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Warning: TT: undefined function: 32O&GCHORIONIC VILLUS SAMPLING (CVS)/ AMNIOCENTESISHello my name is Dr. Amirah, how are you? May I know why you have come here today?Okay I will give you some explanation regarding this procedure, but first may I ask what do you understand by this term?Amnioc...

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CHORIONIC VILLUS SAMPLING (CVS)/ AMNIOCENTESIS Hello my name is Dr. Amirah, how are you? May I know why you have come here today? Okay I will give you some explanation regarding this procedure, but first may I ask what do you understand by this term? Amniocentesis is offered to patients that have an increased risk for fetal abnormality, this procedure enables us to diagnose the conditions (mcm DS, structural abnormality) in utero. Since you are (bla2 the risk factors or ask abt risk fx) that is why we are offering this. This procedure is usually done at 15 wks gstation. Buat dekat hospital jugak, mcm normal appointment. So mcm biasa, the doctor will do an ultrasound of your abdomen to look at the baby (mcm scan biasa), the sampling only takes 30 seconds. We will be applying antiseptic on your abdome, and a small needle is inserted and guided using ultrasound. A small amount of amniotic fluid ard your baby will be collected and sent to the lab. Then we will look at your baby’s heart beat to just as reassurance. You can then go home. As in any other procedure, there are some risks. There is a small risk of miscarriage (1%) and also small risk of bleeding, infection or leakage of fluid. Some of your babies blood can go into your circulation, if you are a rhesus negative we will be giving you anti D igG again risk is minimal. It will take abt 2 weeks to know the actual results weather or not the baby is having Down’s / other chromosomal or structural abnormality. We can then discuss on what we want to do. Any questions? Chorionic Villus Sampling can be done from 10 weeks onwardand is a similar procedure. It is a similar procedure as amniocentesis, only that we would also be taking a sample from the placenta to obtain more information. Within 48 hrs we can estimate (99% accurate) the results of your baby, however the actual results will only be available after 1-2 wks. The risk of miscarriage is similar to amniocentesis. If done to early there is a risk of causing limb deformity/clip palate, so usually we will wait until at least 11 weeks to carry out this procedure. Both are simple and quick procedures, that should not be too uncomfortable. It is done to help diagnose certain abnormalities in your baby and is relatively safe, despite having a few small risks that you are know aware abt. Any question?

COUNSELLING: TRIAL OF SCAR ( VBAC) 1. 2. 3. 4. 5.

Introduce yourself Confirm the patient's name and problem Inform the patient that it is good to have her husband together during the discussion Ask patient whether she knows about her condition, any preference in her option Inform the patient of the options that she has: o vaginal delivery --> Trial of Scar o LSCS 6. Tell patient that we need to assess the patient condition first whether the condition is favourable for: o any short stature -->CPD o pelvic cavity size o exclude placenta previa o exclude other contraindication 7. Explain that there is risk in every procedure o risk of scar dehiscence 0.5% (if use oxytocin 0.8%, if use prostaglandin 2.45%)--> Therefore need to deliver in tertiary hospital where OT ,NICU and blood bank available o we will monitor her closely (baby and vital sign to see sign of uterine rupture ie tachycardia, hypotension, vaginal bleeding, sudden loss of contraction, scar tenderness, continuous abdominal pain in between uterine contraction) o can give option to patient for epidural o however there is still risk of failed TOS --> need to proceed to LSCS 8. Explain pro and con TOS o fast recovery o but we don’t know exact time for delivery, need to see progress of labour 9. Explained another option (LSCS), also explained pro and con o risk of adhesion lead to difficult surgery o risk of injury to bowel and bladder o risk of bleeding and blood transfusion o the advantage is operation is done in planned environment o explain that 2nd LSCS will limit family size o if want to do BTL, can do together o explained that the next pregnancy should be manage by LSCS 10. Give opportunity to patient to ask any further questions 11. Ask patient preference whether have decided or not 12. If can’t answer question from patient, get an appointment to refer patient to senior colleague or consultant for better picture 13. Provide patient pamphlet for any further information

VBAC : Hi my name is Dr amiarah, how are you today? I understand you have come to ask regarding delivery options. Before that may I ask some questions? 1. Previous C-sec history: a. why did you go into c-sec before? b. How many cms were you dilated? c. How heavy was your baby? d. How old is your baby now? e. Did the surgeon tell you what type of scar was done? Vertical scar or transverse? f. How was your healing after the surgery? g. Do you have any medical illness? 2. Current pregnancy history a. So, currently do you have any preference of delivering your baby? b. Vaginal birth is possible, since you have only done c-sec once c. and It was done for a non recurring problem (emergency) therefore you may be a suitable candidate. d. Before allowing you to undergo a VBAC we must exclude any other contraindications for vaginal delivery generally via ultrasound (breech, PP) 3. Information regarding VBAC a. Have you ever heard abt VBAC? We also call it as Trial of scar. It is a vaginal delivery after a c-sec., b. However 70-80% of those undergoing VBAC are successful and have successful vaginal deliveries subsequently. 4. Risk: a. uterine scar due to the c-sec is a risk of uterine rupture /scar dehiscence is 0.5% or 0.8% if you are going to be induced for labour, however during the induction process there will be continuous monitoring done. b. VBAC/TOS fails, we would have to do an emergency c-section for you similar as before. (kalau dia ada good dilatation in previous pregnancy dia before dia deliver (cthnya 5/6 cm) kita boleh ckp it is a good indicator) 5. Disadvantage of VBAC: a. A VBAC will not allow you to set the date of delivery. b. Allow you to heal much faster following the delivery. c. You would also have no limitation to the number of subsequent deliveries. 6. Offer other options: An elective C-sec a. Disadvantages: i. Risks relating to the surgery such as injury to organs or bleeding. ii. It might also be a difficult surgery if there are adhesions due to your previous surgery. iii. You also might have to limit your family size as having more than 3 c-secs incresase risk of rupture. b. advantages i. it carries a smaller risk of uterine rupture (0.1%) ii. we will be able to set the date of delivery and iii. the operation is done in a planned environment.? Do you have any questions? Are you satisfied with the explanation that I have provided and have clear view of options?

CONSENT FOR ELECTIVE CAESERIAN SECTION 1. Introduction 2. Explain indication - breech presentation - previous scar - placenta previa major - macrosomic baby - unstable lie - fibroid / cyst obstructing the lower segment 3. Explain on procedure - we will give admission form to admit to ward one day prior to operation - ELSCS at 38 weeks - fasting start at 12MN - blood taking for FBC and GXM 2 pints pack cells - also take consent for blood transfusion and hysterectomy in case anything happened - CBD will be inserted in the morning before operation - prophylaxis antibiotic will be given - operation done by epidural/ CSE – anaest will review before operation - duration 30-45 minutes or up to 1 hour - lower abdomen will be cut for 10cm, baby out, placenta out, sutured 4. How will she come out of the room? - IV drip - Catheterized - Cancer patient  admit to HDU 5. How would recovery like?

-

Next day can start to mobilise, drink and eat as usual 3-4 days hospital staying (not like normal vaginal delivery)

6. Explain complication Early - anaesthetic complication : nausea, vomiting, headache - bleeding / PPH (a little bit more compare to normal vaginal) - injury to bladder/ colon  rarely happen. And we have experienced staff to manage - infection  will be given antibiotic Late -

decrease family size, limit to 3 lscs only adhesion next pregnancy LSCS

7. Postpartum - 3 days monitoring in the ward for any bleeding - give prophylaxis s/c heparin 5000iu thromboprophylaxis - Wound inspection at day2 - monitor urine output, CBD will be romeved if patient can ambulate well 8. Advice patient on contraception - need to have good spacing 2 years - use contraceptive device that has good pearl index - -ensure patient compliance - -TCA 6 weeks at family planning clinic 9. Ask for any enquiries

INSTRUMENTAL DELIVERY – COUNSELLING Scenario: G2 P1+0 under epidural, pushing for 2 hours  exhausted. VE is favorable. So you decide to do a Vacuum/Ventouse delivery. Counsel her. 1. Indication/Why? Since you are tired/exhausted, I will help you out using this instrument 2. Steps/How? a. GA/local/spinal anaesthesia – and you already are under epidural b. Place the vacuum cup 3cm away from the baby anterior fontanelle c. Traction is applied when only contraction d. Direction of traction is perpendicular to the cup e. Application time should not exceed more than 20 minutes 3. You may need episiotomy/any extra care – a. to assist the vacuum delivery, to increase space available at perineum & to prevent perineal tear b. episiotomy/ perineal tear: thus would need repair which later would need proper care: analgesic (for pain), and antiseptic (for pernial care) 4. Complications a. Anaesthetic : difficulty in breathing b. Surgical: bleeding & infection c. Obstetric i. Baby : - Intracranial hemorrhage. - Scalp edema ( resolved within 24hours) ii. Mother - Fail instrumental delivery  C-section - Vaginal tear, cervical tear - Extended tear  bowel outlet  fecal incontinence 5. How long will be for recovery a. Staying in hospital: depends on fetal conditions. Usually only overnight if there is no complications b. Keep mobile c. Can breastfeed as usual

COUNSELLING: BREECH / ECV IMPORTANT POINTS IN BREECH COUNSELLING: 1. “Can I deliver normally/vaginally?” = There are several ways of delivering a breech baby: a. Breech vaginal delivery :Possible, but there are complications to the baby & the outcomes is poor b. C-section c. ECV 2. What are the other options? a. ECV b. C-section 3. Explain on ECV & successful rate: a. Try to turn the baby’s head down by applying pressure on abdomen b. Safe, but a little uncomfortable c. 50% successful rate 4. Contraindication for ECV a. PP b. APH c. Oligohydromnio / polyhydromnio d. Mother refuse e. Uterine abnormality 5. Complications of ECV a. Failed ECV b. Baby turn back into reversion c. PROM d. Fetal distress e. Uterine rupture f. Placenta abruption / placenta suppression EXAMPLE:

1. 2.

A procedure where we externally try and rotate your baby to allow you to be able to normal vaginal delivery. It is usually done at 37 weeks when your baby is already term because: a. Before term baby usually akan pusing balik. b. Kalau fail kita akan buat c-sec, so nak reduce complications of prematurity 3. Success rate 50-70%, reversion rate 5% 4. This procedure may be a little bit uncomfortable and if during the procedure experience any discomfort you can ask to stop the procedure. 5. There are a few complications to the procedure, however the complications are very rare (wear boxer 5. Advice wife on cleanliness and hygiene - if having vaginal discharge,seek treatment ,need to treat infection first 6. Give folic acid supplement to prevent neural tube defect 7. Give other choice to patient if they don’t want wait and see.. - if still young --> can wait - if getting older --> clomiphene -->IUI --> IVF

DYSMENORRHEA Ddx in mind: PID, endomteriosis, adenomysis, fibroid. Intro: hi my name is Dr Amirah may I know why you have come here today? HOPI: How long have you been having this problem? SOCRATES Is your menstrual cycle regular? Ask hx of menstrual cycle. Berapa hari? Berapa pad? Ada clots? Initially mcmtu ke? Every cycle ada pain ke? Progressively increasing in pain? Do you need to take medication? Is it relieved? Does it affect your daily activities? Associated symptoms: - Vaginal discharge - Dyspareunia - Intermenstrual bleeding Sexual history: - do you use protection? Drug history: - are you taking hormonal contraception? Does it help reduce the pain? Systemic involvement: cough/ bloody sputum/urine pattern/bowel pattern. PE: no apparent findings (kalau adenomyosis / fibroid uterus besar in bimanual) cervical motion tenderness/adnexal tenderness/ uterine tenderness? Explain that other investigations need to be done to rule out the disease. Ultrasound findings dpt dx adenomyosis and fibroid je. Kalau ada symptoms of PID explain yang dia kena makan antibiotics sbb kita suspect dia ada pelvic inflammatory disease. Diagnostic procedure yang kita boleh buat is only laparaoscopy, untuk both endometriosis and PID. Ceftriaxone 250 mg IM in a single dose + Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days Endometriosis:

FAMILY PLANNING (CONTRACEPTION) =Method of avoiding Pregnancy WHY? 1. for spacing the family 2. to prevent any pregnancy in future (has completed family) CHARACTERISTICS OF IDEAL METHOD • highly effective • Should have no side effect. • Should be independent of intercourse. • Should be reversible. • Should be cheap & widely available. • Acceptable to all cultures & religions. • Administration by healthcare personnel not required Effectiveness of contraceptions  All contraceptives will fail occasionally- some are much more effective than others.  Failure rates are usually expressed as :No. of failures/100 women years (the no. of pregnancies one would expect to occur if 100 women were to use the method for one year).

Contraception consultation (GATHER approach) – Dr Saw’s notes Greet Ask  History: age, parity, breast feeding or not, past medical & surgical history, drug history  Enquire about women’s knowledge of contraception  Her past contraceptive history  Her preference  Future plan Tell  Inform adequately on available and appropriate methods Help her to get to the right decision Explain- Further discussion on the method the woman chooses  Mode of action  Effectiveness, Benefits  How to use the method  Side effect and risks, effect on future fertility  How to manage missed pills Return- Follow-up plan: No need unless she wants to change the method or unbearable side effects

NATURAL FP (PERIODIC ABSTINENCE) How? Not suitables for: -By observation of naturally occuring CF of the  Cycle length 35 days PCOS fertile phase of the menstrual cycle & avoiding  Breastfeeding Sex during that time  Menopausal symptoms  Women taking hormonal medication **viability of sperm in the female tract (2-7 days) **life span of ovum(1-3 days) Calendar Method Cervical mucus method Symptothermal method (rhythm method) (Billing method) (Basal body temperature) General rule is to record Requires sensing and -It is recorded before getting the length of 6 cycles observing the cervical mucus out of bed changes over time -To estimate the beginning of fertile period by substracting Oestrogen induced changes at -Progesterone secretion is 18 days from the length of mid cycle: associated with a rise in basal the shortest cycle -Increase in amount of clear, thin body temperature of about -To estimate the end of fertile and stringy mucus 0.5°C period by substracting 11 With ovulation: -Prior to ovulation the temp is days from the longest cycle -mucus becomes opaque, sticky usually below normal body and much less stretchy or temperature Example is if cycles of 26-32 disappear all together days -The of ovulation correspond clos -periodic abstinence should be ely to the day of peak mucus practice from day 8 to day 21 **Intercourse is permitted **If practice alone, it requires beginning on the 4th day after the abstinence until the night of last day of sticky, wet mucus 3rd day of a shift in temperature Abstinence begins when the mucus becomes sticky and moist. Intercourse resumes the night of either the 3rd day of a temp shift or the 4th day after the last day of sticky, wet mucus which ever is later

ORAL CONTRACEPTIVE PILLS (OPC) Combined OPC (COCP) Progestogen-only pills (POP) (ethynil estradiol + progestogen)

(progestogen)

Ethynil Estradiol (EE) Lower EE doses = lower side effects - VTE, nausea, breast tenderness and bloating 20mcg formulation = more break-through bleeding

Why choose POP? Indication -women who had the risk of estogenic SE of COCP -breastfeeding, older age -VTE, migraine, smoke, HPTN, valvular HD, DM

Type of Progestogen

Contraindicate in -Pregnancy -undiagnosed vaginal bleed -Severe arterial disease -liver adenoma

2nd generation -Norethisterone 1mg or Levonorgestrel 150mcg 3rd generation -Desogestrel 150mcg -Gestodene 150mcg Norgestimate 250mcg Spironolactone derivative -Drosperinone 3mg (Yasmin)

Mode of Action COCP 1. Suppression of ovulation -By prevention of ovarian follicular maturation -By interrupting the oestrogen-mediated positive feedback on the hypothalamic-pituitary axis thus preventing LH surge 2. Thicken the cervical mucus -↓ sperm penetrability 3. Alteration of the endometrium -reducing likelihood of implantation

Type of POP -Etynodiol diacetate 500mcg (femulen) -Norethisterone 350mcg (noriday) -Levonorgestrel 30mcg -Norgestrel 75mcg -Desogestrel - cerazette®

Mode of Action POP 1. Main effect: thicken cervical mucus thus ↓ sperm penetrability of cervix 2. Reduce receptivity of endometrium to implantation 3. Suppress ovulation -will result in -irrregular menstruation (~40% cases) -amenorrhoeic if completely suppressed (1015% cases) -normal menstrual (50% cases) 4. Reduce fallopian tube motility Advantages of POP 1. High efficacy: failure rate 0.3-5/100 woman per year 2. Readily reversible method of contraception 3. Not related to intercourse 4. No artificial oestrogen component -No SE 5. Do not masked onset of menapause 6. Efficacy increases with age

Advantages of COCP 1. High efficacy: failure rate 0.1-3/100 woman per year 2. Readily reversible method of contraception 3. Not related to intercourse 4. Improve menorrhagia: ↓ incidence IDA 5. Less dysmenorhoea 6. Predictability of menses (so bleh plan nk gi umrah) 7. Reduction risk of diseases: ectopic pregnancy, ovarian cyst, ovarian cancer, endometrial cancer & PID *PID- ↓ risk tuh bila compare dgn IUCD Disadvantages of COCP (or Side Effect of Disadvantages of POP (or Side Effect of POP) COCP) 1. Strict adherence to the rules of pill taking is 1. CVS disease: venous thromboembolism (VTE), essential raised BP and risk of MI 2. Pattern of bleeding is unpredictable 3. ↑ incidence ectopic pregnancy (if fail) 2. Risk of breast cancer & cervical cancer compared to COCP, but ↓ compared to sexually 3. Risk of liver ca, cholestasis or gallstones 4. Masked onset of menopause active non-contraceptive user 5. Worsening of migraine attacks 4. Efficacy reduced if weight > 70kg Effect on further fertility:- Fertility return within 3months

How to take the pills? (21cycle) -One pill every day for 21 days within first 5 days of cycle -Followed by 7 days of pill free period (will have ‘withdrawal bleed’) -Best to be taken at same time every day *why?- constant hormonal level all the time If miss the pill? Missed 1 pill? Take 1 ASAP (within 24h) then take all others as usual Missed 2 or more pills? Take 1 ASAP (within 24h) then take all others as usual + condoms for the next 7 days When to stop? No need to stop: In fit & healthy women + no contraindication -but regular bleed & normal level estrogen will mask the onset menopause -so advise to stop at the age of 50 & continue with other method

How to take the pills? (28cycle) -One pill every day taken on first day of cycle -Taken continuously without a break -A MUST- taken at the same time every day (if terlewat pun not more than 2-3H apart)- *why?to increase the effectiveness If miss the pill? Miss more than 3h -additional precautions for 2 days If vomiting within 3h of dose or sever diarrhoea -additional precautions for 7 days after reco...