Obstetrics and Gynaecology

Yapa Wijeratne
Faculty of Medicine
University of Peradeniya
 Q1

1. Identify A-G
2. Write the corresponding letters in
order of most effective method to
least effective method
• A – Female condom

• B – Levonorgestrel releasing intra uterine contraceptive

device (Mirena®)

• C – Copper T-380 A intrauterine contraceptive device

• D - Depot medroxy progesterone acetate injectable

suspension

• E – Norplant subdermal contraceptive implant system

• F – Combined oral contraceptive pill

• G- Male condoms

E>B>F=D>C>G>A
 % of women experiencing an
unintended pregnancy within the
first year of use
1 2
Method Typical use Perfect use
4
No method 85 85

Withdrawal 27 4
Periodic abstinence 25
Calendar 9
Ovulation method 3
6
Sympto-thermal 2
Post-ovulation 1
Condom - Female 6 21 5
Condom - Male 5 15 2
Combined pill and minipill 3 8 0.3
DMPA (Depo-Provera) 3 3 0.3
IUD (copper T) 4 0.8 0.6
Mirena (LNG IUS) 2 0.1 0.1
LNG implants (Norplant) 1 0.05 0.05
Female sterilization 0.5 0.5
Male sterilization 0.15 0.10

Emergency contraceptive pills: Treatment initiated within 72 hours after unprotected

intercourse reduces the risk of pregnancy by at least 75%.
Q2
A) 21 yrs old unmarried girl presents to your clinic after having
unprotected sex last night. What method/s that you can use in
this patient as post-coital contraceptive method/s.

B) A 35 yrs old healthy woman with two children aged 3 & 5 yrs
requests an emergency contraceptive after unplanned coitus 4 days
ago. Name a method that you would offer to this woman.
A.
1 – Postinor2®
take one tab immediately and the second tablet 12 hrs later
2 – Combined oral contraceptive pill
Take 4 tablets immediately and repeat the same dose 12 hrs
later

B.

Copper T 380-A intrauterine contraceptive device

• A copper-releasing IUD (Cu-IUD) can be used within 5 days

of unprotected intercourse as an emergency contraceptive.
However, when the time of ovulation can be estimated, the
Cu-IUD can be inserted beyond 5 days after intercourse, if
necessary, as long as the insertion does not occur more than
5 days after ovulation.
 Q3
1. How long can it be used
2. List 2 advices you would
give after inserting this to
a patient
3. What should you do if a
woman gets pregnant
after placing it
1. 10 years (6-8)

2.
Expect some bleeding PV for a few days

Check for the presence of the threads (Specially during

menstruation period)

First 3-4 menstrual periods may be heavier than normal

Take paracetamol tablets if she develops lower abdominal pain.

Follow up – In one month and thereafter annually

Prompt medical advice should be taken if

- the threads are not felt
- delayed menstrual period (Pregnancy?)
- Severe abdominal pain Prolonged or excessive bleeding
 3. Cu-T Pregnant
• Exclude ectopic
• Counsel regarding risks
– Miscarriage
– Preterm delivery
– Infection
• Remove if threads +
• Advise prompt return for Rx of complications
(Bleeding, pain, discharge, fever etc)
 If threads Neg.
- US Scan - identify in utero
- counsel
- check at delivery
- check Post partum - X’ Ray
• Timing of insertion
1st seven days of the cycle (Ideal during menstruation)

• Removal of IUD
pregnancy
Perforation
Acute PID
Menopause – one year after last period

• Absolute contraindications
Pregnancy
Acute/Chronic PID
Abnormal uterine bleeding
Suspected/confirmed genital tract malignancy

• What you should ask in the Hx:

LRMP – to rule out possibility of pregnancy
Mucopurulent vaginal discharge - ? PID
Q4

1. Name above items and write one non-contraceptive

benefit of each above given methods
2. 30 yrs old female who is on OCP has forgotten to take
her last two pills. what advise would you give her?
1)
A - Levonorgestrel releasing intra uterine contraceptive device (Mirena®)
B – Male condom
C – Combined oral contraceptive pills
2)
A- Improves menorrhagia
Decrease dysmenorrhoea and pelvic pain in patients with endometriosis

B- Protection against STD

Protection from carcinoma of the Cx

C- Relief of menstrual problems

Regularizes previously irregular cycles
Decrease number of days of bleeding and amount
Improves iron deficiency anaemia
Relieves and reduces premenstrual tension
Protection against ovarian and endometrial cancers
Decreases incidence of benign breast cysts and fibroadenoma
Prevent ectopic pregnancy
Missed
pills
 Q5
1. What is the
advice you would
give to the
patient when
prescribing this

2. List 3 Common
side effects
 Advice
• Postinor contains two tabs. Treatment necessitate to take 2 tabs

• Reliable (75%) post coital contraceptive method if it takes <72 hrs

after unprotected sex

• 1st tab should be taken immediately. 2nd tab should be taken 12hrs
after the 1st dose

• If vomiting occurs within 2hrs of intake take another tab.

• Can cause irregularity to your next menstrual period

• Not a method of abortion

• No adverse effects to an already existing pregnancy

• Adverse effects – Nausia, Lower abd pain, breast tenderness,

Vomiting

• Consult a physician if you missed your next period

• Advise her about proper use of suitable contraceptive method

 Q6

Mother giving breast milk to child,

looking far away
1. List 2 correct techniques when
breast feeding
2. List 2 maternal complications due to
incorrect technique of breast
feeding
• Correct technique:
a) Good exposure of both mother and baby.
b) Posture- Mother sitting comfortably. The baby
is held with his head ,neck and body in one line
supported by the mother’s forearm.
c) Good attachment- The areola covered by baby’s
mouth with the lower lip everted and cheeks
should be puffed out.
d) Eye contact to be maintained.
e) Each feed to be around 20 minutes.

• Maternal complications:
a) Cracked nipples
b) Breast abcess
 Q7

• How do you prepare a patient for

LSCS
• What are the complications of LSCS
• Consent

• Co-ordinative part- inform aneasthetist, PHO and theatre.

• Keep fasting 8 hours

• Investigations- Grp & DT( Reserve 1 unit)

• Pre-medication- Metachlopromide 10mg oral, Famotidine 20mg oral

• (Emergency- O2, IV Ranitidine 50mg, IV Metachlopromide 10mg, )

• Na Citrate 0.3M 30ml. Mother in left lateral position.

• Send Urinary cather, IV antibiotics ( Metronidazole 500 mg,

Cefuroxime 750 mg ( 1 vial each) to theatre.)
 Complications of LSCS
• Anaesthetic – Gastric acid aspiration (
Mendelson’s synd)

• Immediate- PPH, shock, damage to

bladder, ureters or colon

• Early- Sepsis, Wound complications

(Haematoma, dehiscence)

• Late- risk of scar rupture in future

pregnancies, incisional hernia, intestinal
obstruction due to adhesions
 Q8
Give 4 risk factors from this antenatal record (Two slides)
• Short stature
• Previous death in-utero
• Previous miscarriages
• Blood pressure of 160/110
• Proteinuria
• Grand multi para
 Q9
• Tick the items used in manual removal of placenta
1 Plasters

2 14G foley catheter

3 14G IV cannula

4 Vacuum cup
5 A pair of gloves

6 Cusco’s speculum

7 IV drip set

8 Vulsellum

9 IV metronidazole

10 Betadine
1 Plasters

2 14G foley catheter

3 14G IV cannula

4 Vacuum cup
5 A pair of gloves

6 Cusco’s speculum

7 IV drip set

8 Vulsellum

9 IV metronidazole

10 Betadine
 Q10

1. Identify/name
the instrument
2. Write 2 uses
1. Cusco’s bivalve self retaining vaginal
speculum

2.
• In obtaining a Pap smear
• In obtaining a high vaginal swab
• To visualize the cervix & vaginal wall in
pelvic examination
• Insertion /removal of IUCD
Q11

1. What
do you
see
2. Write 2
causes
1. Secondary arrest

2. CPD
OP position
Inadequate uterine contractions

Mx:
CPD – Em LSCS
Exclude obstruction

OP position Increase oxytocin infusion rate

Inadequate uterine contractions Observe and if no progression
Em LSCS
Q12 Write a clinical condition where
each of these drugs are used
Oxytocin
Augmentation of labour.
Active Mx of 3rd stage labour & control PPH.
Following evacuation of uterus.

Mg sulphate
As eclampsia prophylaxis.

Hydralazine
In Pre-eclampsia and eclampsia.

Ergometrine
Prophylaxis against excess heamorrhage foll. delivery
Therapeutic- In PPH: atonic uterine bleeding.
In atonic uterine bleeding foll. Miscarriage, expulsion of H.
mole.
• Q 13
• Counsel this 30 yrs old patient who is
diagnosed to have an incomplete
miscarriage
• Introduce yourself, put the patient at ease

• Explain what has happened ( Most miscarriages

are due to fetal anomalies, there is nothing that
she could have done to prevent the miscarriage )

• The need to undergo surgery ( Evacuation of

retained products under GA)

• Preparation for the next pregnancy – wait at least

3 months, during this period take folic acid

• Early antenatal clinic booking and regular follow

up.

• Ask whether patient has any questions to ask

• Q 14
• Ask 5 leading questions to determine
the severity of this patients
condition who has a blood pressure of
160/100 mmHg
1. Frontal Headache- unrelieved by simple
analgesia.
2. Visual disturbance- flashing lights and
spots
3. Epigastric pain
4. Nausea/ Vomiting
5. Swelling
6. Malaise
Q 15
Write the
names
of the 5
abnormalities
you see.
Normozoospermia
Oligozoospermia
Asthenozoospermia
Teratozoospermia
Oligoasthenoteratozoospermia
Azoospermia
Aspermia
Leukocytospermia
When all the spermatozoal parameters are normal
together with normal seminal plasma ,WBCs and
there is no agglutination.
When sperm concentration is < 20 million/ml.
Fewer than 50% spermatozoa with forward
progression(categories (a) and (b) or fewer than 25%
spermatozoa with category (a) movement.
Fewer than 30% spermatozoa with normal
morphology.
Signifies disturbance of all the three variables
(combination of only two prefixes may also be used).
No spermatozoa in the ejaculate.
No ejaculate.
more than 1 million white blood cells per ml of semen
 Normal values
Volume 2.0 ml or more
pH 7.2-7.8
Sperm concentration 20x106 spermatozoa/ml or more

Total sperm count 40x106 spermatozoa or more

Motility 50% or more with forward progression or

25% or more with rapid progression
within 60 min after collection

Morphology 30% or more with normal morphologyb

Vitality 75% or more live

White blood cells Fewer than 1x106/ml
• sensitivity of 89%, poor specificity
repeat semen samples provides
greater specificity.

• At least two samples, preferably

taken at least two or three weeks
apart, should be analyzed.
• Newly formation of sperm to transport
& to present in ejaculate, it takes ~74
days. Therefore ideally it has to be
repeated ~2-3 months later.
• Q16
• What is the advise you would give
regarding obtaining a semen sample
for analysis
• This test is conducted to check for male factor
subfertility.

• Specimen should be produced by masturbation.

• Abstinence from intercourse for 3-4 days.

• Condoms should not be used for collection as they contain

spermicide.

• Coitus interruptus is not recommended as the first part of

the ejaculate contains the highest concentration of sperm.

• Wide mouthed sterile plastic container will be provided.

• Sample should be delivered to the lab within 30 min. of

collection.
Q17
1. Identify
2. List 3 prerequisites in using these instruments
3. Give 3 indications for these instruments
Wrigley’s Forceps
Always prior to applying forceps
1. Abd examination – Head engaged?
2. Confirm that the cervix is fully
dilated
3. Empty the bladder
4. Check station of the presenting
part
5. Position of the foetal skull –
Position of the saggital suture &
posterior fontanelle
Prerequisites for applying forceps
• Valid indication must be present

• Suitable presentation- vertex,face, aftercoming head of breech.

• Rule out cephalopelvic dispropotion.

• Engaged Presenting part. Position of the fetal head should be

known.

• Cervix should be fully dilated.

• Bladder emptied- preferably by catherisation.

• Ruptured membranes.

• Abdominally head should not be palpable. If more than 1/5th

palpable abandon vaginal delivery.
Indications for forceps delivery
1. Delay in progression of second stage of labour

2. Maternal exhaustion

3. Medical problems which require avoidance of

excessive maternal effort

4. Fetal distress in the second stage

5. Delivery of the after coming head of a breech

presentation
Q18
1. Name the required instruments in order of use
when obtaining a pap smear
2. What is the fixative and the stain used
1. F - Cusco’s bivalve self retaining vaginal
speculum
G - Ayre’s wooden spatula
B - Cytobrush/ Endocervical brush
A - Glass slides

2. Fixative – 95% Alcohol

Stain- Papanicolaou stain

(The glass slide is fixed in 95% alcohol for 30

minutes and air dried before sending to the
histology lab)
Q19

1. Name 5 instruments in an episiotomy

set.

2. List 3 complications of an episiotomy

3. What are the advise given to mother

after repairing an episiotomy
Complications of episiotomy
– Immediate-
• Extension of the incision

- Early
• Vulval haematoma
• Infection
• Wound dehiscence

– Late
• Dyspareunia
 Advise to mother following
episiotomy
• Keep the area dry and clean.
• Do not pull out the sutures, they are
absorbable (~3wk)
• Do not clean with hot water.
• Do not use antiseptics, soap is sufficient.
• Drink plenty of water, eat more
vegetables, fruits to avoid constipation
• Can wear a sanitary pad to keep area dry.
Q20
What instruments are used in
the following procedures in
order of use

1. Dilatation & Curettage

2. Repair of a cervical tear

1. D&C :

• Performed under GA
• Placed in lithotomy position
• Local antiseptic cleaning & draping
• Empty bladder: using a metal catheter
• Sims’ double bladed posterior vaginal speculum is
introduced
• Anterior lip of cervix held by vulsellum
• Olive pointed malleable graduated metallic uterine
sound to confirm position & length of cavity
• Cervical canal dilated with Hegar’s graduated dilators
• Uterine curette – sharp end for benign lesions and
blunt end used for suspected malignant lesions
• Curetted material preserved in 10% formal saline and
sent to histology lab with a short clinical history.
Post procedure care:

• Give paracetamol 500 mg by mouth as needed.

• Oxytocin 10 U given foll. ERPC

• Offer other health services, if possible, including tetanus

prophylaxis, counselling or a family planning method.

• Advise the woman to watch for symptoms and signs requiring

immediate attention:
- prolonged cramping (more than a few days);
- prolonged bleeding (more than 2 weeks);
- bleeding more than normal menstrual bleeding;
- severe or increased pain;
- fever, chills or malaise;
- fainting.
Repair of a cervical tear

• Anaesthesia is not required for most cervical tears. For

tears that are high and extensive, give pethidine IM

• Good light source and patient is placed in lithotomy position.

• Sims’ speculum is introduced

• Gently grasp the cervix with Green armytage forceps. Apply

the forceps on both sides of the tear and gently pull in
various directions to see the entire cervix. There may be
several tears.

• Close the cervical tears with continuous chromic catgut (or

polyglycolic) suture starting at the apex (upper edge of
tear), which is often the source of bleeding.
 Q21
• What are the instruments found in a
delivery set.
 Q 22
Name following diameters
 Q 23 Identify following
cervical cerclage techniques
A B
 Identify following cervical
cerclage techniques
McDonald technique Shirodkar technique

Shirodkar -> I -> Internal Os

Q 24 Identify following patterns of
abnormal progress in labor
Q25

1 2

1. Identify
2. Name which one you would use in the following
procedures
• To insert an IUCD
• In vaginal hysterectomy
• In D&C
• In obtaining a pap smear
• Repair of a cervical tear
• Cusco’s bivalve self retaining vaginal
speculum
a) Inserting an IUCD
b) Obtaining a pap smear

• Sims’ double bladed posterior vaginal

speculum
a) Vaginal hysterectomy
b) Dilatation and curettage
c) Repair of a cervical tear
Q26
Complications
• Inter-menstrual bleeding
• Pelvic inflammatory disease
• Expulsion (1st 3 months)
• Perforation
Q27

1. Identify
2. List an indication and a
contraindication
Name of instrument – Ring pessary

Indications for use of vaginal pessary

a) Prolapse of uterus
b) urinary incontinence
c) cystocele
d) rectocele

Contraindications
a) Active infections of the pelvis or vagina, such as
vaginitis
b) Pelvic inflammatory disease
c) Patients who are noncompliant or unlikely to
follow up
d) Allergy to silicone or latex
Q28

Foetal movement chart

1. How to advise mother to maintain a
Foetal movement chart
2. When do you call it abnormal
3. List 3 causes for reduced FM
4. List 3 non invasive tests to assess
foetal well being
Test sensitive for fetal well-being after 28 weeks

Physiology of normal third trimester fetal movement

• Fetus spends 10% of its time making gross movements
– Active fetal periods last 40 minutes
– Inactive fetal periods last 20 minutes (<75 minutes)
• Fetal activity peaks with maternal Hypoglycaemia
– Usually occurs between 9 pm and 1 am
– Activity not increased after meals or glucose load

Advise to mother:

» Patient self monitors kick counts daily at home

» Count performed at same time every day
» Lie on left side in comfortable location
» Count fetal movements to a count of 10-12 in 12 hours
» If perceived movements are <10/12hrs seek medical
advise
Causes of reduced foetal movements:
• Normal sleep phase
• Physiological
• Reduced maternal perception
• Sedative drugs given to mother
• Polyhydramnion/oligo
• Intrauterine asphyxia

Non-invasive tests to assess foetal well being:

• CTG
• USS- foetal growth & Liquor., biophysical profile,
• Umbilical artery Doppler
Q29

A) What is the
condition
B) What is the
diagnosis
C) Give 2 causes
USS abd given
H.Mole
•Absence of a foetus (In complete mole) Presentation

•“Snow Storm” appearance 1. Vaginal bleeding

2. Passage of vesicular
grape like structures per
vaginum
3. Hyperemesis
4. Early onset PIH
Examination findings
1. Anaemia
2. F>D
Investigations
1. USS abd.
2. S. hCG
3. CXR
Management
1. Evacuation
2. Follow up (2 yrs)- hCG
assays
3. Contraception
4. Chemotherapy +/-
 Q30

Basal body temperature

chart (BBTC)

1. What is the day of ovulation

2. What advise you give on using this

3. On which day according to the chart would you do

the following

a. Post Coital Test

b. Progesterone levels to detect ovulation
c. Endometrial biopsy
d. HSG
e. IUI
 0.5-1 0F (0.2-0.5 0C)
Ovulation
2 days
1. Day 14 of the cycle.

2. There is a biphasic pattern of variation in ovulatory cycle.

• Begin recording temp. on the first day of the period- day 1

on the chart.

• Measure the oral temp. using a clinical thermometer.

• Mark the date in the column and shade the area on the day
of menses.

• Take the oral temp daily on waking before getting out of

bed. ( do not wash mouth)

• Days when intercourse takes place should be noted with an

arrow.
a. Post Coital Test- day 12-13 in a regular
28 day cycle.
b. Progesterone levels to detect ovulation –
Day 21 in a 28 day cycle.
c. Endometrial biopsy- Day 21-23 in a 28
day cycle.
d. HSG- First 10 days of the cycle.
e. IUI- washed sperms are placed in the
uterine cavity at the time of ovulation.
Ovulation detected by follicular growth
monitoring by USS.
 Note:
• These questions were given in the
past OSCEs in various medical
faculties.
• Original slides were modified in good
faith to provide updated & user
friendly presentation.
• Every effort is made to ensure
accuracy of the material. But the
practices can be slightly different.