Medicine

METHODOLOGICAL INSTRUCTIONS

METHODOLOGICAL INSTRUCTIONS

TO PRACTICAL LESSON FOR 5-Th YEAR STUDENTS

OF FACULTY OF FOREING STUDENTS

Content module 2.

LESSON 5 (6 hours)

 

Themes:

1. Operative obstetrics. (2 hours)

2. Lacerations of the birth canal. (2 hours)

 3. Postpartum septic diseases.  (2 hours)

Aim: to learn examination of pregnant patients, to know the indications to operations for preparing birth canal for labor, to learn the indications, conditions and the technique for forceps delivery and vacuum extraction of the fetus, to know the complications of this operations. to learn the biomechanism of labor in deflexed cephalic presentation, recognise the deflexed vertex, brow, face presentation; be able to diagnose anatomically contracted pelvis, to make a plan of labour management in different types of contracted pelvis.

To learn examination, diagnostic, treatment and preventing measures of puerperal sepsis. Understand the danger of the TORCH infections, be able to diagnose, treat and prevent their effects.

Professional orientation of students: in obstetric practice there are cases ( insufficiency  of uterine contraction,  fetal abnormality, hemorrhage, preeclampsia and others) when  is needed to urgently finish the labor. In these cases the operations preparing the birth canal for labor are used. There are some conditions in obstetrics practice which need emergency delivery or exclude of pushing. In such cases forceps delivery are used often. If indications and conditions of the operation are well evaluated, and technique is correct, maternal and fetal risks decreased. Obstetrics forceps is an instrument for traction, not for rotation.

Common management of pregnants with toxoplasmosis, acute Toxoplasmosis, Rubella, Chlamidia, Mycoplasma, Syphillis and other prenatal and postnatal infections and with viral invasion is extremely important.

 

1. Methodology of Practical Class: 9.00-12.00.

Tasks for practical work 1.

·                              To perform amniotomy on phantom.

·                              To perform episiotomy on phantom

·                              To perform perineotomy on phantom

·                              To learn the design and structure of obstetric forceps.

·                              To learn the technique of this operation on phantom.

Tasks for practical work 2.

·                       To measure the external and internal pelvic sizes.

·                       To measure basic and additional pelvic sizes

·                       To evaluate the results of basic and additional methods of pelvic measurement.

·                       To make a diagnosis.

·                       To make a differential diagnosis between different types of contracted pelvis.

·                       To make a plan of investigation and management of pregnancy and labor in different types of contracted pelvis.

·                       To indicate the probable weight of fetus.

·                       To make a plan of management of pregnancy and labor in case of big fetus, preterm labor and prolonged gestation.

Tasks for practical work 3.

·                 To take medical history, perform general examination.

Before beginning the assessment, wash hands thoroughly, assemble necessary equipment, and explain the procedure to the patient.

BLOOD PRESSURE

Measure blood pressure per assessment schedule.

PULSE

Assess rate and regularity.

TEMPERATURE

Determine temperature.

FUNDUS

Put on clean examination gloves. Position woman with knees flexed and head flat. Just below umbilicus, cup hand and press firmly into abdomen. At the same time, stabilize the uterus at the symphysis with the opposite hand. If fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to woman's umbilicus. Lay fingers flat on abdomen under umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between umbilicus and top of fundus. If the fundus is above the umbilicus, this is recorded as plus fb or cm; if below, as minus fb or cm. If fundus is not firm, massage it gently to contract and expel any clots before measuring distance from umbilicus. Place hands appropriately; massage gently only until firm. Expel clots while keeping hands placed. With upper hand, firmly apply pressure downward toward vagina; observe perineum for amount and size of expelled clots.

BLADDER

Assess distention by noting location and firmness of uterine fundus and by observing and palpating bladder. Distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a waterfilled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the woman's right side. Assist woman to void spontaneously. Measure amount of urine voided. Catheterize as necessary. Reassess after voiding or catheterization to make sure the bladder is not palpable and the fundus is firm and in the midline.

 LOCHIA

Observe lochia on perineal pads and on linen under the mother's buttocks. Determine amount and color, note size and number of clots; note odor. Observe perineum for source of bleeding (e.g., episiotomy, lacerations).

PERINEUM

Ask or assist woman to turn on her side and flex upper leg on hip. Lift upper buttock. Observe perineum in good lighting. Assess episiotomy site or laceration repair for intactness, hematoma, edema, bruising, redness, and drainage. Assess for presence of hemorrhoids.  

·                 To evaluate of the results of additional methods investigations, ultrasonography

·                              To make previous diagnosis.

·                              To make plan of treatment of puerperants with septic complications. 

·                              To prescribe medicines for treatment of puerperal sepsis.

·               To prognose  results of each TORCH infections agent’s invasion for fetus, for delivery, for neonatal outcome..

·               To diagnose danger of chronic, acute and first episode of TORCH infection, especially viruses.

·               To make the plan of treatment in different types infectiong.

·               To confirm  the plan of treatment of Toxoplasmosis, Rubella, Chlamidia, Mycoplasma, Syphillis, Cytomegalovirus, Herpes virus.

 

 

2. Individual Students Program.

1.     Clinical signs of threatened perineal rupture.

2.     Indications for perineotomy, episiotomy, amniotomy.

3.     Technique  of perineotomy, episiotomy, amniotomy.

4.     Steps of performing perineotomy, episiotomy.

5.     Steps of performing amniotomy.

6.     Indications for perineotomy, episiotomy, amniotomy.

7.     Analgesia for operations on perineum in labor.

8.     Management of postoperative period in puerperants with sutures on perineum.

9.     Contracted pelvis. Peculiarities of biomechanism of labor in contracted pelvis.

10.               Big fetus. Peculiarities of pregnancy and labor.

11.               Pelvic classification according to form of contractions.

12.               Anatomically and clinically contracted pelvis.

13.               Diagnosis of contracted pelvis.

14.               Pelvic classification according to degree of contraction.

15.               Often occurred contracted pelvis: generally contracted pelvis, flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis.

16.               Principles of pregnancy management in contracted pelvis.

17.               Principles of labor management in contracted pelvis.

18.               Cardinal moments of labor in different types of contracted pelvis.

19.               Vasten’s and Cagenmayster’s sign.

20.               Lacerations of the birth canal.

21.               Etiology and pathogenesis of perineal and cervical lacerations.

22.               The main  microbial agents of puerperal sepsis and their properties.

23.               Classification of puerperal genital tract infection ( after Sazonov and Bartels).

24.               Pathogenesis of puerperal  genital tract infection.

25.               Local  manifestation of septic process in postpartum laceration.

26.               Clinic manifestation of septic process when infected laceration widespread.

27.               Clinic manifestation of peritonitis, endotoxic shock and progressive thrombophlebitis.

28.               Clinic manifestation of general septic process.

29.               Surgery treatment  methods of  puerperal sepsis:

a.     Preparing to operation;

b.     Technique of surgical treatment;

c.      Poostoperative management;

30.               Main principles of medicine treatment of puerperal sepsis:

a.                  Local treatment;

b.                 Antibiotics therapy;

c.                  Desintoxicational  therapy;

d.                 Immunostimulativ therapy;

e.                  Vitamin therapy;

f.     Other therapeutic measures.

 

3. Seminar discussion of theoretical issues 12.30-14.00.

1.     Forceps delivery. Vacuum extraction of the fetus.

2.     The determination of the operation of obstetrics forceps.

3.     The general design of obstetrics forceps.

4.     The indications for application of obstetrics forceps.

5.     The conditions for the operation of obstetrics forceps.

6.     The technique for the operation of obstetrics forceps.

7.     Anesthesia for the operation.

8.     The complications caused by obstetrics forceps.

9.     Classification of perineal and cervical lacerations.

10.   Prevention and  treatment of perineal and cervical lacerations.

11.   Etiology, pathogenesis, and classification  of uterine rupture.

12.   Diagnosis and treatment of different types of uterine rupture by the location and  degree.

13.   Preventive measures of birth canal lacerations.

14.   Disjunction of syphilis, acute uterine inversion. Diagnosis and treatment.

1.        Treatment of septic complications.

2.        Main methods to avoid puerperal sepsis.

3.        Infections at pregnant.

4.        Etiology and pathogenesis of perinatal infections.

5.        Classification of perinatal infections.

6.        Prevention and  treatment of perinatal infections.

7.        Etiology, pathogenesis, and classification  of Toxoplasmosis

8.        Diagnosis and treatment of Chlamidiosis at pregnants.

9.        Preventive measures of perinatal infections.

10.   Laboratory and instrumental metods of perinatal infections diagnosis.

 

4. Test evaluation and situational tasks.

 

Theme: 1. Operative obstetrics.

1. Forceps may be used to:

                A - Rotate the fetal head;

                B - Augment maternal voluntary pushing efforts;

                C - Change the position of the fetal head;

                D -  Flex the fetal head.

2. The application of obstetrics forceps is indicated in such cases:

                A - Preterm labor;

                B - Fetal distress;

                C - Fetopelvic disproportion;

                D - Fetal macrosomia.

3. What are the requirements for the forceps delivery?

      A - Uterine contractions must be present;

                B - The cervix must be fully dilated;

                C - The membranes must be ruptured;

                D - All of the above.

4. Vacuum-extraction may be used to:

A - Rotate the fetal head;

B - Augment maternal voluntary pushing efforts;

C - Change the position of the fetal head;

D - Flex the fetal head.

5. What are the requirements for the vacuum-extraction?

A - Uterine contractions must be present;

B - Cervix must be dilated;

C - Membranes must be ruptured;

D - All of the above.

Theme: 2. Lacerations of the birth canal.

1. First degree of cervical rupture is diagnosed in case:

A. rupture till 2 cm

B. incomplete rupture

C. 3 cm

D. 2 - 3 cm on both sides

E. 4 cm on one side

 

2. Classification of uterine ruptures according etiology:

A. spontaneous, traumatic rupture of the uterus

B. only spontaneous rupture

C. only traumatic rupture

D. only spontaneous threatening rupture

E. all the answers are wrong

 

3. Signs of threatening perineum rupture are:

A. over tension of perineum tissue

B. swelling

C. cyanosis

D. pallor

E. all above

 

 

Theme: 3. Postpartum septic diseases. 

1. The etiology of postpartum pelvic infections is most commonly:

A - Gram-positive aerobes;

B - Gram-negative aerobes;

C - Gram-positive anaerobes;

D - Gram-negative anaerobes;

E – Polymicrobial.

2. All of the following are true statements concerning metritis Except:

A - Fever is a characteristic feature;

B - Uterine tenderness is a characteristic feature;

C - Diminished or absent bowel sounds may indicate an extensive infection;

D - Infection usually is associated with a leukocytosis in the range of 15000-20000 cells/mL.

3. Compared with cesarean delivery, after vaginal delivery, postpartum urinary infections are:

A - Less common;

B - As common;

C - More common.

4. All of the following are characteristics of a pelvic abscess as complication of postpartum metritis Except:

A - Persistent fever;

B - Paradoxical sense of well-being;

C - Localized pain or tenderness on abdominal  examination;

D - Delayed return to gastrointestinal function;

E - Evidence of pelvic mass on imaging.

5. The standard treatment for septic pelvic thrombophlebitis in the postpartum period is:

A - A switch from double- to triple antibiotic therapy;

B - Placement of an inferior vena cava sieve;

C - Empiric treatment with heparin;

D - Administration of fever-reducing drugs and rest.

Real-life situation to be solved:

6. A 27-year-old woman delivered by cesarean section. The patient was afebrile before the surgery and was given one dose of prophylactic antibiotics at the time of umbilical cord  clamping. Her immediate postpartum course is unremarkable. She is bottle feeding and lactation has not begun. On the third postpartum day, she develops a fever to 38,2°C with chills and lower quadrant abdominal pain. Examination reveals a tender uterine fundus and somewhat diminished but not absent bowel sounds. There is a slightly foul lochia, and the cervix is tender to manipulation. The breast are contender. A complete blood count reveals a hematocrit of 29 and a white blood cell count of 14,500 with a left shift. What is the most likely diagnosis  and management?

 

5. Student's individual work from 14.15 till 15.00 hrs.

Students, who have not passed control in «MOODLE» system, should stay for individual work and write test control. Students work with thematic training tables, train in computer class, work with license examination test "KROK" and the department database tests, in-depth study of topics according to an individual study program, etc.

 

6. Student should know:

1.        The structure of case history

1.        Instruments for obstetric operations.

2.        Indications for perineotomy, episiotomy, amniotomy.

3.        Technique of perineotomy, episiotomy, amniotomy.

4.        Management of postoperative period in puerperants with sutures on perineum

5.        The construction of  obstetrics forceps.

6.        The determination of the operation of  obstetrics forceps.

7.        The indications for application of obstetrics forceps.

8.        The conditions for the operation of application of obstetrics forceps.

9.        The techniques for the application of obstetrics forceps.

10.   Anesthesia for the operation.

11.   The complications caused by obstetrics forceps.

12.   Biomechanism of labor in deflexed cephalic presentation.

13.   The definition of biomechanism of the labor.

14.   The classification of deflexed presentation.

15.   The deflexed vertex presentation – diagnosis, the cardinal movements of labor, prognosis, the management of labor.

16.   The brow presentation – diagnosis, the cardinal movements of labor, prognosis, the management of labor.

17.   The face presentation – diagnosis, the cardinal movements of labor, prognosis, the management of labor.

18.   Prognosis and complications of the labor in deflexed presentation.

19.   The deforms of the fetal head in deflexed presentation.

20.   The methods of operative delivery in deflexed presentation.

21.   Etiology and pathogenesis of abnormal development of pelvis.

22.   Sizes of normal pelvis.

23.   Principles of dispensary monitoring for the pregnant women with contracted pelvis.

24.   Methods of pregnant  and puerpera investigation.

25.   Estimation of external and internal pelvic sizes.

26.   Clinic and management of physiologic pregnancy and labor.

27.   Cardinal moments of labor in flexed and deflexed vertex presentations.

28.   Medical and social-biological causes of preterm labor and postterm pregnancy.

29.   The sense of toxoplasmosis, listeriosis, chlamidiasis, mycoplasmosis in preterm labor.

30.   Biological readiness of mother’s organism for labor.

31.   Medical conditions of pregnancy .

32.   What specialist do consult pregnant women?

33.   How often do medical conditions can complicate the course of a pregnancy.

34.   Etiology and pathotogenesis   of puerperal sepsis.

35.   Four  stages of  puerperal sepsis.

36.   Principles of medical and surgical treatment of puerperal sepsis.

37.   Principles of postpartum or postoperative  care of pregnant women with puerperal sepsis.

38.   Predisposing to infections at pregnants.

39.   Classification of TORCH infections.

40.   Symptoms of infections.

 

 

7. Student should be able to:

1.     To take anamnesis from a patient.

2.     To make general physical examination.

3.     To make obstetric examination.

4.     To reveal  the indications for labor preparing operations.

5.        To estimate the dates of looking over of birth canal during I and II periods of labor.

6.        To perform  amniotomy on phantom.

7.        To evaluate the indications and contraindications to the application of obstetrics forceps.

8.        To choose the method of delivery.

9.        To take female history.

10.   To perform external examination of pregnant woman.

11.   Show the cardinal movements of labor in flexed cephalic presentation on phantom.

12.      Measure the pelvis sizes.

13.      Diagnose the beginning of labor.

14.      Count the probable date of labor, probable weigh of the fetus.

15.      Perform examination different organs and systems of patient.

16.      To evaluate the results of additional methods of pelvic measurement.

17.      To make a diagnosis.

18.      To make a differential diagnosis between different types of contracted pelvis.

19.      To make a plan of investigation and management of pregnancy and labor in different types of contracted pelvis.

20.      Make a diagnosis of preterm labor and postterm pregnancy.

21.      To elect the doctor’s tactics and the most appropriate therapy in case of the menace of the pregnancy interruption.

22.      Plan of management of the pregnant patients with different medical illnesses.

23.      Plan the treatment of the pregnant patients with different medical illnesses.

24.      Plan the delivery of the pregnant patients with different medical illnesses.

25.      Plan the postpartum care of the pregnant patients with different medical illnesses.

26.      To take history  and conduct the general and obstetric examination.

27.      To evaluate the information from additional methods of examination.

28.      To diagnose  of puerperal sepsis.

29.      To conduct differential diagnosis  with extragenital causes of fever.

30.      To prescribe medicines for treatment of puerperal sepsis.

31.      To conduct special measures to avoid of puerpereal sepsis.

32.       To prognose  results of each TORCH infections agent’s invasion for fetus, for delivery, for neonatal outcome.

33.       To diagnose danger of chronic, acute and first episode of TORCH infection, especially viruses.

34.       To make the plan of treatment in different types infectiong.

35.       To confirm  the plan of treatment of Toxoplasmosis, Rubella, Chlamidia, Mycoplasma, Syphillis, Cytomegalovirus, Herpes virus.

36.         To interpret results of pregnancy sonogram and immunologic tests.

 

 

8. Correct answers of test evaluations and situational tasks:

I

1 – B;

2 – B;

3 – D;

4 – B;

 5 – D.

 

II

1.     A

2.     A

3.     E

 

III

1. A, C, D. 2. C, D, E. 3. A, C, D. 4. The pregnancy should be interrupted by hysterotomy. Sterilization is to be performed. 5. The pregnancy should be interrupted by suction curettage.    

1. A. 2. D. 3. B.4. Suturing of the cervix after bringing it into vie at the vulva by speculum.  The first suture is applied above 1-2 cm of the angle of the wound and suture outward. 5. Mediolateral episiotomy is indicated

 1. E. 2. B. 3. A. 4. B. 5. C. 6. Metritis is highly likely. Pelvic abscess is possible but it is early for this to develop. Septic pelvic thrombophlebitis is possible but likewise unlikely at this time. Management at this time should include single-agent antibiotic therapy.

 

 

9. References:

The main:

1.     Obstetrics and gynaecology. Williams & Wilkins Waverly Company. – Third Edition.- 1998. – P. 237 - 246.

2.     Danforth’s Obstetrics and gynaecology. - Seventh edition.- 1994. – P. 351 – 464.

3.     Basic Gynecology and Obstetrics. – Norman F. Gant, F. Gary Cunningham. – 1993. – P. 444 - 456.

4.     Obstetrics and gynecology. – Pamela S.Miles, William F.Rayburn, J.Christopher Carey. – Springer-Verlag New York, 1994. – P. 74 - 77.

5.     Operative obstetric

 

Additional:

1.     Order № 503 from 28.12.2002 «Improvement of ambulatory obstetric-gynecological help».

2.     Order № 582 from 15.12.2003 «Clinical protocols from the obstetric and gynecological help».

3.     Order № 620 from 29.12.2003 «Organization of grant of stationary obstetric-gynecological and neonatal manuals».

4.     Order № 676 from 31.12.2004 «Clinical protocols from the obstetric and gynecological help».

5.     Order № 782 from 29.12.2005 «Clinical protocols from the obstetric and gynecological help».

6.     Order № 234 from 10.05.2007 «Instruction of organization bacteriological laboratories in the infectious checking system in obstetric permanent establishments».

7.     Order № 906 from 27.12.2007 the «Perinatal infections».

8.     Order № 901 from 27.12.2006 «Postdate pregnancy».

9.      Order № 900 from 27.12.2006 «Fetal distress at pregnancy  and during births».

10.             National program for prevention HIV- infection, treatment care and supporting HIV – patients in 2009-2013years – adopted 19.02.2009.

11.             Order  № 716 from 14.11.2007 “Prevention of HIV transmission from mother to infant” .

 

 

Methodical instruction has been worked out by: Korda I.V.

 

Methodical instruction was discussed and adopted at the Department sitting

27.05.2011. Minute № 13

Methodical instruction was reviewed and adopted at the Department sitting

24.05.2012. Minute № 13

Methodical instruction was discussed and adopted at the Department sitting

23.05.2013. Minute № 10

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute № __

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute № __

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute № __

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute № __