MEDICAL LICENSING OSCE December 8, 2019
OBSTETRICS AND GYNECOLOGY
SITE: RMH
Objectives:
The objective of this OSCE is to evaluate whether an Intern doctor in Rwanda can
actively and confidently manage a woman with PPH.PPH is still the most common
cause of maternal death in Rwanda and in the World. We expect an intern doctor to
be able to actively and comprehensively offer the non-surgical management of PPH
and be aware of surgical technics which are used and required in case other options
have failed.
The intern have to demonstrate the capacity to coordinate the team involved in the
management of PPH and effectively examine and manage a patient with Obstetric
emergency due to Hemorrhage.
Examination have to include: ABC assessment
Quick Initiation of resuscitation
Establishing the cause of PPH
Non surgical management of uterine atony
Know surgical management of uterine atony.
This station will also evaluate whether the intern has the capacity to incorporate
Uterine Balloon Temponade into the management of PPH once massage and
uterotonic have failed to stop bleeding.
Time allocated: 12 minutes, including 5 minutes for examination and management
of the patient with PPH, 7 minutes particularly allocated to UBT (Uterine Balloon
Temponade)
Actors required: Mama Noelle, Mama Nathalie possibly for UBT??? , The Interns to
be examined, a nurse and examiners.
Information to the Interns
The examine will have to start by presenting a brief history of Mutoni who has
delivered.
MEDICAL LICENSING OSCE December 8, 2019
OBSTETRICS AND GYNECOLOGY
SITE: RMH
Mutoni is a 25 years old primigravida who was admitted in our labor ward for
induction of labor at 41 weeks GA. She received two doses of misoprostol 50 ug per
os 4 hours apart then started contracting . During her labor an ARM was done when
she was at 5 cm and her labor was augmented with Oxycitocin. She was having 4
contractions in 10 minutes lasting 30 seconds each for the last 5 hours till she
delivered a live baby boy with APGARs of 8 then 10 at 1 and 5 minutes respectively.
AMTSL was done as per the protocol but after delivery of the placenta Mutoni kept
at bleeding heavily fresh blood mixed with clots. The midwife has performed
uterine massage and gave Oxycitocin 20 IU which is still learning now at a rate of
100cc/h. As the Mutoni keeps at bleeding despite the efforts by midwife She decides
to call the Intern who was in admission for help with the management of this patient
Examiner: Ask the intern now to play his/her role for the evaluation and
management of this patient. 5pts
Interns:
The needs to start by calling for more help (More midwives and
doctors if available)
Assess for hemodynamic and emergency stability (The intern needs to
state all components of Airway, breathing and circulation.
Examiner: While the intern is assessing hemodynamic state the examiner give the
following findings: BP: 100/55, mmHg, continuous active vaginal bleeding, with cool
peripheries and sweaty
Intern: Need to initiate resuscitation
Two large bore IV lines using catheter number 16
Send blood samples for blood grouping and cross matching,
Bed moved into head down position
Give Oxygen and monitor O2 sat using a monitor or pulse oxymetor
Give IVF bolus NaCL or Rl 2-3 l/30min
Insert a Foley catheter to measure output
Start blood transfusion after cross matching or use O negative if available,4
unities as average.
Ask a team member to record vitals signs every 15 minutes
Intern: Intern needs to continue with the identification of the cause of PPH 5pts
1.Uterine atony
First cause of PPH is uterine atony and most common: It is important that the
intern specify how uterine atony is confirmed or excluded:
o The abdominal exam shows a boggy uterus, not contracted usually
with a fundus above the umbilicus.(Information from the examiner).
2.Retained placenta /products of conceptions
Placenta and membranes have to be examined and complete, no expulsions
of further products at the application of fundal pressure. Manual exam into
the uterus may be required only if not sure.
Examiner inform that the placenta is complete and no PoC are remaining in
the uterus.
3. Vaginal, perineal or cervical laceration, Inspection of the perineum, use of Sims
speculum to examine the vagina and the cervix. No tear is seen as the examiner
inform the intern
4. Coagulopathies: Clotting profiles, very rare.
Examiner: The examiner inform the intern that the uterus is boggy, enlaged and
non contracting while the rest of exam is normal(No placenta retention nor
lacerations found) and is continuously bleeding. The examiner ask the intern how
he /she would chronologically manage this patient. The examiner needs to prompt
further management options by indicating that the patient is continuously bleeding
despite each of the following interventions as the intern state them
Intern answers should consist of: 4pts
1.Non surgical management options which include:
Bimanual uterine massage
Uterotonics including: Syntocinon bolus (10IU) and in IVL for 4 hours can
reach 80IU of Syntocinon
Cytotec 800 mcg sublingual
Ergometrine 500 mcg with half IV and half IM
The examiner inform the intern that the patient has failed to stop bleeding and now
has lost 2.5 L of blood according to what the midwife has estimated. What else to
do?
Intern: The intern should add as option Uterine balloon tamponade 1pts
Examiner: Ask again the intern to state clearly indication for the use of uterine
balloon tamponade in case of PPH. 2pts
Intern answers 2 indications:
PPH due to atony when Bimanual Uterine massage and uterotonics have both
failed. The UBT does not replace the two above
When temporally control of PPH is needed before referring the client to a
higher level of care
Examiner: The supporting team does not know details about the kit of UBT and the
examiner ask the intern to specify all the materials required for the kit (4pts for 4
correct answers)
Intern answers:
Two rings forceps
Sims speculum
Foley catheter
Condom
IV set Saline
Infusion bag with
Suture string
Examiner: Ask the intern to place the UBT and evaluate if the following steps
have been respected. Answers for each step can be prompted by asking what
is necessary for each. 3pts
Step one: Preparation
o Assembling of the kit
o The intern explain the woman what is going to be done
o Prophylactic ATB is given 2g Ampicillin or cephalosporin
o Made sure the bladder is empty
o Made sure the cause of bleeding is atony not lacerations or retained
POC
Step 2: Trans-vaginal placement
o The intern can expose the cervical opening with a Sims speculum and
clamp the ant lip of the cervix with a sponge or rings forceps
o Insert the condom attached to the catheter under direct visual control
and with the aid of a second forceps, make certain that the entire
condom is inserted past the cervical canal
Step 3:Inflation
o Inflate the UBT by connecting the opening end of the catheter to the
giving set which is connected to an infusion bag
o Inflate condom with saline 300ml-500mls
o Clamp catheter when desired volume is achieved and bleeding is
controlled
o If bleeding does not stop with 15 minutes of initial inflation of the
UBT, abandon the procedure and seek surgical intervention
immediately (If the intern does not give this answer the examiner can
prompt it by asking when to abandon the procedure)
o A pen mark at the level of the uterine fundus should be placed and can
help to diagnose cancelled bleeding if it raises
Step 4.Post UBT elements (Client monitoring) and instructions
o Keep the UBT in situ 12-24 hours
o Continue to monitor the patient closely (BP, Pulse, urine output, pallor
and active bleeding, uterine tone)
o Continue Oxytocin infusion for 6-8 hours
o The device should not remain insitu for more than 24hours
o When the client is stable after 12-24 hours deflate condom by letting
out 200cc of saline every hour
Examiner: What if Uterine Balloon tamponed has failed:
3 Surgical management for uterine atony (4 pts for 4 correct answers)
Call for help or refer the patient to an advanced institution with UBT in situ
General anesthesia is the one indicated
Re-examine in theater: Make sure no lacerations, no POC and while the
patient is still actively bleeding.
Move to laparotomy: (add 2pts for 2 correct answers)
Uterine artery ligation
B lynch sutures
Internal iliac artery ligation (only if experienced with this technic)
If all fails Hysterectomy is the final option
THANKS
