COURSE IN OBSTETRICS AND GYNAECOLOGY

LEARNING OUTCOMES OF THE COURSE IN OBSTETRICS AND GYNAECOLOGY

 At the completion of this course, the students should  be able to:

1. define and explain the basis of women's health care;
2. describe bio ethical principles in relation to the provision of evidence-based health care to women;
3. counsel and manage all aspects of normal pregnancy, labour, delivery and puerperium, and explain the basis of such management;
4. Identify, counsel and manage common gynecological problems, and explain the basis of such management;
5. Identify common obstetric and gynecological emergencies, formulate appropriate management plans, commence initial management, and explain the basis of such management;
6. Identify common abnormalities of pregnancy, labour, delivery and puerperium, formulate appropriate management plans, commence initial management and explain the principles of such management;
7. describe and explain the principles of the measures adopted in the early diagnosis of gynecological malignancies, and counsel women in this regard;
8. function effectively as medical officers providing primary health care to women in the community, perform under supervision, basic tasks and clinical procedures which are essential duties of intern house officers in obstetrics and gynaecology, and pursue post graduate studies in the future;
9. design a clinical audit, critically appraise different options of management, and write reflective reports on their experiences in relation to the provision of health care to women;
10. describe the principles involved in ensuring patient safety, and clinical risk management, in the provision of health care to women;
11. describe basic medico-legal issues and procedures in relation to women’s health care;
12. perform a literature search on a given topic, formulate a presentation using MS PowerPoint, and make an oral presentation to peers.

 

COURSE STRUCTURE

Year 1 Semester 2 to Year 2 Semester 3

• Interactive and Flipped Lecture Discussions and Audio Visual Presentations                     -08 hours
• Visits to a hospital                                                                                                      – 20 Hours (4 hours X 5 visits) 

Year 2 Semester 4

• • Introductory Clinical Appointment                                                                                         – 01 week (24 hours)

Year 2 Semester 4 to Year 5 Semester 9

• Interactive and Flipped Lecture Discussions, Audio Visual Presentations and Simulation Based training                                                                                                                                                                                     – 122 hours

Year 3 Semester 5 to Year 4 Semester 8

• 1^st Clinical Appointment                                                                                                               – 04 weeks (160 hours)
• 2^nd Clinical Appointment                                                                                                              – 04 weeks (160 hours)

Year 5 Semester 9 to Year 5 Semester 10

• Professorial Appointment                                                                                                            –08 weeks (356 hours)

 

 COURSE CONTENT

• General Topics

• Pre pregnancy care
• Antenatal care for low- risk pregnancies
• Antenatal care for high- risk pregnancies 
• Management of Labour and delivery
• Obstetric Emergencies
• Postnatal Care
• Common Gynaecological Problems
• Subfertility
• Sexual and Reproductive Health
• Early pregnancy problems 
• Gynaecological oncology
• Urogynecology and pelvic floor problems

 

TEACHING AND LEARNING METHODS 

• Interactive and flipped lecture discussions and audio- visual presentations, face to face and online
• Task based learning and student presentations, face to face and online
• Clinical training and experiential learning in hospitals, and shadowing house officers
• Case presentations and Case- based Discussions ( CbD)
• Bedside teaching and learning (BSTL)
• Simulation based training
• Multidisciplinary CbD and Student Seminars
• Critical appraisal of different management options in women’s care and reflective writing  
• Maintaining a log book and portfolio
• Independent (self- directed) learning

Intended Learning Outcomes of the Interactive and Flipped Lecture Discussions and Audio Visual Presentations – 8 Hours

Year 1 Semester 2 to Year 2 Semester 3

The students should be able to describe:

• the important anatomical landmarks of the fetal skull and female pelvis, and understand their clinical significance
• the possible presentations and positions of the fetus, and the presenting diameters of the fetus in relation to the maternal pelvis
• the principles  of the mechanisms of normal labour
• how to use the last menstrual period  to establish the estimated date of delivery and calculate the gestational age of the pregnancy
• The clinical anatomy of the female genital tract and its relevance to obstetrics and gynaecology
• the menstrual cycle, its control, menarche, menopause
• the pathophysiology of abnormal uterine bleeding
• the basis of anatomical, physiological and endocrinological changes in pregnancy and their relevance in clinical practice
• abnormalities in the development of the human embryo
• abnormalities in the development of the female genital tract
• the common gynaecological problems (heavy menstrual bleeding, abdominal discomfort and pain, subfertility, vaginal discharge, utero vaginal prolapse) 

The students should be able to list:

• the possible causes of the common gynaecological problems (heavy menstrual bleeding, abdominal discomfort and pain, subfertility, vaginal discharge, utero vaginal prolapse) 

The students should be aware and be able to understand the principles of:

• how to carry out a clinical interview and obtain a clear, focused, relevant, chronological obstetric history and how to  examine a pregnant woman
• how to carry out a clinical interview and obtain a clear, focused, relevant, chronological gynaecological history, including a detailed, structured menstrual history, and how to examine a woman 

 

Intended Learning Outcomes of the visits to a hospital – 20 Hours ( 4 hrs X 5 Visits) 

Year 1 Semester 2 to Year 2 Semester 3

Hospital Visits

• Antenatal Clinic
• Gynacological Clinic
• Antental Ward
• Gynaecological Ward
• Labour ward and post natal ward

 The students should be able to observe:

• clinical interviews and the obtaining of clear, focused, relevant, chronological, obstetric histories from pregnant women
• the examination of pregnant women
• clinical interviews and the obtaining of clear, focused, relevant, chronological, gynaecological histories , including a detailed, structured menstrual history from women
• the examination of   women 
• communications with patients and their families with empathy, respecting cultural values, confidentiality and privacy
• and recognize the importance of a self introduction and  obtaining informed consent prior to examining a woman
• and recognize the importance of a female chaperone when examining a woman
• the communication of relevant details to the patient and the family in plain (non-technical) language
• the conduct of an antenatal clinic
• the conduct of a gynaecological  clinic
• women being monitored during labour, and the use of the National Partogram and the  Modified Obstetric Early Warning System ( MOEWS) chart
• postnatal care of women and their babies

 

Year 2 Semester 4 to Year 5 Semester 9

Intended Learning Outcomes of the Interactive and  Flipped Lecture Discussions, Audio Visual Presentations

General Topics – 17 Hr

The students should be able to define women’s health, sexual and reproductive health (SRH) and state SRH Rights and Sustainable Development Goals

The students should be able to describe:

• bio ethical principles in relation to the provision of health care to women
• the principles of professionalism and ethical clinical practice
• the four core component areas and the 12 categories of learning outcomes identified by the UGC
• the principles involved in the   provision of evidence based health care to women
• and explain the basis of anatomical, physiological and endocrinological  changes in pregnancy and their relevance in clinical practice
• the provision of women’s health care in the community
• basic medico-legal issues and procedures in relation to women’s health care
• perform a literature search on a given topic, formulate a presentation on MS Powerepoint and make an oral presentation to peers
• how to design a clinical audit, critically appraise different options of management, and write reflective reports on their experiences in relation to the provision of health care to women
• the principles involved in ensuring patient safety, clinical governance and  risk management in the provision of health care to women
• the importance of obtaining consent and consenting process in the care of minors (Fraser/Gillick competence)
• the ethical principles of safeguarding minors from an abusive environment
• the importance of patient confidentiality, data protection and legal aspects of obtaining informed consent
• concepts of child protection
• rights of women and their  family members
• the Abortion Act of Sri Lanka

 The students should be aware and be able to understand the principles of:

• how to carry out a clinical interview and obtain a clear, focused, relevant, chronological obstetric history, examine a woman and present a case
• how to carry out a clinical interview and obtain a clear, focused, relevant, chronological gynaecological  history, including a detailed structured menstrual history, examine a woman  and present a case
• how to obtain a focused, relevant history from a subfertile couple, examine a subfertile couple   and present a case

 

Pre pregnancy care – 1 Hr

 The students should be able to describe :

• the principles of pre pregnancy counseling (including life style modifications , fertility period,  peri conceptional folic acid and counseling couples with common genetic derangements or a previous child with a genetic disorder)
• interventions carried out at the field level in Sri Lanka for pre pregnancy counseling
• common non-communicable diseases affecting pregnancy and relevant screening tests
• medical eligibility criteria (MEC) for contraception and the principes involved in  giving  appropriate contraceptive advice using MEC taking into account client’s social and medical conditions
• assessment of  risks in a couple preparing for pregnancy
• the principles of multidisciplinary care and referrals  to other specialties where necessary

 The students should be able to:

• draw a pedigree tree when relevant

 Ante natal care for low risk pregnancies  – 4 Hr

The students should be able to describe:

• the model of antenatal care delivery in Sri Lanka, and the importance of the field service and its integration into the care package 
• the principles of conducting a booking visit
• the rationale of basic investigations conducted during pregnancy and interpret their results
• the principles of safe prescribing in pregnancy including how pregnancy affects pharmacodynamics and pharmacokinetics
• methods of screening for genetic and structural anomalies of the fetus
• the role of ultrasound scanning in dating of pregnancy and assessment of fetal wellbeing.
• how to use the last menstrual period and ultrasound dating to establish the estimated date of delivery and calculate the gestational age of the pregnancy
• the assessment of risk factors in pregnant women in order to classify them as low risk or high-risk pregnancies
• the roles of different categories of staff in delivery of antenatal care.
• shared care in provision of care for low risk pregnancies
• possible complications during pregnancy and how to screen for and detect them.

 Ante natal care for high risk pregnancies  – 35 Hrs

 The students should be able to describe the possible causes, methods of  screening for,  the diagnosis and management of high risk pregnancies including:

• Multiple pregnancy
• Breech presentation
• Rhesus alloimmunization
• Small for dates
• Large for dates
• Infections in pregnancy ( including viral and STI)
• Antepartum hemorrhage
• Preterm labor, Prelabour  rupture of membranes, Preterm prelabour rupture of membranes
• Thromboembolic disorders
• ‘Post-dates pregnancy’ and Post term pregnancy
• Intrauterine fetal demise and stillbirths

 The students should be able to describe the pathophysiology, risk factors, the effects on the pregnant woman and her fetus, the  common complications,  and the management of the following  conditions  complicating pregnancy

• Anaemia
• Hypertension 
• Hyperglycaemia.
• Cardiac disease
• Renal disorders
• Respiratory disorders
• Hepatic disease including obstetric cholestasis
• Mental health disorders
• Epilepsy
• Thyroid disease
• Obesity.
• HIV
• Thrombophilia
• Extremes of age ( young teenager < 17yrs, elderly woman > 38 yrs) and grand multiparity

.The students should be able to describe and evaluate:

• the risks and modifications required to continuing therapeutic medications during pregnancy
• the methods available for antenatal assessment of fetal wellbeing
• the principles of detecting fetal abnormalities
• the role and the use of ultrasound scanning during pregnancy

 The students should be able to describe:

• important, national health indices / statistics / indicators related to women’s health
• describe strategies which could be adopted to improve these indices / statistics / indicators further
• the risk factors and causes for maternal   morbidity and mortality and the strategies which need to be adopted to reduce maternal   morbidity and  mortality
• the risk factors and causes for  perinatal  morbidity and mortality and the strategies which need to be adopted to reduce perinatal  morbidity and  mortality
• the role of multidisciplinary care and appropriate referrals to other specialties where necessary
• the principles of ‘ breaking bad news’  and handling various emotional and social problems  of patients
• the use of SBAR as a tool for communication with patients, family members, colleagues and other health care providers.
• the impact of pregnancy on daily living
• the needs and adjustments in management of special groups of women e.g. women who refuse blood or blood products, and women carrying socially stigmatized pregnancies

 Management of Labour and delivery – 12 Hrs

 The students should be able to describe:

• and demonstrate anatomical landmarks of the fetal skull and female pelvis
• and demonstrate possible presentations and positions of the fetus,  and the presenting diameters of the fetus in relation to the maternal pelvis
• physiology of normal labour including stages, phases and normal time durations of each
• and demonstrate mechanism  of normal labour
• diagnosis of onset of labour
• diagnosis of normal labour
• identification of abnormal labour
• care during labour.
• benefits of a labour companion
• methods of analgesia in labour, their side effects, complications and limitations
• assessment of fetal wellbeing during labour
• and demonstrate the maintaining of a partogram
• indications, contraindications, methods and complications of induction and augmentation of labour
• interpretation of CTG tracing and classifying them as normal, suspicious or pathological.
• rationale and principles of performing a vaginal examination during labor to assess cervical status, station, fetal presentation, position and color of amniotic fluid
• principles of performing an amniotomy
• principles of setting up an oxytocin infusion according to protocols and guidelines
• surgical anatomy of an episiotomy and perineal tears and principles of perineal repair
• demonstrate the conduct of a normal delivery
• benefits of delayed cord clamping
• benefits of skin to skin contact of neonate
• methods, indications and complications of instrumental vaginal delivery
• indications, steps and complications of cesarean delivery
• preparation of a woman for an instrumental vaginal delivery or cesarean delivery
• identification and repair of obstetric anal sphincter injury

 Obstetric Emergencies – 6 Hr

 The students should be able to describe:

• how physiological changes in pregnancy impact on its complications
• the risk factors, etiology, pathophysiology and preventive measures of obstetric complications such as cord prolapse, postpartum hemorrhage, hypertensive disorders of pregnancy, shoulder dystocia, retained placenta and acute inversion of the uterus
• principles of the management of complex vaginal deliveries e.g. twins, breech
• demonstrate the management of complex vaginal deliveries e.g. twins, breech
• the principles of the  key management steps in obstetric emergencies such as cord prolapse, postpartum hemorrhage, hypertensive disorders of pregnancy, shoulder dystocia, retained placenta and acute inversion of the uterus
• and demonstrate key management steps in obstetric emergencies such as cord prolapse, postpartum hemorrhage, hypertensive disorders of pregnancy, shoulder dystocia, retained placenta and acute inversion of the uterus
• the causes, consequences, identification, clinical features and management of neonatal asphyxia
• the causes and immediate management of maternal collapse during labour
• the early recognition of shock in a pregnant woman
• the key steps in the management of an asphyxiated neonate
• the principles and steps involved in providing immediate care to a collapsed pregnant woman
• the principles adopted in communication (use of SBAR tool) during obstetric emergencies
• the role and importance of teamwork in obstetric emergencies
• the principles in counseling patients and their families in obstetric emergencies

 Postnatal Care – 4 Hr

 The students should be able to describe:

• the active management of the third stage of labour
• the maintaining of a Modified Obstetric Early Warning chart
• normal puerperium and its common abnormalities
• the contraceptive choices available for postpartum women, and the principles in providing contraceptive counseling
• the risk factors, causes, etiology, recognition and management of puerperal sepsis 
• the etiology, recognition and management of postpartum collapse due to various complications such as pulmonary embolism, septic shock, haemorrhagic shock and severe hypertension 
• the importance and care of the perineum during the puerperium
• the implications, clinical features, recognition and management of postpartum mental disorders
• the importance of breastfeeding and the management of common feeding issues
• the roles of other healthcare professionals in managing women in the postpartum period
• the domiciliary care model for postpartum women in Sri Lanka

 Total 77 Hours  ( General Topics and Obstetrics)

 

Common Gynaecological Problems – 15 Hr

The students should be able to describe:

• the menstrual cycle, its control,  menarche, and  menopause

 The students should be able to describe and explain the causes, clinical features, etiology, pathophysiology and principles of management of

• vaginal discharge
• pruritus vulvae
• post coital bleeding
• dysmenorrhea (primary and secondary)
• pelvic infections
• pain in the vulva including Bartholin cyst and abscess
• uterovaginal prolapse
• chronic pelvic pain
• vulvar dystrophy
• primary and secondary amenorrhea
• abnormal uterine bleeding (AUB)
• Uterine Leiomyomata and Adenomyosis
• Benign ovarian neoplasms
• problems of the climacteric (symptoms, AUB, osteoporosis and hormone replacement therapy)

 The students should be able to describe and explain the principles of counseling  and obtaining  informed consent for the  following procedures:

• hysterosalpingogram, hydosonography
• dilatation and curettage
• evacuation of retained products of conception
• endometrial sampling
• diagnostic and operative laparoscopy
• hysteroscopy
• total abdominal hysterectomy with and without conservation of ovaries
• vaginal hysterectomy 
• laparoscopic hysterectomy
• laparotomy for benign gynaecological conditions and ectopic pregnancy
• myomectomy

 Subfertility – 4Hr

 The students should be able to define  primary and secondary subfertility

• The students should be able to  describe common causes of infertility
• ovulatory dysfunction
• male factor
• tubal factor
• endometriosis
• coital dysfunction
• unexplained infertility

 The students should be able to  describe and explain the principles of:

• semen analysis
• endocrine evaluations
• tubal patency tests
• ultrasound examinations  in subfertility
• diagnostic laparoscopy and hysteroscopy
• ovulation induction
• artificial reproductive techniques
• gamete donation
• surgical treatment of subfertility
• the management of complications arising during investigation and treatment of subfertility

 Sexual and Reproductive Health –6 Hr

 The students should be able to describe mechanisms of action, indications, contraindications, their limitations, advantages and complications of the following contraceptive methods:

• hormonal
• permanent
• natural
• long acting reversible , Including PPIUD
• emergency

 The students should be able to describe

• the process of informed choice of contraception by the client
• the problems posed by unplanned pregnancy
• post abortion care
• care of survivors of sexual assault
• principles of surgical procedures and pre and post-operative care in gynaecology

 The students should be able to describe and explain:

• Sexually transmitted Infections (STI) prevalent in Sri Lanka
• epidemiology of STI in Sri Lanka
• STI transmission and their prevention
• importance of contact tracing
• symptoms and signs of common STIs
• management of common STIs
• effects of STIs on pregnancy and their management
• management of STIs in rape victims

 Early pregnancy problems  - 6 Hr

 The students should be able to describe:

• development of female genital tract and developmental  abnormalities
• causes of bleeding and/or pain in early pregnancy.
• classification of miscarriage
• presentation and management of miscarriage, ectopic pregnancy and pregnancy of unknown location
• use of ultrasound and hormonal assessment in early pregnancy problems
• use of anti-D in early pregnancy bleeding

 The students should be able to describe and explain the etiology, characteristics and modes of management of:

• normal and exaggerated symptoms of early pregnancy
• miscarriage
• ectopic pregnancy
• gestational trophoblastic disease
• acute retention of urine in early pregnancy

 The students should be able to describe and explain the role of the following in the investigation of early pregnancy problems:

• clinical features, including signs of collapse
• hematological investigations and Rhesus status
• urine pregnancy test and serum bhCG
• pelvic ultrasound
• laparoscopy

 Gynaecological oncology – 6 Hr

 The students should be able to describe and explain:

• surgical anatomy of the genital tract (including a basic knowledge of normal histology)
• epidemiology, etiology, diagnosis, management and prognosis of common gynecological cancers
• common presenting symptoms and signs of gynecological cancers
• screening for papillomavirus, preclinical phases of invasive cervical carcinoma and management of those with positive results
• short and long term complications of surgery, chemotherapy and radiotherapy
• endometrial hyperplasia, its etiology, prognosis and management
• histological classification and staging of cervical, endometrial and ovarian carcinoma
• principles of palliative care
• principles of breaking bad news to a patient/family.

 

Urogynecology and pelvic floor problems – 3 Hr

 The students should be able to describe and explain:

• pelvic anatomy in relation to factors that help in maintaining the uterus in its normal position
• anatomy and physiology of the bladder in relation to the maintenance of urinary continence
• etiology and pathophysiology of urinary incontinence  (stress incontinence, urge incontinence and mixed incontinence)
• classification and components of uterovaginal prolapse
• the concepts of investigations carried out in women with urinary incontinence including urodynamics
• common symptoms associated with uterovaginal prolapse
• clinical features of urinary tract infection, urodynamic stress incontinence and an overactive bladder
• basic concepts of treatment approaches in management of uterovaginal prolapse, urinary incontinence and their untoward effects
• basic concepts of Burch colposuspension, pelvic repair with and without hysterectomy and sling procedures
• non-pharmacological and pharmacological therapies in urinary incontinence

 Revision Assignments and Discussions, and Preparation for the Final MBBS Examination – 3 Hr

Total = 43 Hours ( Gynae & Revision)

GRAND TOTAL = 120 Hours ( 2.4 Credits)

 

 Year 2 Semester 4

Intended Learning Outcomes of the Introductory Clinical Appointment – 1 week (24 Hrs)

Monday to Saturday 8.00am to 12.00 noon

 

Clinical Competence	Professionalism and Attitudes
The students will be introduced to the following Basic Clinical Skills:	The students will observe and be introduced to:
carrying  out a clinical interview and obtaining a clear, focused, relevant, chronological obstetric history, performing a detailed  examination of a pregnant woman, and presenting a case (2days)	communicating with patients and their families with empathy, respecting cultural values, confidentiality and privacy recognizing the importance of a  self introduction and  obtaining informed consent prior to examining a woman recognizing the importance of a female chaperone when examining a woman recognizing the limitations of their personal  skills and abilities, and seeking advice from other professionals where appropriate communicating relevant details to the patient and the family in plain (non-technical) language
carrying out a clinical interview and obtaining a clear, focused, relevant, chronological, gynaecological  history  and presenting a case ( 1 Day)
performing  a gynaecological pelvic examination ( speculum and bimanual) on a manikin and presenting  hypothetical findings(1day)
demonstrating  on  manikins the possible presentations and positions of the fetus, the presenting diameters of the fetus in relation to the maternal pelvis, and the mechanisms of labour(1Day)
documenting  given data onto the National Partogram (1Day)

 

Year 3 Semester 5 - Year 4 Semester 8

Intended Learning Outcomes of 1^st Clinical Appointment  – 4 weeks (160 hrs)                            

Monday to Saturday 8.00am to 12.00 noon + Casualty Days X 6 + Casualty Weekend X 1 

Patient Interview and Examination
Clinical Competence	Professionalism and Attitudes
The students should  be able to :	The students should be able to:
carry  out a clinical interview and obtain a clear, focused, relevant, chronological obstetric history, calculate the estimated date of delivery (EDD) and gestational age ( GA), perform a detailed  examination of a pregnant woman, and present a case carry out a clinical interview and obtain a clear, focused, relevant, chronological, gynaecological  history, including a structured menstrual history,  and present a case perform  a gynaecological pelvic examination ( speculum and bimanual) and present  the findings formulate  a differential diagnosis using ‘hypothetico-deductive’ reasoning  differentiate normal changes in pregnancy from the abnormal recognize an acutely unwell obstetric or gynecological patient	demonstrate an understanding of the provision of holistic women's health care abide by the bio ethical principles in relation to the provision of health care to women communicate with patients and their families with empathy, respecting cultural values, confidentiality and privacy carry out a self introduction and  obtain informed consent prior to examining a woman always obtain  a female chaperone when examining a woman recognize  the limitations of their personal  skills and abilities, and seek advice from other professionals where appropriate observe and assist in communicating  relevant details to the patient and the family in plain (non-technical) language protect confidentiality and obtaining specific consent when divulging information to third parties recognize specific situations where patient confidentiality is breached (e.g. Notifiable diseases) demonstrate an understanding of protect rights of patients and their family members demonstrate an understanding of the Abortion Act of Sri Lanka respond appropriately  to the requirements of children, adolescents and the elderly

 

Pre pregnancy Care
Clinical Competence	Professionalism and Attitudes
The students should be able to :	The students should be able to:
assess risks in a couple preparing for pregnancy draw a pedigree tree advice regarding lifestyle modifications, fertility period and periconceptional folic acid make referrals to other specialties where necessary give appropriate contraceptive advice using MEC taking into account a woman’s social and medical conditions	assist in providing   pre pregnancy counseling assist in counseling  couples with common genetic derangements or a previous child with a genetic disorder
Ante natal  Care for low risk women
Clinical Competence	Professionalism and Attitudes
The students should  be able to :	The students should be able to:
carry out a general, system and obstetric examination and present the findings review and interpret investigation results assess risk factors in a pregnant woman and classify them as low risk and high-risk pregnancies accordingly assist  in assessment and management  of women presenting for review measure blood pressure in a pregnant woman using the correct techniques measure symphysio fundal height (SFH) using the correct technique ,  and chart on a centile chart. determine the   lie, presentation and probable position of a singleton fetus auscultate fetal heart recognize  normality and deviation from normality of a  pregnancy recognize possible complications in pregnancy perform urine analysis and interpret results	recognize the importance of the Field Service in provision of antenatal care and its integration into the care package. evaluate the roles of different categories of staff in delivery of antenatal care. communicate and extract relevant information from women and their families respect the rights of women and their families to receive respectful care. evaluate the impact of pregnancy on a woman’s daily living explain clinical finding to woman and their families and be aware of their perceptions of risk recognize the importance of considering all three key components of evidence based medical care viz providing individualized care based on current best available evidence, personal knowledge and skills and the facilities available, and the patient’s values and preferences.

 

Ante natal  Care for high risk women
Clinical Competence	Professionalism and Attitudes
The students should be able to :	The students should l be able to:
recognize common high risk pregnancies observe adjustments in care needed in providing care for mothers with common high risk pregnancies identify  additional investigations needed for management of patient with common high risk pregnancies observe the use of anti D in pregnancy observe multi disciplinary referrals where necessary	observe effective communications with patient, family members, colleagues and other health care providers, using SBAR as a tool evaluate the impact of social problems on pregnancy especially when complicated. show empathy towards the patient and other team members in a healthcare team recognize their limitations and seek help when needed
Management of Labour
Clinical Competence		Professionalism and Attitudes
The students should be able to :		The students should be able to:
diagnose labor and its stages recommend an appropriate method of pain relief to a woman in labor maintain a partogram observe and assist in interpreting CTG tracings and to classify them as normal, suspicious and pathological under direct supervision of a specialist, senior registrar, or an experienced senior house officer perform a vaginal examination during labor to assess cervical status, fetal presentation, position, station, presence of caput and moulding, and color of amniotic fluid observe an amniotomy observe and assist in the setting up of an oxytocin infusion according to  guidelines and protocols observe the identification of abnormal labour and its management assist for a normal delivery observe and assist  active management of the third stage of labour prepare a patient for and assist an instrumental vaginal delivery prepare a woman for and assist in a cesarean delivery observe an episiotomy and its repair identify obstetric anal sphincter injury maintain accurate documentation		explain the process of labor to a woman in simple language recognize the importance of respectful labor care and a positive childbirth experience. recognize women in distress, be empathetic and offer help involve women in making management choices respect a woman’s autonomy advise and assist the labour companion when needed recognize their limitations and seek help when needed
Obstetric Emergencies
Clinical Competence		Professionalism and Attitudes
The students should be able to :		The students should l be able to:
observe and assist in the immediate management of acute complications of pregnancy such as shoulder dystocia, cord prolapse, postpartum hemorrhage, retained placenta and acute inversion of the uterus recognize shock in a pregnant woman observe and assist in the key steps in managing an asphyxiated neonate observe and assist in providing immediate care to a woman who has cardio respiratory collapse antenatally, intra partum or post partum		observe communication  skills during obstetric emergencies (Ie : Use of SBAR tool) recognize the importance of teamwork in obstetric emergencies observe and assist in counseling patients and their families in emergencies
Management of the post partum period
Clinical Competence		Professionalism and Attitudes
The students should be able to :		The students should be able to:
maintain a MOEWS chart  recognize normal and abnormal changes of puerperium observe and assist in performing the key steps of managing a woman with puerperal sepsis observe and assist in counseling a postpartum woman regarding contraceptive choices, including PPIUD advise and assist women to adopt the correct technique of breastfeeding and manage related common problems		recognize the roles of other healthcare professionals in managing women in the postpartum period demonstrate empathy towards women who have problems during the puerperium, and also towards their families

 

Gynaecological Problems
Clinical Competence	Professionalism and Attitudes
The students should be able to :	The students should be able to:
obtain informed consent, and assist for the following procedures: cervical smear endometrial sample evacuation of retained products of conception dilatation and curettage observe and assist in multidisciplinary referrals when needed	communicate with patients, and also their family members, regarding their conditions and the proposed management  plan counsel the patients regarding various gynecological interventions
Sexual and Reproductive Health
Clinical Competence	Professionalism and Attitudes
The students should be able to :	The students should be able to:
interview and obtain a relevant, focused  history from a woman/couple attending family planning clinic observe and assist in counseling  a woman/couple attending  a family planning clinic observe and assist in carrying  out core activities of a family planning clinic	explain the importance of family planning for women’s health, safe motherhood and women’s empowerment evaluate the need to deal with care providers’ personal biases in providing contraception

  

Early pregnancy problems
Clinical Competence	Professionalism and Attitudes
The students should be able to :	The students should be able to:
Interview and obtain a relevant, focused  history and  examine a woman with an early pregnancy problem and present a case formulate  a differential diagnosis using ‘hypothetico-deductive’ reasoning  recognize women who require immediate resuscitation and to describe the emergency resuscitative measures formulate a basic management plan	explain to the woman and her partner  the possible outcome/s and plan of management recognize the personal and social impact of the diagnosis of a miscarriage, ectopic pregnancy or gestational trophoblastic disease empathize with the woman and her partner

 

Learning Outcomes of 2^nd  Clinical Appointment  – 4 weeks (160 Hrs),

Monday to Saturday 8.00am to 12.00 noon + Casualty Days X 6 + Casualty Weekend X 1 

Patient Interview and Examination
Clinical Competence	Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment, the students should be able to :	In addition to strengthening the learning outcomes of the 1st Clinical Appointment, the students should be able to:
obtain a focused, relevant history from a subfertile couple, examine a subfertile couple   and present a case observe and assist in abdominal and vaginal sonography assist in ensuring patient safety, clinical governance and  risk management in the provision of health care to women assist in obtaining consent and consenting process in the care of minors (Fraser/Gillick competence) assist in child protection and safeguarding minors from an abusive environment	communicate  relevant details to the patient and the family in plain (non-technical) language
Basic procedures
Knowledge and Clinical Competence	Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment, the students should l be able to :	In addition to strengthening the learning outcomes of the 1st Clinical Appointment, the students should l be able to :
prepare a patient for basic procedures maintain accurate and adequate clinical notes perform the following procedures under direct supervision:                          setting up an oxytocin infusion                          episiotomy and suture of an episiotomy                          maintain a MEOWS chart                   cervical smear                    obtain swabs for microbiological investigations	observe and assist in  obtaining informed consent for basic procedures use appropriate instruments and technique for common procedures recognize  the importance of adherence to management guidelines and protocols

 

Common surgical procedures, pre-and postoperative care
Knowledge and Clinical Competence	Professionalism and Attitudes
The students should  be able to:	The students should be able to:
describe commonly performed surgical procedures in obstetrics and  gynecology explain basic principles of surgical procedures including indications, contraindications, procedure, possible complications and aftercare evaluate methods used in postoperative pain management evaluate and analyze the rationale behind the principles of postoperative fluid management in an uncomplicated patient  List recognized complications of these surgical procedures and describe how they can be identified observe, assist and discuss management of common complications of obstetric and gynecological surgery observe the documentation of intra operative notes, discharge summaries and diagnosis cards	counsel and obtain informed consent for common surgical procedures in obstetrics and  gynecology communicate the agreed postoperative management plan to healthcare team, patient and family Provide relevant advice on discharge from hospital, including advice on when to seek medical advice urgently (‘safety netting’) and follow up in the field and hospital
Pre pregnancy Care
Clinical Competence, Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should be able to:
provide   pre pregnancy counseling , under supervision

 

Ante natal  Care for low and  high risk women
Clinical Competence	Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should  be able to:	In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should be able to:
describe adjustments in care needed in providing care for mothers with common high risk pregnancies identify  additional investigations needed for management of patient with common high risk pregnancies, and interpret their results identify women who require  anti D identify women who require  multi disciplinary referrals where necessary observe the conduct of a multidisciplinary consultation/clinic describe the principles of and observe the “break of bad news” and the handling of various emotional disturbances  of women and their families	assist in effective communications with patient, family members, colleagues and other health care providers, using SBAR as a tool evaluate the importance of multidisciplinary clinics/meetings in managing pregnancy complications recognize the needs and adjustments in management of special groups of women e.g. women who refuse blood or blood products, and  women carrying socially stigmatized pregnancies
Management of Labour
Clinical Competence		Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should be able to:		In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should be able to:
interpret CTG tracings and to classify them as normal, suspicious and pathological set up of an oxytocin infusion according to  guidelines and protocols identify abnormal labour and describe its management perform  a normal delivery carry out active management of the third stage of labour perform an episiotomy and its repair		provide respectful labor care and ensure a positive childbirth experience for the woman

 

 

Obstetric Emergencies
Clinical Competence, Professionalism and Attitudes
The students should be able to strengthen the learning outcomes of the 1st Clinical Appointment:
Management of the post partum period
Clinical Competence, Professionalism and Attitudes
The students should be able to strengthen the learning outcomes of the 1st Clinical Appointment:
Gynaecological Problems
Clinical Competence, Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should be able to:
obtain informed consent, and assist for the following procedures: -          hysterosalpingogram -          diagnostic and operative Laparoscopy and hysteroscopy -          endometrial sampling -          total abdominal hysterectomy with and without conservation of ovaries / vaginal hysterectomy /laparoscopic hysterectomy -          laparotomy -          abdominal and transvaginal ultra sonography observe and assist in multidisciplinary referrals when needed
Subfertility
Clinical Competence	Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should  be able to:	In addition to strengthening the learning outcomes of the 1st Clinical Appointment the students should be able to:
Interpret the results of the following investigations -          Hormone profile                      Seminal fluid Analysis -          Hysterosalpingography Counsel a couple about basic treatment plan and explain               common causes of infertility -          ovulatory dysfunction -          male factor -          tubal factor -          endometriosis -          coital dysfunction -          unexplained infertility Explain the principles of investigations in subfertility: -          semen analysis -          endocrine evaluations -          tubal patency tests -          ultrasound Explain the principles of: -          ovulation induction and its complications -          surgical treatment of infertility (Fibroids / Endometriosis)	recognize  the psychological, emotional and social impacts of infertility empathize with a subfertile couple utilise the availability of fertility treatment options in the government system
Early pregnancy problems
Clinical Competence, Professionalism and Attitudes
The students should be able to strengthen the learning outcomes of the 1st Clinical Appointment:

  

Basic Clinical Skills

Prior to the commencement of the Professorial Appointment , the students should be able to:

• interview and obtain a  clear, concise and  chronological history from:

a pregnant female and a  gynaecological  patient

• carry out a complete examination  of a pregnant female.
• carry out a complete examination of a gynaecological patient ( including examination of an abdomino pelvic mass, and  speculum & bimanual vaginal examination).
• present a brief summary of a pregnant female and a gynaecological  patient
• document given data into a Partogram.

Learning Outcomes of Professorial  Appointment  –  8 weeks (356 Hrs),

Monday to Saturday 8.00am to 12.00 noon + Casualty Days X 12 + Casualty Weekends X 2

Patient Interview and Examination
Clinical Competence		Professionalism and Attitudes
The students should be able to strengthen the learning outcomes of the 2nd  Clinical Appointment		The students should be able to strengthen the learning outcomes of the 2nd  Clinical Appointment
Basic procedures
Knowledge and Clinical Competence		Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment, the students should be able to :		The students should be able to strengthen the learning outcomes of the 2nd  Clinical Appointment:
perform the following procedures under direct supervision: -          artificial separation of membranes -          amniotomy
Common surgical procedures, pre-and postoperative care
Knowledge and Clinical Competence		Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment, the students should be able to :		The students should  be able to strengthen the learning outcomes of the 2nd  Clinical Appointment
assist at  commonly performed surgical procedures in obstetrics and  gynecology assist in the management of  possible complications and aftercare assist in  postoperative pain management assist in  postoperative fluid management in an uncomplicated patient  assist in recognizing  complications of these surgical procedures practice the documentation of intra operative notes, discharge summaries and diagnosis cards
Pre pregnancy Care
Clinical Competence, Professionalism and Attitudes
The students should be able to strengthen the learning outcomes of the 2nd  Clinical Appointment
Ante natal  Care for low and  high risk women
Clinical Competence		Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd t Clinical Appointment the students should  be able to:		In addition to strengthening the learning outcomes of the  2nd  Clinical Appointment the students should be able to:
assist in  adjustments in care needed in providing care for mothers with common high risk pregnancies assist in requesting  additional investigations needed for management of patient with common high risk pregnancies, and interpreting  their results assist in prescribing anti D for  women who require  it assist in multi disciplinary referrals where necessary assist in the  conduct of a multidisciplinary consultation/clinic assist in “breaking  of bad news” and the handling of various emotional disturbances  of women and their families		assist in adjusting the  management of special groups of women e.g. women who refuse blood or blood products, and  women carrying socially stigmatized pregnancies
Management of Labour
Clinical Competence					Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should be able to:					The students should l be able to strengthen the learning outcomes of the 2nd Clinical Appointment and be able to:
assist in the management of women with suspicious or pathological CTG tracings assist in identifying and managing abnormal labour					Recommend where needed, an alternative path of action
Obstetric Emergencies
Clinical Competence			Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should be able to:			In addition to strengthening the learning outcomes of the 2nd Clinical Appointment the students should be able to:
demonstrate on simulators, the immediate management of acute complications of pregnancy such as shoulder dystocia, cord prolapse, postpartum hemorrhage, retained placenta and acute inversion of the uterus assist in the early detection and management of  shock in a pregnant woman			assist in communications during obstetric emergencies (Ie : Use of SBAR tool) assist the   team managing an obstetric emergencies
Management of the post partum period
Clinical Competence			Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should be able to:			The students should be able to strengthen the learning outcomes of the 2nd Clinical Appointment
assist in the insertion of an IUCD, including PPIUD
Gynaecological Problems
Clinical Competence, Professionalism and Attitudes
The students should l be able to strengthen the learning outcomes of the 2nd  Clinical Appointment
Sexual and Reproductive Health
Clinical Competence				Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should be able to:				In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should l be able to:
interview and obtain a relevant, focused history from a woman/couple attending a clinic for Sexually Transmitted Infections              ( STI) observe and assist in counseling a woman/couple attending a STI clinic				counsel a woman/couple diagnosed as having a STI recognize the personal and social implications of the diagnosis of a STI
Subfertility
Clinical Competence	Professionalism and Attitudes
In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should be able to:	In addition to strengthening the learning outcomes of the 2nd  Clinical Appointment the students should be able to:
Explain the principles of -          diagnostic and therapeutic laparoscopy and hysteroscopy -          artificial reproductive techniques -          gamete donation	examine the issues surrounding artificial reproductive techniques, gamete donation, surrogacy and adoption
Early pregnancy problems
Clinical Competence, Professionalism and Attitudes
The students should  be able to strengthen the learning outcomes of the 2nd  Clinical Appointment:
Gynaecological oncology
Clinical Competence	Professionalism and Attitudes
The students should be able to:	The students should  be able to:
recognize and identify presenting symptoms and signs of gynecological cancers observe and assist in the diagnosis, management and counselling of women with common gynecological cancers observe and assist in the screening for papillomavirus, preclinical phases of invasive cervical carcinoma and management of those with positive results recognize and identify short and long term complications of surgery, chemotherapy and radiotherapy recognize,  identify and assist in the management of  endometrial hyperplasia classify and stage cervical, endometrial and ovarian carcinoma observe and assist in  palliative care observe and assist in   breaking the news of a cancer to  a woman and her family observe and assist in   counseling a patient with cancer and her family regarding a basic management plan and prognosis explain the importance of screening for cervical cancer explain the management plan to a woman who has a positive cervical smear test obtain consent from a woman undergoing surgery for a gynecological malignancy	evaluate the implications of diagnosis of a gynecological malignancy on a woman and her family empathize with a woman and her family  when a gynaecological malignancy is diagnosed counsel the woman and her family that the method of treatment decided upon, must be followed
Urogynecology and pelvic floor problems
Clinical Competence	Professionalism and Attitudes
The students should be able to:	The students should be able to:
obtain a relevant history from a woman with uterovaginal prolapse or urinary incontinence and carry out the examination recognize and identify common symptoms associated with uterovaginal prolapse recognize and identify clinical features of urinary tract infection, urodynamic stress incontinence and detrusor instability identify  the presence and degree of a uterovaginal prolapse and classify its   components explain the investigations and treatments in uterovaginal prolapse and urinary incontinence observe and assist in  investigations carried out in  women with urinary incontinence including urodynamics observe and assist in  management and counselling of women with uterovaginal prolapse, urinary incontinence and their untoward effects observe and assist in  Burch colposuspension, pelvic floor repair with and without hysterectomy and sling procedures observe and assist in nonsurgical  therapies in utero vaginal prolapse and urinary incontinence	identify the personal and social implications of urinary incontinence recognize the reluctance of women to discuss uterovaginal prolapse or urinary incontinence and their associated  issues empathize with women having these problems recognize and be able to identify major complications that could ensue from treatments for these problems
Clinical Training /Experiential Learning
Clinical Competence, Professionalism and Attitudes
The students will be able to:
‘role play’ as  house officers ,under supervision in  the  wards,  labour rooms, outpatient clinics, operation theaters of the Teaching Hospital ‘shadow’ house officers in their duties

 

Log Book

1. Demonstration  on a model :  

a)      different presentations and positions of the fetal head and the different presenting diameters

b)      mechanism of labour in different positions of the vertex                                          

c)      assisted vaginal breech delivery            

d)      management of shoulder dystocia      

e)      management of cord prolapse                     

1. Normal  deliveries                                           4
2. Suturing of episiotomies / perineal tears       4

 

N.B. * One  each of  Nos  : 2 & 3  must  be completed before commencing the Professorial Appointment

           Each item should be certified by the Clinical Supervisor. 

 Portfolio

1. Maintaining partograms                                                                                                                   4
2. Performing vaginal examinations in labour                                                                                        4
3. Performing amniotomy under supervision                                                                                         2
   1. Observing / assisting for supra cervical Foley Catheter insertions                                                                                               for ripening of cervix or induction of labour (IOL)                                               2
4. Observing / assisting for  IOL with vaginal prostaglandin                                                                  2
5. Observing / assisting for  IOL  or augmentation of labour with intravenous oxytocin infusions              2
6. Interpreting CTG                                                                                                                           3
7. Observing  / assisting  for instrumental vaginal  delivery                                                                   2
8. Observing / assisting  for management of a retained placenta                                                            2
9. Assisting for caesarean delivery                                                                                                          3
10. Assisting  for major gynae surgery                                                                                                       2
11. Assisting  for minor gynae surgery                                                                                                     2
12. Performing cross matching of blood and observing blood transfusions                                                    3
13. Insertion of IUCD under supervision                                                                                                    1
14. Gynae pelvic Examinations under supervision of senior staff:                                                                                                                                                           Speculum   2    +    Bimanual   2   +  Prolapse   2
15. Pelvic examination under anaesthesia after obtaining informed consent                                                   2
16. Foley Catheter insertions into urinary bladder                                                                                        2
17. Carrying  out cervical (Pap) smears                                                                                                      2 
18. Case summaries                                                                                  Obst     3     +                Gynae  3
19. Diagnosis cards                                               LSCS     3    +     Major Gynae   3       +    Minor Gynae   3
20. Operation notes                                              LSCS     3    +     Major Gynae   2       +    Minor Gynae    2
21. Reflective reports                                                                                                       Obst 3 + Gynae 3
22. Counseling under supervision                                                                                    Obst 2 + Gynae   2
23. Essays  ( Topics of student’s  choice = 1 each in Obst & Gynae.                                                                             Stipulated Topics = 1 each in Obst & Gynae)                                                                                        4

      N.B  * One each of Nos 1,2  7, 10, 13, 19 , 21 & 22  must  be completed                                                                              before commencing the Professorial  Appointment.

           Each item should be certified by the Clinical Supervisor.  

 

ASSESSMENT STRATEGY

 Formative Assessments

• Case presentations and CbD during the 1^st and 2^nd Clinical Appointments
• Assessments during ward rounds, BSTL and supervised clinical training,  during Professorial Appointment
• Assessment of individual tasks and group tasks assigned to students, online and face to face                                                                                                                                                     
• Log book and portfolio assessments , during the 3^rd week of the 2^nd clinical appointment, during the 5^th week of the Professorial Appointment   and within three days before  the end of the Professorial Appointment 
• Case Presentations, CbD, mini Clinical Evaluation Exercise and Direct Observation of Procedural Skills during Professorial Appointment                                                                                    

 Continuous (In Course)  Assessments 

• Objective Structured Clinical Examination (OSCE) within three days of commencement of the Professorial Appointment:  06 stations of 06 minutes duration each, on basic clinical skills and attitudes.    - 05 marks
• OSCE within three days before the end of the Professorial Appointment: 10 stations of 08 minutes duration each on core knowledge, skills and attitudes.                                                                                                - 15 marks

 Eligibility to appear for the End of Course Assessments (Final  MBBS Examination) 

• Satisfactory completion of 17 weeks of clinical appointments
• Satisfactory completion of log book and portfolio

 End of Course Assessments (Final  MBBS Examination)

• Written Paper I          (05 SEQ)                                                             02 hours         - 20 marks
• Written Paper II        (20 MTF type MCQ + 30 SBA)                              02 hours           - 20 marks
• Obstetric Case                                 20 mins. with patient, 20 mins. with examiners      - 20 marks
• Gynaecological Case                     20 mins. with patient, 20 mins. with examiners          - 20 marks
• Contribution from Continuous (In Course) Assessments                     05 + 15                 - 20 marks
• Total                                                                                                                       - 100 marks                                   

* SEQ= Structured Essay Question, MTF = Multiple True False, MCQ= Multiple Choice Questions, SBA = Single Best Answer

 The Continuous Assessment marks out of 20, will be considered only for the first attempt at the end of course assessment (Final MBBS Examination). For subsequent attempts the marks out of 80 will be converted to a mark out of 100

RECOMMENDED BOOKS

1)      Obstetrics by Ten Teachers 21^st Ed. International Students’ Edition. Louise E Kenny & Jennie E Myers Eds. CRC Press, Taylor & Francis Group (Students should download the 20^th Edition of 2017, which is available online, free of charge)

2)      Gynaecology by Ten Teachers 21^st Ed. International Students’ Edition. Helen Bickerstaff & Louise E Kenny Eds. CRC Press, Taylor & Francis Group (Students should download the 20^th Edition of 2017, which is available online, free of charge)

3)      Oxford Handbook of Obstetrics and Gynaecology 3^rd Edition 2016, Sally Collins, Sabaratnam Arulkumaran, Kevin Hayes, Simon Jackson & Lawrence Impey Eds. Oxford University Press. (New edition should  be available in 2022)

4)      Obstetric Emergencies – A Practical Manual. Sanjeewa Padumadasa and Malik Goonewardene Eds. CRC Press, Taylor & Francis Group 2021

5)      Basic Sciences for Obstetrics and Gynaecology. Core Materials for MRCOG Part 1. Austin Ugwumadu Ed. 2014. Oxford University Press (Students should download this, which is available online, free of charge )

 

 SUPPLEMENTARY  READING (OPTIONAL)

• Lees, C., Bourne, T., & Edmonds, K. (Eds.). Dewhurst’s Textbook of Obstetrics & Gynaecology (9th Ed., 2018). Wiley-Blackwell.
• Luesley, D. M., & Kilby, M. D. (Eds.). Obstetrics & Gynaecology: An Evidence-based Text for MRCOG (3rd Ed. 2016). CRC Press. Taylor & Francis Group.
• Nelson-Piercy, C. Handbook of Obstetric Medicine (6th Ed. 2020). CRC Press. Taylor & Francis Group.UK
• World health Organisation. WHO Guidelines and Recommendations. relevant to Obstetrics and Gynaecology. Latest Editions. Available from:  www.who.int
• International Federation of Gynaecology and Obstetrics. FIGO Guidelines and Statements. Latest Editions. Available from www.figo.org
• Royal College of Obstetricians and Gynaecologists. London. Guidelines and Research Services; Latest Editions. Available from: www.rcog.org.uk
• National Institute for Health and Care Excellence. Nice Clinical Guidelines relevant to Obstetrics and Gynaecology. Latest Editions. Available from: www.nice.org.uk
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RANZCOG Guidelines and Statements. Latest Editions. Available from: www.ranzcog.edu.au
• American College of Obstetricians and Gynaecologists. ACOG Clinical. Clinical Guidance and Committee Opinions. Latest Editions. Available from: www.acog.org.
• Sri Lanka College of Obstetricians and Gynaecologists. SLCOG Guidelines and Position Statements. Latest Editions. Available from www.slcog.lk