Course syllabus: Obstetrics & Gynaecology

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Course syllabus: Obstetrics & Gynaecology


Part of Curriculum: MED
-
401


Revised and updated
:
28
.0
2
.2012


Approved by the Programstyret for medisin


date
:


Authors:

Ganesh Acharya and Kari Flo



Duration of the course:

1
8

weeks


Learning objectives:

The main objective of the course is to develop and consolidate the knowledge
(understanding), skills and attitudes required to achieve competence in managing common
and important clinical problems in the field of women`s health.


The
outcomes of the course are defined as the theoretical knowledge, practical skills and
personal attitudes acquired by the students in the discipline of obstetrics and gynaecology as
specified below.


The level of required knowledge is defined based on SOLO

(
S
tructure of
O
bserved
L
earning
O
utcomes) taxonomy and the evaluation will be based on student’s ability to (S1 = identify or
define; S2 = describe; S3 = rationally relate S4 = discuss and analyse).

The level of practical skills will be evaluated accordi
ng to Miller's pyramid of clinical
competence (M1= knows; M2= knows how; M3= shows how; M4=does on a professional
level) for each of the outcomes. The attitude will be assessed based on the ability of the
student to conduct professionally and ethically, an
d understand how different personal views
can affect patient care and the doctor patient relationship.



Content of the curriculum


Attitude

The student should be able to:

a)

Practise with a professional appearance and caring attitude.

b)


Set at ease a woman presenting with gynaecological problems so that she feels
comfortable and confident enough to give a complete history and consent to
examination.

c)

Show respect and understanding to various emotions that a pregnancy may cause

and
use app
ropriate wording to the questions asked.

d)

Understand the importance of teamwork and be able to explain and appreciate the
roles of different professionals working in the field of women’s health in the hospital
as well community setting (e.g. General practit
ioners, Midwives, Nurses, Social
workers etc).

e)

Support and respect the women’s choices and decisions.



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Skills

By the end of the course the students should be able to achieve the following:


Communication and history taking

a)

Develop the communication skil
ls to discuss issues relevant to women’s health such as
menstruation, sexuality, contraception, fertility, pregnancy and labour, continence,
pelvic pain and malignancies with a patient.

b)

Take a comprehensive history of a previous and current pregnancy; reco
gnise features
of a normal pregnancy and signs representing abnormality.

c)

Take a gynaecological history including menstrual, sexual and contraceptive details.

d)

Explain findings of a clinical examination, results of investigations (e.g. laboratory
tests, imag
ing etc) and discuss management plan with the patient in an appropriate
setting in a clear and sensitive manner.

e)

Develop basic communication skills in breaking bad news such as following a
diagnosis of intrauterine fetal death, gynaecological malignancy o
r sexually
transmitted disease etc.


Physical examination


a)

Examine the external genitals and identify common vulval disorders.

b)

Perform a vaginal speculum examination, identify the cervix, take a cervical smear
and recognize lesions suspicious of cervical

cancer.

c)

P
erform bimanual pelvic examination and interpret signs of uterine enlargement,
adnexal mass and pelvic tenderness.

d)

Identify
ascites and the differential diagnosis of abdominal distension.

e)

R
ecognize signs of utero
-
vaginal prolapse

and be able to assess this by speculum
examination.

f)

Take appropriate and relevant microbiological samples.

g)

Insert and remove an intrauterine contraceptive device (IUD) and contraceptive
implant.

h)

Know the basics of obstetric clinical examination such as sy
mphysis
-
fundal height
measurement, Leopold’s maneuvers (e.g.
determine fetal lie, presentation, relationship
of the presenting part to the pelvis)
and
auscultation

of fetal heart.

i)

Differentiate between singleton and multiple pregnancies and interpret signs

of
polyhydramnios and oligohydramnios.

j)

Take blood pressure and perform a urine dipsticks test to check for proteinuria and
glucosuria.

k)

Understand the mechanics of normal delivery.

l)

Basic knowledge of management of normal delivery and labour and recognise
abnormalities such as failure to progress and fetal distress.

m)

Participate in simulation training and have an understanding of the management of
certain obstetrical emergencies such as breech delivery, the use of ventouse and
forceps, shoulder dystocia and
postpartum haemorrhage.



Knowledge

After completing the course the student should have the knowledge and a clear understanding
of:


Reproductive biology

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a)

Normal and pathological anatomy of the reproductive organs (vulva, vagina, uterus, tubes
and ovaries).

b)

Physiology of menstrual cycle including ovulation and pathophysiology of menstrual
disorders.

c)

Development of the placenta, embryo and fetus.

d)

Synthesis and actions of sex steroids, oxytocin and prostaglandins.

e)

Physiological changes in pregnancy and puerper
ium.

f)

Basics of teratogenicity, dysmorphogenesis and effects of medication, lifestyle factors
(e.g. smoking, alcohol, drug abuse), radiation and environmental factors on the
developing embryo and fetus.


Gynaecological diseases including gynaecological
cancer

a)

Demonstrate sound basic knowledge of common and important benign diseases in
gynaecology (e.g. uterine fibroids, endometriosis, and benign ovarian tumours) including
their aetiology, pathogenesis, diagnosis, management and prevention.

b)

Recognise and
describe the management of common gynaecological emergencies (e.g.
ectopic pregnancy, incomplete abortion, acute pelvic inflammatory disease, torsion of an
ovarian cyst etc.)

c)

Explain the significance of an abnormal cervical smear and its management.

d)

List a
nd describe the aetiological and risk factors of cervical and vulval neoplasia and
endometrial carcinoma.

e)

Describe and explain the significance of peri
-
menopausal and postmenopausal bleeding.

f)

Describe the staging and management of cervical and endometrial
carcinoma and
subsequent follow
-
up.

g)

Describe the methods used in diagnosing of ovarian carcinoma and associated difficulties,
the nature of the surgery and the subsequent chemotherapy.

h)

Screening, diagnosis and management of breast cancer.



Subfertility

a)

L
ist the causes of infertility in male and female.

b)

Interpret values of a seminal fluid analysis.

c)

Assess the woman for evidence of ovulation/anovulation.

d)

Describe the methods to investigate fallopian tube patency and interpret the results.

e)

Have basic knowled
ge of ART (assisted reproductive technology).


Urogynaecology and pelvic floor

a)

List the causes of urinary incontinence in women.

b)

Describe the possible impact of pregnancy and child birth on urinary and faecal
incontinence.

c)

Describe the procedure of urodyna
mics to a patient.

d)

Describe the management of stress incontinence and detrusor over activity to a patient.

e)

Describe the

aetiology,
classification and management of utero
-
vaginal prolapse.



Menstrual disorders

a)

Elicit a menstrual history to identify that a
patient has menstrual disturbance.

b)

Recognise the various pathologies associated with heavy menstrual periods, describe the
appropriate investigations and the medical and surgical management.

c)

Discuss the options of medical and surgical management of the men
strual disorder with a
patient.

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d)

Recognise the causes of primary and secondary amenorrhoea, and suggest appropriate
investigations.


Menopause

a)

Recognise the problems and changes associated with the menopause.

b)

Advise a woman on the advantages and disadvant
ages of hormone replacement therapy,
and what options are available.


Contraception and termination of pregnancy

a)

Advise a woman, from adolescence to menopause, of contraception choices and the
advantages and disadvantages of the various methods available.

b)

Provide appropriate counselling and advice to a women seeking emergency contraception.

c)

Counsel a couple about sterilisation and what options are available.

d)

Understand important details about the Abortion Law, and the doctor`s responsibilities to
women who

request termination of pregnancy.

e)

Counsel a woman about
the availability of different methods of abortion and associated
benefits and risks.


Genito
-
urinary medicine

a)

Understand the effect f sexually transmitted infection on health, especially the impact of
chlamydia and gonorrhoea on tubal disease and risk of ectopic pregnancy.

b)

Provide appropriate counselling and treatment advice to women diagnosed with
chlamydia, gon
orrhoea, syphilis, and sexually transmitted viruses (HIV, Hepatitis B and
C, Herpes simplex), and understand the risk of transmission to the fetus or neonate.

c)

Recognize the association between human papilloma virus infection and the lower genital
tract can
cer and give information on HPV vaccine.


Sexuality

a)

Describe the features of normal sexual response in the female and male.

b)

Explain how illness, age, pregnancy or medication might interfere with sexual response.

c)

Recognise features of sexual dysfunction.


Pre pregnancy care

a)

Explain to a patient the importance of health and events at the time of conception and
their impact on subsequent pregnancy outcome.

b)

Explain the importance of taking folic acid supplementation periconceptionally.

c)

Describe the
importance of good blood sugar control in diabetics and avoiding (or
changing to a different medication) of certain medicines during pregnancy in patients
which chronic diseases.


Antenatal care

a)

Explain and discuss the significance of screening for fetal a
nd maternal disorders and list
commonly offered screening tests (haemoglobin, blood group and Rh
-
typing, Rubella
antibodies, VDRL
-
test) and tests offered to specific risk groups (e.g. hepatitis B and C,
HIV, toxoplasma antibodies, glucose tolerance test et
c.)

b)

Follow normal development of pregnancy until term and recognize symptoms and signs
of abnormal development during antenatal care.

c)

Describe commonly used criteria for the stratification of pregnancies in low and high risk
categories and criteria for ref
erral from primary care to specialist care.

d)

Recognize psychological problems in pregnancy including the fear of childbirth,
depression etc. and make an appropriate referral to the specialist.

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e)

Demonstrate an understanding of antenatal education. Recognize w
arning signs of
domestic violence and other risks to pregnant woman and her unborn child. Discuss the
criteria and describe the procedures for communicating concerns to social services and
child protection authority.


Maternal medicine

a)

Describe the aetiolo
gy, pathophysiology, diagnosis, investigations and management of
common pregnancy associated disorders, such as hyperemesis gravidarum,
preeclampsia including HELLP syndrome, gestational diabetes etc.

b)

Have a basic understanding of chronic diseases (e.g. d
iabetes mellitus, hypertension,
congenital heart diseases, epilepsy, inflammatory bowel diseases etc) that influence
the course and outcome of pregnancy and describe their management using
multidisciplinary approach

c)

Describe the main direct and indirect causes of maternal mortality and morbidity
(preeclampsia, thromboembolism, postpartum haemorrhage, sepsis, cardiac diseases,
psychiatric illness etc) and their prevention.


Fetal medicine

a)

Describe the methods and expla
in the importance of determining gestational age
accurately and risks of pre
-

and postmaturity.

b)

Describe the routine use of ultrasound screening in pregnancy and its benefits and
drawbacks.

c)

Describe basic principles and indications for prenatal diagnosis
and have a basic
understanding of noninvasive (ultrasound imaging, fetal DNA in maternal circulation)
and invasive (chorionic villous biopsy, amniocentesis, fetal blood sampling) methods
of prenatal diagnosis.

d)

Describe methods used to assess fetal structur
al defects and fetal well
-
being
(ultrasound, Doppler, cardiotocography, fetal
-
ECG etc).

e)

Have a general understanding and be able to list some fetal conditions that are lethal
(e.g. anencephaly, bilateral renal agenesis, Trisomy 13), treatable in utero (fet
al
anaemia due to red cell alloinmmunization, twin
-
twin transfusion syndrome) or
require postnatal surgery (congenital heart defects, abdominal wall defects etc.)

f)

Describe the methods used in assessing the risk of women having a fetus with
chromosome defec
t.

g)

Define fetal growth restriction, list important causes and explain how to diagnose and
discuss management principles.


Labour

a)

Recognise the risk factors for preterm labour, and describe the management principles of
preterm labour (advantage of antenatal

corticosteroid therapy, tocolysis and in utero
transfer to a unit with intensive neonatal care facilities).

b)

Recognise common obstetric emergencies and have a basic understanding of their
management.

c)

Recognise maternal and fetal risks during pregnancy, lab
our and delivery.

d)

Have an understanding of methods used for pain relief in labour.

e)

Be familiar with management of the third stage of labour including prophylaxis and
treatment of postpartum haemorrhage.


Postnatal care

a)

To be able to provide appropriate pos
tnatal care of mother and infant including advice on
breastfeeding.

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b)

Demonstrate the ability to provide appropriate advice and care to women who had
operative vaginal delivery, episiotomy or perineal tears.

c)

Describe postoperative care of women who had a cae
sarean section.

d)

Recognise and describe the management of puerperal fever, mastitis, breast abscess and
puerperal psychiatric disorders.


Ethics and law

a)

Describe the doctor`s legal and professional duties to the pregnant woman and the fetus.

b)

State the
provisions of the Abortion Law (1978) and Biotechnology Law (2003).

c)

Outline the legal and professional guidelines relevant to doctors’ conscientious objection
to participation in abortion care.

d)

Discuss the ethical and legal status of the fetus.

e)

State the i
mplications for providing contraceptive advice and treatment to young people
less than 16 years.

f)

Outline the ethical issues involved in prenatal screening and testing.


Perinatal mortality and morbidity

a)

Understand and be able to define terminologies such a
s abortion, stillbirth, neonatal death
and perinatal death.

b)

Understand the importance and have knowledge of procedures for the collection of
perinatal statistics (Medical Birth Registry).

c)

Describe important causes of stillbirths and neonatal deaths.


Globa
l health

a)

Discuss the reasons for differences in causes and rates of caesarean section, maternal
mortality and perinatal mortality in different countries and their impact on global
maternal and child health.

b)

Have a good understanding of law regarding femal
e genital mutilation (FGM), be able
to diagnose FGM, give appropriate advice regarding pregnancy and delivery and make
a specialist referral when appropriate.

c)

Have a basic understanding of tropical infections that affect maternal and neonatal
health.

d)

Discu
ss the risks associated with obstructed labour, such as vesico
-
vaginal fistula,
uterine rupture, sepsis etc.

e)

Describe the risks and complications associated with illegal abortion, such as
haemorrhage, uterine perforation, sepsis etc. and their management.


Surgical procedures


a)

Understand and describe the

most common operations in obstetrics and gynaecology

b)

Describe principles of pre
-

and postoperative care for day surgical procedures and major
gynaecological operations.

c)

List common complications of gynaeco
logical surgery and describe their management.


Seminars

Seminars are conducted in a small group (10
-
12 students) setting using real clinical scenarios.
Students must participate actively in the discussion of the cases. Seminars last approximately
2
hours each including break.

a)

Dysfunctional uterine bleeding and pelvic infections.*

b)

Early pregnancy problems, such as spontaneous abortion, ectopic pregnancy, gestational
trophoblastic disease and termination of pregnancy including legislation.*

c)

Contracepti
on.

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d)

Management of normal labour including monitoring maternal and fetal well
-
being and
progress of labour, pain relief in labour, conducting a normal delivery and prophylaxis of
postpartum haemorrhage.

e)


Management of abnormal labour including recognition o
f abnormal labour, interpretation
of partogram, CTG, and management of intrapartum and postpartum haemorrhage.*

f)

Management of abnormal labour using simulation exercises for breech delivery, shoulder
dystocia, ventouse and forceps delivery.*


*The seminars
marked with the asterisk (*) will be given only to the international exchange
students during the course (Med 4001). The Norwegian students will be given these
seminars during their 6
th

study year.


Clinical weeks in obstetrics and gynaecology

Attend minim
um of two morning clinical meetings (preferably on Tuesdays and Thursdays,
so that the students can also benefit from the internal resident teachings given on those days)

Bed
-
side teaching in group with one teacher (1 hour)

Attend Gynaecology clinic (1 da
y)

Gynaecological ward (1 day, take history and examine one patient)

Attend Antenatal clinic (1 day)

Obstetric ward (two 8
-
hours shifts in the labour ward. Student must attend at least one
delivery).


Teaching and Learning Methods:


The learning objective

will be achieved by using a variety of teaching methods, e.g. lectures,
seminars and small group work, practical laboratory work, simulations, training in the skills
laboratory using phantoms and models, clinical case presentations, bedside teaching, and
observation of the clinical and laboratory tasks performed by the peers. During the Obstetrics
and Gynaecology course each student gets a total of 142 hours of teaching as specified in the
following table.



Gynaec
ological
Patholo
gy

Reprod
uctive
Physiol
ogy

Micro
biolog
y

Obstetric
s and
Gynaeco
logy

Radiolo
gy and
Imagin
g

End
ocri
nolo
gy

Breast
Surge
ry

Pharma
cology

Epidem
iology

Introdu
ction,
film &

evaluati
on

Total

Lectur
es

7

8

2

44

1

1

2

4

2

5

7
6

laborat
ory
Course

12


2








14

Semin
ars




12

1






13

Skills
lab




4







4

Clinica
l
placem
ent




3
5







3
5

Total

19

8

4

9
5

2

1

2

4

2

5

14
2

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Mandatory attendance and approval required:


For all students


Attendance in the skills laboratory:



2 sessions


Only for international exchange students
(2
-
weeks clinical placement will be arranged toward
the end of the course)


Attendance at morning clinical meeting


2 sessions

Attendance at the labour ward



1 delivery


NB: The Norwegian students will be given the clinical teaching and some seminars
in the
sixth year.


Recommended Learning Resources:

Textbooks

Bergsjø P, Maltau JM, Molne K, Nesheim BI:
OBSTETRIKK OG GYNEKOLOGI
.
Gyldendal Akademisk.

Baker P and Kenny L.
Obstetrics by Ten Teachers
. 19 ed . 2011

Monga A and Dobbs S.
Gynaecology by Ten T
eachers
. 19 ed. 2011

Impey L. Child T.
Obstetrics and Gynaecology
4. ed. Willey
-
Blackwell, 2012 .


International exchange students may use textbooks as advised by their respective institutions.


Websites

http://legeforeningen.no/Fagmed/Norsk
-
gynekologisk
-
forening/Veiledere/


http://www.helsedirektoratet.no/publikasjoner/nasjonal
-
faglig
-
retningslinje
-
for
-
svangerskapsomsorgen
-
fullversjon/Sider/default.aspx