Obstetrics and Gynaecology
Clinical Skills: History, Examination and Documentation
Obstetric and gynaecological history, examination, Leopold manoeuvres, consent and documentation for MBBS, mapped to NMC code OG35.
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Clinical Skills: History, Examination and Documentation
Obstetric and gynaecological history, examination, Leopold manoeuvres, consent and documentation for MBBS, mapped to NMC code OG35.
This chapter builds the clinical, communication and documentation skills central to obstetrics and gynaecology. It covers obstetric and gynaecological history taking, systematic examination including Leopold manoeuvres, gestational age and expected date calculation, emergency recognition and referral, informed consent and ethics, and the writing of case records, discharge summaries and referral notes with infection prevention.
High-yield: Clinical Skills: History, Examination and Documentation
- An obstetric history records the last menstrual period, expected date of delivery, gravidity, parity and the course of the current pregnancy.
- Gravidity is the total number of pregnancies and parity the number of births beyond the age of viability.
- A gynaecological history includes the menstrual, obstetric, contraceptive, sexual and cervical screening history.
- The expected date of delivery is calculated by Naegele's rule, adding nine months and seven days to the first day of the last menstrual period.
- Obstetric abdominal examination assesses fundal height, lie, presentation, position and the foetal heart.
- The four Leopold manoeuvres systematically determine foetal lie and presentation on abdominal palpation.
- Emergency recognition and timely referral of conditions such as eclampsia, haemorrhage and obstructed labour save lives.
- Good communication and counselling with empathy and clear language are core clinical skills in obstetrics and gynaecology.
- Informed consent requires explaining the procedure, its benefits, risks and alternatives in a language the woman understands.
- A structured case record documents the history, examination, diagnosis and management plan clearly and legibly.
- A discharge summary communicates the diagnosis, treatment given and follow-up plan to the woman and other clinicians.
- A referral note conveys the reason for referral, relevant findings and treatment already given to the receiving unit.
- Universal precautions treat all body fluids as potentially infectious and are the basis of infection prevention.
- Medical ethics in obstetrics rests on autonomy, beneficence, non-maleficence, justice and confidentiality.
Clinical skills essentials
- **Obstetric history:** Last menstrual period, expected date of delivery, gravidity and parity.
- **Leopold manoeuvres:** Four palpation steps to determine foetal lie and presentation.
- **Informed consent:** Explain procedure, benefits, risks and alternatives in understandable language.
- **Universal precautions:** Treat all body fluids as infectious; foundation of infection prevention.
NMC competencies in this chapter
- **OG35.1:** Obstetric and gynaecological history taking
- **OG35.2:** Clinical examination and provisional diagnosis
- **OG35.3:** Emergency recognition and referral
- **OG35.5:** Gestational age determination and expected date of delivery
- **OG35.7:** Informed consent
- **OG35.8:** Case record writing
- **OG35.9:** Discharge summary
- **OG35.11:** Universal precautions and infection prevention
Frequently Asked Questions
What is the difference between gravidity and parity?
Gravidity is the total number of pregnancies a woman has had, while parity is the number of births beyond the age of viability. Both are recorded in the obstetric history.
What are the Leopold manoeuvres?
A set of four abdominal palpation steps used to determine the foetal lie, presentation and position, a core skill in obstetric examination.
How is the expected date of delivery calculated?
By Naegele's rule: add nine months and seven days to the first day of the last menstrual period, assuming a regular 28-day cycle.
What are universal precautions?
The practice of treating every patient's blood and body fluids as potentially infectious, using barriers such as gloves and safe sharps handling, the foundation of infection prevention.
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