Practical skills Gyn/Obs

Labour management (partogram, PV, delivery)

Station

Dilatation

Effacement

Amniotic fluid

Moulding

Insert pics from

Never do PV exam if theres bleeding. Can be sign of placenta praevia in which case its cntraindicated.

Only do once in every four hours or so as it increases chance of infection.

Explain and consent.

Then empty bladder. Ask urinate or emputy the bladder via catheter.

Wash hands and put gloves

Was geneita area from front to back with clean water.

Insection - check for infection or scars etc that can affect deiivery

Wait until she has finished a contraction.

Take deep slow breathes.

Seerate labour and gently insert first two fingers

check position of cervix - early it will be posterior and then later anterioir and easy to reach

then check consistency and then effacement (thick like tube or thin like band?)

Then check the dialation (not excitations) by the inner cervica kenght next to the baby

1 cm = one finger tighty

2cm = one finger losely

3cm = two fingers tightl

4cm = two lose fingers

5 cm - little more than two lose fingers

And then the rest is based on the finger stuff

At 10 cm fully dilated and you wont be able to feel the cervix in front of the baby's head!

Make sure there is no cervix by feeling around the head

Only at this stage the mother can safely push down without risking a cervical tear

Then check the station = is it higher up, hard to reach or lower down in the vagina or next the cervix (can give based on relative position to the spine)

Then check for the bag of membranes = bulging. Can break during labour or even before it.

Check the coour of iqour. If yellow or colourless with HR normal, probably okay, If green meconium then can be sigh of distress and risk

Dark green r thick = baby maybe in trouble

EEncoruage to walk to progress labour.

consent

clean

inspect

after contraction

Prepare patient. Seperate labia and insert.

Position

Conistsnecy

effacement

dilatation

station

check for moulding and caout stuff (CPD stuff)

bag of membraned and liqour colour

remve and mell for offense and take away

https://www.youtube.com/watch?v=x17vY7_3M2M

Cervical ripening is different from effacement. Cervical ripening can happen before labour and is boosted by stuff like sweepng, baloon induction, pg etc

Oxytocin drip

Suturing (perineal tear, episiotomy)

During second stage of laour, wait till the baby's head corwning is seen.

Then infiltrate local anethetic. MEdial + on the angle (medio ateral) and then lateral to that and also to the vaginal mucosa.

Have a finger between the skin and the presneting part, so can protect the presenting part.

Then cut medio lateral using the epis scissors, having a finger below the presenting part to protect it, Put when contraction so less bleeding. Then second stage completes and then inject oxytocin?

Then wait for 15 to 30 mins to check for bleeding or PPH just in case. Otherwsie need to again open sutures.

Put a swab up there, cloth to stop bleeding to check for any bleeding or tears in the birth canal. Then remove the cloth and then put hand inside to remove clots. Remove all clots.

Then put field above on the belly.

Then infiltrate local anteshteic around the tear before the remair. everywhere around the tear. Remmeber to aspirate a bit and check for venous blood before putting the anesthetic in. otherwise eill hit a vein.

And then do the epis repair according to below.

Then wipe off. ensure all swabs removed and vagina admits two fingers

Then do anal exam to check whether can feel any sutures. IF yes, then take off and re do. The delivery pack is a sterile procedure!!!!

always have a pressure applying upwards on the ueterus when applying downward pressure to the chord. Important!! to prveent inversion, dont the chord without puttig upward pressure

when you cans see the placenta in the vulva change the direction upwards

note the manner in which the other hand is grasping the uteerus

palpation to check for contraction every 15 min and then every haf an hour from 2 hours.

check bp as well. remember sheehans.

How to perform one

First anesthesia in the vaginal opening and perinuem

lateral one is more painful and longer to heal but prevents anal

absorbabe sutures used

Epis repair

over the apex one stitch

then conitnous suture over the vagina mucosa

then do a last instrument tie knot

Or can do a figure of eight thingy? or another manovre fr conitniuty?

then stitch muscle layer by continuous none licking suture (not interupted one by one???)

change needle to skin needle

then far far near near stitch the skin through interrupted suture (or use a subcuticular stitch continous?? for less chronic pain?)

episcissors-60 cause 60 degrees

vaginal mucosa avoid too deep because close proximity to the rectum?

What if breached rectum?

if injury to rectal mucosa then must take steps to release and remove the sutures completely... check whether you can feel the sutures on the anal mucosa. If yes, then release and remove the sutures completely. And then put again, so wont be infected etc.

But if tear reaches anal mucosa? Fourth degree tear? Then need special perineal repair procedure?

Thats different from the stitches reaching the rectal mucosa.

Manual removal of the placenta (at LSCS)

Retained placenta = pacenta not removd for 30 to 60 mins. If stable can wait for one hour.

First need to catheterise and empty the bladder

Then put dominant hand inside and follow the course of the umbiical cord until placenta is reached. Pull the cord with the other hand at this stage to trace.

Used non dominant hand to apply counter pressure

And then find plane of seperation and then take off placenta

The non dominant hand should continuously feel and then support taking the placenta out

Make sure not placenta inversion detach the whole placenta first into the hand and then take it out

Support the rest of the uterus to prevent inversion

And then after taking out check whether the uterus contracts well. If not then may still have placenta inside. And then inspect vulva for tears.

If pulling the cord then must make sure to feel the fundus to revent uterine inversion. If stable can even transfer to a better facuty for MROP

Very painful so must put GA or ketamine or pethidine

First must make sure that the placenta isnt lying over the vagina and easily pullable out. Then out hand inside. If cervix closed then apply pressure until you get in

If th placenta doesnt seperate with gentle pressure, then consider remoing fragments and it as placenta accreate and transfter to theatre to do a sub total hysterectomy

If still bleeding then do PPH protocol like manual compression and baloon etc and misoprostol etc Inspect placenta to see whether its complete and nothing missing

Next time higher risk of placenta retained so give borth in a higher ecnter that can manage better.

Keep fasting or with only clear liquids or iv fluids until concious and can eat or if theres a suspicion keep fasting longer in case there is a further procedure to be done.

Clinical pelvimetry

Suturing methods

https://www.youtube.com/watch?v=TFwFMav_cpE

Use the above video as based and everything else added below

OSCE guide videos on the suturing techniques

https://geekymedics.com/category/surgery/suturing/

Horona Labour room stuff

PV exam stuff How to do normal delivery? Check guidelines adhil sent

Catheterisation and bladder drainage >> Female catheterisation

Put on two pairs of gloves (sterile procedure) Put lube on non dominant hand other side Take swab Devide the swab into five parts. (can use betadine instead?) Use non dominant hand to use each swab wiping from anterior towards the anus Only one stroke. Left near. Right near. Left far. Right far. And then center. Discard and put on new gloves if needed. Then assistant opens the catheter and you take it, its sterile. So only take the edge of it and put the lube on there. Bathe it. And bathe lube along the first part of the tube. Then open lips and put it right at the middle of the urethral hole. Press it gentle. And then remove the bag from the rest of the tube. Can attach urine bag at the end or a tray. Wait till urine comes. Then afterwards can pull out. or can inject distilled water to fill baloon and hold it in place. How to remove catheter?

How to put in males? And remove?

PV exam >>

check note above. Its to fill the partogram but labour rooms dont need partogram Since all HOs and not shift much. Know whats going on. So just to get idea and fill notes in BHT.

Delivery stuff >>

Need to put gown and gloves - double layer. Need to be there after fully dilatation and when close to end of 2nd stage. Mother starts to bear down when head reaches cervix and oxytocin contractions begin. When close to crowning, must do epis. First give local anethetic, by applying on it. Keep two fingers between the vagina and the baby's head so wont prick the baby. Then give anethetic. Thrice. Left/middle, incision and then right. Then deliver the baby. Hold down below the vagina until the head is seen and then support it. Deliver it out. Support the perineum when the head is coming out. After the head is out, materal bearing down is discouraged. Retraction of head and delayed second stage can be sign of shoulder dystocia. And then place the baby down, and wait till it breathes. Then the nurse wipes it. Wait for some while before clamping cord. Put the other forceps near the mothers end. And then the plastic one close to the fetal end, giving some sppace. Then cut using the scissors. And then wipe the edge with alcohol to clean. Then the baby is sent off and the nurse checks and clothes it. apgar score. Then the cord is delivered. Activie management begins. IM oxytocin given and baby is given vitamin injection? Uterine massage. And apply gentle control cord traction while emanwhile supporting the uterus from above so it doesnt invert itself. first pull downward direction, while supporting. and then when placenta is close, pull upwards. And then take out. Inpect the placenta for any damages or torn out or if edges not smooth. And then put hand to remove any clots or to do manual removal. Then clean up ad wait half an hour for epis repair making sure no bleeds.

Suturing epis >>

First remove the towel thats inside. and let the blood floor. And absord blood using a cloth. Then put hand inside to remove any clots inside. Then inpsect vagina for any other tears. Then put betadine in wound. Change gloves? Then out local anetshteucs, on all four sides and covering all areas. Start with one stitch and know above the apex. Make sure vaginal mucosa stitches are deep. Sticth until skin/ hymenal remnants with continious sutures. Then at the skin end with knot. Then stitch muscle layer. USe interruppted sutures. bite from side to side and then tie. Must stich muscle by putting the bite as close as to the skin but biting the muscle And then going deep to the wound and coming out from the other side Then stich skin by a mattress suture. Bite the skin and go superfically to the wound and come out from the other side skin And then bite back in from the skin and go supperfically to the other part of skin And then come out and tie the knot from that side Go like this in an interrupted fashion. Go superfically to the middle of the wound and close it. Each time wiping any blood and cutting off stitch close. And lastly tie. Then inpsect and check for any bleeding still coming out. check whether the vagina permits too fingers and no clots or swabs inside Then do an anal exam and check whether can feel sutures from the other side. If can must take off and do again. Then take gloves off and document everything that was done.

https://www.youtube.com/watch?v=duPxBXN4qMg