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MRCOG PART 2 SBAs and EMQs

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notes326
EMQ1462
SBA2091
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NA Posted by naila A.

A) I'll  review  her notes to see the weight of the  last delivery  and any intrapartum or post partum complications such as shoulder dystocia ,birth asphyxia or uterine atony.I,ll review the growth pattern of the fetus and growth scan to exclude macrosomia.I'll review partogram and note the pattern of 1st stage of labour ,colour of liqour and use of syntocinon.I'll examine the mother and note her pulse ,temprature ,BP and state of hydration.I'll assess the adequacy of  the analgesia given to her and note if she has an iv line.I,ll do an abdominl examination to assess the fetal size and engagement of fetal head.I'll do pelvic examiantion and note the signs of obstruction such as  caput and moulding of head.I'll look for any mal position or malpresentation .
 B) Maternal request at this stage is an indication for cs.Maternal refusal to undergo operative vaginal delivery in case of fetal distress or maternal exhaustion is an indication to take her for cs.Signs of obstruction that is caput and moulding of fetal head indicate need for cs.Mild cephalopelivc disproprtion assessed clinically or malposition such as occipitotransverse or persistant occipito posterior  with fetal distress should be manged with cs.Malpresentation such as brow or face  in mentoposterior postion is an indication for cs.Breech should be managed with cs.
  C) To reduce maternal morbidity at this stage the cs should be undertaken by an experianced operator .prophylactic antibiotics in the form of single dose of broad spectrum antibiotic should be given.She should be cathterised before operation to reduce the risk of injury to bladder.Abdomen should be opened with low transverese incision to reduce the risk of wound dhescence,infection ,pain and heamatoma formation as compared to vertical abdominal incision . Bladder should be reflected from lower uterine segment to decrease the risk of injury to bladder.Uterus is opened by transverse incision in lower segment taking care that the inA) I'll  review  her notes to see the weight of the  last delivery  and any intrapartum or post partum complications such as shoulder dystocia ,birth asphyxia or uterine atony.I,ll review the growth pattern of the fetus and growth scan to exclude macrosomia.I'll review partogram and note the pattern of 1st stage of labour ,colour of liqour and use of syntocinon.I'll examine the mother and note her pulse ,temprature ,BP and state of hydration.I'll assess the adequacy of  the analgesia given to her and note if she has an iv line.I,ll do an abdominl examination to assess the fetal size and engagement of fetal head.I'll do pelvic examiantion and note the signs of obstruction such as  caput and moulding of head.I'll look for any mal position or malpresentation .
 B) Maternal request at this stage is an indication for cs.Maternal refusal to undergo operative vaginal delivery in case of fetal distress or maternal exhaustion is an indication to take her for cs.Signs of obstruction that is caput and moulding of fetal head indicate need for cs.Mild cephalopelivc disproprtion assessed clinically or malposition such as occipitotransverse or persistant occipito posterior  with fetal distress should be manged with cs.Malpresentation such as brow or face  in mentoposterior postion is an indication for cs.Breech should be managed with cs.
  C) To reduce maternal morbidity at this stage the cs should be undertaken by an experianced operator .prophylactic antibiotics in the form of single dose of broad spectrum antibiotic should be given.She should be cathterised before operation to reduce the risk of injury to bladder.Abdomen should be opened with low transverese incision to reduce the risk of wound dhescence,infection ,pain and heamatoma formation as compared to vertical abdominal incision . Bladder should be reflected from lower uterine segment to decrease the risk of injury to bladder.Uterus is opened by transverse incision in lower segment taking care that the incision is not too low as there is risk in case of second stage cs to open into vagina.Delivery of the head need special care as there is risk of tears in lower segment and risk of injury to fetal head.Uterus need to be relaxed at this stage by the use of appropriate anesthesia for bringing the head gently to incision line.Flexion of wrist should be avoided with head deep down untill it is brought up to incision line.After the delivery of the baby angles should be catched with green armtge before the delivery of placenta to prevent excessive bleeding from angles.Manual removal of placenta should be avoided as it can cause excessive bleeding.Uterus should be stiched in two layers .Stiching of peritonium is not needed for peritonisation . It increase the operative time without added benifit.Skin should be closed with subcuticular stiches as it cause less pain and it is more cosmetic.Post operatively thromboprophylaxis should be given taking care of epidural .Early mobilisation and adequate  hydration should be advised.Early eating prevent paralytic ileus.Dressing should be removed after 24 hours and wound should be kept clean and dry. cision is not too low as there is risk in case of second stage cs to open into vagina.Delivery of the head need special care as there is risk of tears in lower segment and risk of injury to fetal head.Uterus need to be relaxed at this stage by the use of appropriate anesthesia for bringing the head gently to incision line.Flexion of wrist should be avoided with head deep down untill it is brought up to incision line.After the delivery of the baby angles should be catched with green armtge before the delivery of placenta to prevent excessive bleeding from angles.Manual removal of placenta should be avoided as it can cause excessive bleeding.Uterus should be stiched in two layers .Stiching of peritonium is not needed for peritonisation . It increase the operative time without added benifit.Skin should be closed with subcuticular stiches as it cause less pain and it is more cosmetic.Post operatively thromboprophylaxis should be given taking care of epidural .Early mobilisation and adequate  hydration should be advised.Early eating prevent paralytic ileus.Dressing should be removed after 24 hours and wound should be kept clean and dry.