Index

MRCOG Part 1: Clinical Skills & Surgical Principles — Comprehensive Deep-Dive Study Guide

Exam Weighting: Moderate (Clinical Skills 15–20 Qs + Core Surgical Skills 5–10 Qs) Scope: History taking, clinical examination, investigations, clinical decision-making, surgical principles, consent, instruments, basic procedures, risk management Format: Tables, clinical scenarios, mnemonics, exam pearls

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Table of Contents

1. Clinical History & Examination
2. Investigations & Data Interpretation
3. Clinical Decision-Making & Risk Assessment
4. Principles of Safe Surgery
5. Surgical Anatomy & Common Procedures
6. Surgical Instruments & Sutures
7. Informed Consent & Medico-Legal
8. Risk Management & Patient Safety
9. Perioperative Care
10. Appendix: High-Yield Exam Facts & Mnemonics

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1. Clinical History & Examination

1.1 Obstetric History

Detailed Obstetric History Components — with clinical reasoning:

History Component	What to Ask & Why	Clinical Decision This Informs
Maternal age	<16: safeguarding; >35: increased trisomy, PET, GDM; >40: increased CS, maternal death risk	Referral for screening, consultant-led care
Parity definition (UK)	Para = number of previous pregnancies ≥24 weeks (viable); parity = term + preterm births	Antenatal pathway; nulliparous vs multiparous risks differ
Obstetric History — detailed per pregnancy	Year, gestation, mode of delivery (SVD, instrumental, CS — elective/emergency), indication for intervention, complications (PET: BP, proteinuria, gestation of onset; GDM: diet-controlled vs insulin; PPH: estimated blood loss, cause; Shoulder dystocia: birth weight, manoeuvres needed; Perineal trauma: degree), baby birth weight, sex, outcome (alive, stillbirth, NND), neonatal problems (NICU, jaundice, hypoglycaemia)	Predicts recurrence risk — e.g., previous CS → VBAC trial vs ERCS; previous severe PET → aspirin 75mg from 12wk; previous GDM → early GTT at 16-18wk; previous shoulder dystocia → avoid induction, elective CS?
Gynaecological history	Fibroids (previous myomectomy? — rupture risk in labour), endometriosis (previous surgery, symptoms — may affect fertility, dyspareunia, chronic pain), infertility (duration, investigations, treatment: ovulation induction, IVF, donor egg — generates enormous catalogue of information needed for the pregnancy)	Informs mode of delivery, anaesthetic plan, need for serial growth scans
Medical History — deeper probes	Hypertension: pre-existing vs gestational, target BP, medications (ACEi/ARBs → discuss high-risk), end-organ damage?). Diabetes: type 1 vs 2, duration, control (HbA1c), complications (retinopathy, nephropathy, neuropathy) — retinopathy screening in pregnancy. Cardiac: congenital, valvular, ischaemic, NYHA class, medications — planned delivery in cardiac centre. Renal: CKD stage, creatinine clearance, proteinuria. Thrombophilia: previous VTE, type of thrombophilia, anticoagulation plan. Epilepsy: seizure type, frequency, AED levels, last seizure. Asthma: step-up plan, steroid use, acute management. Autoimmune: SLE, APS, RA — disease activity, serology (Ro/La, aPL), medications. Mental health: antenatal/postnatal depression, bipolar, psychosis, current medication, perinatal mental health team involvement	Determines place of care (tertiary vs DGH), anaesthetic assessment, need for critical care planning
Surgical History — details	CS (number, indication, type of incision — low transverse vs classical — classical = uterine rupture risk in labour, need elective CS at 37-38wk), myomectomy (open vs laparoscopic? — full-thickness breach? — risk of rupture), laparoscopy (indication, entry technique, complications), colposcopy/LLETZ (depth of excision, CIN grade — risk of cervical incompetence), appendicectomy (Pfannenstiel vs McBurney — adhesions?), bladder/ureteric surgery (incontinence surgery, TVT/TOT — may need CISC postpartum)	Vaginal birth after CS (VBAC) decision, risk of cervical weakness, need for cervical length surveillance
Drug history — specific	Folic acid 400μg daily (or 5mg if diabetic, on AEDs, previous NTD, coeliac, or BMI >30), aspirin 75mg (if PET risk), LMWH (if thrombophilia/previous VTE), thyroid replacement (check TSH), insulin, steroids, immunosuppressants, biologics, AEDs (especially lamotrigine — pregnancy increases clearance, dose adjustment needed), antidepressants (SSRIs — lowest effective dose, paroxetine associated with fetal cardiac defects, avoid in pregnancy), antihistamines, antibiotics	Dose adjustments needed? Third-trimester adjustment? Need for monitoring (AED levels, TFTs, HbA1c)

Obstetric Abbreviations & Shorthand: - GTPAL (Gravida, Term, Preterm, Abortions, Living) - Parity = number of previous pregnancies ≥24 weeks (UK definition) - Miscarriage = pregnancy loss <24 weeks (UK definition) - Stillbirth = baby born with no signs of life ≥24 weeks - Neonatal death = death within first 28 days of life - Perinatal death = stillbirths + early neonatal deaths (first 7 days) - PMH / POH / PGH / SH / DH / FH — standard abbreviation

1.2 Gynaecological History

Key Components:

Component	Key Details
Presenting Complaint	Bleeding (heavy, irregular, intermenstrual, postcoital, postmenopausal), pain (dysmenorrhoea, dyspareunia, pelvic pain), discharge, prolapse, urinary symptoms, infertility, mass
Menstrual History	Menarche, cycle length & regularity, duration, volume (pictorial blood loss assessment chart — PBAC), dysmenorrhoea, intermenstrual bleeding, postcoital bleeding, LMP
Menstrual Definitions	Menorrhagia (>80mL blood loss / >7 days), polymenorrhoea (<21 days), oligomenorrhoea (>35 days), amenorrhoea (primary: no menarche by 16yr; secondary: >3-6 months no menses), metrorrhagia (irregular interval), intermenstrual (between periods), postcoital (after sex), postmenopausal (>12 months after menopause)
Obstetric History	As above
Contraceptive History	Current and past methods, satisfaction, side effects, why changed
Cervical Screening	Date of last smear, result, colposcopy history, HPV vaccination
Sexual History	Dyspareunia (superficial vs deep) — superficial suggests vulval/vaginal cause; deep suggests endometriosis/PID/adnexal pathology
Urinary Symptoms	Frequency, urgency, nocturia, incontinence (stress, urge, mixed), hesitancy, incomplete emptying, dysuria, haematuria
Bowel Symptoms	Constipation, tenesmus, incontinence, prolapse-related
Menopausal Symptoms	Vasomotor (hot flushes, night sweats), urogenital atrophy (vaginal dryness, dyspareunia, recurrent UTIs), mood changes, sleep disturbance, libido
Past Medical & Surgical	As above, with specific: DVT/PE, osteoporosis, breast disease, cancer

1.3 Clinical Examination in O&G

Obstetric Examination:

Examination Component	What to Assess
General	BP, pulse, temperature, O2 saturations, pallor, oedema
Abdominal	Fundal height (gestational age in cm from 20wk), lie (longitudinal/transverse/oblique), presentation (cephalic/breech/shoulder), engagement (fifths palpable), FHR, scar tenderness, uterine tone (soft/hard/relaxing between contractions), tenderness, palpable contractions
Vaginal (in labour)	Cervical dilatation, effacement, station, position, consistency, membranes intact/ruptured, colour of liquor (clear/meconium/blood), presenting part, caput, moulding, pelvic assessment
Postnatal	Uterine involution (fundal height decreasing ~1cm/day), lochia (rubra/serosalba/alba), perineum/episiotomy/CS wound, breasts, legs (DVT signs), mental state
Cervical Screening	Speculum examination, cervix visualised, ectropion, polyp, discharge, lesions

Gynaecological Examination:

Examination Component	What to Assess
General	BMI, BP, pallor, thyroid, hirsutism, acanthosis nigricans, and hair distribution, breast exam
Abdominal	Masses (distinguish pelvic vs abdominal), tenderness, ascites, scars, hernias
Speculum	Vaginal walls (atrophy, discharge, lesions), cervix (ectropion, polyps, contact bleeding, discharge, os appearance), swabs
Bimanual	Uterus (size, shape, position — anteverted/retroverted/axial, tenderness, mobility), adnexae (masses — size, shape, tenderness, fixity, nodularity), pouch of Douglas (tenderness, nodularity), cervical excitation
Rectal (occasional)	Rectocele, mass, blood, sphincter tone
Pelvic Organ Prolapse Quantification (POP-Q)	Points: Aa/Ba (anterior), C (cervix/cuff), D (posterior fornix), Ap/Bp (posterior), GH (genital hiatus), PB (perineal body), TVL (total vaginal length)

1.4 Patterns of Symptoms — Clinical Reasoning for MRCOG Part 1

Common Clinical Presentations:

Presentation	Key Differential Diagnoses	Key Discriminator(s)
Postmenopausal bleeding	Atrophic vaginitis (most common), endometrial cancer, HRT-related, cervical polyp, cervical cancer, vaginal cancer	TVS endometrial thickness <4mm = low risk; >4mm → outpatient hysteroscopy + biopsy
Heavy menstrual bleeding (HMB)	Fibroids (submucosal most symptomatic), adenomyosis, endometrial polyp, anovulation/endometrial hyperplasia, PID, coagulopathy (von Willebrand's most common), IUD, thyroid disease	TVS, SIS, hysteroscopy; PBAC score >100
Acute pelvic pain	Ectopic pregnancy (adnexal mass + positive hCG ± rupture), ovarian cyst accident (rupture, haemorrhage, torsion — twisted pedicle, dermoid most likely to torsion), PID (bilateral pain + discharge + fever), appendicitis, UTI, renal colic, degenerating fibroid (pregnancy), endometritis, miscarriage	Pregnancy test FIRST; then TVS, FBC, CRP
Chronic pelvic pain	Endometriosis (70% — cyclical pain, deep dyspareunia), PID/adhesions, adenomyosis, ovarian cysts, IBS (pain related to bowel), pelvic congestion syndrome (pain worse on standing, dull ache), musculoskeletal, psychological	Laparoscopy gold standard for endometriosis; TVS for structural causes
Vaginal discharge	Physiological, bacterial vaginosis (thin, grey, fishy), candidiasis (thick, white, itchy), trichomoniasis (green, frothy, offensive), chlamydia/gonorrhoea (mucopurulent), cervical ectropion, foreign body, fistula	Swabs (HVS, NAAT for CT/NG); microscopy
Urinary incontinence	Stress (SUI — 55%: coughing, sneezing, exercise — urethral hypermobility or ISD), urge (UUI — 30-40%: detrusor overactivity), mixed (15%), overflow (retention — diabetes, MS), total (fistula)	History + bladder diary + 1h pad test; urodynamics if surgery planned
Infertility (female)	Anovulation (PCOS 30%, hypothalamic, hyperprolactinaemia), tubal disease (PID, endometriosis, previous ectopic), endometriosis (30% of infertile), advanced age, fibroids (submucosal), uterine anomaly, cervical factor	Day 21 progesterone, AMH, FSH/LH, TVS, HSG/HyCoSy, laparoscopy + dye
Infertility (male)	Abnormal sperm (oligo/astheno/teratozoospermia — 40% of couples), azoospermia (obstructive vs non-obstructive), varicocele (most common correctable cause), hypogonadism, genetic (Klinefelter, Y microdeletion), sexual dysfunction	Semen analysis (WHO criteria: >15M/mL, >32% progressive motility, >4% normal morphology)

1.5 Abdominal Examination — Detailed

Inspection: Scars (Pfannenstiel, midline, transverse, laparoscopy ports, C-section, hernia repair), distension (obesity, pregnancy, ascites, mass, bowel obstruction), striae gravidarum, linea nigra, caput medusae, hernias (umbilical, incisional, inguinal, femoral — palpate for inguinal hernia via canal, femoral below inguinal ligament)

Palpation: - Superficial: Guarding, tenderness, masses - Deep: Organomegaly (liver, spleen — measure in cm), pelvic masses (distinguish uterus from adnexal), ballotment (pregnant uterus = fluid thrill) - Obstetric specific: Symphysis-fundal height (SFH in cm = gestational age ± 2 from 20-36wk), Leopold's manoeuvres: (1) fundal pole (2) fetal back (3) presenting part (4) descent

Percussion: Shifting dullness (ascites >500mL), dullness over mass/pregnancy, tympany over bowel

Auscultation: FHR (Doppler from 12wk, Pinard stethoscope from 20wk), bowel sounds

Special Tests: Ballotement, fluid thrill, shifting dullness

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2. Investigations & Data Interpretation

2.1 Haematology

Test	Pregnancy Normal	Non-Pregnant Normal	Clinical Significance
Hb	110-140 g/L (physiological fall in 2nd tri)	120-160 g/L	Anaemia (<110g/L in pregnancy, <105 if severe)
MCV	80-100 fL	80-100 fL	Microcytic: iron deficiency, thalassaemia; macrocytic: B12/folate deficiency
WCC	6-16 x 10⁹/L (↑ in labour/postpartum)	4-11 x 10⁹/L	Leucocytosis in infection; raised in labour
Platelets	Normal-mild decrease (gestational thrombocytopenia), 100-400	150-450	<100: ITP, PET, HELLP, DIC
Ferritin	>15-30 μg/L; low = iron deficiency	30-150 μg/L	Acute phase reactant, falsely high in inflammation
B12	Decreased (physiological) >150 ng/L	200-900 ng/L	Deficiency: macrocytic anaemia, neurological
Folate (RBC)	>340 nmol/L	340-1400 nmol/L	Deficiency: megaloblastic, NTD risk
Fibrinogen	4-6 g/L (↑ 50%)	2-4 g/L	↓ in DIC, massive haemorrhage; ↑ in pregnancy baseline
D-dimer	Elevated normally in pregnancy (not useful)	<500 μg/L	Limited utility in ruling out VTE in pregnancy
Blood group + Ab	As per booking	—	Anti-D needed for RhD-negative if partner RhD+

2.2 Biochemistry

Test	Non-Pregnant Reference	Pregnancy Reference	Notes
Urea	2.5-7.5 mmol/L	2.0-5.5 (decreased)	Decreased due to increased GFR
Creatinine	60-110 μmol/L	35-75 μmol/L (decreased)	Pregnancy GFR +50%, so Cr lower
Uric acid	150-350 μmol/L	May rise to term	↑ in preeclampsia (300+), helps differentiate PET from other causes
ALT/AST	10-40 IU/L	Similar or slightly decreased	↑ In PET/HELLP (ALT usually higher than AST in PET), AFLP, viral hepatitis, cholestasis
Bilirubin	<21 μmol/L	Similar	↑ in HELLP, AFLP, cholestasis
Bile acids	<10 μmol/L	Normal <14	↑ in intrahepatic cholestasis of pregnancy (ICP) >10-14, severe >40
Albumin	35-50 g/L	25-35 g/L (decreased)	Decreased due to haemodilution
CRP	<5 mg/L	May be slightly ↑	Useful with caution; acute phase response
hCG	<5 IU/L	Varies by gestation	Doubles ~48h in early pregnancy; peaks 8-10wk
PAPP-A	—	1.0 MoM average (lower in trisomy 21 risk)	Combined test marker
β-hCG	<5 IU/L	Free β-hCG MoM in combined test	↑ in trisomy 21, molar pregnancy
Oestriol	—	Unconjugated in quadruple test	↓ in trisomy 18 and 21
Inhibin A	—	↑ in trisomy 21	Quadruple test component
AFP	<10 kU/L	↑ in NTD (≥2.5 MoM); ↓ in trisomy 21/18	Quadruple test, anencephaly, open NTD, multiple pregnancy

2.3 Arterial Blood Gas & Acid-Base

Parameter	Normal Non-Pregnant	Normal Pregnancy	In Labour
pH	7.35-7.45	7.40-7.45 (slight alkalosis)	7.40-7.45 (maternal)
PaO₂	11-13 kPa	13-14 kPa (↑)	Similar
PaCO₂	4.7-6.0 kPa	3.7-4.2 kPa (↓)	3.5-4.0
HCO₃-	22-28 mmol/L	18-22 mmol/L (compensated)	Similar
Base excess	-2 to +2	-3 to 0	May be lower

Cord Blood Gases (Normal Ranges): - Umbilical Artery (UA) — reflects fetal/metabolic status: | Parameter | Normal Range | |-----------|-------------| | pH | 7.15-7.35 (mean 7.27) | | pCO₂ | 5.3-8.5 kPa | | pO₂ | 1.0-3.5 kPa | | Base deficit | 2-8 mmol/L (<12 considered abnormal) | | Lactate | 1-5 mmol/L (>8 suggests compromise) |

• Umbilical Vein (UV) — reflects placental/maternal status: | Parameter | Normal Range | |-----------|-------------| | pH | 7.25-7.45 (mean 7.34) | | pCO₂ | 3.8-5.8 kPa | | pO₂ | 2.5-6.0 kPa | | Base deficit | 1-5 mmol/L |

• UA-UV difference: Normally pH difference <0.02-0.03. Larger difference >0.15 suggests acute cord compression with respiratory acidosis

• Type of Acidosis:
• Respiratory: ↑ pCO₂, normal base deficit — acute cord compression, maternal hypoventilation
• Metabolic: ↓ pH, ↑ base deficit — tissue hypoxia, anaerobic metabolism — more significant
• Mixed: Both ↑ pCO₂ and ↑ base deficit — most common in significant HIE

2.4 Urine Analysis

Test	Normal	Abnormal	Clinical Concern
Protein	Negative/trace	≥1+ (≥0.3 g/L)	PET screen (urine PCR / 24h <300mg normal), UTI
Glucose	Negative	Glycosuria common in pregnancy	GTT if persistent/fasting
Ketones	Negative	+++	Hyperemesis, starvation, DKA
Blood	Negative	+	UTI, stones, glomerular, menses
Nitrites	Negative	+	UTI (specific but not sensitive)
Leucocytes	Negative	+	UTI (sensitive but not specific)
Leucocyte esterase	Negative	+	UTI screen
Specific gravity	1.005-1.025	—	Reflects hydration

24-hour Urine Collection: - Protein: <300 mg/day normal; 300-5000 mg/day moderate; >5000 mg/day severe (nephrotic range) - UTI: >10⁵ CFU/mL of a single organism - Cortisol: 6-42 nmol/24h (may increase in pregnancy)

2.5 Microbiology Swabs

Test	Indication	Interpretation
HVS (High Vaginal Swab)	Discharge, BV screen	Gram stain: Lactobacilli = normal, Gardnerella + clue cells = BV
NAAT (CT/NG)	Screen for Chlamydia/ Gonorrhoea	Positive = treat + contact tracing
GBS swab (vaginal + rectal)	35-37wk screen (selective UK)	Positive = IAP in labour
Low vaginal swab (LVS)	Routine booking including trichomonas	—
Endocervical swab	Chlamydia (NAAT)	Most sensitive for CT
Urethral swab	Gonorrhoea (culture)	In symptomatic males; urethral for Neisseria
First-catch urine	Chlamydia screen (NAAT)	Non-invasive CT screen
Mid-stream urine (MSU)	UTI screen	Culture + sensitivity
Perianal swab	GBS screen; threadworm	—
Virology	HSV (vesicle fluid), VZV (vesicle base)	Viral PCR, electron microscopy, serology
Trichomonas	HVS wet mount	Motile flagellates
Fungal	HVS microscopy	Pseudohyphae in candida

2.6 Hormonal Assays

Hormone	When to Measure	Interpretation
FSH	Day 2-5 of cycle	>10 IU/L: reduced ovarian reserve; >25 IU/L: perimenopause; >40 IU/L: postmenopausal
LH	Day 2-5	LH:FSH ratio >2:3 suggestive of PCOS
Oestradiol	Day 2-5	<100 pmol/L: low, as in menopause; 200-600 pmol/L: good follicular phase; peak >200 pmol/L triggers LH
Progesterone	Day 21 (7 days before next period)	>30 nmol/L confirms ovulation; >10 nmol/L suggests ovulation may have occurred
Testosterone	Random (morning)	Total + SHBG + calculated free androgen index (FAI = total T/SHBG x 100). ↑ in PCOS, CAH, tumour
17-OHP	Random (morning, follicular phase)	>30 nmol/L (basal) suggests 21-hydroxylase deficiency; ACTH stimulation test for confirmation
Prolactin	Random (fasting, avoid stress/breast exam)	>500 mIU/L but <1000 mIU/L: mild elevation (stress, drugs, hypothyroidism, PCOS); >2000: prolactinoma
AMH	Random (any cycle day)	<5 pmol/L = low reserve; >35 pmol/L = high (PCOS). Age- and lab-specific reference
TSH	Any day	0.35-4.94 mIU/L non-pregnant; 0.3-3.0 first tri; 0.3-3.0 pregnancy 2022 RCOG guidance: TSH <2.5 in first tri
Free T4	With TSH	9-19 pmol/L
Vitamin D	Any	25-OH D3 >50 nmol/L sufficient; <25 nmol/L deficient; 30-50 insufficient
hCG	Quantitative β-hCG	Via gestation chart; serial q48h in early pregnancy

2.7 Urine hCG & Pregnancy Testing

• Urine hCG: Positive from ~10-14 days post-conception (before missed period)
• Sensitivity: Most home tests detect 25 IU/L
• Serum β-hCG: Detected from day 8-9 post-ovulation
• Discriminatory zone: β-hCG ~1500-2000 IU/L = intrauterine gestational sac should be visible on TVS
• Doubling time: ~48h in early pregnancy (until 6000 IU/L); slower after

2.8 Imaging Interpretation

Imaging	Key Interpretation Principles
TVS — Early Pregnancy	GS at 4.5-5wk, yolk sac at 5wk, fetal pole at 5.5-6wk, cardiac activity at 6wk, CRL 7-13wk for dating
TVS — Follicular Tracking	Lead follicle 18-24mm at ovulation; endometrial thickness >7mm
TVS — Endometrial Thickness	<4mm postmenopausal = low cancer risk; 5-15mm proliferative; >15mm suspicious if unopposed oestrogen or PMB
HSG	Uterine cavity shape, tubal patency, peri-fimbrial spill; spill delayed/failed = proximal/distal tubal block
SIS/Sonohysterography	Focal (polyp, fibroid) vs global (thickened lining) endometrial lesions
CT (non-OB)	Hounsfield units: air -1000, fat -100, water 0, soft tissue +40-80, bone +400-1000, calcification +100-400
MRI	T1: fat bright, fluid dark; T2: fluid bright, fat variable. Uterine zones visible on T2: junctional zone (inner myometrium) <12mm
Mammogram	Mass, microcalcifications (malignant: pleomorphic, branching), asymmetry, distortion

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3. Clinical Decision-Making & Risk Assessment

3.1 Clinical Reasoning — Key Principles

History-taking Patterns: - Obstetric emergencies: Always assess ABC; first 5 minutes critical - Gynaecological emergencies: Rule out pregnancy FIRST (always check β-hCG) - Pelvic pain: Ectopic must always be considered in reproductive-age woman

Key Clinical Questions to Ask for Common Presentations:

Symptom	Must-Ask Questions
Vaginal bleeding in early pregnancy	Amount? Clots? Pain? Tissue passed? Shock symptoms? Known pregnancy? Previous scan?
Abdominal pain in pregnancy	Onset? Site? Radiation? Relation to contractions? Vaginal bleeding? Fetal movements? Nausea/vomiting?
Headache (late pregnancy)	BP? Timing? Severity? Neurological symptoms? Vision changes? Epigastric pain?
Shortness of breath (pregnancy)	Onset? Severity? Chest pain? Cough? Oedema? PMH—asthma, PE, cardiac?
Reduced fetal movements	Gestation? When last felt? Pattern? Risk factors (FGR, smoking, PET)? CTG now!
Postmenopausal bleeding	Onset? Amount? One-off or recurrent? HRT? Tamoxifen? Previous normal smear?
Acute urinary retention	Recent surgery? Medication? Constipation? Fibroids? Prolapse? Neurological?

3.5 Clinical Reasoning in Specific Obstetric & Gynaecological Scenarios

Acute Abdomen in Pregnancy:

Condition	Presentation	Investigation	Management
Appendicitis (most common non-obstetric surgical emergency in pregnancy)	RIF pain (may be higher in 3rd tri), N&V, fever, tachycardia	Ultrasound (graded compression), MRI if inconclusive (no ionising radiation), avoid CT unless essential and discussion with radiologist	Laparoscopy (1st/2nd tri) or laparotomy (3rd tri); open procedure over McBurney's; proceed even if diagnosis uncertain — perforation increases maternal/fetal mortality
Adnexal torsion	Sudden severe unilateral lower abdominal pain, N&V, may radiate to flank/thigh; peritonism; mass on US	TVS + Doppler (absence of blood flow suggestive but not diagnostic, 60% sensitive); US may show enlarged oedematous ovary, 'whirlpool sign' of twisted pedicle	Emergency laparoscopy — detorsion (even if black — function recovers); oophoropexy; oophorectomy only if frankly necrotic; recurrence ~2-5%
Ovarian cyst haemorrhage/rupture	Acute onset pain after intercourse/exercise, peritonism, may have shock	US with free fluid in POD, FBC (falling Hb), pregnancy test (ectopic excluded)	Resuscitate; diagnostic laparoscopy if unstable or diagnostic doubt; conservative if haemodynamically stable and no mass
Degenerating fibroid (red/carneous degeneration)	Localised pain over fibroid, mild fever, low-grade tenderness, pregnant uterus	US: fibroid with heterogeneous echotexture, no Doppler flow in central avascular area; FBC: mild WCC rise, normal CRP/CRP may be high	Supportive: analgesia (paracetamol, NSAIDs avoided in 3rd tri), rest; rarely requires surgery (if suspicion of torsion/pedunculated)
Ureteric colic	Loin-to-groin colicky pain, haematuria	US (sensitivity lower in pregnancy — physiological hydronephrosis), MRI urography	Conservative (fluids); if obstructed: ureteric stent or nephrostomy

3.6 CTG Interpretation — Clinical Decision-Making Framework

FIGO 2015 3-Tier CTG Classification:

Category	Baseline (bpm)	Variability (bpm)	Decelerations	Interpretation	Action
Normal	110-160	5-25	No decelerations or early decelerations	Fetus not hypoxic	Continue monitoring; consider conservative measures if risk factors present
Suspicious	100-110 or 160-170	<5 for 40-90 min or >25 for 30 min	Variable decelerations present but not pathological (lasting <60 sec, not dropping <60 bpm, recovering quickly); Late decelerations with normal variability	May represent fetal hypoxia; requires evaluation	Conservative measures: left lateral, IV fluids, O₂, stop oxytocin, consider tocolysis if hyperstimulation; assess progress of labour
Pathological	<100 or >170 (persistent)	<5 for >90 min; sinusoidal pattern (>10 min)	Variable decelerations: severe (>60 sec, <60 bpm); Late decelerations absent variability; Atypical variable; Prolonged deceleration (>3 min but <10 min)	Fetal acidosis likely; requires urgent intervention	Immediate action: conservative measures + FBS if feasible (pH <7.20 → expedite delivery); if FBS not possible/cord prolapse/fetal compromise → deliver urgently (Category 1 CS)

Criteria for STAN/ST Analysis (if available): - ST depression >80 μV - ST elevation >100-150 μV - Episodic T/QRS rise >0.10 - Baseline T/QRS rise >0.05 - Biphasic ST (event 2-3 combined with abnormal CTG)

3.7 Interpretation of Fetal Blood Sampling (FBS)

pH Result	Interpretation	Action
≥7.25	Normal	Repeat within 30-60 min if CTG remains suspicious/pathological
7.21-7.24	Borderline (pre-acidosis)	Repeat within 30 min if CTG still pathological
≤7.20	Acidotic	Immediate expedited delivery (Category 1 CS or instrumental) — but must also consider clinical context, fetal reserve, and duration of labour
≤7.00 (pre-terminal)	Severe acidosis	Expedite delivery with neonatal team present for resuscitation

Contraindications to FBS: Maternal infection (HIV, HBV, HCV, HSV with active lesions), fetal bleeding disorder, <34 weeks gestation, face/brow presentation, cervical dilatation <3cm

Alternative: Fetal scalp lactate >4.8 mmol/L equivalent to pH <7.20; advantage: smaller sample needed, less likely to fail

3.8 Obstetric Resuscitation Priorities

Emergency	First Actions	Key Points
Massive PPH (>2000mL)	CALL for help, 4 large-bore IVs (14G/16G), crossmatch 4+ units, activate MHP, tranexamic acid 1g IV, oxytocin 5U slow IV + infusion, fluid resuscitation (warm blood and fluids), cell salvage, massive transfusion protocol (1:1:1 RBC:FFP:platelets), 4Ts assessment, consider ROTEM/TEG	Keep ahead of blood loss; earlier surgical intervention -> less coagulopathy; goal-directed transfusion
Eclampsia	ABC, MgSO₄ 4g IV over 5-10 min (loading), then 1g/h infusion; assess for recurrence; if recurrent: additional 2g bolus; control BP (labetalol 20mg IV, nifedipine); CT head for atypical features; call ITU/anaesthetics; plan delivery after stabilisation (not necessarily immediate CS — unnecessary if post-ictal and CTG normal)	Recurrence in 10-20% without loading dose; MgSO₄ superior to phenytoin/diazepam for eclampsia prevention and treatment (Collaborative Eclampsia Trial); reflexes lost FIRST -> RR depression -> respiratory arrest
Anaphylaxis in O&G	CALL; remove trigger; IM adrenaline 0.5mg (1:1000) anterolateral thigh, repeat q5min; ABC, high flow O₂, IV fluids; chlorphenamine 10mg IV; hydrocortisone 200mg IV	Latex = common in O&G; note: avoid syntocinon (may contain latex in syringe); cetirizine/ranitidine IV if refractory
Cord Prolapse	CALL; knee-chest/Trendelenburg; elevate presenting part (2 fingers in vagina to lift off cord); filling bladder with 500-700mL saline (to elevate presenting part); tocolysis (terbutaline 250μg SC); emergency CS; do not attempt to replace cord	Category 1 CS; time to delivery <30 min; if cord pulseless, still deliver (resuscitation possible)
Maternal Collapse	CALL 2222 cardiac arrest team; ABC; L tilt 15-30° (manual uterine displacement if supine necessary); perimortem CS within 5 min if no ROSC and gestation >20wk (relieves aortocaval compression, allows effective CPR)	CPR modifications: hand position slightly higher on sternum (displaced by gravid uterus), defibrillation energy same as non-pregnant, IV access above diaphragm

3.9 Commonly Tested Clinical Scenarios in MRCOG Part 1

Scenario	Key Diagnostic Feature	Next Step
22yr, lower abdo pain, positive β-hCG, adnexal mass	Ectopic pregnancy	TVS: adnexal mass with yolk sac/embryo? Free fluid in POD? USS + serial β-hCG; if confirmed: laparoscopic salpingectomy vs methotrexate (if unruptured, <3.5cm, no cardiac activity, hCG <1500-5000 depending on protocol)
30yr, 38wk, PV bleeding, no pain	Placenta praevia (painless APH)	Do NOT do vaginal exam; confirm with TVS; crossmatch; steroids if <36wk; plan CS at 38-39wk (37wk if major + bleeding)
28yr, 35wk, abdominal pain with PV bleeding	Placental abruption (painful APH)	CTG for fetal distress; crossmatch; FBC/coag; if fetal distress + viable: emergency CS; if mild abruption + no fetal distress: conservative
34yr, 16wk, vaginal bleeding, cervical os open	Miscarriage (inevitable/incomplete)	TVS: retained products? Threatened cervix? Expectant vs medical vs surgical (ERPC)
26yr, GBS-negative, PPROM at 30wk	Preterm prelabour rupture of membranes (PPROM)	Confirm with speculum (pooling, ferning, Nitrazine), high vaginal swab, FBC/CRP; steroids (betamethasone), antibiotics (erythromycin 10d — ORACLE), monitor for chorioamnionitis; deliver when infection or at 37wk
40yr, PM bleeding, endometrial thickness 6mm on TVS	Endometrial cancer suspicion	Outpatient hysteroscopy + endometrial biopsy (Pipelle); if failed: in-patient hysteroscopy & curettage; endometrial cancer treatment: TAH BSO + pelvic lymphadenectomy if high risk
32yr, irregular periods, BMI 34, acne, hirsutism, LH:FSH 3:1	PCOS	Check: testosterone, SHBG, 17-OHP to exclude CAH, prolactin, TSH, FSH; GTT if BMI elevated; Rotterdam criteria = 2 of: (1) oligo/anovulation, (2) clinical/biochemical hyperandrogenism, (3) polycystic ovaries on US
28yr acute unilateral pelvic pain, afebrile, nausea, enlarged ovary on US	Ovarian torsion	Emergency laparoscopy; detorsion irrespective of colour; recurrence ~5%; no need for oophorectomy unless frankly necrotic
25yr, recurrent UTI, atrophic vaginitis symptoms, good response to topical oestrogen	Urogenital atrophy	Diagnosis of exclusion; check FSH >40 if <45; treat with topical oestrogen; can use with or without systemic HRT
35yr, chronic pelvic pain, dysmenorrhoea, dyspareunia, tender uterosacral ligaments	Endometriosis	Diagnostic laparoscopy; treatment: medical (COC, POP, dienogest, GnRH agonist) vs surgical (excision/ablation)

Tool	Purpose	Components	Interpretation
MEOWS / MEWS	Maternity Early Warning Score	RR, SpO₂, temp, HR, BP, consciousness, urine output	Escalation triggered by deviation
qSOFA	Sepsis screen	RR ≥22, SBP ≤100, altered mentation	≥2 → high risk, check lactate
Bishop Score	Cervical favourability for IOL	Dilatation (0-3), effacement (0-3), station (0-3), consistency (0-2), position (0-2)	Score ≥6 favourable; ≤5 unfavourable
Pulmonary Embolism Severity Index (sPESI)	PE risk stratification	Age >80, cancer, chronic lung disease, HR ≥110, SBP <100, O₂ sat <90%	sPESI 0 = low risk, consider early discharge
Glasgow Coma Scale (GCS)	Consciousness level	Eye (1-4) + Verbal (1-5) + Motor (1-6) = 3-15	<8: severe; 9-12: moderate; 13-15: mild
Alvarado Score	Appendicitis	RIF pain, anorexia, N+V, fever, WCC, shift to left, migratory pain	1-4 low, 5-6 intermediate, 7-10 high probability
NICE DVT Risk (Well's)	DVT probability	Cancer, paralysis/surgery, immobilised, tenderness, entire leg swollen, calf >3cm, pitting oedema, collaterals, previous DVT, alternative diagnosis	≥2 = DVT likely; <2 = unlikely
CRB-65	Pneumonia severity	Confusion, RR ≥30, BP <90/60, age ≥65	0 = home; 1-2 = hospital; 3-4 = ICU

3.3 Ethical Principles in O&G

Principle	Definition	Clinical Application in O&G
Autonomy	Patient's right to self-determination	Informed consent, refusal of treatment (including CS, blood transfusion), choice of contraception, decision about pregnancy
Beneficence	Act in patient's best interest	Recommending interventions that benefit mother and baby
Non-maleficence	First do no harm	Avoiding unnecessary interventions, minimising surgical risks
Justice	Fair distribution of resources	Equal access to fertility treatment, screening, healthcare regardless of age, ethnicity, disability
Respect for Persons	Dignity, privacy, confidentiality	Chaperones, consent, sensitive history-taking, safeguarding

Clinical Scenarios Requiring Ethical Consideration: - Refusal of CS — Competent pregnant woman can refuse any intervention even if fetal compromise (Montgomery verdict, Re MB, St George's NHS Trust v S) - Maternal vs fetal conflict — Court has never forced a competent woman to undergo treatment for fetal benefit - Termination of pregnancy — Abortion Act 1967: two medical practitioners, <24wk (GB), <12wk (NI), grounds A-G - Fraser competence — Under 16s consent if 'Gillick competent' (mature enough to understand implications) - Mental Capacity Act — Presume capacity; assess ability to understand, retain, weigh information and communicate decision - Confidentiality — Breach allowed in exceptional circumstances (child protection, serious harm to others) - Safeguarding — Must refer if child protection concerns; female genital mutilation (FGM) mandatory reporting - Advance directives — Must be followed if valid and applicable (but not for treatment of a pregnant woman?)

3.4 Medico-Legal Principles

Key Legal Cases: - Montgomery v Lanarkshire (2015) — Doctor must disclose material risks; materiality judged by what a reasonable person in patient's position would consider significant; shared decision-making - Chester v Afshar (2004) — Failure to warn of a small risk of paralysis led to liability even though procedure done correctly - Bolam v Friern HMC (1957) — Standard of care: a doctor is not negligent if their practice is accepted by a responsible body of medical opinion - Bolitho v City Hackney (1997) — The medical opinion relied upon must be logical and defensible - Sidaway v Bethlem RHG (1985) — (Pre-Montgomery) Established doctrine of informed consent re: risk disclosure - Re MB (1997) — Competent pregnant woman can refuse treatment for any reason, including irrational, as long as she understands - St George's v S (1998) — Cannot force a competent woman to have a CS even if fetus would die - Whitehouse v Jordan (1981) — Error of judgment not necessarily negligence if within standard of care

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4. Principles of Safe Surgery

4.1 WHO Surgical Safety Checklist

Three Phases:

Phase	Key Checks
Sign In (before anaesthesia)	Patient identity, procedure, site, consent confirmed; allergy checked; difficult airway/aspiration risk; IV access; estimated blood loss
Time Out (before incision)	Team introduced; antibiotic prophylaxis given within 60 min; essential imaging displayed; team confirms patient, site, procedure; anticipated critical events
Sign Out (before leaving theatre)	Instrument count correct; specimen labelled; equipment issues identified; key concerns for recovery

4.2 Surgical Site Infection Prevention

Measure	Evidence/Recommendation
Antibiotic prophylaxis	Single dose within 60 min before incision; cefazolin 2g IV most common; repeat if blood loss >1500mL or >4h procedure
Hair removal	Clipping NOT shaving (razors cause micro-abrasions)
Skin preparation	2% chlorhexidine in 70% alcohol (if not contraindicated); allow to dry
Normothermia	Active warming (forced-air blanket) — prevents vasoconstriction and poor wound oxygenation
Glycaemic control	Maintain blood glucose <10 mmol/L (hyperglycaemia impairs neutrophil function)
Oxygenation	Maintain SpO₂ >95%; 80% FiO₂ during and after surgery
Wound classification	Clean (1-2% SSI risk), clean-contaminated (3-5%), contaminated (5-15%), dirty (15-30%)
Sterile drapes	Sterile field maintained; iodine-impregnated drapes for prolonged procedures

4.3 Common Surgical Complications & Prevention

Complication	Risk Factors	Prevention
Haemorrhage	Emergency surgery, coagulopathy, anticoagulation, placenta praevia, fibroids, previous surgery	Pre-op optimisation, blood group + crossmatch, cell salvage, tranexamic acid
Surgical Site Infection	Diabetes, obesity, smoking, prolonged surgery, emergency, poor nutrition	Antibiotic prophylaxis, skin prep, normothermia, proper haemostasis, drain use?
VTE	Surgery (esp. pelvic), cancer, immobility, obesity, pregnancy/ postpartum, COC	LMWH prophylaxis (4-6wk for cancer surgery), TED stockings, early mobilisation, IPC devices intraop
Nerve Injury	Improper positioning, thin patients, retractors	Knowledge of nerve anatomy: brachial plexus (shoulder abduction >90°), common peroneal (Lloyd Davies stirrups), femoral (retractors), obturator (deep retraction in pelvis), sciatic (poor limb positioning)
Bowel Injury	Previous surgery (adhesions), endometriosis, malignancy, Crohn's	Careful adhesiolysis, proper entry technique, identification of anatomy, timely referral
Bladder/Ureteric Injury	Prior CS, endometriosis, large fibroids, malignancy, pelvic mass	Catheterisation, identification of ureters (peristalsis), IV indigo carmine/methylene blue, cystoscopy post-op
Anaesthetic Complications	Aspiration, MH, anaphylaxis, difficult airway	GA in O&G: RSI with cricoid pressure, pre-oxygenation, LMA for some laparoscopic, epidural/spinal for most CS, MSU for categories

Surgical VTE Risk Categories (RCOG):

Category	Risk	Prevention
Low	Minor surgery <30 min, no RF, age <40, no COC	Early mobilisation
Moderate	Major surgery >30min OR minor + RF (age >60, obesity, COC, cancer, varicose veins)	LMWH + TED stockings
High	Major surgery + multiple RF OR cancer + major surgery OR prior VTE	LMWH + IPC + TED + consider extended prophylaxis

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5. Surgical Anatomy & Common Procedures

5.1 Laparotomy

Type	Incision	Indications
Midline	Vertical midline (xiphisternum to pubis)	Emergency laparotomy, ovarian mass (suspected malignancy), gynaecological cancer staging, removal of large pelvic masses
Pfannenstiel	Transverse suprapubic (2cm above pubic symphysis)	CS, benign gynaecological laparotomy (myomectomy, hysterectomy — benign, but modern trend for laparoscopic), tubal surgery
Joel-Cohen	Transverse skin incision 3cm below inter-spinous line; blunt dissection of layers	CS — preferred in some units for reduced blood loss, shorter operative time, faster recovery
Maylard	Transverse incision with rectus muscle division (transection)	Better access to lateral pelvis; used for large ovarian masses, pelvic lymphadenectomy
Cherney	Transverse with rectus tendon division from pubic bone	Access to retropubic space (Burch colposuspension), lower urinary tract surgery
Paramendian	Vertical para-midline	Older incision; rare now

Anatomical Layers in Midline Incision: 1. Skin 2. Subcutaneous fat (Camper's fascia + Scarpa's fascia) 3. Rectus sheath (anterior layer) 4. Rectus abdominis muscle (separated in midline — linea alba) 5. Rectus sheath (posterior layer at arcuate line) 6. Transversalis fascia 7. Preperitoneal fat 8. Peritoneum

5.2 Caesarean Section (CS)

Aspect	Details
Classification	Category 1: immediate threat to life (decision to delivery <30 min); Category 2: maternal/fetal compromise not immediately life-threatening (<75 min); Category 3: no maternal/fetal compromise but needs early delivery; Category 4: elective timed
Incision	Low transverse (lower uterine segment — popularised by Kerr; less haemorrhage, stronger healing); classical (upper segment — rare, for extreme preterm/transverse lie/placenta praevia anterior/previous classical)
Uterine closure	Single vs double layer; continuous sutures (vicryl); avoiding locked continuous (ischaemia risk)
Peritoneal closure	No longer recommended (no benefit, may increase adhesions)
Rectus sheath closure	Continuous with delayed absorbable suture (1 PDS/nylon)
Skin closure	Subcuticular absorbable suture vs staples vs glue
Thromboprophylaxis	LMWH 6-8h after CS if additional RFs; TED stockings; early mobilisation
Key anatomical landmarks	Peritoneal fold (bladder flap formed from vesicouterine peritoneum), lower uterine segment (isthmus, develops after 12wk), broad ligament
Complications	Haemorrhage (atonic 1%, traumatic <1%), bladder injury (0.1-0.3%), ureteric (rare <0.05%), uterine extension/angular tear, infection (endometritis 5-10%), wound infection (2-5%), VTE, ileus, scar dehiscence/rupture (0.5% for LSCS vs 2% classical)
Risk of uterine rupture in VBAC	0.2-0.5% with one previous LSCS; 1% if previous LSCS + IOL

5.3 Laparoscopy

Aspect	Details
Indications	Diagnostic (chronic pelvic pain, infertility, endometriosis), operative (ectopic pregnancy, ovarian cystectomy, myomectomy, TLH, TL, adhesiolysis, endometriosis ablation/excision), sterilisation
Entry Techniques	Veress needle (closed — blind, classic: Palmer's point left upper quadrant if previous midline scar) vs Hasson (open — direct mini-laparotomy, safest in previous abdominal surgery) vs direct trocar (no pneumoperitoneum first) — all have proponents
Pneumoperitoneum	CO₂ gas (inert, highly soluble, non-explosive) insufflated to 12-15 mmHg
Patient Positioning	Lloyd Davies/Lithotomy with Trendelenburg (gynae) or reverse Trendelenburg (upper abdo); shoulder blocks for steep Trendelenburg
Port Placement	Umbilicus (10-12mm camera); suprapubic (5mm); lateral (5mm); careful with epigastric arteries
Complications	Entry injury (bowel 0.04%, vascular 0.02-0.1% — major vessels: aorta, IVC, iliac), gas embolism (rare but catastrophic, 'mill wheel' murmur, decreased ETCO₂), shoulder tip pain (referred from phrenic nerve irritation by CO₂), TURP syndrome (if using glycine/sorbitol), nerve injury, port site hernia, wound infection, adhesions
Contraindications	Severe cardiorespiratory disease, raised ICP, diaphragmatic hernia, bowel obstruction, peritonitis (relative), multiple previous laparotomies (relative)
Gasless Laparoscopy	Abdominal wall lift device; for patients who cannot tolerate pneumoperitoneum

5.4 Hysteroscopy

Aspect	Details
Diagnostic	Outpatient (no anaesthesia, mini-hysteroscope 3-5mm, vaginoscopic approach no speculum); saline distension medium
Operative	General/regional anaesthesia; cervical dilatation to Hegar 7-9; distension with sorbitol/mannitol/glycine (for use with diathermy — non-conductive, isotonic) or saline (for bipolar diathermy, considered safer — no TURP risk)
Distension Media	Normal saline (bipolar diathermy), glycine 1.5% (monopolar), sorbitol/mannitol (monopolar), CO₂ (diagnostic only)
Fluid Deficit Monitoring	Limit deficit: saline 2500mL, non-electrolyte 1500-2000mL (more rapid warning with <1000mL in older patients)
TURP Syndrome	Excessive absorption of hypotonic glycine/sorbitol → hyponatraemia, cerebral oedema, seizures, coma, pulmonary oedema, cardiac arrest. Treatment: stop procedure, diuretics (furosemide), hypertonic saline (if severe hyponatraemia <120 mmol/L), monitoring in HDU
Procedures	Polypectomy, myomectomy (submucosal fibroids — FIGO type 0,1,2), endometrial ablation/resection (NovaSure, microwave, balloon, rollerball, TCRE), adhesiolysis (Asherman's), septoplasty (uterine septum), tubal cannulation, targeted biopsy
Complications	Perforation (1%, most in outpatient, usually manage conservatively if not in fundus with no intra-abdominal injury), cervical trauma, bleeding, infection, fluid overload, gas embolism (rare), hyponatraemia
Contraindications	Pregnancy, active PID, known cervical malignancy, heavy bleeding limiting view, inability to dilate cervix

5.5 Colposcopy

Aspect	Details
Indications	Abnormal cervical screening (HPV positive + abnormal cytology), three consecutive inadequate smears, visible cervical abnormality, post-coital bleeding, follow-up after CIN treatment
Equipment	Colposcope (binocular, 5-40x magnification, green filter to highlight blood vessels), Acetic acid 3-5%, Lugol's iodine (Schiller's test — stains glycogen-rich normal epithelium mahogany brown)
Transformation Zone (TZ)	The area between original squamous-columnar junction and new SCJ. Type 1: fully ectocervical; Type 2: extends into endocervical canal but fully visible; Type 3: partially visible/not visible
Acetowhite Change	Abnormal epithelium turns white after acetic acid (reversible coagulation of proteins in high N/C ratio cells). Higher grade -> denser white -> faster appearance -> slower disappearance
Mosaicism & Punctation	Abnormal blood vessel patterns in CIN: punctation (capillary loops), mosaic (vessel pattern surrounding blocks of epithelium). Coarse -> fine denotes severity
Atypical Vessels	Dilated, irregular, corkscrew — suspicious for invasive cancer
Reid Score	Combined scoring of margin, colour, vessels, and iodine staining to predict CIN grade
Swede Score	Alternativa to Reid Score; 0-10
Biopsy	Punch biopsy from most abnormal area; ECC (endocervical curettage) if TZ3; LLETZ (Large Loop Excision of Transformation Zone) — both diagnostic and therapeutic
CIN Treatment	LLETZ (most common), laser ablation, cone biopsy (for microinvasion suspicion), cryotherapy (if small, fully visible, low-grade), cold knife conisation
Complications	Bleeding (primary <5%; secondary at 5-10 days in 2-5%), infection, cervical stenosis (rare), cervical incompetence (rare, more with cold knife cone)
Follow-up	HPV test at 6 months post-treatment; if negative, return to routine recall

5.6 Vaginal Surgery

Procedure	Indications	Key Steps
Vaginal Hysterectomy	Prolapse, HMB (if no adnexal pathology), endometrial hyperplasia (low-risk)	Anterior/posterior colpotomy, clamp and ligate pedicles (uterosacral-cardinal, uterine, ovarian/round ligament), vaginal cuff closure
Anterior Repair	Cystocele (anterior compartment prolapse)	Anterior vaginal wall incision, bladder dissection, plication of pubocervical fascia, excess vaginal skin excision
Posterior Repair	Rectocele (posterior compartment prolapse)	Posterior vaginal wall incision, rectal dissection, plication of rectovaginal fascia/levator ani, perineorrhaphy
Manchester Repair	Uterine prolapse (cervical elongation, no uterine body descent)	Amputation of cervix + shortening of Mackenrodt's ligaments + anterior/posterior repair; preserves uterus
Sacrospinous Fixation	Apical prolapse (vault/uterine)	Fixation of vault to sacrospinous ligament (right usually, to avoid sigmoid)
TVT/TOT (mid-urethral sling)	Stress urinary incontinence	Synthetic mesh tape placed mid-urethra: TVT — retropubic (behind pubic bone); TOT — transobturator; TVT-Abbrevo — single incision
Colpocleisis (Le Fort)	Total prolapse in frail/elderly non-sexually active	Obliteration of vaginal lumen (partial: Le Fort)
Perineal Repair	Episiotomy or 1st/2nd degree tear	Continuous non-locking suture; 2-0/3-0 vicryl rapid
3rd/4th Degree Tear Repair	Obstetric anal sphincter injury (OASI)	Rectal mucosa (3-0 PDS), internal anal sphincter (3-0 PDS), external anal sphincter (3-0 PDS, overlap or end-to-end), perineal muscles, skin. Prophylactic antibiotics, postoperative stool softeners

5.7 Myomectomy

Approach	Indications	Considerations
Abdominal	Large fibroids (>12wk), multiple, deep intramural	Laparotomy; uterine incision: principles of minimal incisions, vertical midline for fundal, transverse for anterior; closed in layers; meticulous haemostasis; use vasopressin/tourniquet for blood loss; postoperative risk of adhesions
Laparoscopic	Smaller fibroids, fewer, superficial	Laparoscopic suturing required; power morcellation (risk of occult sarcoma — contained morcellation bags now used); longer operating time
Hysteroscopic	Submucosal fibroids (FIGO 0,1,2)	Resectoscope; fluid management critical; GnRH agonist pre-op to shrink and reduce vascularity
Complications	Haemorrhage (most common), hysterectomy (risk), adhesion formation, infection, recurrence, uterine rupture in subsequent pregnancy (risk if full-thickness myometrial breach)

5.8 Hysterectomy

Type	Description	Indications
Total Abdominal (TAH)	Uterus + cervix via laparotomy	Large fibroids, suspected malignancy, endometriosis, adhesions
Vaginal (VH)	Uterus + cervix via vagina	Prolapse, small uterus, adequate vaginal access
Laparoscopic (LH)	Laparoscopic dissection +/- vaginal component	Benign disease, smaller uterus, faster recovery
Subtotal (STAH)	Uterus only, cervix left	To avoid bladder/ureteric injury if severe endometriosis, or to preserve cervical function (weak evidence)
Radical (RH)	Uterus + cervix + parametrium + upper vagina + nodes	Cervical cancer (early stage)
Oophorectomy	Bilateral/unilateral	Risk-reducing if BRCA, endometriosis, ovarian cyst, tubo-ovarian abscess
TAH vs VH vs LH	Comparison: LH has fastest recovery, lower infection, more expensive, longer OR time; TAH for large/complex; VH for prolapse

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6. Surgical Instruments & Sutures

6.1 Basic Surgical Instruments

Instrument	Use	Details
Scalpel	Skin incision	#10 (large curve — abdominal incisions), #15 (small curve — fine dissection), #11 (pointed — stab incisions), #12 (hooked — for suturing), #20 (larger than #10); handles #3 (for #10/#11/#12/#15), #4 (for #20/#23)
Scissors	Cutting	Mayo (heavy, curved or straight — cutting heavy tissue/sutures), Metzenbaum (fine, curved — delicate tissue dissection), McIndoe (long), Cooper (strabismus), dissecting (various: Potts, Pott-Smith), suture removal
Needle Holder	Holding needle	Mathieu (ratchet, may have scissors built in), Hegar (general), Olsen-Hegar (needle holder + scissors), Mayo-Hegar (larger — heavy tissue), Castroviejo (for ophthalmic/microsurgery, spring-loaded), Ryder (finer — vascular)
Tissue Forceps	Grasping tissue	Toothed (Lane, Bonney — hold tough tissue: fascia, skin, uterus) vs non-toothed (Debakey — gentle, for delicate tissue: bowel, vessels); Adson (fine, with or without teeth), Maingot
Artery Forceps	Haemostasis	Halstead mosquito (small, curved/straight — fine vessel control), Spencer Wells (medium), Kelly (medium, longer), Roberts (large), Moynihan (large — bulldog clamp for bowel), Lane's tissue forceps, Kocher's (with teeth — traumatic), Cushing
Retractors	Exposing surgical field	Self-retaining: Balfour (abdominal), Bookwalter (heavy laparotomy — table-mounted), Lone Star (perineal/vaginal), Gelpi (deep perineal), Weitlaner (small self-retaining), Morris (Goelet) — larger, fixed. Hand-held: Deaver (deep — large), Langenbeck (smaller), Morris (abdominal wall), Richardson (hand-held), Roux (goat's head)
Clamps	Occluding vessels/tissue	Babcock (atraumatic — grasping bowel/tube/ovary), Allis (traumatic — grasping tissue for traction), Littlewood (Allis-type), Lane's tissue forceps, Duval (lung/ovary), sponge holder (Rampley's for swab on stick)
Curettes	Removing tissue	Flush (cervix — larger), Sims (sharp — for D&C), blunt (less traumatic), chorionic (for ERPC evacuation)
Dilators	Cervical dilation	Hegar (numbered 1-12 — most common), Pratt (numbered differently; larger tip), Hawkins-Ambler, Hank (tapered)
Trocars	Laparoscopy ports	Size 5mm, 10-12mm; bladed vs dilating (visual entry); disposable vs reusable; Hasson cannula (open laparoscopy); Palmers point / left upper quadrant entry in previous midline scar

6.2 Sutures

Suture Material	Type	Handling	Absorption	Tensile Strength	Tissues	Examples
Catgut (plain)	Natural, braided (chromic = coated)	Poor knot security	7-10 days (plain), 21-28 days (chromic)	Low, lost rapidly	Subcuticular, ligation small vessels, episiotomy	Plain catgut, Chromic catgut
Polyglactin 910	Synthetic, braided	Excellent	60-90 days	Absorbed by 60d	Obstetric, most surgery — fascia, subcutaneous, uterus, vagina, perineum	Vicryl, Vicryl Rapide (30 days)
Polyglycolic acid	Synthetic, braided	Good	60-90 days	60-70% at 2wk, 15-20% at 3wk	General	Dexon
Polydioxanone	Synthetic, monofilament	Good knot security, stiff	180-210 days	70% at 2wk, 25% at 6wk	Fascia, vaginal cuff, deep tissue — long support needed	PDS, PDS II
Polyglecaprone	Synthetic, monofilament	Excellent	90-120 days (high knot strength)	50% at 7d, 20% at 14d, absorbed 90-120d	Short-term tissue apposition; GI/GU	Monocryl
Nylon	Synthetic, monofilament	Good	Non-absorbable	Permanent	Skin closure, vascular, nerve, tendon	Ethilon, Dermalon
Polypropylene	Synthetic, monofilament	Excellent handling	Permanent	High, inert	Cardiovascular, vessel suturing, hernia mesh, tension sutures	Prolene, Surgilene
Silk	Natural, braided	Excellent handling	Non-absorbable	Loses strength over time (slow absorption)	Stay sutures, ligation, skin	Mersilk, Perma-hand
Stainless steel	Metal, monofilament	Stiff	Non-absorbable	Very high	Sternotomy, bone, tension closure	Steel
Polytetrafluoroethylene (PTFE)	Synthetic, monofilament	Good	Non-absorbable	High	Vascular, where you need permanent inert	Gore-Tex

Suture Sizes (USP — bigger number = thinner suture): | Size | Diameter (mm) | Tissues | |------|--------------|---------| | 7-0 (7/0) | 0.05-0.069 | Microvascular, ophthalmic | | 5-0 | 0.1-0.149 | Skin (face), fine vessels | | 4-0 | 0.15-0.199 | Skin, subcuticular, small vessels | | 3-0 | 0.2-0.249 | Subcuticular, small intestine, episiotomy (most common for vaginal repair) | | 2-0 | 0.3-0.339 | Uterus (myometrium), deeper fascia | | 0 | 0.35-0.399 | Abdominal wall closure, rectus sheath | | 1 | 0.4-0.499 | Abdominal wall (heavy), tension | | 2 | 0.5-0.599 | Orthopaedic | | 5 | 0.8-0.999 | Sternotomy wires |

Needle Types: - Cutting: Triangular cross-section; sharp tip for tough tissue (skin, fascia) - Reverse cutting: Cutting edge on outer curve (reduces tissue cutting as it passes) - Round body (tapered): Rounded, for softer tissue (peritoneum, muscle, vessels, bowel) - Blunt: For friable tissue (liver) - Spatula: Flat; for ophthalmic/vascular - Tapercut: Cutting tip + round body; for calcified vessels, tough fascia

6.3 Knot Tying

Knot Type	Use	Details
Instrument tie	Most common — deep or confined spaces	One- or two-handed; can be one-handed technique
Surgeon's knot	Where knot may loosen before second throw (e.g., vessel ligation)	First throw is double-wrapped (2:1) then second is single (1:1)
Two-handed tie	Tension important (closure of fascia)	Most secure; can apply even tension
One-handed tie	Deep/poor access	Less tension control but more useful in confined spaces
Slip knot (Aberdeen)	End of continuous sutures, when reach end	Self-locking; use for subcuticular continuous closure

Key Principles: - Square knot = right-over-left then left-over-right (or vice versa) - Avoid 'granny knot' (same direction twice — slips) - Minimum throws: synthetic braided (3), monofilament (4-5) - For deep sutures, ensure knot is buried (to reduce sinus formation) - The knot should be placed at the side/edge of the incision, never directly over the wound

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7. Informed Consent & Medico-Legal

7.1 Principles of Informed Consent

Legal Requirements for Valid Consent: 1. Capacity — Patient must have capacity (Mental Capacity Act 2005) 2. Voluntariness — No coercion or undue influence 3. Information — Adequate information provided (see Montgomery) 4. Communication — Information given in language/format patient understands

Information to Disclose (Montgomery 2015): - Diagnosis and prognosis - Options for treatment (including no treatment) - Benefits of each option - Risks — all material risks (a reasonable person in patient's position would want to know; includes both common minor risks and rare serious risks) - Consequences of proposed procedure (pain, scars, recovery time, effect on future fertility) - Details of the practitioner performing procedure (if trainee, patient should be informed) - Costs/time implications (especially private) - What to expect before, during, and after

Specific Risks to Disclose in O&G (examples): - Sterilisation: failure rate (~1/200 lifetime), ectopic pregnancy risk - Hysterectomy: loss of fertility, hormonal changes (if ovaries removed) - Myomectomy: recurrence (~20% at 5yr), potential for hysterectomy if uncontrollable bleeding - CS: risks to mother (infection, haemorrhage, VTE, injury to surrounding organs, scar pain, risks in future pregnancies: rupture, abnormal placentation) and baby (respiratory morbidity, lacerations) - VBAC/TOLAC: risk of uterine rupture 0.2-0.5%, scar dehiscence, emergency CS - Mid-urethral tape: risk of bladder perforation (TVT ~5%), voiding dysfunction, mesh erosion, persistent pain - Termination: risk of failure, infection, uterine perforation, Asherman's, psychological impact - Egg freezing: success rates per egg (3-5% live birth per egg, 30-50% per cycle depending on age) - Ovulation induction: multiple pregnancy risk (clomiphene ~10%, gonadotrophins ~20%)

7.2 Competence & Consent in Special Circumstances

Situation	Key Legal Principle
Under 16 (Gillick competence)	Fraser ruling — competent if mature enough; otherwise parental consent; best interest test if disagreement
Adults lacking capacity	Best interests decision (Mental Capacity Act); involve family, IMCA if no family; cannot be detained for treatment of physical illness under MHA 1983
Emergency	Doctrine of necessity — treatment given to save life/prevent serious deterioration
Advance Decision	Valid if patient >18, written, signed, witnessed, specific; applies to future incapacity; cannot refuse basic care (food, fluids)
Pregnant women	Competent woman may refuse any treatment (even surgery) for any reason, including fetal benefit — cannot be overruled for fetal protection (St George's v S, Re MB)
Blood Transfusion (Jehovah's Witness)	Valid Advance Directive; alternatives (cell salvage, iron, EPO); cannot force transfusion on competent adult; can for child if life-threatening
Consent for examination of intimate areas	Specific consent required; chaperone offered; patient can withdraw at any time; can request trainee not present
Video recording	Specific written consent needed; for education/training/publishing — separate consent from clinical consent

7.3 Consent for Surgical Procedures

• Written consent required for most surgical procedures
• Verbal consent sufficient for minor procedures (e.g., speculum examination, simple HVS)
• Valid throughout: Consent remains valid unless withdrawn or circumstances change
• Withdrawal: Patient may withdraw consent at any time, even during procedure
• Blanket consent: Patient asked 'do you consent to X' — does not cover extra procedures beyond scope
• Consent by proxy: Parent for child under 16 (unless Gillick competent)
• Consent for simultaneous additional procedures: Should be discussed pre-op (e.g., diagnostic laparoscopy + possible procedure)
• Trainee performing procedure: Patient must be informed and agree

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8. Risk Management & Patient Safety

8.1 Clinical Risk in O&G

High-Risk Areas in O&G: - Obstetric: Shoulder dystocia, PPH, eclampsia, cord prolapse, uterine rupture, failed instrumental delivery, neonatal resuscitation, stillbirth - Gynaecological: Laparoscopic entry injuries, ureteric/bladder injury during hysterectomy, failed sterilisation, retained instruments/swabs, complications of termination - General: Medication errors, wrong site surgery, missed diagnosis, communication failures, inadequate handover, poorly supervised trainees

Strategies to Reduce Risk: - WHO checklist — ensures correct patient/site/procedure - Team briefing/debriefing — before/after theatre lists - Proformas — structured notes (e.g., labour ward admission proforma, CTG annotation template) - SBAR — standardised handover: Situation, Background, Assessment, Recommendation - Early Warning Scores — MEOWS improves recognition of deterioration - Drills & Simulation — regular practice of emergencies (shoulder dystocia, eclampsia, PPH, cord prolapse) - Guideline adherence — RCOG Green-top Guidelines, NICE, MBRRACE-UK recommendations - Morbidity & Mortality meetings — learning from adverse events - Datix/incident reporting — no-blame reporting culture

8.2 Clinical Governance

Seven Pillars of Clinical Governance (NHS):

Pillar	Definition	Examples in O&G
Clinical Effectiveness	Evidence-based practice	Following NICE guidelines, RCOG green-tops
Risk Management	Identifying & minimising harm	Datix, M&M meetings, PROMPT training
Patient & Public Involvement	Engaging patients in care decisions	Patient satisfaction surveys, Maternity Voices Partnership
Clinical Audit	Closing the audit loop	Prophylactic antibiotic timing, CS rates, induction rates
Staffing & Staff Management	Right staff, right skills, right numbers	Mandatory training, competence assessments
Education & Training	Ongoing development	Drills, simulation, CPD, eLearning
Information Management	Data collection & confidentiality	Maternity dashboard, HES data, termination notification

8.3 Concise Risk Management Principles (Examples)

Specific Principles for Common O&G Scenarios: - Shoulder Dystocia: CALL FOR HELP, McRoberts' + suprapubic pressure (not fundal), internal manoeuvres (Woods' screw, Rubin's, delivery of posterior arm, Gaskin all-fours), last resort (symphysiotomy, Zavanelli, intentional clavicular fracture). Document: time sequence, HELPERR mnemonic, birth weight, neonatal outcome, debrief - PPH: ABCD assessment; 4Ts (Tone, Trauma, Tissue, Thrombin); call for help; oxytocin first line; mechanical (uterine massage, bimanual compression), medical (ergometrine, carboprost, misoprostol, tranexamic acid), surgical (Bakri balloon, compression sutures B-Lynch, uterine artery ligation, hysterectomy) - Cord Prolapse: Call for help; knee-chest/Trendelenburg position; elevate presenting part (fingers in vagina); bladder filling; tocolysis; emergency CS - Eclampsia: ABCD; IV lorazepam/diazepam; MgSO₄ loading + maintenance; monitor reflexes/RR/urine; treat hypertension; delivery planning; notify ITU - Failed Instrumental Delivery: Know limits — maximum 3 pulls, 2 attempts; never attempt progressively more difficult (e.g., mid-cavity Ventouse after failed low-cavity forceps); senior obstetrician present; consider theatre for attempted and failed; document fully - Maternal Collapse: ABC; call arrest team; left lateral tilt; perimortem CS within 5 minutes if >20wk; follow adult ALS protocol (but note: avoid aortocaval compression, MgSO₄ toxicity?)

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9. Perioperative Care

9.1 Preoperative Assessment

Domain	Assessment
History	Comorbidities, medications, allergies, anaesthetic history (previous GA/RA, airway problems, MH, PONV, difficult intubation), fasting status, bleeding tendency, last food/drink
Examination	Airway (Mallampati grade: I-IV, mouth opening, neck mobility), CVS (BP, HR, murmurs, JVP, oedema), RS (auscultation, SpO₂), BMI, abdominal/pelvic
Investigations: FBC (anaemia, infection, platelets), U&Es (renal function, electrolytes if comorbidities), coagulation screen (if bleeding risk, anticoagulation, liver disease — PT, APTT, fibrinogen), G&S/XM (if haemorrhage risk — crossmatch depends on procedure: CS 2 units, myomectomy 2-4 units, laparotomy for ovarian mass 2-4 units, hysterectomy for malignancy 4-6 units), ECG (if age >65 or cardiac RF), CXR (if indicated), pregnancy test, TFT (if thyroid disease), HbA1c (if diabetes), LFT (if liver disease/heparin use), amylase (if recent acute abdomen?), echocardiogram (if cardiac disease), PFTs (if severe asthma/restrictive lung disease)

Optimisation Protocols in Detail:

Condition	Preoperative Management
Anaemia (Hb <110 g/L)	Iron studies: if iron deficiency — IV iron (ferric carboxymaltose/w iron) faster than oral; oral ferrous sulphate 200mg TDS = 65mg elemental Fe; B12/folate if macrocytic; consider EPO if severe anaemia refusing blood
Hypertension	Continue ACEi/ARBs? Hold on morning of surgery (risk of hypotension under anaesthesia); Continue β-blockers to prevent reflex tachycardia; target BP <140/90
Diabetes	HbA1c target <69 mmol/mol (<8.5%); Type 1: start variable rate IV insulin infusion (VRIII) day of surgery; Type 2: hold metformin (risk of lactic acidosis if renal impairment/NBM), hold gliptins/GLP-1 agonists, hold SGLT2i (euglycaemic DKA risk); long-acting insulin given at reduced dose (50-80%); regular CBG monitoring
Anticoagulants	Warfarin — stop 5 days pre-op, LMWH bridging; DOACs — stop 24-72h depending on drug/renal function; LMWH VTE prophylaxis dose vs treatment dose bridging; INR <1.5 before surgery
Anti-platelets	Aspirin — continue for secondary prevention (hold for high-risk spinal/epidural 5-7d); Clopidogrel — stop 5-7d pre-op, bridging with LMWH; Ticagrelor — stop 3-5d
Antiepileptics	Continue through surgery (give with sips of water); lamotrigine/levetiracetam — increased clearance in pregnancy, may need loading dose; valproate — folate supplementation
Immunosuppressants	Prednisolone — perioperative 'stress dose' (hydrocortisone 50-100mg IV TDS) if >10mg/day >2 wk; Methotrexate — continue (no increased infection risk); Biologics — timing with surgery (stop 1 cycle pre-op depending on half-life)
Obesity (BMI >40)	Bariatric beds? CPAP for OSA; difficult airway: anaesthetic review; laparoscopic feasibility? wound infection risk; higher doses of LMWH; consider epidural
Optimisation	Anaemia correction (iron if ferritin <30), BP control, blood glucose optimisation (HbA1c target <8.5%), smoking cessation (ideally 6-8wk before), weight loss (if BMI >35, consider delaying for bariatric if elective), medication review (especially anticoagulants, hypoglycaemics, antihypertensives)
Specific O&G	Fibroids (size, number, position), endometriosis (severity, adhesion risk), previous surgery (abdominal scars, adhesion risk), ovarian mass (US characteristics, CA-125, ROMA)
Planning
- Anticoagulant management: LMWH bridging if mechanical heart valve/VTE within 3 months/ higher risk;
- Prophylaxis: Antibiotics, LMWH, TED stockings, IPC
Consent	As per Section 7

9.2 Postoperative Care

Aspect	Management
Immediate recovery	Airway patency, breathing, circulation, oxygen, pain control, nausea/vomiting, temperature, urine output, bleeding (vaginal/drains/wound), level of consciousness
Enhanced Recovery After Surgery (ERAS)	Minimally invasive preferred; carbohydrate loading pre-op; multimodal analgesia (paracetamol + NSAIDs + opioid-sparing); early feeding (clear fluids 2h after extubation, light diet 4h); early mobilisation (out of bed day 0/1); avoid NG tubes, avoid drains; goal-directed fluid therapy
Pain management	WHO analgesic ladder: Step 1 (paracetamol), Step 2 (dihydrocodeine/tramadol), Step 3 (morphine/oxycodone/MST), adjuvants (NSAIDs, gabapentin, lidocaine patches). PCA for laparotomy. Consider TAP block, ilioinguinal block, rectus sheath catheter for laparotomy
Fluid balance	1:1 replacement of ongoing losses; 0.9% saline (avoid large volumes in prolonged surgery — hyperchloraemic metabolic acidosis) vs Hartmann's/Balanced crystalloid. Monitor: urine output (0.5 mL/kg/h), daily weight, fluid chart, CVP in HDU/ITU
Wound care	Observe for infection (redness, discharge, dehiscence, pyrexia); dressing removed day 1 or earlier if wet; shower after 48h; suture removal: face 5-7d, scalp 7-10d, trunk 10-14d, limbs 10-14d
Bowel care	Early oral intake; laxatives (if opioid + pelvic surgery: docusate + senna); avoid constipation — important after prolapse surgery
Diet	Advance as tolerated; clear fluids then free fluids then light diet then normal; avoid prolonged fasting
Mobilisation	Day 0/1 — sit out, physio; progressive mobilisation; TED stockings until fully mobile
Thromboprophylaxis	As per RCOG — LMWH for duration of admission + 7 days (benign) or 4-6 wk (cancer) depending on VTE risk assessment
VTE signs	Unilateral leg swelling/pain/tenderness, SOB, chest pain, haemoptysis, tachycardia — urgent Doppler/CXR/CTPA
Follow-up	6-8 week follow-up for gynaecological surgery; wound check at 2wk; sick note, activity restrictions (e.g., no heavy lifting for 6-8 wk after laparotomy)

9.3 Specific Postoperative Complications

Complication	Timing	Signs & Management
Haemorrhage	Immediate (0-24h)	Tachycardia, hypotension, oliguria, low Hb, distended abdomen, increasing drain output. Resuscitate + return to theatre/blood transfusion/FAST scan
Primary haemorrhage (intra-op)	Immediate	Check pedicles, sutures, haemostatic agents, call for senior help
Reactionary haemorrhage	4-12h post-op	Rebound of BP after anaesthesia causing a slipped ligature/vessel to bleed
Secondary haemorrhage	5-14 days post-op	Infective erosion of vessel; usually smaller but can be significant; manage underlying infection, may need return to theatre
Wound infection	5-7 days	Erythema, discharge, pyrexia, raised CRP/WCC; wound swab + antibiotics (flucloxacillin); if pus — open wound, pack
Wound dehiscence	5-14 days	Sudden serosanguinous discharge from wound; fascial dehiscence requires emergency return to theatre for resuture
Urinary retention	0-72h	Inability to void; post-void residual >150mL; catheter for 24-48h (indwelling or intermittent self-catheterisation). More common after prolapse surgery/TVT
UTI	2-7 days	Dysuria, frequency, positive MSU — antibiotics (trimethoprim/nitrofurantoin)
Ileus	2-3 days	Abdominal distension, nausea, vomiting, no passing flatus; bowel rest, NG tube if vomiting, correct electrolyte (K+, Mg), early mobilisation. Differentiate from obstruction
Bowel obstruction	Variable	Absolute constipation, vomiting (maybe faeculent), abdominal distension, colicky pain; abdominal XR — dilated loops, no flatus; CT if needed; may need laparotomy if complete
Atelectasis / Chest infection	24-72h	Reduced air entry, pyrexia, hypoxia — incentive spirometry, chest physio, antibiotics if confirmed infection
DVT	3-10 days	Unilateral calf swelling/pain, Homan's sign unreliable; Doppler US; LMWH bridging to warfarin/DOAC
PE	Variable	Sudden dyspnoea, pleuritic pain, haemoptysis, collapse; CTPA/V/Q scan
Vault haematoma	3-14 days	After hysterectomy: vault bulge, pain, vaginal bleeding; TVS confirmation; if infected: drain under US guidance

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10. Appendix: High-Yield Exam Facts & Mnemonics

10.1 Key Surgical Facts for MRCOG Part 1

Wound Healing Timeline: - Day 0-3: Inflammation (platelet plug, neutrophils, fibrin) - Day 3-14: Proliferation (macrophages -> angiogenesis -> granulation tissue -> fibroblast collagen synthesis) - Day 7-14: Fibroplasia (collagen III -> I, wound strength ~10% by day 7, 30% by 14, 60% at 6wk, 80% at 3mo) - Day 10-180: Remodelling (collagen cross-linking, scar maturation, strength up to 80% pre-op)

Key Numbers: - Antibiotic prophylaxis given: within 60 min before incision - Hair removal: clipping (not shaving) - Surgical site infection risk: clean 1-2%, clean-contaminated 3-5%, contaminated 5-15% - LMWH timing: 6-8h post-surgery; extended 4-6wk for cancer - Suture size: 3-0 for most skin, 2-0 for uterus, 0-1 for fascia - Incision depth: midline incision layers = skin -> fat -> anterior rectus sheath -> rectus muscle -> posterior rectus sheath -> transversalis fascia -> peritoneum - Bowel prep: not routinely recommended (elective) - Laparoscopy insufflation: 12-15 mmHg CO₂ - Laparoscopy complication: bowel injury 0.04%, large vessel 0.02-0.1% - Hysteroscopy: normal saline for bipolar diathermy; limit fluid deficit 2500mL (saline)/1500-2000mL (glycine/sorbitol) - LLETZ: avoid during pregnancy; follow-up HPV 6 months post-op

Critical Perioperative Points: - Clipping not shaving hair - Skin prep: chlorhexidine alcohol = superior to aqueous povidone-iodine - Normothermia: forced air warmer - Antibiotic prophylaxis: within 60 min - LMWH: 6-8h post-surgery - Cell salvage available for high-risk haemorrhage - 'Time Out' before skin incision - Swab and instrument count before closure - VTE risk assessment on admission and when changed

10.2 Mnemonics

Surgical Hand Instruments — 'Some Laymen Prefer Stupid Points': - S: Scalpel - L: L: Ligasure/clamp/forceps - P: Probes, retractors - S: Scissors - P: Needle holders, pick-ups

Eponymous Retractors — 'Deep Large Medium Retract Whole Great': - Deaver (deep) - Langenbeck (medium) - Morris (abdominal wall retractor) - Richardson (handheld) - Weitlaner (self-retaining) - Gelpi (deep perineal)

Suture Types — 'In Cleaning, Prevent Permanent Damage': - I — Inside = absorbable (Vicryl, PDS) - C — External = non-absorbable (Nylon, Prolene) - P — Monofilament (less infection, less tissue trauma) - P — Braided (stronger, better knot security, more infection risk) - D — Delayed absorbable for fascia (PDS → 180 days)

Laparoscopic Entry — 'Veress Or Hasson + Pneumoperitoneum Trocars': - V: Veress needle (closed) - O: Open (Hasson mini-laparotomy) - H: Hasson approach in scars/obesity - P: Palmer's point (LUQ — 3cm below costal margin mid-clavicular) - T: Direct trocar entry (no pneumoperitoneum)

Wound Healing Phases — 'Healing Is Really Time-dependent': - H: Haemostasis - I: Inflammation - R: Regeneration (granulation) - T: Tissue remodelling

Fascial Closure — '1cm then 1cm apart, tissue incorporated 1cm each side': - Stitches placed 1cm from wound edge - Spaced 1cm apart - Monofilament delayed-absorbable suture (PDS/nylon size 1) - Suture:wound length ratio at least 4:1 - Continuous or interrupted (continuous faster, equally strong)

Principles of Safe Surgery — 'Time Out, Sign In, Sign Out': - T = Time Out (before incision: WHO & team) - O = Outside infection prevention (antibiotics, normothermia, glucose, hair clip) - S = Sign In (identity, consent, site, allergies, airway) - I = Instruments count, specimens labelled - S = Sign Out (team debrief, counts correct, recovery plan)

Complications of Laparoscopy — 'Vessels Always Bleed In Numbers': - V = Vascular injury (aorta, IVC, iliac, epigastric — ~0.02-0.1%) - A = Adhesions (increased with previous surgery) - B = Bowel injury (~0.04%) - I = Insufflation problems (gas embolism, subcutaneous emphysema) - N = Nerve injury

ERAS Principles — 'Carbohydrate Preload Reducing Recovery Time': - C = Carbohydrate loading 2h pre-op - P = Paracetamol + NSAIDs (multimodal analgesia) - R = Reduced fasting (clear fluids before 2h) - R = Rapid mobilisation (out of bed day 0/1) - T = Thromboprophylaxis

Consent Requirements — 'Capacity Voluntariness Information Communication': - C: Capacity (MCA 2005) - V: Voluntary (no pressure) - I: Information (Montgomery material risks) - C: Communication (patient understanding)

Post-Operative Fever Evaluation — '5 Ws': - Wind: Atelectasis (24-48h), pneumonia (48-72h) - Water: UTI (48-72h), line infection (3-5d) - Wound: SSI (5-7d), haematoma, abscess (7-14d) - Walk: DVT/PE (3-10d) - Wonder (drugs): Drug fever (any time after 3-5d)

VTE Prevention — 'Teds, LMWH, IPC, Mobilise': - T: TED stockings - L: LMWH (appropriate dose) - I: Intermittent pneumatic compression - M: Mobilise early

10.3 Exam Pearls

1. Consent key point: Montgomery requires disclosure of material risks — a reasonable person would want to know about the risk of shoulder dystocia (0.2-0.5%), not just that the baby would be delivered by CS
2. WHO checklist: Three phases — Sign In (before anaesthetic), Time Out (before incision), Sign Out (before leaving theatre)
3. IV access: Two large-bore cannulae (14G minimum 16G) for any surgery with expected blood loss >500mL
4. BP + Trendelenburg: If patient is in steep Trendelenburg, BP may appear higher due to head position
5. Gas embolism: 'Mill wheel' murmur in precordium, ↓ ETCO₂, ↓ SpO₂; stop insufflation, put patient head down, 100% O₂, central line aspiration
6. Fascial dehiscence: Sudden serosanguinous vaginal/abdominal discharge is pathognomonic
7. Antibiotic timing: Giving antibiotics >60 min before incision = worse than not giving (no longer at peak tissue levels)
8. VTE risk after CS: Risk remains 6 weeks postpartum; extended prophylaxis for high risk
9. TURP syndrome: Prevention: limit deficit; monitoring: hourly fluid assessment; treatment: stop, furosemide, hypertonic saline if Na <120 mmol/L
10. Cervical preparation: For 1st trimester TOP or operative hysteroscopy in nulliparous: misoprostol 400μg vaginally 3h before

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10.4 Perioperative Bleeding Risk & Blood Product Management

Procedure	Estimated Blood Loss	Group & Save / Crossmatch
Suction evacuation / ERPC	100-300 mL	No sample
Diagnostic laparoscopy	<50 mL	G&S only
LLETZ / cone biopsy	Minimal-50 mL	No sample
Diagnostic hysteroscopy + biopsy	<50 mL	No sample
Vaginal hysterectomy	200-500 mL	G&S
Abdominal hysterectomy (benign)	200-800 mL	G&S (crossmatch 2u if high risk)
Laparoscopic hysterectomy	100-400 mL	G&S
Myomectomy (open)	500-2000 mL	Crossmatch 2-4 units
Caesarean section (elective)	500-1000 mL	G&S
Caesarean section (emergency)	800-1500 mL	G&S (or crossmatch if high-risk)
Caesarean hysterectomy	2000-5000 mL	Crossmatch 6+ units
Laparotomy for suspected ovarian cancer	500-1500 mL	Crossmatch 2-4 units
Explorative laparotomy for ectopic	200-2000 mL	G&S or crossmatch

Massive Transfusion Protocol (MTP): - Indication: haemorrhage >2000 mL (or >150 mL/min, or >50% blood volume in 3h, or SBP <90 despite 2L fluids) - Activation: call haematology, send FBC + coagulation + fibrinogen + ABG - Initial pack: 4 units RBC + 4 units FFP (1:1 ratio) — aim for Hb >80, fibrinogen >2 g/L, platelets >50 - Goal-directed: guided by ROTEM/TEG if available — faster, reduces blood product usage - Cryoprecipitate/pooled fibrinogen for hypofibrinogenaemia (<1.5 g/L in PPH, <2.0 g/L in major trauma) - Platelets if count <75 (RCOG) or <50 (major haemorrhage) - Tranexamic acid: 1g IV over 10min, then 1g over 8h — WOMAN trial: reduced death from bleeding in PPH - Cell salvage: reduce allogenic transfusion; safe in O&G (controversial in malignancy — not standard evidence contraindicating; RCOG supports use) - Calcium: Ca gluconate 10mL IV (RBC citrate chelates calcium -> hypocalcaemia -> coagulopathy)

Reversal of Anticoagulation in O&G Emergencies: | Drug | Reversal Agent | Dose | |------|---------------|------| | Warfarin | Vitamin K + PCC (Beriplex/Octaplex) | Vit K 5-10mg slow IV (onset 6-24h) + PCC 25-50 IU/kg (immediate) | | LMWH (therapeutic) | Protamine sulphate | 1mg per 100U enoxaparin (incomplete reversal, max 50mg) | | DOACs | Andexanet alfa (for apixaban/rivarelbaban), idarucizumab (for dabigatran) | Specific reversal agents; if not available: PCC | | Unfractionated heparin | Protamine sulphate | 1mg per 100U heparin |

10.5 Common Postoperative Complications — Detailed Management

Complication	Onset	Clinical Features	Investigations	Management
Haemorrhage (primary)	Intra-op or immediate	Hypotension, tachycardia, pallor, decreased urinary output, increasing drain output, abdominal distension	FBC (Hb drop may be delayed), FAST US (free fluid), CT if stable	Resuscitate (warm fluids, blood products); surgical exploration (return to theatre); identify bleeding source — vessel retraction? check pedicle sutures, B-Lynch suture for atony; if not correctable -> hysterectomy
Haemorrhage (reactionary)	4-12h post-op	As above, often after BP rises as patient warms/awakes from anaesthesia	As above	As above
Haemorrhage (secondary)	7-14 days	Vaginal bleeding, may be smaller volume, associated with infection	FBC, US, swab	If infection: treat; if massive: surgical
Wound Infection	5-7 days	Erythema, wound tenderness, purulent discharge, pyrexia, ↑CRP/WCC	Wound swab M+C, blood cultures if febrile	Open and drain if fluctuant/purulent; antibiotics (flucloxacillin, co-amoxiclav, clindamycin if penicillin-allergic); wound packing if required; consider VAC dressing if significant dehiscence
Wound Dehiscence (superficial)	5-10 days	Separation of skin and subcutaneous tissue — serosanguinous discharge	Examine wound: is fascia intact?	If superficial: wound swab, pack with saline/alginate, secondary intention healing; if fascial dehiscence -> emergency repair
Wound Dehiscence (fascial/burst abdomen)	5-10 days	Sudden gush of serosanguinous fluid, wound gaping, bowel visible or palpable under skin	Emergency surgical assessment; CT to confirm extent	Immediate return to theatre; wound lavage, primary closure with tension sutures (loop nylon/PDS) or mesh if infected; ICU post-op
Urinary Tract Infection	2-7 days	Dysuria, frequency, pyrexia, supra-pubic pain	MSU culture	Antibiotics per sensitivity (nitrofurantoin, trimethoprim, cephalexin if pregnant: avoid TMP in 1st tri, avoid nitrofurantoin near term — neonatal haemolysis)
Urinary Retention	0-72h	Inability to void, suprapubic discomfort	Bladder scan post-void for residual volume (>150mL = clinically significant); catheter may be required	Catheterisation: in-out or indwelling (if after prolapse surgery or TVT, 24-48h on free drainage then TWOC); consider bethanechol/ distigmine (rarely); check for UTI
Deep Wound / Pelvic Abscess	7-14 days	Spiking pyrexia, rigors, malaise, neutrophilia; may have vaginal discharge or peritonism	TVS/CT abdomen: collection; FBC	Drain: US/CT-guided (preferred) or surgical (laparoscopy vs colpotomy); culture-directed antibiotics (broad spectrum: Tazocin/piperacillin-tazobactam, or meropenem if severe); remove any foreign material (mesh, retained swab)
Ileus	2-4 days	Abdominal distension, absent bowel sounds, nausea, vomiting, no flatus	AXR: small bowel dilated loops, no obstructive ladder pattern	Nil-by-mouth, NG tube (if vomiting), IV fluids with K+ (hypokalaemia worsens ileus), early mobilisation, avoid opiates if possible, consider chewing gum (evidence supports reducing ileus)
Small Bowel Obstruction	Variable (early if adhesion-related, late if hernia/band)	Colicky pain, distension, constipation, vomiting (faeculent), high-pitched bowel sounds	AXR: dilated loops, valvulae conniventes, air-fluid levels; CT: transition point, closed loop	NBM, NG, IV hydration, surgical referral; consider water-soluble contrast (Gastrografin) for adhesive SBO — both diagnostic and therapeutic; if complete obstruction/ischaemia -> laparotomy
Venous Thromboembolism (DVT)	3-10 days (up to 6wk)	Unilateral calf/suprapubic pain, swelling, warmth, tenderness, Homan's sign (unreliable)	Doppler US of legs (compression US); D-dimer NOT reliable post-surgery/pregnancy	Therapeutic LMWH (enoxaparin 1.5mg/kg OD or 1mg/kg BD); DOACs if not pregnant; warfarin with LMWH overlap if long-term; TED stockings; mobilisation; monitor for PE
Pulmonary Embolism	Variable (3-10 days common)	Sudden dyspnoea, pleuritic chest pain, haemoptysis, hypoxia, tachycardia, collapse	ECG (S1 Q3 T3 — right heart strain; tachycardia; RV strain), CTPA (pregnancy: V/Q scan if CXR normal), ABG (↓PaO₂, ↓PaCO₂)	ABC, high flow O₂, fluid resuscitation, therapeutic LMWH (first-line) or thrombolysis if massive (life-threatening) PE; call ITU; urgent further investigation if massive
Pyrexia of Unknown Origin	Variable	Persistent fever not settling	5 Ws: Wind (atelectasis), Water (UTI), Wound (infection), Walk (DVT/PE), Wonder (drug fever); cultures (blood, urine, sputum, wound), CXR, TVS for collection	Treat cause; remove central lines if suspected; review all cultures day 3 post-op; escalate antibiotic if clinically deteriorating
Nerve Injury	Immediate or delayed	Foot drop (common peroneal — poorly positioned stirrups), thigh numbness (femoral — retractor), medial leg numbness (saphenous), groin numbness (ilioinguinal/genitofemoral), wrist drop (brachial plexus — arm abduction >90°)	Neurological examination; EMG/NCS if persistent	Physiotherapy; most recover over weeks-months; prevention with correct positioning (Lloyd-Davies stirrups at correct height, arms not abducted >90°, avoid direct pressure on peroneal nerve)
Compartment Syndrome (Lloyd-Davies)	6-24h post-op	Severe calf pain out of proportion, tense swelling, paraesthesia, pain on passive stretch (dorsiflexion) of foot	Clinical diagnosis; compartment pressure monitoring >30 mmHg	Emergency fasciotomy — medial and lateral incisions; risk: patient in Lloyd-Davies stirrups for >4h; prevention: avoid lithotomy >4-6h, release stirrups during prolonged surgery

11. Urinary Retention Post-Pelvic Surgery — Detailed

Incidence: - 15–25% after prolapse surgery (especially anterior repair + colposuspension) - 2–5% after simple hysterectomy - Up to 40% after mid-urethral sling (TVT/TOT) — highest in TVT (tension-free vaginal tape)

Pathophysiology: - Pelvic dissection: surgical dissection in the pre-vesical space (retzius) and around the bladder neck → detrusor denervation (parasympathetic fibres from S2–S4) - Bladder neck distortion: suspension sutures / mesh placement → altered bladder neck angle → functional obstruction - Oedema + inflammation: post-surgical swelling of the bladder neck and urethra → mechanical obstruction - Pain + opioid analgesia: reflex increases in urethral sphincter tone via sympathetic (hypogastric nerve) outflow → 'guarding reflex' - Pre-existing voiding dysfunction: common in prolapse patients (prolapse compresses urethra → 'latent' voiding difficulty unmasked by surgery)

Diagnosis: - Clinical: inability to void spontaneously within 4–6 hours post-op + suprapubic discomfort/distension - Post-void residual (PVR) : ultrasound bladder scan or in-out catheterisation - <100 mL = normal - 100–150 mL = borderline - >150 mL = clinically significant retention (specificity ~90%) - Distinguish: retention vs oliguria (check fluid balance, examine bladder, scan)

Management:

Phase	Intervention	Duration	Notes
Immediate	In-out catheter (12–14 FG) ± indwelling catheter if PVR >300mL or symptomatic	Single drain or 24h	Document volume; check for UTI; consider alpha-blocker (e.g., tamsulosin 400μg OD) if prostate-like obstruction
First failed TWOC	Indwelling catheter on free drainage	24–48h	Gives time for oedema to resolve; consider bethanechol 10–25mg TDS/QDS (parasympathomimetic — rarely used; side effects: flushing, sweating, bradycardia)
Second TWOC	Catheter out after 48h; measure PVR	If PVR <150mL → success	If fails again → intermittent self-catheterisation (ISC)
Persistent retention	Teach ISC (intermittent self-catheterisation)	2–4 weeks (until spontaneous voiding returns)	Most resolve by 4–6 weeks; refer to urogynaecology if >6 weeks
Long-term failure	Urodynamics to exclude detrusor underactivity or bladder neck obstruction	—	Consider urethral dilatation, urethrolysis, or sacral neuromodulation (rarely needed)

Prevention: - Avoid intra-operative bladder over-distension (keep drain bag below bladder level) - Identify patients at high risk (pre-op voiding symptoms, previous incontinence surgery, older age, diabetes with autonomic neuropathy) - Counselling: inform patient pre-op of expected temporary catheterisation - Early mobilisation and adequate analgesia (minimise opioids — use paracetamol + NSAIDs as base) - Consider prophylactic alpha-blocker (tamsulosin) in high-risk patients — limited evidence, but NICE acknowledges potential benefit

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12. Pelvic Abscess / Infected Haematoma — Detailed

Definition: Localised collection of pus (or infected blood) in the pelvis following gynaecological surgery, usually arising from infected haematoma or anastomotic leak

Presentation: - Timing: spiking fevers 7–14 days post-op (classic timing — can be earlier if contaminated surgery) - Symptoms: rigors, malaise, anorexia, lower abdominal/pelvic pain, vaginal discharge (purulent, offensive), diarrhoea/tenesmus (if collection irritates rectum), nausea - Signs: pyrexia (intermittent >38.5°C), tachycardia, lower abdominal tenderness ± peritonism, tender pelvic mass on bimanual exam, cervical excitation, sluggish bowel sounds

Risk Factors: - Hysterectomy (especially vaginal or laparoscopic — more haematoma than abdominal?) - Surgery for PID / tubo-ovarian abscess / endometrioma / ovarian dermoid (spillage) - Diabetes, obesity, immunosuppression, smoking, prolonged surgery, blood transfusion - Incomplete haemostasis → haematoma formation → secondary infection - Bowel injury (especially unrecognised serosal tear or rectal injury during endometriosis dissection)

Differential Diagnosis: - Wound infection / superficial collections - Urinary tract infection (check MSU) - Atelectasis / pneumonia (5 Ws: Wind, Water, Wound, Walk, Wonder) - Drug fever (antibiotics, anaesthetic agents) - Retained swab / instrument (swab count check — always check surgical count) - Clostridium difficile colitis (if on prophylactic antibiotics) - Septic pelvic thrombophlebitis (rare — fever despite antibiotics + exclusion of all other causes)

Diagnosis:

Investigation	Finding	Sensitivity/Specificity
FBC	Neutrophilic leucocytosis ± left shift	Non-specific
CRP	Markedly elevated (>100–200 mg/L)	Sensitive but non-specific
Blood cultures	May be positive (polymicrobial — anaerobes + coliforms + streptococci)	Positive in ~30–50%
TVS (Transvaginal Ultrasound)	Complex collection with internal echoes, septations, fluid-debris level, gas (hyperechoic foci with 'dirty' shadowing)	Sensitivity 70–80% for pelvic collections
CT abdomen/pelvis	Low-attenuation collection with enhancing rim ('ring enhancement'), ± gas bubbles, ± mass effect on adjacent organs	Gold standard — sensitivity >95%
MRI	Useful if contraindication to CT (pregnancy) — T2 hyperintense collection with restricted diffusion (pus)	Good sensitivity, less available

Microbiology (polymicrobial — gut flora origin):

Organism	Frequency	Typical Surgery
E. coli	40–60%	Any pelvic surgery
Bacteroides fragilis	20–40%	Bowel involvement, contaminated field
Peptostreptococcus spp.	20–30%	Anaerobic component
Enterococcus faecalis	10–20%	Post-hysterectomy
Streptococcus spp. (group B, viridans)	10–15%	Vaginal surgery
Staph. aureus / MRSA	<5%	Wound-related, nosocomial

Treatment:

Category	First-Line	Duration	Notes
Antibiotics (empiric)	Piperacillin-tazobactam (Tazocin) 4.5g IV TDS	5–7 days (extend if not drained)	Covers Gram-negatives, anaerobes, Enterococcus; if penicillin-allergic → meropenem 1g IV TDS or ceftriaxone 2g IV OD + metronidazole 500mg IV TDS
Drainage (if collection >4cm)	US-guided transvaginal drainage (preferred if posterior collection — through posterior fornix / cul-de-sac)	Single procedure or catheter left in situ 24–48h	90% success; drain pus → send for M+C; low complication rate (<5% bowel/vascular injury)
Alternative drainage	CT-guided transgluteal drainage (for deep or high pelvic collections — through piriformis muscle)	Catheter left 3–7 days	Higher success than transvaginal if collection not accessible vaginally; risk of sciatic nerve injury, gluteal pain
Surgical drainage	Laparoscopy (lysis of adhesions, drain placement) or laparotomy (if extensive, multi-loculated, or failed percutaneous drainage)	—	Higher morbidity, but definitive if adhesions/ loculations; take cultures; copious lavage
Colpotomy	Through posterior fornix into pouch of Douglas	—	Only if collection bulging into vagina; limited access

Important Considerations: - Always check swab count — retained swab mimics abscess and is a medicolegal claim waiting to happen - CT/US guidance: send aspirated pus for M+C; catheter drainage allows serial flushing (normal saline 10–20mL TDS) - Remove any foreign material: mesh (if abscess tracks to TVT/mesh sling → partial/excision may be needed) - Septic shock: start broad-spectrum IV antibiotics + fluid resuscitation + source control urgently; escalate to critical care - Prevention: prophylactic antibiotics (cefuroxime 1.5g + metronidazole 500mg at induction), meticulous haemostasis, avoid haematoma formation, consider drain (closed suction) if raw pelvic surface area large

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13. Nerve Injuries in O&G Surgery — Detailed

General Principles: - Overall incidence: 0.5–2% of all gynaecological laparotomies/laparoscopies - Most are transient neurapraxia (conduction block without axonal disruption) — recover over weeks to months - Mechanisms: compression (stirrups, retractors, assistants leaning) > stretch (extreme hip flexion/abduction) > transection (sharp dissection — rare) > ischaemia (prolonged pressure) - Medicolegal: nerve injuries are a common source of litigation — document positioning and any known risk factors pre-operatively

Causes by Mechanism:

Mechanism	Example	Typical Nerves Affected
Patient positioning	Lithotomy (stirrups)	Common peroneal, femoral, saphenous, sciatic, obturator
	Arm abduction >90°	Brachial plexus (lower trunk), ulnar nerve
	Supine / Trendelenburg	Brachial plexus (upper trunk — shoulder braces)
Self-retaining retractors	Lateral blades on psoas muscle	Femoral nerve (most common in O&G), genitofemoral, lateral cutaneous nerve of thigh
	Deep blades in obturator fossa	Obturator nerve
Surgical dissection	Pelvic side wall (lymphadenectomy, endometriosis)	Obturator, genitofemoral, femoral, sciatic, lumbosacral trunk
	Inguinal region / abdominal incisions	Ilioinguinal, iliohypogastric, genitofemoral
Compression (indirect)	Haematoma / abscess	Femoral nerve (compression by iliacus haematoma)

Detailed Nerve Anatomy & Injury Patterns:

Nerve	Root Origin	Motor Function	Sensory Distribution	Mechanism of Injury	Clinical Presentation	Prevention
Common peroneal (lateral popliteal)	L4–S2 (sciatic division)	Foot dorsiflexion + eversion (tibialis anterior, peronei)	Lateral leg + dorsum of foot (except 1st web space)	Lithotomy stirrups — direct compression of nerve against lateral head of fibula (stirrup pole); most common lower limb nerve injury in O&G	Foot drop (unable to dorsiflex foot → steppage gait), loss of eversion, numbness over lateral leg/dorsum; plantar flexion intact	Calf support, not knee support; avoid prolonged lithotomy (>4h); pad the fibular neck area; use Lloyd-Davies stirrups with correct height (hip flexion 80–100°)
Femoral nerve	L2–L4	Hip flexion (iliopsoas) + knee extension (quadriceps)	Anterior thigh + medial leg (saphenous branch)	Self-retaining retractor blade compressing nerve against psoas muscle (most common); or lithotomy with extreme hip flexion; iliacus haematoma	Quadriceps weakness — difficulty climbing stairs, 'giving way' of knee; loss of knee jerk; numbness anterior thigh + medial leg (saphenous); N.B.: patient may present as 'falling' post-op	Avoid deep lateral retractor blades; position blades on rectus sheath, not psoas; release retractors periodically; limit hip flexion in lithotomy
Saphenous nerve (terminal branch of femoral)	L3–L4	Pure sensory	Medial leg and foot (medial malleolus to medial foot arch)	Compression of saphenous nerve at the medial knee (stirrup support); or femoral nerve injury with saphenous involvement	Numbness along medial leg/foot; no motor deficit	Pad the medial knee / calf support area in stirrups
Obturator nerve	L2–L4	Adduction of thigh (adductor longus, brevis, magnus) + external rotation	Medial thigh	Retractor blade in obturator fossa (during pelvic side wall dissection, lymphadenectomy); or deep endometriosis excision in obturator fossa	Adductor weakness — difficulty crossing legs, hip adduction against resistance; numbness medial thigh; may be subtle (most patients compensate with other adductors)	Avoid excessive retraction in obturator fossa; identify nerve in high-risk dissections (landmark: 2–3 cm below psoas, at pelvic side wall)
Lateral cutaneous nerve of thigh (LFCN)	L2–L3	Pure sensory	Lateral thigh (from greater trochanter to mid-thigh)	Retractor compression at inguinal ligament; or lateral incisions (Pfannenstiel — retraction)	Meralgia paraesthetica — burning pain, paraesthesia, numbness over lateral thigh; no motor deficit; usually self-limiting over weeks	Avoid prolonged traction with retractors; pad iliac crest area
Ilioinguinal nerve	T12–L1	None (motor to internal oblique, transversus abdominis — usually insignificant)	Inguinal + medial upper thigh + mons pubis + labia majora / scrotum	Entrapment during Pfannenstiel or low transverse incisions (suture entrapment or neuroma) — especially if incision extends laterally beyond lateral border of rectus	Burning groin pain ± numbness medial thigh/labia; worsened by extending thigh; Tinel's sign at incision site	Gentle dissection during incision; avoid incorporating nerve in fascial closure; identify and preserve if possible
Genitofemoral nerve	L1–L2	Cremaster (male)	Labia/groin (femoral + genital branches)	Retractor pressure on psoas during laparoscopy; or direct injury during lymphadenectomy in obturator fossa	Numbness or burning in labia majora / medial groin; no motor deficit	Same as ilioinguinal
Sciatic nerve	L4–S3	Hip extension, knee flexion, all foot/ankle movements	Posterior thigh + entire leg below knee	Lithotomy with extreme hip flexion + abduction; or posterior pelvic dissection (e.g., sacral colpopexy, presacral dissection)	Severe deficit: foot drop (common peroneal component usually more affected than tibial), hamstring weakness, numbness posterior thigh + leg	Avoid prolonged lithotomy with hip flexed >90°; release one leg periodically during long procedures
Brachial plexus	C5–T1	Shoulder + arm + hand	Arm + forearm + hand	Arm abduction >90° during surgery (assistant leaning on arm, shoulder braces in Trendelenburg)	Upper trunk (C5–C6): shoulder abduction + elbow flexion weakness (Erb-Duchenne); Lower trunk (C8–T1): hand weakness, clawing (Klumpke's)	Tuck arms at sides (or abduct <90°); avoid shoulder braces if possible; pad elbows

Recovery & Prognosis: - Neurapraxia (most common): conduction block without axonal loss → recovery in 2–12 weeks (complete) - Axonotmesis: axonal disruption but Schwann cell sheath intact → recovery 3–12 months (regrowth 1 mm/day) - Neurotmesis: nerve transection — very rare in O&G; requires surgical repair (epineural microsurgery); recovery incomplete - EMG/NCS: helpful if no improvement by 4–6 weeks; differentiates neurapraxia from axon loss; guides prognosis

Management of Suspected Nerve Injury: 1. Document the deficit immediately — baseline neurological exam, site, date 2. Exclude surgical cause — haematoma/abscess compressing nerve (MRI if suspect) 3. Physiotherapy — range of motion, passive stretching (prevents contractures), active exercises as tolerated 4. Foot drop: ankle-foot orthosis (AFO) splint prevents equinus deformity + improves gait 5. Pain management — neuropathic agents (gabapentin, amitriptyline) if neuropathic pain present 6. EMG/NCS at 4–6 weeks if no improvement — guides prognosis 7. Surgical exploration — only if nerve transection suspected (intra-operative recognition) or compressive lesion (haematoma) requiring evacuation

Key Prevention Strategies for Nerve Injuries: - Lithotomy positioning checklist (USE ANP ): - Allow adequate padding — gel pads under knees, avoid direct pressure on fibular head - No abduction >90° — limit hip abduction to 30–45° - Position stirrups at equal height, avoid hyperflexion (hip flexion 80–100°) - Avoid self-retaining retractors on psoas muscle — use rectal or malleable blades for lateral retraction; release retractors every 30 min - Tuck arms at sides with neutral wrist position (avoid over-extension at elbow — ulnar nerve) - Limit lithotomy time to <4 hours — if longer, consider releasing one leg at a time periodically - Document positioning in operative notes — particularly for high-risk patients (obesity, diabetes, peripheral neuropathy, known spinal stenosis)

10.6 Specific Surgical Emergencies

Laparoscopic Entry Injuries: - Major vessel injury (aorta, IVC, iliac vessels): incidence 0.02-0.1% — most catastrophic complication - Recognition: sudden drop in ETCO₂, hypotension, tachycardia, blood in Veress/around trocar, haemoperitoneum, retroperitoneal haematoma - Immediate action: convert to laparotomy (make midline incision immediately), apply pressure, call for senior help (vascular surgeon), crossmatch 4-6 units, resuscitate with warm fluids, repair vessel (primary repair or patch) - Never remove the trocar until you can see the vessel and control it — the trocar may be tamponading the injury

• Bowel injury: incidence ~0.04% overall; higher in previous abdominal surgery, adhesions, thin patients
• Recognition: may be immediate (faecal odour, visible bowel content) or delayed (peritonitis 24-72h later)
• Immediate repair: primary closure in two layers (if small, clean, and no gross contamination); resection + anastomosis if large or devascularised; laparotomy or laparoscopically-assisted
• Delayed presentation: considered in any patient with sepsis, abdominal pain, distension, vomiting post-laparoscopy; CT with oral contrast may show extravasation

Gas Embolism: - Rare but potentially catastrophic complication of laparoscopy - Pathophysiology: CO₂ enters venous system through injured vessel or directly through Veress needle - Recognition: ↓ETCO₂, ↓SpO₂, hypotension, tachycardia, 'mill wheel' murmur on precordial auscultation, dysrhythmia, right heart strain on ECG - Treatment: Stop insufflation, release pneumoperitoneum, left lateral decubitus (Durant's position) — traps gas in right atrium, central line to aspirate gas, hyperbaric oxygen if available, inotropic support - Prevention: correct Veress placement (aspiration test for blood/gas), low pressure insufflation, entry at 90° to abdominal wall (avoids preperitoneal placement)

Bowel Injury at Open Surgery (Laparotomy): - Most common: enterotomy during adhesiolysis, especially in repeated laparotomies, severe endometriosis, cancer surgery - Recognition: visible bowel content, gas, faecal odour, bile staining - Repair: small <1cm clean defect -> interrupted 3-0 vicryl/PDS in two layers (full-thickness + seromuscular) - Larger/poor blood supply -> resection with primary anastomosis - If gross contamination: copious lavage, delayed wound closure, broad-spectrum antibiotics - Colorectal injury: may require defunctioning stoma/colostomy (especially if low rectal, associated with mesh, or anastomotic leak risk)

Ureteric Injury: - Incidence: 0.2-1% in gynaecological surgery; higher in radical hysterectomy (1-2%), laparoscopic hysterectomy, large endometriosis/ fibroids/adhesions, pelvic side wall dissection - Mechanisms: ligation/transfixion (most common — suture through ureter), kinking (from sutures pulling across), crushing (clamp), devascularisation (stripping of adventitial blood supply), transection (sharp dissection) - Affected segments: 1. At pelvic brim — where ureter crosses the uterine artery ('water under the bridge') — most common site in TAH 2. Near uterosacral ligaments where ureter passes 1-2cm lateral to cervix 3. At bladder trigone (during vaginal cuff closure) - Recognition intra-op: - Suspect if there's fluid accumulation in the pouch of Douglas, unexpected haematuria, or inability to identify ureter peristalsis - IV indigo carmine/methylene blue + cystoscopy: if no dye seen effluxing from one ureteric orifice, suspect injury - Direct inspection: trace ureter from pelvic brim to bladder, look for kinking, ligature, or transection - Repair: - If ligated: remove suture immediately; check for patency — may require stent if oedematous - If transected lower third (most common): ureteric reimplantation (ureteroneocystotomy) — mobilise ureter, reimplant into bladder via submucosal tunnel (anti-reflux = Leadbetter-Politano or extravesical Lich-Gregoir) - If transected middle/upper third: ureteroureterostomy (end-to-end anastomosis) over a stent, tension-free, spatulated - If extensive loss: Boari flap or psos hitch, or ileal interposition - All: JJ stent for 6-8wk post-repair, drain in extraperitoneal space, prophylactic antibiotics - Delayed recognition: flank pain (but may be asymptomatic — up to 30%), fever, 'silent' hydronephrosis + UTI, or vaginal leakage of urine (ureterocutaneous/ureterovaginal fistula) - Investigations for delayed diagnosis: CT urogram (CT IVU), renal US (hydronephrosis), retrograde pyelogram, creatinine in leaking fluid (vaginal fluid creatinine >> serum)

10.7 Anaesthesia in O&G — Expanded Detailed Guide

1. Regional vs General Anaesthesia — Comparison

Aspect	Regional (Spinal/Epidural/CSE)	General Anaesthesia
Indications	Elective/urgent CS (Category 3–4), labour analgesia, perineal/ vaginal surgery, patient preference	Category 1 CS (fetal distress), failed regional, maternal refusal of regional, coagulopathy, sepsis, raised ICP, certain cardiac conditions (e.g., some congenital heart disease), major haemorrhage
Advantages	Mother awake at delivery, immediate skin-to-skin, reduced maternal haemorrhage (less PPH), lower risk of aspiration, less neonatal respiratory depression (no GA drugs crossing placenta), lower risk of failed intubation	Rapid onset, predictable airway control, suitable for prolonged/complex surgery, can bypass contraindications to regional
Disadvantages	Time to establish (spinal: 5–10 min; epidural: 20–30 min), hypotension (sympathetic block), failed block (redo or conversion to GA), PDPH risk, LA toxicity, contraindicated in coagulopathy/ sepsis /raised ICP	Aspiration risk (pregnancy delays gastric emptying — 40% ↑ gastric volume), failed intubation (~1:250 vs 1:2000 non-obstetric), neonatal respiratory depression, uterine atony (volatile agents >1 MAC), PONV, maternal awareness (rare, ~0.1% during CS under GA)
Haemodynamics	Hypotension common (sympathectomy); treated with fluids + vasopressors	More stable if well-managed; hypotension on induction common
Post-op pain	Excellent — spinal opioids give 8–24h relief; epidural catheter can continue	Requires systemic opioids ± TAP block ± PCA; higher pain scores day 0–1
Neonatal effects	Minimal drug transfer (small doses); Apgar scores comparable	Some drugs cross placenta (thiopentone/propofol — transient depression); volatile agents minimally cross; overall safe if well-managed

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2. Spinal Anaesthesia — Detailed

Anatomy: - Spinal cord ends at L1/L2 in adults (at birth it ends at L3; by age 2 it ascends to L1/L2) - Safety: always perform spinal below L2 — standard interspaces: L3/4 or L4/5 - Surface landmark: Tuffier's line (line joining iliac crests) crosses L4 spinous process or L4/5 interspace - Conus medullaris (spinal cord termination) — puncturing above L2 risks direct cord injury

Drugs: - Bupivacaine 0.5% heavy (hyperbaric): baricity = 1.027 (heavier than CSF — specific gravity ~1.003–1.009); hyperbaric solution sinks in CSF — useful for predictable spread with gravity - Dose for CS: 2.0–2.5mL (10–12.5mg) — higher doses for longer surgery - Dose for perineal surgery: 1.0–1.5mL — lower dose, may use a 'saddle block' - Fentanyl: 15–25μg — enhances intra-op anaesthesia, mild prolongation - Diamorphine: 300–400μg (preservative-free) — provides post-op analgesia for 8–24h; risk of delayed respiratory depression (monitor 24h post-op: respiratory rate, sedation scores) - Preservative-free morphine: 100–200μg — alternative long-acting opioid; more pruritus and nausea than diamorphine

Level of Block Required: - Caesarean section: T4 to S5 — need T4 level to cover peritoneum (somatic) and uterus (visceral); loss of cold sensation to T4 = adequate surgical block - Perineal surgery: S2–S5 only (saddle block) — spares lower limb motor function - Testing level: ice (cold sensation) or light touch; loss of cold sensation ~2 dermatomes ahead of loss of touch

Physiological Effects — Sympathetic Block: - Sympathetic outflow = T1–L2 → block of these fibres causes: - Vasodilation (arteriolar + venous) → ↓ SVR → hypotension (most common complication — incidence 15–30%) - Venous pooling → ↓ preload → ↓ cardiac output - Unopposed vagal tone → bradycardia (especially if block above T4 — cardioaccelerator fibres T1–T4) - Management of hypotension: - Pre-loading: IV crystalloid 500–1000mL (controversial — recent evidence suggests limited benefit; unnecessary fluid loading → worsening heart failure + dilutional anaemia) - Vasopressors: - Phenylephrine (α-agonist): 50–100μg IV bolus — first-line in obstetrics (does not cross placenta, no fetal acidosis); can be infused at 25–100μg/min - Ephedrine (mixed α+β): 3–6mg IV — second-line (crosses placenta, may cause fetal tachycardia/acidosis) - Left uterine displacement — manual or wedge → prevents aortocaval compression (supine hypotensive syndrome)

Complications of Spinal Anaesthesia:

Complication	Incidence	Features	Management
Hypotension	15–30%	↓BP ± nausea (nausea = early sign of cerebral hypoperfusion)	Fluids, vasopressor (phenylephrine first-line), LUD
PDPH	<1% (with 25–27G pencil-point)	Fronto-occipital headache worse upright, neck stiffness, photophobia, tinnitus, diplopia (CN VI)	Conservative → EBP
Total spinal	Very rare (<0.01%)	Severe hypotension + bradycardia, loss of consciousness, apnoea, fixed dilated pupils (block reaches cervical cord + brainstem)	Airway control (intubate/ventilate), vasopressors, atropine, supportive care until block resolves (hours)
Nerve injury	0.1–1%	Paraesthesia, numbness, weakness — usually transient	Neurology consult, MRI if persistent, conservative
Spinal haematoma	<0.001%	Severe back pain, radicular pain, bladder/bowel dysfunction, paraplegia	Emergency MRI (within 6h), neurosurgical decompression (laminectomy); prevention: stop LMWH 12h before, stop antiplatelets as per guidelines
Infection	<0.01% (superficial); meningitis/abscess very rare	Back pain, fever, meningism, neurological deficit	Urgent MRI, LP, IV antibiotics, neurosurgical drainage
Urinary retention	Common	Inability to void after spinal wears off	Catheterisation (usually resolves in 12–24h)
Back pain	Up to 25%	Localised backache, self-limiting	Analgesia, reassurance; resolves over days

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3. Epidural Anaesthesia — Detailed

Anatomy: - Epidural space: lies between ligamentum flavum (posterior) and dura mater (anterior); contains fat, areolar tissue, blood vessels, lymphatics, nerve roots - Loss of Resistance (LOR): as needle passes through ligamentum flavum (dense, fibrous) → enters epidural space → loss of resistance to saline (preferred — clearer endpoint) or air (risk of venous air embolism, patchy block with air) - Negative pressure: epidural space has slight negative pressure (−2 to −10 cmH₂O) — more pronounced in sitting position - Depth from skin to epidural space: 4–6 cm (obesity: may be 8–10 cm)

Drugs and Dosing Regimens:

Drug	Concentration	Duration	Notes
Bupivacaine	0.1–0.25%	90–120 min	Most commonly used; cardiotoxic in overdose (see LAST section)
Levobupivacaine	0.1–0.25%	90–120 min	Less cardiotoxic than bupivacaine (pure S-enantiomer); preferred in pregnancy
Ropivacaine	0.1–0.2%	90–120 min	Less motor block, less cardiotoxic; good for walking epidural
Fentanyl	2 μg/mL (added)	—	Enhances block, reduces local anaesthetic needs; risk of pruritus, nausea
Adrenaline	1:200,000–1:400,000	—	Added to prolong LA action, reduce systemic absorption, and as marker for IV injection

Test Dose: - 3 mL of bupivacaine 0.25% + 1:200,000 adrenaline (contains 15μg adrenaline) - If IV injection: HR increases by 20–30 bpm within 15–30 seconds (positive test) - If subarachnoid: rapid onset of spinal block (within 1–2 minutes) - Limitation: adrenaline test unreliable in labour (contractions cause HR variability); in labouring women, test dose sensitivity is lower - Alternative test: aspiration for blood/CSF, fractionated dosing (give 3–5mL, wait, then repeat)

Top-Up Regimens for Caesarean Section: - Standard: 15–20 mL lidocaine 2% + adrenaline 1:200,000 + fentanyl 100μg + bicarbonate 2mL (8.4%) — bicarbonate speeds onset by raising pH of acidic lidocaine - Alternative: levobupivacaine 0.5% 15–20 mL + fentanyl 100μg - Onset: ~5–8 minutes for surgical anaesthesia (T4 level) - Check block adequacy: loss of cold sensation to T4 bilaterally before incision

Complications of Epidural Anaesthesia:

Complication	Incidence	Features	Management
Dural puncture (wet tap)	~1% (higher in trainees, obesity, multiple attempts)	Free-flowing CSF from Tuohy needle	Convert to spinal (needle-through-needle) or re-site at different interspace; catheter can be placed intrathecally for continuous spinal anaesthesia (controversial — higher risk of infection/ PDPH); warn patient re PDPH; prophylactic EBP controversial
Failed block	5–10% (higher in obesity, previous spinal surgery, multiple attempts)	Inadequate surgical block ± asymmetry, patchy block, missed segments	Top-up with stronger agents; consider re-siting; convert to GA if inadequate
Intravenous injection (LAST)	Rare (<0.1%)	See LAST section below	Immediate lipid emulsion; stop injection; resuscitate
Catheter migration	0.1–0.5%	Catheter moves IV (loss of block effect, +ve adrenaline test), intrathecal (rapid high block), or subdural (patchy high block)	Test dose if suspect; replace catheter
Epidural haematoma	<0.001%	Severe back pain, radicular pain, leg weakness, bladder dysfunction	Urgent MRI → neurosurgical decompression within 6–8h
Epidural abscess	<0.001%	Back pain, fever, tenderness, neurological deficit (triad: back pain + fever + neurological symptoms)	Urgent MRI → neurosurgical drainage + IV antibiotics (catastrophic if untreated — permanent paraplegia)
Infection (superficial)	1–3%	Insertion site redness, tenderness, discharge	Remove catheter, swab, antibiotics; escalate if signs of deep infection

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4. Combined Spinal-Epidural (CSE) — Detailed

Concept: Combines rapid onset/dense block of spinal with flexibility of epidural catheter for top-ups

Indications: - Labour analgesia for high-risk patients likely to need operative delivery (obesity, previous CS, multiple pregnancy, malpresentation) - Elective CS where prolonged surgery expected or for post-op epidural analgesia - Trial of instrumental delivery in theatre (spinal gives rapid surgical block; catheter provides extensibility)

Techniques:

Technique	Method	Advantages	Disadvantages
Needle-through-needle (Nettle)	Tuohy needle in epidural space; long fine spinal needle (25–27G Whitacre/spinal) passed through Tuohy needle → punctures dura → inject intrathecal drugs → remove spinal needle → thread epidural catheter	Quick, single interspace, low PDPH rate (small-gauge pencil-point needle)	May not reach CSF if Tuohy deviated from midline; catheter threading can be difficult after spinal (CSF leak → ? difficulty); higher cost
Two-space technique	Separate epidural at one interspace (e.g., L1/2 or L2/3) + spinal at lower interspace (L3/4 or L4/5)	Catheter threading independent of spinal; higher success rate for catheter placement	Two punctures; more time-consuming; patient less comfortable

Typical Doses: - Intrathecal component: 25μg fentanyl + 2.5mg bupivacaine (labour analgesia); for CS: standard spinal dose - Epidural component: low-concentration bupivacaine 0.1% + fentanyl 2μg/mL as needed

Complications: Same as spinal + epidural combined — PDPH if wet tap, failed block, LA toxicity from epidural dosing, infection

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5. Post-Dural Puncture Headache (PDPH) — Detailed

Pathophysiology: - Dural puncture → CSF leak through the hole → ↓ CSF volume → ↓ CSF pressure → brain 'sags' → traction on pain-sensitive intracranial structures (meninges, cranial nerves, blood vessels) → headache - CSF leak rate: ~10–15 mL/h through a 25G needle hole; loss of 10% of total CSF volume (150mL) triggers symptoms - Low CSF pressure also causes compensatory cerebral vasodilation (Monro-Kellie doctrine) → worsens headache

Risk Factors for PDPH:

Factor	Higher Risk	Lower Risk
Age	20–30 years (peak)	>40 years (↓ incidence, ↓ severity)
Sex	Female (especially pregnancy — hormones soften dura?)	Male
Needle size	Larger needles → larger hole → more leak	Smaller = less risk (27G > 25G > 22G)
Needle type	Cutting needle (Quincke, bevel) — cuts dural fibres	Pencil-point (Whitacre, Sprotte) — separates fibres; PDPH ~50–70% lower
Bevel orientation	Bevel perpendicular to dural fibres (cutting needle)	Bevel parallel to dural fibres (longitudinal) — separates rather than cuts fibres
Previous PDPH	2–4× increased risk	No prior history
BMI	Lower BMI → thinner dura?	Obesity may be protective (increased intra-abdominal pressure → ↑ CSF pressure)
Number of attempts	Multiple punctures increase risk	Single attempt
Pregnancy	Physiological hyperhydration → more CSF volume? Mechanism unclear	Non-pregnant

Timing: - Onset: 24–48 hours post-puncture (delayed because patient is supine initially and CSF leak accumulates over time) - Can present earlier (especially large dural puncture with 16G Tuohy needle — may be immediate) - Duration: 2–7 days if untreated (80–85% resolve spontaneously within 7 days)

Clinical Features: - Headache: severe, frontal or occipital, often bilateral - Postural component: worse on sitting/standing, relieved by lying flat (key diagnostic feature) - Neck stiffness: due to meningeal traction - Photophobia: common - Tinnitus: 'whooshing' sound in ears - Diplopia: CN VI palsy (abducens nerve) — longest intracranial course, most susceptible to traction; usually transient, resolves with EBP - Nausea/vomiting: vagal stimulation from meningeal traction - Hearing loss: sensorineural (CN VIII stretched in internal auditory meatus) — usually subclinical

Differential Diagnosis: - Cortical vein thrombosis (CVT) — non-postural, neurological signs, seizures — MRV to differentiate - Migraine, meningitis (fever, neck stiffness + photophobia — more severe, non-postural) - Pre-eclampsia (hypertension, proteinuria, headache) - Pneumocephalus (if air used for LOR — headache from intracranial air)

Management:

Stage	Intervention	Evidence
Conservative	Bed rest (avoid straining), hydration (oral/IV 1.5–3L/day), simple analgesia (paracetamol 1g QDS, ibuprofen 400mg TDS, codeine 30–60mg), caffeine (oral 300mg or IV 500mg caffeine benzoate — mild effect, short-lived)	80–85% resolve in 2–7 days; conservative alone insufficient for severe PDPH
Epidural Blood Patch (EBP) — Gold Standard	Own blood 10–20 mL (aseptically drawn from arm) injected into epidural space at (or one level below) original puncture site; procedure: aseptic, LOR to saline, stop on radicular pain or 20mL reached; patient remains flat 1–2h post-procedure	Success: 90–95% first dose; 97–99% if repeated once; mechanism: blood patch clots over dural hole → raises subarachnoid pressure → immediate relief; long-term: dural hole is sealed by fibrin and collagen deposition
EBP — if first fails	Repeat EBP; consider alternative site; use imaging (fluoroscopy/US) if difficult anatomy	Second EBP effective in 70–80% of those who failed first
Surgical repair	Only if EBP fails repeatedly and symptoms severe	Extremely rare; direct dural repair (open or endoscopic)

Complications of EBP: - Immediate: back pain (50–70%, resolves in 24–48h), radicular pain (if nerve root compression from injectate), transient ↑ headache (from ↑ CSF pressure) - Late: failed patch (~5–10%), infection (very rare — strict aseptic technique), nerve root irritation, subdural haematoma (rare), arachnoiditis (extremely rare)

Prevention of PDPH: - Use smallest-gauge pencil-point needle (25–27G Whitacre/Sprotte) - Keep bevel parallel to dural fibres (for cutting needles — less relevant for pencil-point) - Limit number of attempts - Prophylactic EBP after accidental dural puncture: controversial — some evidence reduces need for EBP, but some studies show no benefit and risk of infection - Intrathecal catheter for 24h: may reduce PDPH by reducing CSF leak via inflammatory reaction around catheter (small studies)

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6. General Anaesthesia for CS — Detailed

Indications: - Category 1 CS (immediate threat to life of woman or fetus — fetal bradycardia, cord prolapse, placental abruption, uterine rupture, massive PPH where no time for regional) - Failed regional anaesthesia (inadequate block requiring conversion ~2–5%) - Maternal refusal of regional anaesthesia - Contraindications to regional: coagulopathy (platelets <70–80 × 10⁹/L, LMWH within 12h, warfarin not reversed), sepsis/bacteraemia (risk of spinal/epidural abscess), raised ICP (coning risk on dural puncture), certain cardiac conditions (e.g., some congenital heart disease, severe aortic stenosis — relative, anaesthetist discretion) - Maternal preference (rare) - Massive haemorrhage — unstable haemodynamics → definitive airway

Physiological Changes of Pregnancy Relevant to GA: - FRC ↓ 20% (by term — diaphragm pushed up by gravid uterus) - O₂ consumption ↑ 20% (metabolic demands of pregnancy) - Result: pregnant woman desaturates ~80% faster than non-pregnant (safe apnoea time: pre-oxygenated pregnant woman ~2–3 min vs non-pregnant ~5–8 min) - Airway oedema: increased capillary permeability + fluid retention → narrowing of pharyngeal/laryngeal inlet (smaller ETT needed: 6.5–7.0 mm ID) - Delayed gastric emptying (progesterone effect): increased gastric volume + lower oesophageal sphincter tone → aspiration risk

Rapid Sequence Induction (RSI) — Step by Step:

1. Pre-oxygenation (denitrogenation):
2. 100% O₂ via tight-fitting facemask for 3–5 minutes of tidal volume breathing
3. Alternative in emergency: 4 vital capacity breaths over 30–60 seconds (less effective but better than nothing)
4. Target: end-tidal O₂ >90% before induction

5. High-flow nasal oxygen (HFNO) : 70 L/min O₂ via nasal cannulae during apnoeic period — extends safe apnoea time (THRIVE technique); increasingly used in obstetric GA but evidence evolving

6. Positioning:

7. Ramp position (head up 30° + neck extended) — aligns oral, pharyngeal, and laryngeal axes; improves laryngoscopy view
8. Left uterine displacement (wedge under right hip or manual) — prevents aortocaval compression

9. Head elevated to level of sternal notch (difficult airway positioning)

10. Induction Agents:

11. Propofol: 2 mg/kg IV — rapid onset (30–45 sec); preferred in modern practice; uterine relaxation minimal; antiemetic
12. Thiopentone: 4–5 mg/kg IV — standard for decades; can cause hypotension (especially in hypovolaemia), no antiemetic effect

13. Ketamine: 1–2 mg/kg IV — for haemodynamically unstable/septic patient (dissociative anaesthetic, maintains SVR)

14. Neuromuscular Blockade:

15. Suxamethonium: 1–1.5 mg/kg IV — depolarising; onset 30–60 sec, duration 4–6 min; side effects: fasciculations, myalgia, hyperkalaemia (risk in: burns, denervation, muscular dystrophy — avoid), MH trigger

16. Rocuronium: 1 mg/kg IV — non-depolarising; onset 45–60 sec (at high dose); duration 30–60 min; reversible with sugammadex 16 mg/kg (if available) — makes it acceptable for RSI (modified RSI) when suxamethonium contraindicated

17. Cricoid Pressure (Sellick's Manoeuvre):

18. 10 N applied awake (to allow swallowing)
19. 30 N once unconscious (firm pressure on cricoid cartilage — compresses oesophagus against cervical spine to prevent passive regurgitation)
20. Release if: difficult intubation (cricoid may distort larynx / worsen view) OR active vomiting (risk of oesophageal rupture)

21. Controversial: recent evidence questions efficacy — cricoid pressure may reduce aspiration risk but may worsen laryngoscopy view; OAA and DAS guidelines support its use but recommend release if grade 3+ laryngoscopy

22. Intubation:

23. Laryngoscopy: Macintosh blade (curved) — size 3 or 4
24. ETT: 6.5–7.0 mm ID (cuffed) — smaller than non-pregnant (7.5–8.0) due to airway oedema
25. Depth: 20–22 cm at teeth (average)
26. Confirmation: capnography (mandatory — continuous ETCO₂ waveform = confirmed tracheal intubation)

27. Bougie: always have ready in obstetric theatres

28. Maintenance of Anaesthesia:

29. O₂ + N₂O (50:50 or 40:60 ratio) — nitrous oxide provides second-gas effect, reduces volatile requirement
30. Volatile agent: sevoflurane (1–2%) or isoflurane (0.5–1 MAC) — keep ≤1 MAC to avoid uterine atony
31. Target: BIS monitoring (40–60) if available — reduces awareness risk
32. After delivery: reduce volatile (uterine contraction needed), increase opioids (fentanyl/morphine)

33. Avoid: desflurane (less uterine relaxation but airway irritation) — acceptable though NICE considers all volatiles suitable

34. Awake Extubation:

35. Criteria: patient awake, following commands (squeeze hand, open eyes), breathing spontaneously (TV >5 mL/kg, rate 10–20), airway reflexes intact (cough/gag), adequate reversal of neuromuscular blockade (TOF ratio >0.9)
36. Position: head-up 30° (reduces aspiration)
37. Technique: pre-oxygenate with 100% O₂, suction oropharynx, deflate cuff, remove on inspiration, check airway patency post-extubation
38. Recovery: lateral position (recovery position) to protect airway

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7. Failed Intubation in Obstetrics — Detailed

Background: - Incidence: ~1 in 250 (0.4%) obstetric GAs vs 1 in 2000 (0.05%) in non-obstetric population - Reasons for higher incidence: pregnancy-induced weight gain, breast enlargement (impedes laryngoscope handle + short thyromental distance), pharyngeal/laryngeal oedema (increased Mallampati grade — up to 30% progress by one class in pregnancy), fluid retention → tongue swelling, increased chest wall mass

Predictors of Difficult Airway (LEMON): - Look externally: facial / neck anatomy, obesity, short neck, limited jaw protrusion, large breasts - Evaluate 3-3-2 rule: mouth opening >3 finger-breadths, hyoid-mental >3, thyroid-hyoid >2 - Mallampati: Class III/IV — note: can change rapidly in labour - Obstruction: stridor, neck masses, trauma - Neck mobility: reduced extension (arthritis, previous cervical spine surgery)

OAA/DAS Obstetric Difficult Airway Guidelines (2015) — Summary Algorithm:

Plan A — Initial tracheal intubation: - Pre-oxygenate + cricoid pressure - Max 2 attempts at laryngoscopy (different blade/operator/bougie) - No more than 2 attempts by experienced anaesthetist; 3rd attempt = failure - If fails → Plan B

Plan B — Maintain oxygenation (supraglottic airway): - Insert 2nd-generation supraglottic airway (i-gel® or LMA ProSeal®/Supreme®) — has gastric drain tube and higher seal pressure - Ventilate with cricoid pressure released (if hindering ventilation) - Max 2 attempts - If adequate ventilation → decision: - Category 1/2 CS: proceed with supraglottic airway + cricoid pressure; category 1 CS must proceed — cannot wake patient - Category 3/4 CS: wake patient (priority: maternal safety) → attempt regional or plan for awake fibreoptic intubation - If no ventilation → Plan C

Plan C — Facemask ventilation: - Two-person bag-mask ventilation (two-handed jaw thrust + Guedel airway) - Cricoid released - Oropharyngeal suction - If no ventilation → Plan D

Plan D — Front-of-neck access (cricothyroidotomy): - Scalpel-bougie-tube technique (Universal emergency surgical airway): 1. Identify cricothyroid membrane (CTM) 2. Horizontal stab incision through skin + CTM (scalpel size 10 blade) 3. Rotate scalpel 90° to open, insert bougie through hole 4. Railroad 6.0 mm cuffed ETT over bougie (<6.0 — most are too small to ventilate) 5. Confirm with capnography - Alternative: needle cricothyroidotomy (percutaneous cannula 14G + jet ventilation) — lower risk of bleeding but less reliable ventilation

Key Safety Points: - Call for help early — as soon as difficult airway recognised - Never persist beyond 2 attempts at laryngoscopy — oedema worsens fast - If mother cannot be intubated or ventilated → front-of-neck access within seconds - Have a difficult airway trolley in every obstetric theatre — includes: laryngeal masks (i-gel sizes 3/4/5), bougie, McCoy blade, videolaryngoscope (e.g., McGrath, C-MAC), cricothyroidotomy kit, capnography - Document failed intubation — inform patient + notes; recommend anaesthetic review for future deliveries

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8. Local Anaesthetic Toxicity (LAST) — Detailed

Causes: - Accidental IV injection — most common cause (during epidural test dose or top-up; during peripheral nerve block) - Overdose — excessive dose for body weight - Rapid absorption — highly vascular site (intercostal block highest absorption rate) - Delayed clearance — hepatic impairment, cardiac failure, extremes of age, pregnancy (decreased protein binding → more free drug)

Clinical Features — Spectrum of Toxicity:

Stage	Signs & Symptoms
Early (prodromal) — CNS excitation	Perioral tingling/numbness, metallic taste, tinnitus, visual disturbances (blurred vision, diplopia), lightheadedness, slurred speech, agitation, confusion
Intermediate — CNS depression	Seizures (generalised tonic-clonic — due to blockade of inhibitory pathways → unopposed excitation), loss of consciousness
Late — Cardiorespiratory	Cardiovascular collapse — hypotension, bradycardia, arrhythmias (bupivacaine most cardiotoxic — binds to sodium channels with slow off-rate → refractory VT/VF), respiratory depression/arrest, asystole

Bupivacaine Cardiotoxicity: - Most potent cardiotoxic LA (lipophilic, highly protein-bound, slow channel dissociation) - Arrhythmias: wide QRS, VT → VF (often refractory to defibrillation) - Safer alternatives: levobupivacaine (40% less cardiotoxic), ropivacaine (pure S-enantiomer, 70% less cardiotoxic than bupivacaine)

Treatment (AAGBI / RESUS Council Guidelines):

1. Stop injection immediately
2. Call for help — cardiac arrest team
3. Airway: secure airway, 100% O₂, hyperventilate (↓ PaCO₂ ↓ cerebral blood flow → ↓ LA delivery to brain?)
4. Seizures: benzodiazepines (midazolam 2–5mg IV) or propofol (thiopentone if propofol unavailable)
5. Cardiovascular instability:
6. Standard ALS protocols — but reduce adrenaline doses (≤1μg/kg — higher doses may impair lipid emulsion efficacy)
7. Avoid vasopressin (impairs lipid emulsion action — animal studies)
8. Avoid lidocaine as antiarrhythmic
9. Amiodarone 300mg IV for VT/VF (preferred antiarrhythmic)
10. Prolonged CPR may be needed (LA redistributes slowly)
11. Intravenous Lipid Emulsion (ILE) — Intralipid 20% :
12. Bolus: 1.5 mL/kg over 1 minute (≈100 mL for 70kg patient)
13. Infusion: 0.25 mL/kg/min (≈350 mL over 15min)
14. Repeat bolus (max 2×) if cardiovascular stability not achieved
15. Continue infusion until haemodynamic stability (max total: 12 mL/kg)
16. Mechanism: 'lipid sink' — binds LA in plasma; also provides high-energy substrate to myocardium (free fatty acids for oxidative metabolism)
17. Consider cardiopulmonary bypass if refractory cardiac arrest

Prevention: - Test dose with adrenaline (see epidural section) - Fractionated dosing: inject in 3–5 mL increments, wait 30–60 sec between doses - Aspirate before injection — to check for blood / CSF (but false-negative rate up to 2%) - Ultrasound guidance for peripheral nerve blocks (reduces IV injection) - Use safer agents (levobupivacaine, ropivacaine) for high-dose blocks - Calculate maximum safe dose: bupivacaine = 2 mg/kg (with adrenaline = 2.5–3 mg/kg); lidocaine = 3–4 mg/kg (with adrenaline = 7 mg/kg)

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9. Malignant Hyperthermia (MH) — Detailed

Definition: Rare (1:10,000–1:50,000), life-threatening, autosomal-dominant pharmacogenetic disorder of skeletal muscle calcium regulation → uncontrolled calcium release from sarcoplasmic reticulum → hypermetabolic crisis

Triggers in Anaesthesia: - Suxamethonium (depolarising muscle relaxant) - All volatile anaesthetics (halothane, sevoflurane, isoflurane, desflurane, enflurane) - Safe agents: propofol (TIVA), ketamine, opioids, benzodiazepines, non-depolarising muscle relaxants (rocuronium, atracurium), nitrous oxide, local anaesthetics

Clinical Features (time course — usually within 30–60 min of trigger exposure):

Sign	Mechanism	Early vs Late
↑ End-tidal CO₂	Increased metabolic rate → ↑ CO₂ production	Earliest sign — despite ↑ minute ventilation
Masseter spasm	Trismus — may be first sign, especially with suxamethonium	Early
Tachycardia	Hypermetabolic state ± catecholamine release	Early
Tachypnoea	Respiratory compensation for metabolic acidosis	Early
Hyperthermia	Uncontrolled thermogenesis from muscle contraction and cellular metabolism	Late sign — temperature can rise 1–2°C every 5 min
Muscle rigidity	Generalised (may be severe)	Progresses
Metabolic acidosis	Lactic acidosis (anaerobic metabolism)	Progresses
Rhabdomyolysis	Muscle breakdown → ↑ CK (may reach 100,000s U/L), myoglobinuria (→ acute kidney injury)	Later phase
Hyperkalaemia	Leakage of K+ from damaged muscle cells → cardiac arrest if untreated	Progresses
DIC	Late complication of profound metabolic disturbance	Late
Cardiac arrest	Hyperkalaemia ± acidosis ± arrhythmias	Terminal

Treatment (MH Association of the UK Guidelines):

1. STOP triggers immediately — disconnect vaporiser, change breathing circuit and CO₂ absorbent, use new anaesthetic machine or bypass with O₂ flow 10 L/min through circuit
2. 100% O₂ — hyperventilate (↑ minute ventilation 2–3× normal) to blow off CO₂
3. Dantrolene 2.5 mg/kg IV — first-line treatment:
4. Inhibits calcium release from sarcoplasmic reticulum
5. Infuse rapidly (each vial = 20 mg dantrolene + 3g mannitol, dissolved in 60mL sterile water — requires aggressive mixing)
6. Repeat 2.5 mg/kg every 5–10 min until signs controlled (masseter spasm resolves, ETCO₂ ↓, rigidity ↓)
7. Total dose may exceed 10 mg/kg in severe cases
8. Cooling — active cooling measures: IV cold saline, ice packs to axillae/groin/neck, cold gastric/peritoneal lavage; stop cooling at core temp 38°C
9. Correct acidosis — NaHCO₃ 1–2 mmol/kg IV, guided by arterial blood gas
10. Treat hyperkalaemia:
11. Calcium gluconate 10 mL 10% IV (cardioprotection — stabilises myocardium)
12. Insulin 10 units + 50% dextrose 50 mL IV
13. Salbutamol nebulised (if persistent)
14. Consider haemodialysis if refractory
15. Monitor — invasive arterial BP, CVP, core temp, ETCO₂, ABGs (frequent: K+, pH, lactate, base excess), CK, urine output (maintain >1 mL/kg/h — mannitol in dantrolene + forced diuresis with fluids; if myoglobinuria → consider renal protection)
16. Transfer to ICU — ongoing monitoring of: CK falling, renal function, coagulopathy, core temperature

MH Susceptibility: - Previous personal or family history of MH - Known MH-susceptible myopathies: central core disease, multiminicore disease, King-Denborough syndrome, Evans myopathy - Testing: in vitro contracture test (IVCT) — caffeine + halothane challenge on muscle biopsy — gold standard; genetic testing for RYR1 gene mutation (50–70% of MH-susceptible families) - Anaesthetic plan for MH-susceptible patient: TIVA with propofol (no volatile, no suxamethonium); clean anaesthetic machine (purged or dedicated MH-safe machine); monitor ETCO₂ and temperature closely; have dantrolene available

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10. PONV (Post-Operative Nausea & Vomiting) Prophylaxis — Detailed

Apfel Simplified Risk Score: - 4 independent risk factors (each scores = 1): - Female gender - Non-smoker - History of PONV / motion sickness - Post-operative opioids - Risk by number of factors: - 0/4 = 10% risk - 1/4 = 20% risk - 2/4 = 40% risk - 3/4 = 60% risk - 4/4 = 80% risk

Additional obstetric-specific risk factors (add to Apfel): - CS under GA (higher PONV than regional) - Uterotonic agents (carboprost → nausea/vomiting as side effect) - Opioid use in labour prior to CS - Gastroparesis of pregnancy

Prophylaxis Regimens (by risk level):

Risk Level	Strategy	Example
Low (0–1 RF)	No prophylaxis; consider 1 drug if patient preference	—
Moderate (2–3 RF)	1–2 antiemetics; TIVA if GA	Ondansetron 4mg IV + dexamethasone 8mg IV
High (4 RF)	2–3 antiemetics; TIVA; regional anaesthesia preferred	Triple therapy: ondansetron + dexamethasone + cyclizine/droperidol; consider acupressure/ acupuncture as adjunct

Antiemetic Drugs Used in Obstetrics:

Drug	Dose	Timing	Mechanism	Side Effects
Cyclizine	50mg IV/IM	On induction	Antihistamine (H1 antagonist)	Sedation, dry mouth (most common), dysphoria (rare)
Ondansetron	4mg IV (max 8mg)	At end of surgery	5-HT3 antagonist (central + peripheral)	Constipation, headache; avoid if prolonged QT interval (rare); safe in pregnancy
Dexamethasone	8mg IV	On induction (before incision)	Corticosteroid — anti-inflammatory	Single dose safe; no fetal harm at this dose; avoid repeated doses (risk of cleft palate in 1st trimester)
Droperidol	0.625–1.25mg IV	At induction	Dopamine (D2) antagonist	Extrapyramidal reactions (rare at low dose), QT prolongation (FDA black-box warning — but low dose is safe)
Metoclopramide	10mg IV/IM	On induction (weaker evidence)	Prokinetic + D2 antagonist	Dystonic reactions (especially in young women), avoid in Parkinson's

TIVA (Total Intravenous Anaesthesia): - Propofol-based anaesthesia without volatile agents - Reduces PONV by 30–40% compared to volatile-based anaesthesia (propofol has intrinsic antiemetic effect) - Preferred for patients with high PONV risk, especially for CS under GA - Maintenance: propofol TCI (target-controlled infusion) 4–6 μg/mL + remifentanil 0.1–0.2 μg/kg/min

Non-Pharmacological Measures: - Adequate hydration - Minimise opioids (use regional if possible; paracetamol + NSAIDs + TAP block as opioid-sparing strategies) - Avoid nitrous oxide? (controversial — minor increase in PONV, benefits of N₂O may outweigh risk) - Acupuncture / acupressure at P6 (Neiguan) point: evidence of modest benefit (Cochrane review)

Rescue Treatment for Established PONV: - If no prophylaxis given: give ondansetron 4mg IV - If prophylaxis given (e.g., ondansetron): give a drug from a different class (e.g., cyclizine 50mg IV or droperidol 0.625mg IV) - Avoid repeating same class — no benefit

10.8 Cords, Catheters & Drains — Essentials

Urinary Catheters: | Type | Size (FG) | Indications | |------|-----------|-------------| | Foley (balloon) | 12-14 FG (standard drainage), 16-18 FG (if haematuria/clots) | Laparotomy, CS, prolonged labour, urinary retention | | Three-way/catheter | 18-22 FG | Continuous bladder irrigation for haematuria/clots | | Suprapubic catheter (SPC) | 16 FG (via trocar) | Post prolapse surgery, TVT, urethral injury, long-term drainage |

Drains: | Type | Examples | Indications | |------|----------|-------------| | Closed suction (vacuum) | Redivac, Bellovac, Jackson-Pratt | Pelvic/abdominal drainage after laparotomy (decreases seroma/haematoma; not proven to decrease infection) | | Open (passive) | Penrose, corrugated | Superficial wound drainage; not used in modern major surgery | | Tube drain | Robinson, chest drain | Deep pelvic collections, pleural space |

IV Cannulae: - 14G (brown): 2.2mm — massive transfusion, PPH, major haemorrhage - 16G (grey): 1.7mm — major surgery, blood transfusion - 18G (green): 1.3mm — most general surgery, crystalloid infusion - 20G (pink): 1.1mm — low-volume IV fluids, stable patients - 22G (blue): 0.9mm — children, difficult veins, fragile vessels

10.9 Clinical Governance in Detail

Critical Incident Reporting (Datix): - All adverse events, near misses, patient safety incidents must be reported - No-blame culture — encourages reporting without fear of reprisal (unless gross negligence) - Categories: medication errors, equipment failure, slips/trips/falls, communication failures, delayed diagnosis, wrong site surgery, retained swab, blood transfusion errors

Morbidity & Mortality (M&M) Meetings: - Structured review of adverse events and deaths - Swiss Cheese Model (Reason 2000) — multiple layers of defence; when holes in layers align, harm occurs - Root cause analysis (RCA) — systematic approach: identify all contributory factors (human, technical, organisational) - Action plans — measurable changes to prevent recurrence; re-audit to close the loop

Audit Cycle: 1. Define standard (e.g., NICE guideline) 2. Measure current practice 3. Compare with standard 4. Identify areas for improvement 5. Implement change 6. Re-audit (closes the loop)

RCOG Green-Top Guidelines: - Evidence-based clinical guidelines for O&G practice - Levels of evidence: 1a (SR of RCTs) through 5 (expert opinion) - Grades of recommendation: A (high quality) through D (low quality)/good practice points (GPP)

SIGN (Scottish Intercollegiate Guidelines Network): - Grading: A (meta-analysis/RCT), B (observational), C (case series), D (expert opinion)

NICE Guidelines: - Evidence-based recommendations for health and care - Levels: N/A (rather than letter grading) - Technology appraisals, clinical guidelines, public health guidelines

10.10 Summary — Quick-Reference for Common O&G Exam Questions

Key Numbers to Memorise: - 40% of maternal physiological adaptations: CO↑40%, plasma vol↑40%, SVR↓40%, MV↑40%, GFR↑40-50% - 50% of overall pulmonary function change in pregnancy = FRC ↓20%, PaO₂ ↑, - 2-4% of women have fibroids - 10% of pregnancies complicated by miscarriage (clinically recognised) - 6-10% of pregnancies develop gestational diabetes - 2-8% of pregnancies develop preeclampsia - 0.2-0.5% risk of uterine rupture during VBAC (single previous LSCS) - 1% of women have molar pregnancy (higher in extremes of age, previous mole, Asia) - 50% of ectopic pregnancies occur in women with no known RFs - 0.5-1% of pregnancies are ectopic - 30% of women with endometriosis are subfertile - 50% of women with PCOS are overweight/obese - 70% of women with PCOS have menstrual dysfunction - 80% of breast cancers are ER-positive

Best Evidence Flash Cards for MRCOG Part 1:

Trial/Study	Key Finding	Clinical Implication
Collaborative Eclampsia Trial (1995)	MgSO₄ superior to phenytoin/diazepam for eclampsia prevention and treatment	MgSO₄ is first line for eclampsia
MAGPIE Trial (2002)	MgSO₄ reduces risk of eclampsia by 58% in preeclampsia	MgSO₄ for preeclampsia prophylaxis (if severe features)
WOMAN Trial (2017)	Tranexamic acid 1g IV reduces death from bleeding in PPH (RR 0.81)	Add TXA to PPH protocol within 3h of onset
CRASH-2 Trial (2010)	TXA reduces death in bleeding trauma patients	Basis for WOMAN trial in PPH
ORACLE I (2001)	Erythromycin for PPROM improves neonatal outcomes (reduce death, abnormal CUS, CLD)	Antibiotics for PPROM (erythromycin, not co-amoxiclav)
ORACLE II (2001)	Antibiotics for preterm labour with intact membranes does NOT improve outcomes	Do not give antibiotics for PTL with ROM
TERMPROM (1996)	IOL at 41wk reduces CS rate compared to expectant management	IOL at 41+0 to 42+0 — reduces perinatal death (NICE)
Number Needed to Treat (NNT) for IOL at 41wk	1 perinatal death prevented per 400-500 inductions	IOL from 41wk beneficial
ALPHA Study (1995)	Corticosteroids for women at risk of preterm delivery reduce RDS, IVH, NEC	Betamethasone/dexamethasone from 24-34wk
HDFA (2003) / RCOG G-TG	MR reduction for moderate/severe HF NOT improved by betamethasone — but increased risk of infection	No antenatal steroids for elective CS at term (but give if preterm)
Archie Cochrane's insight	75% of women would not have chosen home birth if properly counselled about risk	Informed consent crucial

10.11 Practical Procedures in O&G — Step-by-Step

1. Insertion of Speculum:

Step	Detail
Preparation	Explain procedure, gain consent, offer chaperone, ensure patient empty bladder, position supine with knees flexed and abducted (lithotomy/dorsal recumbent)
Equipment	Cusco's (bivalve) speculum — small, medium, large; warm under running water (or use lubricant — avoid if taking cervical cytology, as may interfere with results — warm water only)
Insertion	Gently separate labia with left hand (gloved), hold speculum in right hand with blades closed and angled 45° to horizontal; insert along posterior vaginal wall to avoid urethra/clitoris
Opening	Once fully inserted, open blades slowly, advance until cervix comes into view — lock screw to hold blades open
End of Procedure	Release lock, partly close blades, withdraw gently — avoid pinching vaginal walls
Swabs	Take before lubricant, speculum exam, or bimanual exam: HVS (posterior fornix), endocervical NAAT (rotating brush in cervical os), liquid-based cytology (Cervex brush — rotate 5 times, rinse in ThinPrep vial)

2. Procedure for Bimanual Examination:

Step	Detail
Position	Dorsal recumbent / lithotomy, empty bladder
Technique	Lubricated index and middle fingers of dominant hand; insert into vagina along posterior wall; palpate cervix (size, position, consistency, tenderness, os)
Uterus	Assess with abdominal hand on lower abdomen pressing down towards pelvis — bimanually 'capture' uterus between internal and external hands: size (weeks size: 6wk = small, 8wk = orange, 12wk = grapefruit, 16wk = midway to umbilicus, 20wk = umbilicus), shape, position (ante-verted/retroverted/axial-version, ante-flexed/retroflexed-flexion), mobility, tenderness
Adnexae	Move abdominal and vaginal hands to each side — 'walk' fingers between adnexa and uterus; assess: ovaries (if palpable — usually 2-3cm, mobile, non-tender), masses (size, consistency, fixity, tenderness), thickening or nodularity of uterosacral ligaments (endometriosis)
Pouch of Douglas	Palpate through posterior fornix — nodularity suggests endometriosis, fullness may indicate mass/fluid/blood

3. Catheterisation (Female):

• Equipment: sterile catheter pack, sterile gloves, 12-14 FG Foley catheter with 10mL balloon, lignocaine gel 2%, drainage bag
• Steps: Explain, consent, expose perineum; sterile technique — swab from clitoris to anus (single direction, discard swab), lignocaine gel into urethra (wait 2-3 min for anaesthesia), insert catheter gently until urine flows, inflate balloon with 10mL sterile water, gently withdraw until resistance felt (balloon seated at bladder neck), connect to bag

4. Setting Up IV Access (Cannulation): - Site: dorsum of hand, forearm, antecubital fossa (14-16G for major surgery/PPH) - Technique: tourniquet above site, clean skin with 2% chlorhexidine in 70% alcohol, stabilise vein with traction, insert cannula at 15-30° angle, observe flashback, advance cannula fully (hub-to-skin), release tourniquet, attach bung/IV line, flush with NS, secure with transparent dressing - Complications: haematoma, extravasation, phlebitis, infection, air embolism, nerve injury (lateral cutaneous nerve of forearm at cubital fossa)

10.12 Communication & Breaking Bad News

SPIKES Protocol for Breaking Bad News (used in O&G: stillbirth, cancer diagnosis, infertility):

Step	Action
Setting up	Private, quiet room; sit down; avoid interruptions; have tissues available; ensure appropriate support people present
Perception	Establish what the patient already knows — "What have you been told so far?" — correct misconceptions
Invitation	"Would you like me to tell you what we found?" — patient may want family present or prefer not to be told fully
Knowledge	Give warning: "I'm afraid the news is not good" — use simple language, avoid jargon, give information in small chunks, wait after each
Empathy	Acknowledge emotion: "I can see this is very difficult for you" — allow silence, do NOT say "I know how you feel"
Summary & Strategy	Summarise what was said, agree next steps, offer written information, arrange follow-up, document conversation

Key Communication Scenarios in O&G: - Stillbirth: Use the baby's name (if parents have chosen one), refer to baby as baby (not 'fetus'), allow parents time with baby, offer memory box, photos, hand/footprints, lock of hair. Explain post-mortem options - Termination for fetal abnormality: Non-directive counselling, support through decision, referral to clinical psychology. Do NOT use terms like 'termination of pregnancy for fetal abnormality' without checking patient preference - Failure of contraception/sterilisation: Full explanation of medical circumstances, referral for independent counselling, offer reversal if appropriate, support through any pregnancy decision - Suspected child protection/safeguarding: Involve appropriate team (paediatrics/safeguarding), inform parents with sensitivity but clearly, document fully, follow local safeguarding policy. Mandatory duty to notify

10.13 Safeguarding — Key Principles for MRCOG Part 1

Types of Abuse: - Physical abuse: hitting, shaking, burning, FGM - Sexual abuse: rape, assault, exploitation by family member/other (including within marriage) - Emotional abuse: persistent criticism, threats, rejection, witnessing domestic violence - Neglect: failure to meet basic needs (food, shelter, medical care, education, emotional care) - Femal Genital Mutilation (FGM): Mandatory reporting duty for healthcare professionals in England and Wales (FGM Act 2003, Serious Crime Act 2015) — must report to police any case of FGM identified in a girl <18

Domestic Violence and Abuse (DVA): - 1 in 4 women experience DVA in their lifetime - Pregnancy is a high-risk period — DVA can start or escalate in pregnancy - Routine enquiry: NICE recommends asking about DVA when women attend antenatal, postnatal, sexual health, or abortion services - Key question: "In the last year, have you been hit, slapped, pushed, or otherwise hurt by someone close to you?" (or use routine screening tool) - If positive response: offer immediate safety planning, refer to specialist DVA services (IDVA - Independent Domestic Violence Advocate), MARAC referral if high risk - Documentation: verbatim notes, body map of injuries

10.14 The 'Take-Home' Messages for MRCOG Part 1 Clinical & Surgical Questions

1. Always consider pregnancy in any reproductive-age woman presenting with abdominal pain, bleeding, collapse — do a pregnancy test first
2. ABCS of maternal resuscitation — Airway, Breathing, Circulation, left lateral tilt (or manual displacement), don't forget the fetus
3. Documentation is medical-legal evidence — document clearly, in real-time, with timestamps and signatures (print name + GMC number)
4. Consent must be informed — Montgomery standard; discuss material risks (reasonable patient would want to know); document the discussion including specific risks mentioned
5. Team communication — SBAR for handover; closed loop communication in emergencies; read back orders; call early for help
6. Most common errors in O&G: failure to recognise sepsis, failure to escalate abnormal observations, failure to call for help early enough
7. CTG abnormalities — Always start with conservative measures (left lateral, fluids, O2, stop oxytocin) before moving to FBS or delivery
8. PPH is the #1 cause of maternal death worldwide — know your drills before it happens
9. Perimortem CS — within 5 minutes of maternal cardiac arrest if >20wk gestation and no ROSC in <4 min
10. Clinical audit is a mandatory part of good practice — the cycle must be closed (re-audit after implementing change)

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