital is going to make another mistake (with your first pregnancy, from which you now have a 3-year-old child, you were originally told it was ectopic, you had a laparoscopy and it turned out to be an intrauterine pregnancy). You are therefore adamant that you do not want them to put anything into the womb when they do a further operation until they are absolutely sure that it is a persistent ectopic pregnancy.
You are obviously extremely upset about what has occurred and you are very cross that the pregnancy wasn’t removed in the first place. You would like to see the person who operated on you first immediately so that you can express your dis-pleasure.
As you are now looking at a further laparoscopy, you want conservative treatment for that tube as you do not want to rule out all possibility of a future pregnancy – your second pregnancy was a right ectopic pregnancy which was removed by laparotomy 18 months ago.
You and your husband very much wanted this pregnancy and you are not quite sure how you are going to tell him all this bad news. You suspect that he is also going to be cross as he cares so much about you.
You are otherwise fit and well and you take no medications and don’t smoke or drink alcohol. You have no family history of any significant diseases and you are not allergic to anything.
26
COMMUNICATION SKILLS – ECTOPIC PREGNANCY
Mark sheet
History
●
Previous ectopic pregnancy – laparotomy
●
Previous normal pregnancy originally thought to be ectopic
●
Current pregnancy thought to be ectopic and had laparoscopic salpingostomy 2 weeks ago
0
1
2
3
4
5
Management plan
●
Explains ultrasound findings and its implications
●
Needs a laparoscopy – encourages salpingectomy, however, accepts her wish for conservative surgery