2016B OSCE Unicorns

OBSTETRICS OSCE 2014 REVIEWER

OUTLINE Have the mother lie down (supine/semi-recumbent) with legs
I. Introduction III. Leopolds Maneuver extended.
II. Computations IV. External Exam Procedure:
a. AOG V. Speculum Exam / Pap 1. Place the 0 mark of the tape measure on the uppermost
b. EDC/EDD Smear border of the symphysis pubis.
II. Fundic Height 2. Run the tape measure along the midline of the abdomen to
Measurements the uppermost border of the uterine fundus.
Apply pressure as necessary to identify the fundus.
I. INTRODUCTION Try moving your hand down the abdomen below the
REMEMBER! xiphisternum until you feel the curved upper border.
ALWAYS SAY WHAT YOU ARE DOING! (Narrate whatever it is youre 3. Take note of the measurement in centimeters
up to!)
Describe the ideal, even though it may not be what you are actually Table 1. Expected Fundic Levels at Certain AOG:
doing (our models for skills arent perfect, di ba?) AOG Fundic Level
The examiner may not be looking right at you as he/she is scoring 12 weeks Just above the symphysis pubis
you, and if you dont describe what youre doing, you may lose 16 weeks Halfway between symphysis pubis and
points. umbilicus
For example, youre supposed to put on gloves before you begin
20 weeks At the level of the umbilicus
the Pap Smear. Say, I will now glove my hands, or I will not put
26 weeks 2-3 fingerbreadths above the umbilicus
on gloves.
32 weeks Halfway between umbilicus and xiphoid
You may or may not, depending on the examiner, describe the
process
position of the patient.
36 weeks At the level of the costal margin
II. COMPUTATIONS 40 weeks 1-2 fingerbreadths below the costal margin
AGE OF GESTATION Measurement of the fundic height correlates closely with the AOG
To compute the age of gestation, make sure you know the last between 20 to 34 weeks
menstrual period (LMP). A discrepancy of > 2cm may be suggestive of a fetus that is
o Ask: Kelan po ang unang araw ng huling regla? small/large for gestational age, multiple pregnancies, or inaccurate
o Make sure to refer to the last normal menstrual period EDD.
Count/Add the number of days from the date of the LMP to the
date of consultation. IV. LEOPOLDS MANEUVERS
Reported in weeks. If there is an extra day, report it as x/7 weeks. Most likely, the model will have a normal presentation, but to be
Example: SUPER DUPER EXTRA SURE, palpate the model and identify the fetal
o LMP: May 17, 2014; Consulted: October 13, 2014 parts. The examiners know what presentation the model has.
May 14 You can palpate deeper if you cant feel anything (especially if the
model is made of hard latex)
June 30
Procedure:
July 31
August 31 MANEUVER 1: FUNDAL GRIP
1. Stand by the patients side (preferably her right side), and face
September 30
towards her head.
October 13 2. Place both hands on the fundus and GENTLY palpate the fetal
TOTAL 149 part.
3. DESCRIBE what is felt:
COMPUTE:
Firm and ballotable HEAD
AOG = 21 2/7 weeks
Round, nodular, and soft/doughy buttocks/legs
ESTIMATED DATE OF CONFINEMENT/DELIVERY (EDC/EDD) 4. REPORT what you have palpated. DO NOT SAY THE FETAL
Know the last menstrual period (LMP). PRESENTATION. Just give the fetal part palpated.
o Ask: Kelan po ang unang araw ng huling regla? 5. Proceed to Leopolds 2
o Make sure to refer to the last normal menstrual period
Use Naegeles Rule: - 3 + 7 +1 MANEUVER 2: UMBILICAL GRIP
o Subtract 3 from the month, add 7 to the days and 1 to the 1. Still facing the patients head!
year 2. Place each hand on the sides of the patients abdomen.
Example: LMP: May 17, 2014 3. Exert GENTLE pressure and palpate for the fetal parts
4. Describe what you feel on each side:
05 17 2014
Smooth, curved BACK
-03 +7 +1
Nodular, smaller parts LIMBS
02 24 2015
5. Describe where you will auscultate for fetal heart tone (FHT)
FHT can be heard on the side of the fetal back
III. MEASURING THE FUNDIC HEIGHT
Describe by saying which QUADRANT it can be heard in
Measure this in CENTIMETERS (LLQ, RLQ, LUQ, RUQ)
Make sure that the mother has recently voided, as the fundal 6. REPORT what you have palpated. What side is the fetal back on?
height can be 3cm higher at 17-20 weeks AOG if the mother has a What side are the fetal small parts on?
full bladder. 7. Proceed to Leopolds 3

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 OSCE 2014 REVIEWER
MANEUVER 3: PAWLICKS GRIP Applying downward pressure on the lower margin of the
1. Still facing towards the moms head! vaginal introitus with your index finger can help enlarge
2. Using the thumb and fingers of one hand, palpate for the fetal the opening and ease the insertion of the speculum
part just above the pubic symphysis in the lower abdomen. You Direct the speculum DOWNWARDS as you insert it, and
can move your hand back and forth as you palpate for the fetal stop if there is resistance.
part, especially if the head is still floating (has not yet engaged) Be careful not to pull on pubic hair or pinch the labia with
3. Describe what you feel. This should confirm what you felt in the speculum.
Leopolds 1. 5. Once inside the vagina, gently turn it to a vertical position,
4. Describe if the fetal part is movable or not. making the blades HORIZONTAL.
Not movable ENGAGED At this point, you may remove your finger from the
Movable not yet engaged introitus
5. REPORT that what you felt in Leopolds 1 is confirmed, then 6. Open the blades gently and allow them to cup with cervix so you
report the presenting part. Also, report if the fetus is engaged or can see it in full view. Lock the speculum.
not.
INSPECT THE CERVIX
6. Proceed to Leopolds 4
If you are tasked to do a speculum exam, proceed with the following
steps:
MANEUVER 4: PELVIC GRIP
7. Position the light so that you are able to see the cervix well
1. Turn so that you are facing the patients FEET
8. Note the following characteristics of the cervix:
2. Using both hands, exert DEEP PRESSURE and direct the fingers
a. Color
towards the pelvic inlet.
b. Position
3. With the fetal back as the reference point, describe the position
c. Characteristics of the surgace
of the fetal head.
d. Presence of ulcerations, nodules, masses, bleeding,
If there is greater resistance on the opposite side of the
or discharge
fetal back, the head should be flexed.
Otherwise, you feel the occiput and the head should be OBTAIN SPECIMEN FOR PAP SMEAR
extended. To obtain a specimen for the pap smear, do the following:
What youre looking for is the cephalic prominence. If you 9. Demonstrate where to get the specimen:
feel it on the same side as the fetal small parts, the head ENDOcervix first, then smear onto the slide
is flexed. If it is on the same side of the back, then the ECTOcervix next, and smear it on the slide.
head is extended. 10. To obtain the specimen, you can use:
4. REPORT what you have palpated. If the head is flexed, then the Cervical scrape place the longer end in the cervical os,
fetus is in VERTEX presentation. If the head is extended, it is a then press, turn, and scrape it in a full circle, making sure
FACE presentation to include the transformation zone and squamocolumnar
junction. Smear specimen onto glass slide.
V. EXTERNAL EXAM Endocervical brush use this to obtain a specimen from
You can perform this exam seated so that you dont have to bend the cervical os. Place it in the cervical os and roll it
over the patient between your thumb and index finger, clockwise and
Warn the patient that you will be touching her genital area. Tell her counterclockwise. Smear specimen onto the slide with a
what you will do gentle painting motion.
Procedure: Cotton-tipped applicator used for pregnant women, as
1. Inspect the mons pubis, labia and perineum for any lesions their cervix are more sensitive
2. Separate the labia majora and inspect the labia minora, Cervical broom to obtain specimens for liquid-based
clitoris, urethral meatus and vaginal opening for any lesions cytology
Take note of any inflammation, ulceration, discharge, 11. Take the fixing agent (hairspray), and spray onto the slide from
swelling, or nodules. Palpate any lesions about a foot away.
3. If there is history or apparent swelling of the labia, check 12. Unlock the speculum and close it SLIGHTLY (MAKE SURE YOU DO
the Bartholins glands NOT CLOSE IT COMPLETELY! Baka may maipit!) Turn the
Insert your index finger into the vagina near the speculum so that the blades are vertical, then slide it out.
posterior end of the introitus, and your thumb outside
the posterior part of the labium majus. Palpate each AMSELs CRITERIA
side at approximately the 4-oclock and 8-oclock This is used to diagnose bacterial vaginosis
position. A score of at least 3 of 4 is diagnostic
Take note of any swelling, tenderness, or discharge Criteria:
1. pH > 4.5
VI. SPECULUM EXAM / PAP SMEAR 2. > 20% clue cells on wet mount examination
PROCEDURE 3. (+) Whiff Test
1. Glove your hands. 4. (+) Homogenous, viscous, milky white discharge
You can choose to glove both, since the gloves arent
limited. OR, you can just glove the hand you use for
Internal Exam (IE)
2. Using the middle and index finger, spread the labia.
3. Grasp the handle of the speculum with your other hand.
4. With the speculum still CLOSED, insert it into the vagina

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 2016B OSCE Unicorns
OBSTETRICS OSCE 2014 REVIEWER
APPENDIX A: #50SHADESOFCERVIX
PAP SMEAR RESULTS AND THEIR INTERPRETATION
Symptoms/ Vaginal Clinical Findings Vaginal pH Whiff Test NaCl Wet KOH Wet Mount
Presentation Discharge (Smell Test) Mount
Bacteria Fishy discharge, Homogenous, Discharge >4.5 (+) Clue Cells (-)
Vaginosis itch (sometimes) adherent, milky
white & Fishy
odor
Candidiasis Itch, discomfort Thick, clumpy, Area is 4.5 (-) (-) WBCs only (+) spores and
curd-like, erythematous pseudohyphae
cottage cheese
appearance
Trichomoniasis Itchm discharge, Frothy gray, Erythematous >4.5 (+) Flagellated
mostly yellow-green cervix protozoans
asymptomatic discharge (strawberry
cervix)

APPENDIX B: SAMPLE CASES

1. A 30-year-old female came in for consult on June 5, 2014 for amenorrhea. She noted that her last menses, which started on April 30, 2014 were
shorter in duration and scanty than usual. Prior to that, last March 20, 2014, she had normal menstruation. Pregnancy test is positive.
a. What are the LMP and AOG of the patient
b. When is her EDC?
The patient had 2 previous pregnancies. For her first pregnancy, the patient delivered at 30 weeks due to severe preeclampsia . The baby died at
nd
the nursery soon after birth. For her 2 pregnancy, she delivered a term baby with no complications. The child is now 2 years old.
c. What is her present OB score?

2. A 36-year-old, known case of Antiphospholipid Antibody Syndrome, came in for regular uterine contractions and bloody, mucoid, vaginal
discharge last June 10, 2014. The first day of her last menstruation was September 19, 2013.
a. What is her AOG?
b. When is her EDC?
th th
This is the patients 5 pregnancy, with 3 consecutive abortions for her first 3 pregnancies. She had assisted reproduction for her 4 pregnancy
and delivered live, term twins, both of which are living today.
c. What is her present OB score?

Answers:
1.
a. LMP: March 20, 2014
AOG: 11 weeks
b. December 27, 2014
rd
Note that since the LMP was in March (3 month), you no longer have to add 1 to the year.
c. OB Score: G3P2 (1101)
2.
a. AOG: 37 5/7 weeks
b. EDC: June 26, 2014
c. OB Score: G5P1 (1032)

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