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OBGYN OSCE STATIONS COMPILATION
BY MUSANKABALA MJ
1. Manual Vacuum Aspiration (MVA)
Miss KM is 22 y/o referral from Mutendere whose LMP was eight weeks ago. She was seen by a CO at Mutendere Clinic who made a diagnosis of incomplete abortion. You repeat the VE and find that the uterus is anterverted, and is eight weeks in size and the os open. Please perform an MVA.
Aspects being assessed
- Greets the client, introduces self.
- Confirms CC and Explains procedure to patient (Gets informed concert).
- Check MVA syringe and charges it (establishes vacuum)
- Puts on apron
- Washes hand/hand scrub and puts on gloves
- Positions pt in Lithotomy position and cleans perineum
- (Puts on new gloves) and Inserts Cusco’s speculum Checks the vagina and cervix for retained POC (Remove with sponge holding forceps)
- Applies antiseptic solution to the cervix
- Paracervical block done and puts tenaculum on cervix @ 12’oclock position
- Identifies appropriate cannula
- Inserts cannula gently into uterine cavity
- Attaches prepared syringe to the cannula
- Evacuates uterus by rotating and moving cannula back and forth within uterine cavity. Empties Syringe by removing aspirate. Do not remove cannula.
- Once uterus empty ( ) Withdraws cannula and removes forceps
- Inspects cervix for bleeding
- Repeats bimanual examination to check size and firmness of uterus
- Continues talking to patient during procedure
- Gives Oxytocin 10IU IM
- Covers the client and reassures the patient
- Washes hands
- Post-abortal care (PAC), Abx, Analgesia.
- Assesses after 2 hours, If vitals stable, allow home.
- Review PRN at local clinic.
2. PAP SMEAR
Scenario: Mrs. Judy Mwale, an accountant by profession would like to be screened for cervical cancer. She is 45 years old ,and has recently heard about the need for women to be screened for cancer of the cervix
Task: 5 MINUTES
Perform a cervical smear. You should inform the woman and the examiner what you are doing as you go along After 5 minutes you will be asked some questions by the Examiner
ASPECTS BEING ASSESSED POSSIBLE SCORE
STUDENT
SCORE
1 Student introduces themselves using full name and explains what they plan to do
2 Student performs an appropriate speculum examination: 3 Ensures that the patient is comfortable 0. 4 Discusses what the procedure will entail 2 5 Select a Cusco’s speculum and inserts appropriately 2 6 Demonstrates a clear view of the cervix 2 7 Taking a smear with Ayre’s spatula 1 8 Indicates what they would do with the specimen i.e putting on slide, slide placed in alcohol based fixative.
9 Carefully removes speculum 1 10 Disposes of gloves and speculum in appropriate instruments and waste disposal buckets
11 Examiner : Give candidate smear report. Can you explain the smear report? Smear shows abnormal result The woman does not have cancer The smear indicates a cytological diagnosis only and needs further tests to establish histological diagnosis
12 Examiner, Ask - What is the most appropriate investigation Colposcopy or direct vision inspection of the cervix (VIA)
13 Examiner , please explain to the woman what a colposcopy/VIA involves Examination of the transformation zone of the cervix Application of stains (acetic acid and iodine) Biopsy and treatment where needed
14 How often should a sexually active woman, with previous normal Pap smear undergo a routine screening? Every 3 years
End of Exam Total
4. EXAMINATION OF THE PLACENTA
26 y/o just gave birth to a health 3.2 kg baby and this placenta. Examine the placenta and do a running commentary during the examination.
i. Wash hands; wear an apron and gloves. ii. The delivery trolley is a good surface to use. iii. Lay out the placenta with the foetal surface uppermost – noting shape, size, colour and smell. iv. The cord is then examined noting the length (normal @ term=40-60cm), the point of insertion, Warton jelly and the presence of any knots. v. Count the vessels in the cut end of the cord (normal=2 arteries + 1 vein). [The absence of one of the arteries can be associated with renal agenesis]. vi. Observe the foetal surface for irregularities. vii. By lifting the cord and holding the placenta up, you can then observe the membranes and inspect for completeness. viii. The placenta is placed on a flat surface and the membranes are spread out in order to look for extra vessels, lobes, or holes in the surface. ix. The amnion is then pulled back towards the cord, thereby separating the membranes to ensure that they are both present. x. The placenta is turned over to inspect the maternal side. xi. The cotyledons are examined to ensure that they are all present, noting any areas of infarction or blood clots. (normal # = 15-20 cotyledons separated by septa). xii. Weigh the placenta (normal @ term = 500-600grams). xiii. Dispose of the placenta as per UTH guidelines. (*Dispose in Sluice room). xiv. Clean away equipment. xv. Remove gloves and dispose-off. Remove apron and Wash hands.
5. OBSTETRIC EXAMINATION (BREECH PRESENTATION)
Scenario: MADAME ZOE, 28-years-old, is in her first pregnancy. Her last normal menstrual period was on 20/04/2013.Her midwife is concerned about the presentation of the baby. Her blood pressure is 120/80 mmHg and the urinalysis is normal. Perform a FULL obstetric palpation and answer questions from the examiner. You are NOT required to examine any other part of the abdominal system. 5 min then Qs.
ASPECTS BEING ASSESSED POSSIBLE SCORE 1 Student introduces themselves using full name and explains what they plan to do
2 Elicits the patient’s gestation 0. 3 Places patient in comfortable semi-recumbent position 0. 4 Exposes abdomen appropriately 0. 5 Inspects and comments appropriately for positive and negative points to include: abdomen distended, no linea nigra, no stretch marks, no scars noted, no fetal movements, everted umbilicus
6 Measures the symphysial fundal height correctly (and blinds tape during procedure)
7 Gives an appropriate measurement (between 35-39 cm) 2 8 Palpates the fetus appropriately. To include, assessment of lie, presenting part and position.
9 Auscultates the fetal heart 2 10 Summarises findings: normal SFH, longitudinal lie, breech presentation, normal fetal heart rate.
11 Has student followed sequences /order of examination 1 12 Examiner : At this point ask - What is the diagnosis? (Suppose it is a breech presentation)
13 Examiner, Ask - What options does this woman have for the delivery of her baby? Elective caesarean section, external cephalic version, vaginal breech delivery
14 Examiner , Ask – Why is a vaginal breech delivery not the most appropriate course of action? Identifies vaginal breech as not favoured due to poorer outcomes for baby(increased perinatal mortality and morbidity)
15 Examiner : Please explain external cephalic version to the patient and how it is performed? Explanation to include : use of tocolysis, no anaesthetic used, performed at term, external pressure to encourage baby to perform a forward or backward roll. Safe for baby but it is monitored. Uses appropriate communication skills, assessing understanding using clear language, giving correct information
(^16) What is the preferred managed plan for a woman with breech if ECV fails? Elective caesarean section
6. CONTRACEPTION: INSERTION OF IUCD
Mrs. J Lungu is a 38 year old who has 4 kids. She is not very sure whether she wants more children and she opts for a long term contraceptive. After counseling She settles for an intra-uterine device and you have been called to insert Mirena.
i. Confirm that the patient understands the method and alternatives and has signed a consent form. ii. Examine the patient to establish the size and position of the uterus to detect cervicitis or other genital contraindications and to exclude pregnancy. iii. Obtain cervical cultures, perform a pregnancy test and give antibiotic prophylaxis if indicated. iv. Use aseptic technique during insertion. v. Administer oral analgesics if needed. vi. Cleanse the cervix and vagina with an antiseptic solution. vii. Administer paracervical block if needed. viii. Grasp the upper lip of the cervix with a tenaculum and apply gentle traction to align the cervical canal with the uterine cavity. ix. Carefully sound the uterus to measure its depth and to check the patency of the cervix. If you encounter cervical stenosis, use dilatation, not force, to overcome resistance. x. The uterus should sound to a depth of 6 to 9 cm. xi. Insertion of MIRENA ® into a uterine cavity less than 6.0 cm by sounding may increase the incidence of expulsion, bleeding, pain, perforation, and possibly, pregnancy. xii. Open the sterile package. xiii. Place sterile gloves on your hands. xiv. Pick up the inserter containing MIRENA ®. xv. Carefully release the threads from behind the slider, so that they hang freely. xvi. Make sure that the slider is in the furthest position away from you (positioned at the top of the handle nearest the IUS). xvii. While looking at the insertion tube, check that the arms of the system are horizontal. If not, align them on a sterile surface or with sterile gloved fingers. xviii. Pull on both threads to draw the MIRENA ® system into the insertion tube xix. Fix the threads tightly in the cleft at end of the handle xx. Set the flange to the depth measured by the sound. xxi. Hold the slider firmly in the furthermost position (at the top of the handle). xxii. Grasp the cervix with the tenaculum and apply gentle traction to align the cervical canal with the uterine cavity. Gently insert the inserter into the cervical canal and advance the insertion tube into the uterus until the flange is situated at a distance of about 1.5–2 cm from the external cervical os to give sufficient space for the arms to open. xxiii. While holding the inserter steady release the arms of MIRENA ® by pulling the slider back until the top of the slider reaches the mark (raised horizontal line on the handle). xxiv. Push the inserter gently into the uterine cavity until the flange touches the cervix. MIRENA ® should now be in the fundal position. xxv. Holding the inserter firmly in position release MIRENA ® by pulling the slider down all the way. The threads will be released automatically.
xxvi. Remove the inserter from the uterus. Cut the threads to leave about 2-3 cm visible outside the cervix.
Note:
If you suspect that the system is not in the correct position, check placement (with ultrasound, for example). Remove the system if it is not positioned completely within the uterus. Do not reinsert a removed system. Remove MIRENA ® by applying gentle traction on the threads with forceps. The arms of the system will fold upward as it is withdrawn from the uterus. The system should not remain in the uterus after 5 years.
8. DELIVERY OF BABY
You have been assisting Ms. Musonad with her labor for 12 hours. It has been an uncomplicated labor and she has progressed well. Now she is fully dilated and the head has descended to the perineum. She is pushing well and the birth is imminent. Demonstrate how you would perform the 2nd^ stage of labour.
- Puts on personal protective barriers (Wears Goggles, Mask, Cap, Shoe cover, Plastic Apron). Places the plastic sheet under the woman’s buttocks.
- Performs hand hygiene and puts on sterile gloves.
- Palpates the supra pubic region to ensure that the woman’s bladder is not full encourages her to pass urine if needed.
- Cleans the woman’s perineum & places clean drape on abdomen.
- Encourages woman for breathing and small pushes with contractions.
- Controls the birth of the head with the fingers of one hand to maintain flexion, allows natural stretching of the perineal tissue, prevents tears, and supports the perineum with other hand using the clean pad.
- Wipes the mucus (and membranes, if necessary) from the baby’s mouth and nose.
- Feels around the baby’s neck for the cord and responds appropriately if the cord is present.
- Allows the baby’s head to turn spontaneously and with the hands on either side of the baby’s head, delivers the anterior shoulder.
- When the axillary crease is seen, guides the head upward as the posterior shoulder is born over the perineum.
- Supports the rest of the baby’s body with one hand as it slides out and places the baby on the mother’s abdomen over the clean towels.
- Notes the time of birth and sex of the baby and tells the mother.
- Clamps and cuts cord. Thoroughly dries the baby and covers with a clean, dry cloth, and assesses APGAR score at 1 min, 5min and 10min.
9. POST ABORTION CARE
Situation : You are in C03 and Ms. Sakala who had heavy bleeding and followed by complete abortion during her 8 weeks of pregnancy is being admitted today. Demonstrate post abortion care.
Provide her emotional support by Explaining the possible cause of early abortion, Listening to her if she wants to talk Reassure her
Advise for home care Drink plenty of fluids and eat nutritious food Rest ofter Avoid heavy work for a week Bathe regularly Use clean pads Avoid sexual intercourse for at least 2 weeks after the bleeding
Counsel the women on family planning choices to avoid unwanted pregnancy / if she wants to delay her next pregnanacy.
11. HISTORY TAKING: ECTOPIC PREGNANCY
YOU HAVE 10 MINUTES FOR THIS STATION
Scenario: Mrs Martha Daka, 28-years-old, is in her first pregnancy at 7 weeks gestation. She has had some vaginal bleeding.
Take a focused history of the presenting complaint [5 MIN] Explain the possible causes of her bleeding to her and what investigations if any you would wish to perform. [This station tests the candidate’s ability to ask questions about bleeding in pregnancy, awareness of the differential diagnosis of ectopic pregnancy, be able to manage patient anxiety and know that ultrasound is the most appropriate investigation].
ASPECTS BEING ASSESSED POSSIBLE SCORE
STUDENT SCORE Student introduces themselves using full name and explains nature of consultation (to find out more about the vaginal bleeding)
1
Elicits date of last menstrual period (^) 1 Elicits details of the bleeding ; amount, start of bleeding, frequency, colour of blood loss, presence of clots or tissue (full mark for any 3, for 2 or less half a mark)
1
Asks if any precipitating factors for the bleeding e.g. trauma/ intercourse? (^1) Elicits severity of abdominal and shoulder pain (both full mark, one give half a mark)
1
Asks about other symptoms e.g. fainting, nausea, vomiting, headaches (for 2 or more full mark, less give half a mark)
1
Asks about contraception prior to the pregnancy (^) 1 Asks about regularity of menstrual cycle before pregnancy (^1) Elicits details of recent cervical smear tests (^) 1 Manages patient anxiety and distress appropriately showing empathy and appropriate communication skills
1
Examiner : At this point ask - What is the differential diagnosis? Miscarriage, ectopic pregnancy, Cervical polyp/ectropion/cancer (full mark for any 3, for 2 or less half a mark)
2
Examiner, Ask - What is the most appropriate investigation Student states transvaginal ultrasound (full mark), ultrasound (half a mark)
2
Examiner , Ask - What structures may be visible on a transvaginal USS in this patient? States gestation sac, yolk sac, foetal pole, heart beat or empty uterus (full mark for 3, half mark for 2 or less)
2
LAST 5 MINUTES OF THE EXAM Ask the candidate the following questions Hand the candidate the ultrasound report showing a missed abortion What is the diagnosis? A missed abortion 2 What are the treatment options for this lady now? For each one, explain how it is performed and how successful they are (whether highly successful or low) Surgical: General anaesthetic, dilatation of the cervix and suction evacuation of the uterus, high success rates
1
Medical: combination of mifepristone and misoprostol. Outpatient based management, high success rates
1
END
12. HISTORY TAKING: ANTEPARTUM HAEMORRHAGE
Scenario: Mrs Mutale M, a 30-year-old pregnant woman has had an episode of vaginal bleeding. Take a history of the presenting complaint and any other information you think is appropriate from the current pregnancy or previous pregnancies. You are NOT expected to take a full obstetric history.
ASPECTS BEING ASSESSED Possible score
Student score Student introduces themselves using full name and explains nature of consultation
Assesses gestation and parity (both to score 1, otherwise 0.5) (^) 1 Elicits details of bleed including: volume of bleeding, nature of loss (i.e. clots), colour (fresh red or brown) (full marks for 2 or more)
2
Asks about associated pain (^) 0. Asks about associated events i.e. intercourse (^1) Asks about previous bleeding to include: previous APH in this pregnancy, in previous pregnancy or early pregnancy vaginal bleeding
1
Asks about date of previous smear, its result and any previous abnormal smears/treatments
Asks about associated risk factors to include: hypertension, pre- eclampsia, smoking, medical problems in current pregnancy (one for adequate, 2 or more for good)
2
Elicits details of possible low lying placenta on earlier scans (^) 0. Asks about blood group, especially rhesus status (both to score good)
EXAMINER, ASK THE FOLLOWING QUESTIONS AND GIVE SCORE Q What is the name given to the presenting complaint? A Antepartum haemorrhage^ 0. Q What is the differential diagnosis for Antepartum Haemorrhage A To include: placental abruption, placenta praevia, local bleeding (vaginal or cervical), vasa praevia (full marks for 2 or more)
3
Q What assessment would be the most useful to differentiate between these causes A ultrasound^ 0. Q What is the likely clinical diagnosis in view of the history? A Placenta praevia^ 0. Q What investigation is^ not^ appropriate if placenta praevia is suspected? A Digital vaginal examination/speculum^2 Q What is the definition of placenta praevia? A A placenta located in the lower segment of the uterus/^ (full marks) Low lying placenta (half a mark)
1
Q How can placenta praevia be classified A Answer to include: major and minor or grades I-4^ (full marks for both)
2
Q How does the grade of placenta praevia affect decisions for delivery A Grades 3 and 4 (or major praevia) or 2b requires caesarean section for delivery,
1
14. COMMUNICATION SKILLS: PREVIOUS CAESAREAN SECTION
Scenario: Mrs Ann Bwalya is a 37 years old woman at 38 weeks gestation and would like to discuss the mode of delivery in her current pregnancy. She delivered her first child 3 years ago, via an emergency caesarean section at 38 weeks for foetal distress.
Task: 5 MINUTES
Discuss with the patient the options for delivery of this pregnancy and future fertility i.e. BTL.
[ This station tests the candidate’s ability to discuss the options for delivery for a previous caesarean section].
NB: Pt. might ask the following questions:
She is keen to try vaginal delivery and want to know the chances of success But she also wants to know risks associated with LSCS If she is offered a vaginal delivery she will accept She may ask specifically if this birth will be a hospital one She may ask if the baby will be monitored continuously She may ask if IOL would be an option in your case
ASPECTS BEING ASSESSED POSSIBLE SCORE
STUDENT SCORE Student introduces themselves (^1) Gathers information regarding previous obstetric history and circumstances regarding the previous LSCS
2
Student clarifies that there were no other complications in the previous pregnancy
2
Student ascertains gestation age of the current pregnancy (^1) Elicits severity of abdominal and shoulder pain (both full mark, one give half a mark)
1
The student talks about the choices regarding mode of delivery i.e elective caesarean section or vaginal birth
3
The student talks about VBAC especially scar dehiscence (^4) The student talks about VBAC being attempted in a hospital setting (^3) The student talks about the role of IOL in this case 1 The student asks the patient to ask questions/comments 1 The student thanks the patient (^1)
End of Exam TOTAL
20
15. COMMUNICATION SKILLS: PPROM
Scenario: Mrs Jane Mwanza 28 years old woman at 36 weeks gestation with spontaneous rupture of membranes. She has had two (2) spontaneous vaginal deliveries previously.
Task: 5 MINUTES
Discuss with patient how you will manage her
ASPECTS BEING ASSESSED POSSIBLE SCORE
STUDENT SCORE
PARTIAL SCORE
NO SCORE 1 Student introduces himself/herself (^1) 2 Notes that the pregnancy is preterm and need to ascertain presenting part
2
3 Talks about conservative management and fetal monitoring in the next 24 hours
3
4 The role of steroids if any ,at this gestation age (^3) 5 Talks about choice of mode of delivery viz-a-viz presenting part
5
6 Mentions the risk of chorioamnionitis should the patient go beyond 24 hours without being delivered
2
7 The role of caesarean section when the presenting part is breech
2
8 The role of the paediatrician at delivery (^2) End of Exam TOTAL
20
