Obstetrics OSCE

Question 1

Antenatal Management of Pre-Eclampsia

Answer 1

• Request blood tests (FBC, group and antibodies, clotting, U+Es, LFTs)
• Request serial BP
• Request CTG
• Request USS
• Request 24 hour urine collection for protein
• Ask about visual disturbances, headache and epigastric pain
• Examine for oedema (pre-tibial, facial and digital) and hyperreflexia
• Outline care plan
• Admission and observation
• Treat hypertension
• Consider delivery if appropriate

Question 2

Antenatal Abdominal Examination

Answer 2

• WIPERQQ
• Inspect for shape, striae gravidarum, linea nigra, scars, foetal movements, rashes
• Measure symphysis-fundal height (blind)
• Palpate and assess for position, presentation engagement, liquor volume
• Auscultate with pinard or doppler (100-160 bpm)
• Inform patient of findings
• Document appropriately
• Complete with peripheral oedema, urine dip and other examination and history as appropriate

Question 3

Management of Breech Presentation at 36 weeks

Answer 3

• Recognise and explain unfavourable factors associated with breech presentation
• Contraindications to vaginal birth (placenta praevia, compromised foetal condition)
• Footling or kneeling breech presentation?
• Previous c section?
• IUGR?
• Large baby?
• Pelvis diameters?
• Offer ECV
• Contraindications to ECV - APH within 7 days, placenta praevia, presumed foetal compromise, IUGR or reduced liquor volume, previous c section, rupture of membranes, footling breech presentation, unstable lie, major uterine/foetal abnormality, pre-eclampsia, diabetes or heart disease
• Explain ECV procedure
• Mention and obtain consent for c section
• Make appropriate follow-up arrangements

Question 4

Management of Missed Miscarriage

Answer 4

• WIPERQQ
• Explain missed miscarriage
• Cause is unknown
• Explain that it is common (20%) and recurrence unlikely
• Option 1 (wait 7-14 days if no signs of infection like temperature, abod pain, foul discharge, increased potential for haemorrhage, and make 14 day appointment to review)
• Option 2 (Surgical - manual vacuum aspiration can be done under GP/outpatient setting using LA or ERPC under GA in hospital setting - risk of perforation 1:200 and risk of retained products 1:100, aftercare includes follow-up and anti-D injection)
• Option 3 (medical management, single dose vaginal misoprostol (800 mg), after care includes pain relief antiemetics pregnancy test 3 weeks following and an appointment in 3 weeks)
• Inform woman to contact unit if new symptoms or worsening of symptoms
• Home with leaflets and support organisation materials
• Give time
• Offer space and tea

Question 5

PCP Station

Answer 5

• WIPER and purpose of consultation
• empathy, OARS and non-verbal communication
• Check what the patient would like to talk about
• Check whether there is anything else they want to explore
• Check what the most important thing to discuss today is
• Explain benefits of the specific factor
• Provide information, strategies and resources
• Check what the patient thinks about the information that has been provided
• Appropriately finish and wish well with next steps

Question 6

Antenatal History

Answer 6

• WIPERQQ
• Explain procedure
• Age
• Rh status
• Surgical history
• Medical history
• Social history
• Obstetric history
• Family history
• Explain screening options
• History of current pregnancy
• Formulate plan of care with patient

Question 7

Routine Antenatal Blood Tests

Answer 7

• WIPERQQ
• Open question and offer to discuss test results
• FBC and explanation of anaemia
• Blood group and antibodies (including Rh status)
• Electrophoresis
• Thalassaemia
• Sickle cell
• Diabetes screen
• Risk factor assessment
• Gestational diabetes (and other gestational conditions)
• Syphilis
• Hepatitis B
• HIV
• ICE

Question 8

Management of PPH

Answer 8

• Call for help (emergency buzzer)
• Massage uterus for contraction and reassure parents
• Request team (senior midwife, obstetric SpR, anaesthetist, porter and scribe)
• As help arrives allocate tasks
• Airway
• Breathing (check and administer high flow O2)
• Circulation (lie flat or head dow, insert 2 wide bore cannulae (grey), FBC clotting thrombin group and cross match 6 units + U+Es and LFTs
• Commence fluid resuscitation (consider O-ve while waiting)
• Monitor (HR, RR, O2 sats and BP
• Inspect blood loss, uterine tone, placenta and membranes and perineum
• Treat with uterine massage (assess need for bimanual compression), further oxytocics (syntometrine, ergometrine, infusion of syntocinon), haemabate IM, misoprostol PR, urethral catheter and hourly urine measurement
• Proceed to theatre if still no resolved
• Document timings, drugs and personnel

Question 9

Active Management of the Third Stage

Answer 9

• Give an oxytocic drug IM
• Skin to skin
• Delay cord clamping when mother and baby well (1-5 minutes)
• Observe for 3 signs of separation (uterine contracts from umbilical level, cord lengthens, gush of blood)
• Guard uterus and perform controlled cord traction
• Catch placenta and tests membranes as delivered
• Check for signs of maternal bleeding
• Check placenta (all cotyledons present, 2 membranes amnion and chorion, complete insertion of the cord, 3 vessels 2A + 1V, and check condition of the placenta)
• Ensure uterus is contracted and there is not excessive bleeding
• Document, including blood loss
• Physiological management (watch and wait, breast feeding)