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OG19.3,OG35.{15-18,20},OG36.3 | Core Procedural Skills — PBL Case

CLINICAL SETTING

Mrs. Lakshmi Devi, a 30-year-old G3P2L2, presents to the gynaecology outpatient department of a district hospital requesting long-acting contraception. Her last delivery was 8 weeks ago — a normal vaginal delivery at term with a left mediolateral episiotomy. She has been counselled about IUD contraception and consents to CuT 380A insertion today. She has no current complaints. Her menstrual periods resumed 3 weeks ago and her last period ended 5 days ago. She has no prior STI history, no pelvic inflammatory disease, and no dyspareunia. Pelvic examination: uterus anteverted, normal size. Cervix appears healthy. The IUCD insertion is performed by a junior resident. Uterine sounding measures 7.5 cm. The device is loaded and insertion is attempted, but the resident encounters resistance at the internal os and applies additional force. The patient reports a sudden sharp pain at the moment of insertion, and the resident notes the inserter has advanced further than expected. No threads are visible at the cervix after the procedure.

Trigger 1: Immediate Post-Insertion Assessment

Following insertion, the patient is pale and sweating. Her pulse is 96 bpm, blood pressure 100/70 mmHg. She has constant lower abdominal pain. Speculum examination shows no IUCD strings visible at the external os. The resident reassures her that this is normal and asks her to return in 6 weeks for a follow-up. The patient is discharged. She presents to the casualty department 4 hours later with worsening abdominal pain, now 8/10 on the pain scale.

DISCUSSION POINTS

  • What complication has most likely occurred at the time of insertion, and what was the technical error that caused it?
  • What should the resident have done at the point when resistance was felt at the internal os and when no threads were visible after insertion?
  • Why were the vital sign changes at the time of insertion clinically significant? What immediate bedside assessment was required before discharge?
Click to reveal Trigger 2: Casualty Assessment and Investigation (discuss previous trigger first!)

Trigger 2: Casualty Assessment and Investigation

In casualty, Mrs. Lakshmi has generalised lower abdominal tenderness with guarding but no rigidity. Her pulse is 102 bpm, BP 98/66 mmHg. A pelvic ultrasound (TVUS) is performed: the uterine cavity is empty. No IUCD is seen within the uterine cavity. The right adnexa shows a hyperechoic structure adjacent to the right ovary. There is a small amount of free fluid in the pouch of Douglas. A plain abdominal X-ray is also requested.

DISCUSSION POINTS

  • What do the TVUS findings tell you about the position of the IUCD? What additional information does the plain X-ray provide that TVUS cannot?
  • What is the clinical significance of the free fluid in the pouch of Douglas in this context?
  • Describe the mechanism by which uterine perforation occurs during IUCD insertion — which specific steps in the insertion technique are most critical for prevention?
Click to reveal Trigger 3: Surgical Decision-Making (discuss previous trigger first!)

Trigger 3: Surgical Decision-Making

The plain X-ray confirms a CuT 380A within the peritoneal cavity in the right iliac fossa. The surgical team is consulted. On examination under anaesthesia, the uterine perforation site is at the right cornua. The IUCD is retrieved laparoscopically from near the right fallopian tube. The perforation is a small serosal rent requiring no suture repair. Mrs. Lakshmi recovers well. On the ward the following day, she asks: 'Can I have another IUCD now that this has healed? And I also want to know — is my episiotomy scar normal? I feel a hard lump in the perineum.'

DISCUSSION POINTS

  • When (if ever) can an IUCD be re-inserted after a uterine perforation, and what counselling is required?
  • Perineal examination reveals a tender 2 cm firm nodule in the scar of the episiotomy. What are the differential diagnoses for a firm, tender perineal scar nodule at 8 weeks post-episiotomy, and what is the most likely diagnosis?
  • What are the criteria for considering a patient for tubal ligation (permanent contraception) rather than long-acting reversible contraception, and how would you counsel Mrs. Lakshmi about this option?
Click to reveal Trigger 4: Cervical Screening Backlog (discuss previous trigger first!)

Trigger 4: Cervical Screening Backlog

While reviewing Mrs. Lakshmi's records for the ward round, the team notices she has never had a Pap smear. She is 30 years old, married since age 19, G3P2. In the district she lives in, there is no organised screening programme — women only present for Pap smears if referred for symptoms. The junior team debates whether to perform a Pap smear before discharge, noting that the cervix was inflamed-appearing on speculum examination.

DISCUSSION POINTS

  • Is Mrs. Lakshmi a suitable candidate for a Pap smear today, given the recent uterine perforation, procedure, and her inflamed cervix? What are the prerequisites before performing cervical cytology?
  • The team debates conventional Pap smear vs liquid-based cytology. What are the key differences in technique, adequacy reporting, and transport between the two methods?
  • How would you explain the purpose and importance of cervical cancer screening to an under-screened rural patient like Mrs. Lakshmi in language she can understand?
Click to reveal Trigger 5: Quality Improvement and System Review (discuss previous trigger first!)

Trigger 5: Quality Improvement and System Review

A week after Mrs. Lakshmi's discharge, the department head reviews the case as a critical incident. She notes that this is the second uterine perforation during IUCD insertion by junior residents in six months. The department needs to develop a formal competency framework and checklist for IUCD insertion, and to design a simulation-based training programme before residents perform the procedure on patients.

DISCUSSION POINTS

  • Design a 10-point procedural safety checklist for IUCD insertion that would have prevented the errors in Mrs. Lakshmi's case. Specify what each checkpoint verifies.
  • What simulation models and task trainers are available for IUCD insertion and other pelvic procedures, and what does research evidence say about the transfer of simulation-trained skills to supervised clinical performance?
  • The NMC competency OG19.3 specifies 'observe/assist' for tubal ligation. Discuss why a permanent procedure such as tubal ligation is deliberately placed at the observe level while IUD insertion (OG35.18) is at the 'skill' level — and what principles guide the NMC's competency level assignments for irreversible vs reversible procedures.

Group Task Assignments

  • Map Mrs. Lakshmi's entire clinical journey and identify the decision points where correct procedure would have changed the outcome.
  • Develop a departmental protocol for the immediate management of suspected uterine perforation during IUCD insertion — covering intraoperative recognition, initial stabilisation, investigation, and escalation criteria.
  • Create a patient-facing information leaflet about CuT 380A insertion, explaining the procedure, expected sensations, warning symptoms requiring urgent return, and follow-up schedule — at a literacy level appropriate for a rural Indian patient.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG35.18] What are the step-by-step safety checkpoints during IUCD insertion that prevent perforation, and what should the inserting clinician do when resistance is felt at the internal os?
  2. [OG35.18] How is uterine perforation recognised immediately post-insertion, and what is the investigation and management pathway for a perforated IUCD?
  3. [OG35.17] What are the causes of a tender firm nodule in an episiotomy scar, and how is each differentiated clinically?
  4. [OG35.15] What are the prerequisites (patient factors and cervical conditions) that must be met before performing a Pap smear, and what makes the conventional vs LBC technique different in practice?
  5. [OG19.3] What is the evidence base for 'observe/assist' as the NMC competency level for tubal ligation, and how does permanent vs reversible status affect procedural learning level assignment?
  6. [OG35.16] What is the complete pathway of cord prolapse following ARM — from predisposing factors through recognition to immediate management?