01 history and examination dr isameldin

Dr. Isameldin Elamin MD DOWH MBBS
Assistant professor
Obstetrics & Gynaecology department

 By the end of this lecture the student should
be able to:
 Take a detailed obstetric and gynaecological
history.
 Describe how to conduct obstetrical and
gynaecological examination.
 Describe how to conduct digital and speculum
pelvic examination.
3/4/2016dr isameldin 2

History in Obstetrics and gynaecology:
 Sensitive topics.
 Sensitive area.
 Sensitive information.
History taking needs to:
 Build a good rapport with the woman.
 Closed room with adequate facilities and
privacy.

 At a booking visit, the history.
must be thorough and meticulously
recorded.
 Ask yourself what you need to achieve.
 Ask why the patient has attended. (May be
routine visit).
 Make sure that the patient is comfortable.

 Polite when talking to the patient.
 Good listener.
 Non judgmental.
 Appearance is suitable before you enter the
room.
 Introduce yourself.
 Tell why you have come to see them.

 Name.
 Age.
 Occupation.
 Marital status.
 Residence.
 Education.
 Booking status.

 Duration of marriage.
 Name of the husband.
 Age of husband.
 Consanguinity.
 Make a note of ethnic background.

 Presenting complaint.
 Details of the presenting problem.
 Reason for attendance if no complaints.
 Write in the patient's own words.

 Arrange in order of occurrence.
 eg:
 1-vomiting / today.
 2-abdominal pain / 2days.
 3-fatigue / 3days.

 Vaginal bleeding.
 Gush of fluid per vaginum.
 Abdominal pain.
 Persistent headache.
 Blurring of vision.
 Edema of hands or face.
 Persistent vomiting.
 Diminished or absent fetal movements.

 Gestational age:
 last menstrual period (LMP) or estimated
date of delivery (EDD)
 Pregnancy duration is 280 days (40 weeks).
 Add 9 month and 7days (14 Arabic) to
calculate EDD. (Naegele`s rule need 28 day
cycle).

 Dates can be calculated from ultrasound before
20 weeks by:
 The crown–rump length is used up until 13
weeks 6 days.
 Head circumference from 14 to 20 weeks.
 After 20 weeks, variability of growth makes
it unsuitable.

 Accurate EDD is important because:
 Serum screening for down’s syndrome.
 Induction of labour for post-dates pregnancy.

 What action has been taken?
Is there a plan for the rest of the
pregnancy?
 What are the patient’s main concerns?
 Have there been any other problems in
this pregnancy?

 First trimester
 Morning sickness.
 Bleeding, pain, discharge.
 Drugs , radiation, febrile illnesses.
 Second trimester:
 Bleeding, pain, discharge, UTI.
 Edema.
 Quickening.

 Bleeding, pain, discharge.
 Fetal movement.
 Symptoms of labour.
 Febrile illnesses.

 Vaccination.
 Ultrasound
 What scans have been performed?
 Why?
 Were any problems identified?

 Gravida – G:
 is the total number of pregnancies regardless
of how they ended.
 Parity – P:
 is the number of live births at any gestation or
stillbirths after 24 weeks.
 In terms of parity, twins count as two.
 (Ten teacher s,19th edition).

 Williams reference:
 Parity is the number of pregnancy reaching
viability, so In terms of parity, twins count as
one.
 G2P1A0L2.(twins in first pregnancy)
 So we consider this in our college.

 Gravida 1, parity 0 A0
 Gravida 2, parity 2A0 (twins).
 Gravida 8, parity 1A6 (abortion 6).
 G8 P1 A6L1 GA 25 weeks.

 Outcome of each pregnancy.
 When.
 G.A.
 Weight.
 Sex.
 Alive or dead now.
 Recurrent miscarriage .

 Fetal growth restriction (FGR).
 Preterm delivery.
 Pre-eclampsia .
 Abruption.
 Congenital abnormality .
 Macrosomic baby.
 Unexplained stillbirth.

 Method of delivery of previous pregnancies
and complications:
 Caesarean section.
 difficult vaginal delivery.
 postpartum haemorrhage.
 significant perineal trauma.
 Breast feeding.

 Periods: menarche, regularity.
 Contraceptive history.
 Previous infections and their treatment.
 When was the last cervical smear? Was
it normal?

 Previous gynaecological surgery.
 Previous ectopic pregnancy.
 Recurrent miscarriage.
 Previous history of sub-fertility and IVF.

 Relevant medical problems:
 Diabetes mellitus.
 Hypertension.
 Bronchial asthma.
 Renal disease.
 Epilepsy.

 Venous thromboembolic disease.
 Sickle cell anaemia.
 Human immunodeficiency virus (HIV)
infection.
 Connective tissue diseases.
 Myasthenia gravis/ myotonic dystrophy.

 Any previous operations.
 Psychiatric history:
 Postpartum blues or depression.
 Depression unrelated to pregnancy.
 Major psychiatric illness.
 Domestic violence.

 Enquiry of other systems.(Systemic review).
 CNS
 RS
 CVS
 GIS
 MUSCLOSKELETALS

 Diabetes, hypertension, genetic problems,
psychiatric problems, etc.
 Thromboembolic disease.
 Pre-eclampsia .
 Congenital abnormality .
 Haemoglobinopathies.
 Tuberculosis.

Multiple pregnancy.
Congenital anomalies.
Cancers (e.g.. Breast).
 Allergies.

 Smoking/alcohol/drugs/ Khat.
 Housing.
 Occupation, partner’s occupation.
 Who is available to help at home?
 Are there any housing problems?

 All medication including over-the-counter
medication.
 Folate supplementation.
 Any regular medications.
 Allergies:
 To what?
 What problems do they cause?

 The history should be summarized in one to two
sentences
 Example:
 MRS X 34 years old teacher G5P3A1 GA 37
weeks with previous C/S known hypertensive
admitted for control of BP.
 Age.
 G_ p_ +_
 GA
 Any chronic condition.
 Cause of admission.

 Principles of infection reduction.
 Remove any wrist watches or rings with
stones.
 Bare arms from the elbow down.
 Wash hands or use gel before and after any
patient contact.

 Maternal weight and height:
 Calculate body mass index BMI. [Weight
(kg)/height (m2)].
 Risk for BMI <20 >30.

 Hypertension diagnosed >140/90 mmHg on
two separate occasions at least 4 hours
apart),
 Measured woman seated or semi-recumbent.
 Use an appropriately sized cuff.
 Use Korotkoff v, (disappearance of sounds).

 Women presenting for a routine visit there is
little benefit in a full formal physical
examination.
 Examine:
 Inspect when enter for gait height etc.
 Eye, tongue, Teeth palm etc.
 Neck, Thyroid often palpable.

 Cardiovascular examination:
 In asymptomatic women with no cardiac history is
unnecessary.
 Flow murmurs can be heard in approximately 80 per
cent of women at the end of the first trimester.
 Breast examination:
 Formal breast examination is not necessary.

 Inspection
 Shape of the uterus
 Asymmetry.
 Fetal movements.
 Scars.
 Striae gravidarum.
 Linea Nigra.

 Palpation: (deep and superficial)
 Symphysis–fundal height measurement.
 Measure SFH and plot on an SFH chart.
 In late third trimester SFH the fundal height is
2 cm less than the number of weeks.

Symphysis–fundal height measurement.

 Fetal lie, presentation and engagement.
 Palpate to count the number of fetal poles.
For multiple pregnancy.
 Lie: longitudinal, oblique or transverse

 The presentation:
 is the part of the fetus in the lower pole of the
uterus overlying the pelvic brim (cephalic,
breech).
 The lie of the fetus:
 is the relation of the long axis of the fetus to the
uterus (could be longitudinal, oblique or
transverse. Only longitudinal lie is normal)

 The attitude:
 is the posture of the fetus (flexion, deflexion,
extension)
 Position:
 the position of the fetal presenting part in the
maternal pelvis in relation to the denominator.

 Denominator are:
 Occiput in vertex presentation
 Sacrum in breech presentation
 Mentum in face presentation
 (e.g. Occipitoanterior, sacroposterior).

 Station:
 is the relation of the presenting part to the ischial
spine. If the presenting part is at the level of
ischial spine, station =0
 Engagement:
 the descent of the biparietal diameter through
pelvic brim. If the head is at the level of ischial
spine the head must be engaged.

 Fundal grip:
 Palpate the fundus (to determine if it contains
breech or head)
 By gentle pressure If breech:
 soft consistency, indefinite, outline
 If head, it is hard, smooth, well defined,
palatable.

 Mobility to differentiate between head and
breech:
 move your fingertips over the fetal mass to
determine.
 If moves freely between fingertips it is the head
 If can’t move independent from the body it is the the
breech.

Lateral Palpation (B): (determine the position of
the fetal back and small parts)

Pelvic palpation (C): 2 maneuvers
Pawlik's manoeuvre, or 1st pelvic grip

2nd pelvic grip for engagement

 Using a two-hand, and watching the woman’s
face, gently feel for the presenting part.
 The head is generally much firmer than the
bottom.

 Assess for engagement.
 5/5th palpable means head not engaged.
 1/5th or 2/5th palpable means head engaged.
 The fetal position:
 Occipito-posterior, lateral or anterior.
 Position is Important when labour begins.

 Fetal heart beat by hand-held device or
Pinard stethoscope.
 Best position is over the fetal shoulder.

 Digital or speculum.
 Consent.
 Female chaperone should be present.
 It is necessary in:
 Excessive or offensive discharge.
 Vaginal bleeding.
 To perform a cervical smear.
 To confirm rupture of membranes.

 To assess the cervix.
 It provide information about:
 Dilation of cervix.
 Position.
 Station of presenting part.
 Consistency of cervix..
 Length of cervix. (Effacement).

 Introduce two fingers into the vagina.
 Bishop score can be calculated.

 Oedema of the extremities.
 Facial oedema.
 Assess reflexes in pre-eclampsia.
 Fundoscopy in hypertension and in
severe pre-eclampsia.

Gynaecological History And Examination

 Same like in obstetrics History.

 (Patient’s own words).
 History of presenting complaint e.g:
 Menstrual problems.
 Pain.
 Subfertility.
 Urinary incontinence.

 Age of menarche.
 Duration of period and length of cycle. (5/28).
 First day of the last period LMP.
 Pattern of bleeding: regular or irregular.
 Amount of blood loss.
 Any inter-menstrual or post-coital bleeding.
 Any pain relating to the period.
 Any medication taken.

 Site, nature, severity.
 Aggravating or relieving factors.
 Relationship to menstrual cycle and
intercourse,
 Radiation.
 Association with bowel or bladder functions.

 Amount, colour, odour, presence of blood
 Relationship to the menstrual cycle
 History of sexually transmitted diseases
(STDS).
 Vaginal dryness (post-menopausal).

 The type of contraception.
 Sexual history:
 Availability of husband.
 Frequency of intercourse.
 Difficulties or pain during intercourse.
 Post coital bleeding.

 Last smear.
 Previous abnormalities
 Menopause (where relevant).
 Date of last period.
 Post-menopausal bleeding.
 Menopausal symptoms.

 Gynaecological history:
 Previous gynaecological history.
 Previous gynaecological treatments or surgery.
 Previous obstetric history:
 Number of children.
 Number of miscarriages.
 All details of pregnancy out comes.

 Previous medical history.
 Family history.
 Enquiry of other systems.(Systemic
review).
 Social history.

 Patient’s consent should be taken.
 Chaperone should be present,
 Watch patient walking into the
examination room.

 Examining the hands and mucous
membranes The supraclavicular area for
Virchow's node (Troissier’s sign).
 The thyroid gland.
 The chest and breasts.
 A general neurological assessment.

 Empty the bladder.
 Patient should be comfortable.
 Lying semi-recumbent.
 Cover patient with a sheet.
 Comprises:
 Inspection.
 Palpation.
 Percussion.
 Auscultation.

 Inspect :
 The contour of the abdomen.
 Distension or mass.
 Surgical scars.
 Dilated veins.
 Striae gravidarum.
 Laparoscopy scars .
 pfannestiel scars.
 Hernias.

 Superficial and deep.
 Area of pain should be examined at the end of
palpation.(soft)
 Palpate 4 quadrant of abdomen.
 Palpate for masses.(deep) the liver, spleen and kidneys.
 Mass can not palpate below it, it is pelvic in origin.
 Look for signs of peritoneum, i.e. Guarding and rebound
tenderness.
Examined for inguinal hernias and lymph nodes.

 Percussion is particularly useful if free fluid is
suspected.
 Look for :
 Dullness in the flanks.
 Shifting dullness’.
 A fluid thrill.
 Aware full bladder is dull due to urinary retention.

 Auscultate for bowel sounds in:
 Bowel obstruction.
 Postoperative patient with ileus.

 Obtain verbal consent.
 Female chaperone should be present.
 Empty the bladder.
 Inspection.
 Good light
 Correct position
inspect the external genitalia and surrounding skin.
 Look for:
 Prolapse
 Sign of stress incontinence.

 Using a bi-valve or Cusco's speculum.
 Has a retaining screw.
 Used for smear or swab.
 A Sim’s speculum.
 Used for prolapse.
 Warm the speculum.
 Use water as lubricant for smear.

 Done to assess the pelvic organs.
 Part labia with left hand.
 Insert one or two fingers of the right hand
into the vagina.
 Palpated cervix.
 Place the left hand on the abdomen.
 Palpate the fundus of the uterus.

 Place the tips of the fingers in the lateral fornix.
 Palpate for adenexa (tubes and ovaries).
 Pushing down with the fingers of the abdominal
hand.
 Look for:
 Swelling or tenderness.
 Palpate the posterior fornix. (Endometriosis).

 Can be used in:
 children.
 Adults who have never had sex.
 Less sensitive than a vaginal.
 Uncomfortable.
 Can detect a pelvic mass.
 Recto vaginal examination may be useful.

 Pass this information to others in a clear and
concise format.
 Summarize positive findings.
 Consider situation.
 Busy ward round.
 Examination.
 Be aware of sensitive information.

 Gynaecology by ten teachers 19 editions.
 Obstetrics by ten teachers 19 editions.
 Oxford hand book of obstetrics and
gynaecology
 http://www.uptodate.com.
 Appendix:
 1-history template obstetric page 14.
 2-history template of gynaecology page2.

01 history and examination dr isameldin

01 history and examination dr isameldin

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