Part 1: Essential skills to achieve during an O&G rotation

Part 1: Essential skills to achieve during an O&G rotation

Sep 22, 2021 1
Emergency Medicine,general practice,o&g,onthepods

There are a lot of differences between Obstetrics & Gynaecology (O&G) and other medical rotations which can be daunting for junior doctors. Skills to achieve in an O&G term will depend on each individual – for budding GPs, learning about antenatal and postnatal care is important.  This is the first in a 3 part podcast series on the essential skills a junior doctor should aim to achieve during an O&G rotation.

 

Summary Writer:  Joshua Brousse de Gersigny

Script Writers:  Rebecca Taylor and Jane McDonnell

Editors:  Rebecca Taylor and Jane McDonnell

Interviewee:  Rebecca Taylor

Interviewer:  Jane McDonnell

 

About Dr Rebecca Taylor

Dr Rebecca (Becky) Taylor is a 6th year O&G trainee. Originally hailing from the UK, she trained at the University of Edinburgh where she also completed her internship and residency, before moving to Australia. She undertook her basic O&G training at Royal Prince Alfred Hospital in Sydney. Rebecca is currently undertaking a two year Gynaecology Fellowship at Royal Prince Alfred Hospital. When Becky’s not knee-deep in amniotic fluid she is a keen swimmer and free diver, a terrible cook and married to an anaesthetist she met at a Cat One Caesarean.

 

About Dr Jane McDonnell

Dr Jane McDonnell is an Obstetrics & Gynaecology Registrar based in Sydney. She completed her medical degree at The University of Notre Dame after completing a Bachelor of Medical Science from The University of Sydney. Jane has a Masters in Public Health from the University of New South Wales and has completed an internship at the World Health Organisation in Geneva. In 2019, she was awarded the JMO Teacher of the Year at Royal North Shore Hospital. Jane is interested in women’s and refugee health, teaching and research. Outside of medicine, she enjoys running and sudoku.

Part 1:  Essential skills to achieve during an O&G rotation

With Dr Rebecca Taylor, Obstetrics & Gynaecology Fellow and Dr Jane McDonnell, Obstetrics & Gynaecology Registrar, based in Sydney, New South Wales, Australia

 

Introduction

There are a lot of differences between Obstetrics & Gynaecology (O&G) and other medical rotations which can be daunting for junior doctors. Skills to achieve in an O&G term will depend on each individual – for budding GPs, learning about antenatal and postnatal care is important. For future GP-Obstetricians, the rotation is an opportunity to develop skills in perineal suturing and normal vaginal deliveries. According to junior doctors, some of the essential skills to achieve include initial assessment of the sick pregnant woman, cannulation, and the post-natal assessment. This is the first in a three-part series. Listen to the other podcasts for discussions on prescribing common medications in O&G and assisting in a Caesarean section.

  • Be methodical
  • Observations
    • Women >20 weeks gestation require a different ‘Between the Flags’ observation chart. Familiarise yourself with this so you know when to act
    • A blood pressure >140/90 is abnormal in pregnancy and a BP of > 170/110 is an Obstetric emergency
  • Symptoms
    • Abdominal pain, uterine tightenings (painful? frequency?)
    • Vaginal bleeding – provoked (intercourse)? Quantify by number of pads used
    • Vaginal discharge – consider rupture of membranes or infection
    • Change in fetal movements
    • Headache, visual disturbance, RUQ or epigastric pain – consider pre-eclampsia
    • Urinary symptoms
  • Examination
    • Vital signs – BP, pulse rate, respiratory rate, oxygen saturations, temperature
    • Abdominal examination – fetal lie (breech, cephalic, transverse), uterus soft / tender / palpable contractions
    • Measure the fundal height – is the fetus growing appropriately for gestational age?
    • Fetal heart rate or CTG depending on gestation
  • Other
    • Speculum examination – consider high vaginal swab (HVS) + low vaginal swab (LVS) which will require supervision initially, or bedside kits for testing presence of amniotic fluid if worried about ruptured membranes
    • Bedside ultrasound (usually performed by senior colleague)
    • Cardiovascular / respiratory examination if relevant symptoms
    • Examine calves if suspicious of DVT
    • If concerned about pre-eclampsia (for example the patient is hypertensive), examine for hyperreflexia, clonus and RUQ tenderness
  • Basic investigations
    • Tailor to the presentation
    • If concerned about pre-eclampsia, test FBC, EUC, LFTs, urate (if severe pre-eclampsia, consider coagulation profile) and Group & Hold (G&H) if any possibility of imminent delivery
    • If bleeding, take FBC, G&H and Kleihauer (to assess mixing of maternal and fetal blood at placental interface)
    • If febrile (2 or more readings of > 37.5°C or one reading > 38°C) take blood cultures, FBC, CRP, and VBG to look for lactate as a marker of severity for sepsis
    • Urine dipstick (if concerns of infection send off for urine MCS, if concerns of preeclampsia assess the spot urine protein-creatinine ratio)
    • If chest pain à ECG
    • May need to order a formal fetal ultrasound if concerns about fetal wellbeing
  • Many reasons for cannulation – wanting an epidural, admission for APH, etc.
  • Use 16G because this allows faster fluid resuscitation in the setting of significant bleeding
  • Most women are vasodilated aiding cannula insertion
  • Optimise positioning and obtain all equipment including local anaesthetic
  • Cannulation in a hand vein is usually the easiest for a patient, but in an emergency wherever you can find an appropriate vein is adequate
  • If you have had 2x attempts without success, seek help from your registrar or an anaesthetics registrar
  • Whenever you are inserting a cannula, take a FBC and G&H at the same time
  • History
    • Assess pain – both patient reported and based on analgesia used on medication chart
    • Blood loss – number of pads, colour of lochia, odour
    • Bowel and bladder function – incontinence of urine, stool or flatus particularly in the setting of third or fourth degree tears
    • Breastfeeding – any associated breast pain or erythema? Has milk come in?
    • Psychological state
  • Examination
    • Vital observations (within normal maternity parameters?)
    • Abdomen – fundus firm and contracted? If a Caesarean has been performed, inspect the wound
    • Perineum – if there has been a sutured tear, examine the perineum
    • In-dwelling catheter – should generally be removed the morning after a Caesarean section or instrumental delivery unless the perineum is very swollen, or there is significant pain which is likely to limit mobilization. If in doubt leave the IDC and check with the registrar
  • Prior to discharge
    • Debrief regarding delivery – this should be performed by the accoucheur
    • Counselling regarding inter-pregnancy interval (patients who have had a Caesarean section should wait at least 18 months prior to the next delivery in order to allow the uterine wound time to heal)
    • If the mother is Rhesus negative and the baby is Rhesus positive à anti-D
    • Discuss postnatal contraception – suitable options for breastfeeding mothers include the Minipill (progesterone-only pill), the Mirena (IUD), and the Implanon – ensure that a follow up with the GP at 6 weeks’ postpartum is organised if she is undecided or would like to discuss further
    • If overdue, Cervical Screening Test which can be done with the GP at 6 weeks’ follow up
    • Detailed discharge letter documenting any important information to the GP
    • Plan for medications including analgesia, antihypertensives (weaning plan)
    • Follow-up appointments (e.g. with cardiologist, renal specialist, O&G team, 75g FGTT repeated at 3 months postpartum if the patient had GDM)
  • The postnatal check is a key window for discussing important women’s health issues that are frequently missed

Related Podcasts

Related Blogs

Tags: #cannulation,#General Practice,#GP,#junior doctors,#O&G,#obstetrics,#obstetrics and gynaecology,#postnatal check,#pregnancy

If you enjoyed listening to this week’s podcast feel free to let us know what you think by posting your comments or suggestions in the comments box below.

If you want to listen to this episode while not connected to WiFi or the internet, you can download it. To find out more go to Apple support (https://support.apple.com/en-us/HT201859)

1 Comment

  1. Dr. MAHAJABEEN.

    February 1, 2022 at 11:45 am

    It was a really useful podcast for JMO’s or Interns on the wards.

    Reply

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