Practical Obstetrics and Gynaecology

General Advice

This chapter is a practical guide to common clinical scenarios you are likely to encounter when working in obstetrics and gynaecology as a medical student or a junior doctor.

• Obstetrics and gynaecology is a unique specialty with its own nuances and quirks. Obstetrics in particular is the only specialty where you will care for two patients at once. Check what you don’t know, especially drug safety and doses, parameters for vital signs, and shorthand abbreviations. PE can mean ‘pre-eclampsia’; MI can mean ‘membranes intact’.

• Ask for help early. You will often be calling for help from seniors, sometimes in the middle of the night and waking them from sleep. Clarify in your opening sentence whether you’re asking for telephone advice or asking for them to attend in person.

• It is a privilege to care for women during experiences such as birth. However, much of what we see is abnormal. Distress is a normal response to an abnormal situation. Acknowledgment of your own emotions is essential to a successful career in O&G.

Common Pitfalls

• Failing to confirm or exclude pregnancy early in your clinical assessment of women in their reproductive years.

  • Urine human chorionic gonadotrophin (hCG) tests are sensitive, but a quantitative hCG from blood is the gold standard with relevance for interpreting ultrasound in the first trimester (see Chapter 6).

  • If a woman has a positive hCG, your next questions are ‘Where is the pregnancy?’ and ‘Is it outside the uterus?’

• Obstetrics is the home of ‘shared decision-making’. It is best to personally review the woman and perform examinations yourself when starting out. Discussing cases with more experienced colleagues and midwives will improve your care. Relying heavily on secondhand clinical information is something that can only be done safely after amassing a great deal of experience.

• Changes to systemic observations in obstetric patients often occur late, and subsequent deterioration can be both sudden and severe.

• Other specialties caring for pregnant women need input from obstetrics to prevent under-treatment and under-diagnosis. Involve your senior colleagues early with these cases.

Acute Lower Abdominal Pain for the Gynaecologist

Acute abdominal or pelvic pain is common reason to be asked to review a woman with a potential gynaecological problem. When asked to review someone in the emergency department, consider:

• Ectopic pregnancy

• Ovarian torsion

• Acute urinary retention

• Haemoperitoneum from a ruptured bleeding ovarian cyst

• Sepsis from a pelvic source

These are the big five which require acute management, but there are other causes of pain to keep in mind.

• A possible ectopic pregnancy can be investigated with an hCG test and ultrasound.

• A possible ovarian torsion is associated with severe pelvic pain requiring opiate analgesia. This is particularly important in the young woman who wishes to preserve her fertility.

• Possible acute urinary retention can be investigated by taking a history and performing an examination. It can be relieved with a urinary catheter.

• A possible haemoperitoneum can be investigated by abdominal ultrasound to look for ‘free fluid’, which is blood in this context.

• PID, which is short for ‘pelvic inflammatory disease’, also stands for ‘probably incorrect diagnosis’—have an open mind about this as an explanation for the patient’s symptoms.