Final Year Clinical OSCE

for medical undergraduates

Final Year Clinical OSCE

for medical undergraduates

Obstetrics and Gynaecology

Yapa WijeratneFaculty of MedicineUniversity of Peradeniya

Q1

1. Identify A-G2. 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 anunintended pregnancy within the

first year of use

Method Typical use1 Perfect use2

No method4 85 85

Withdrawal 27 4

Periodic abstinenceCalendarOvulation methodSympto-thermal6

Post-ovulation

259321

Condom - Female 21 5

Condom - Male 15 2

Combined pill and minipill 8 0.3

DMPA (Depo-Provera) 3 0.3

IUD (copper T) 0.8 0.6

Mirena (LNG IUS) 0.1 0.1

LNG implants (Norplant) 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 unprotectedintercourse reduces the risk of pregnancy by at least 75%.

2

3

3

4

5

6

1

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.

Q2

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 IUDpregnancyPerforationAcute PIDMenopause – one year after last period

• Absolute contraindications Pregnancy Acute/Chronic PIDAbnormal 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

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?

Q4

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 STDProtection from carcinoma of the Cx

C- Relief of menstrual problems Regularizes previously irregular cyclesDecrease 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

Q51. 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 feeding2. 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 nipplesb) Breast abcess

Q 7

• 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

Q8Give 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. CPDOP position Inadequate uterine contractions

Mx:CPD – Em LSCS

OP positionInadequate uterine contractions

Exclude obstruction

Increase oxytocin infusion rate

Observe and if no progression Em LSCS

Q12 Write a clinical condition where each of these drugs are used

OxytocinAugmentation of labour.Active Mx of 3rd stage labour & control PPH.Following evacuation of uterus.

Mg sulphateAs eclampsia prophylaxis.

HydralazineIn Pre-eclampsia and eclampsia.

ErgometrineProphylaxis against excess heamorrhage foll. deliveryTherapeutic- 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 pain4. Nausea/ Vomiting5. Swelling6. Malaise

Q 15

Write the

names

of the 5

abnormalitie

s you see.

Normozoospermia When all the spermatozoal parameters are normal together with normal seminal plasma ,WBCs and there is no agglutination.

Oligozoospermia When sperm concentration is < 20 million/ml.

Asthenozoospermia Fewer than 50% spermatozoa with forward progression(categories (a) and (b) or fewer than 25% spermatozoa with category (a) movement.

Teratozoospermia Fewer than 30% spermatozoa with normal morphology.

Oligoasthenoteratozoospermia Signifies disturbance of all the three variables (combination of only two prefixes may also be used).

Azoospermia No spermatozoa in the ejaculate.

Aspermia No ejaculate.

Leukocytospermia 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.

1. Identify 2. List 3 prerequisites in using these instruments

3. Give 3 indications for these instruments

Q17

Wrigley’s Forceps

Always prior to applying forceps 1. Abd examination – Head

engaged?2. Confirm that the cervix is fully

dilated 3. Empty the bladder4. Check station of the presenting

part5. 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

1. Name the required instruments in order of use when obtaining a pap smear

2. What is the fixative and the stain used

Q18

1. F - Cusco’s bivalve self retaining vaginal speculum

G - Ayre’s wooden spatulaB - Cytobrush/ Endocervical brushA - 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)

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

Q19

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.

What instruments are used in the following procedures

in order of use

1. Dilatation & Curettage

2. Repair of a cervical tear

Q20

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 22Name following diameters

Q 23 Identify following cervical cerclage techniquesA B

Identify following cervical cerclage techniques

McDonald technique Shirodkar technique

Shirodkar -> I -> Internal Os

Q 24 Identify following patterns of abnormal progress in labor

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

Q25

• Cusco’s bivalve self retaining vaginal speculum

a) Inserting an IUCDb) Obtaining a pap smear

• Sims’ double bladed posterior vaginal speculum

a) Vaginal hysterectomyb) Dilatation and curettagec) Repair of a cervical tear

Q26

Complications • Inter-menstrual bleeding • Pelvic inflammatory disease• Expulsion (1st 3 months)• Perforation

1. Identify 2. List an indication and a

contraindication

Q27

Name of instrument – Ring pessary

Indications for use of vaginal pessarya) Prolapse of uterusb) urinary incontinence c) cystocele d) rectocele

Contraindicationse) Active infections of the pelvis or vagina, such

as vaginitis f) Pelvic inflammatory diseaseg) Patients who are noncompliant or unlikely to

follow up h) Allergy to silicone or latex

Foetal movement chart1. How to advise mother to

maintain a Foetal movement chart

2. When do you call it abnormal3. List 3 causes for reduced FM4. List 3 non invasive tests to

assess foetal well being

Q28

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

Presentation

1. Vaginal bleeding

2. Passage of vesicular grape like structures per vaginum

3. Hyperemesis

4. Early onset PIH

Examination findings

5. Anaemia

6. F>D

Investigations

7. USS abd.

8. S. hCG

9. CXR

Management

10.Evacuation

11.Follow up (2 yrs)- hCG assays

12.Contraception

13.Chemotherapy +/-

• Absence of a foetus (In complete mole)

• “Snow Storm” appearance

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 Testb. Progesterone levels to detect ovulation c. Endometrial biopsyd. HSGe. IUI

Q30

Ovulation

0.5-1 0F (0.2-0.5 0C)

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.