Mock Examination Short Cases by Dr Param

Dr Param short case script:

- For exposure, I would like to expose from lower border of the breast to the pubic
hair line (do not mention nipple line! It is nonexistent).
- Can either both do running commentary or present after complete the
examination.
- FH use finger breath, mention: for ex FH is at term, as i got 9 fingers breadth above
the umbilicus times by 2 + 22 = 40 weeks of gestation. (if more than or equal to 40
weeks of gestation, dont say the fundal height is at 40 weeks POG but MUST say AT
TERM)
- Present findings in sequences:
1. Singleton fetus
2. Lie
3. Presentation
4. Engagement
5. Fetal back
6. Liquor
7. EFW:
8. Fetal heart sound best heard at ______ [Can use stethoscope to listen to
fetal heart sound (but not with other lecturers)]

1.

37 weeks of gestation came with contraction pain.

What other history need to ask? Leaking liquor, show, fetal movement

Pts came to PAC, how you manage?

o Do CTG to assess for fetal well being

o Pelvic inspection: 1) pelvic assessment 2)Bishop score
o U/S; check AFI, placenta location, confirm presentation and fetal abnormalities.

In preterm contraction ask about UTI sx - dysuria, fever, suprapubic pain,

frequency
CTG normal, os <2cm how you manage? Send pts back, to come again in a
week time, advice about fetal kick chart
Cardiff count to 10 kick chart. How to explain to mother about it.
Causes of pre-term labour: UTI, multiple pregnancy, macrosomic,
polyhydramnios, fetal abnormality
How to conduct 3rd stage of labour


2.

List some of placenta abnormalities: duplex, bipartite, succinate

Twin pregnancy

Findings: There are multiple fetal poles, 3 poles can be palpated at the maternal
right hypochondrium, left hypochondrium and right lumbar region.
- How to confirm twin? By U/S. What to look for in u/s?
o No of fetus
o Placenta location, calcification, size (bigger in twin)
o Liquor vol
o Presentation
o Fetal abnormalities
o Separate sac or not (chorion)
-

In MCMA, if deliver vaginally, risk to 2ndtwin as has risk of:

o Cord prolapsed
o Fetal distress
o Abruption placeta
o obstructed
-

Complication of twin pregnancy

o Maternal: GDM, PE, PP, anemia (iron deficiency & megaloblastic),

o Fetal: twin to twin transfusion, conjoint, trapped twin

3.
-

Breech
In oblique lie, do U/S after examination, not PI first, worry of placenta previa

In oblique cephalic, can opt for stabilizing induction, but condraindicated in pts
that has previous scar-risk of scar rupture
Causes of breech presentation- placenta previa, polyhydramnios, iugr, pre
term, multiple pregnancy, fetal abnormalities
-

Types of breech- flexed, extended, footling

The most dangerous type? Footling. Why? Can cause cord prolapsed

How to manage cord prolapsed?

Cord presentation definition: Cord protrudes below the presenting part before
rupture of membrane

4.
-

Breech
Complication of breech if allow vaginally

How to deliver breech vaginally if os fully-assisted vaginal delivery with forceps

after coming head
-

5.

Pregnant pts with fibroid came with pain: ddx- red degeneration, in labour

Post date + 7 days for IOL

This pts came to PAC, what to do? Do PI for pelvic assessment and bishop score

If unfavourable, admit for induction with prostin (prostaglandin pessary)

PG function: ripen the cervix

Other method of induction in case pts C/I with prostin

i.
Intrauterine extra amniotic injection with normal saline. Use Foley catheter
inserted into cervix, inject with 5- 10 ml of NS every 15 minutes.

ii.

Laminaria tent (made of seaweed)- hydroscopic expansion of cervix

Sweep & stretch not preferable to be done as can trigger amniotic fluid
embolism

Next review, bishop score favourable, send to LR, what further mx?

i.

Put on CTG, partogram

ii.

Active management of labour- IV infusion of oxytocin, and do ARM

iii.

Review 4 hourly

iv.

Review early if indicated, patient want to bear down

Pts fully, how to deliver?

i.

Do VE to confirm os fully

ii.

Position pts in dorsal position

iii.
Ask the patient to push whenever there is contaction, Take a deep breath, pull
both legs, tilt the head and eyes on abdomen, and bear down like you had
constipation.
iv.
When there is crowning (head descent and distend the perineum, head not
retracted back when no contraction), do mediolateral episiotomy
v.
vi.

Then support the perineum when the mother pushing

As anterior shoulder is delivered give IV syntometrine

vii.
Put baby on mothers abdomen (reason: for bonding, colonisation of mothers
bacteria, breastfeeding)
viii.

Clamp the cord then cut the cord using cord cutting scissor

ix.

Take cord blood for thyroid fx test and G6PD

x.

Deliver the placenta

Primary causes of PPH

Uterine atony
Retained placenta or membrane
Injury to cervix/vagina
Coagulation disorder

- Complication of episiotomy
Early: hematoma, infection, wound breakdown
Late: dyspareunia ( if stitch mucosa or muscle wrongly causing fibrosis of muscles)