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OBSTETRICS AND GYNAECOLOGY

Richard Shaw

Obstetric and Gynaecological History


Formalities
Wash Hands
Introduction - name, age, consent, confidentiality
History of Presenting Complaint
Open Questioning SOCRATES and specific
differential questioning.
o Associated Symptoms
screen for bladder/bowel issues,
vaginal or other orifice discharges
screen for depression (sadness
etc)
Current Pregnancy
o Duration
LMP and EDD from USS
Ngele's Rule: +1 yr, +7d, -3m
How/When did you find out?
o Symptoms
Abnormal
Per vaginal bleeding,
pain/cramps,
dyspareunia
Normal
Fatigue, nausea, vomiting,
urinary frequency, breast
tenderness, constipation,
fluid retention, backache,
weight gain, cravings,
fetal movements after
20w
o Antenatal Care (See Antenatal Visit
Specifics)
USS
18w morphology scan
Vaccinations
MMR
Varicella
Screening Test
Antenatal blood tests
Nuchal Translucency
CVS
Amniocentesis
o Partner
Do you have a partner?
Are they the father?
Was the pregnancy planned?
Was it conceived naturally?
Plans for the future?
Risk Factor Questioning
Specific risk factors to help DDx
Smoking, Alcohol, IDU etc

Menstrual History
Cycle
o Typical cycle length
o Regularity of cycles 21-35d
Bleeding
o 1st day of LMP and duration of menses
3-7d
o Flow
No. pads/tampons used in a day
4/5
Ever needed to double-up?
>80mL/period = heavy
Any flooding or clots?
Post-coital or intermenstrual
bleeding?
Menarche/Menopause ?ranges?
Associated Symptoms
o Primary vs Secondary Dysmenorrhoea
(timing)
o PMS
Obstetric History
Gravidity and Parity (= births >20/52)
o When were these pregnancies?
o Gestations (TermPremAbortLiving/GxPx systems)
o Fetal Outcomes
Ectopics, miscarriages (gestation
at miscarriage) , terminations,
normal birth
o Length of labour
Induced or spontaneous
o Delivery types and fetal presentations
o Sex and birthweight of babies
o Complications (ante, peri, postnatally)
Bleeding, infection, other?
Sexual History
Initial framing question - why and consent.
Are you sexually active?
o No have you ever been sexually active?
o Yes How long have you been sexually
active for? When did you last have a sexual
encounter with someone?
Practices
o Oral, Anal, Vaginal?
o Who does what? Insertive/Receptive,
Ejaculation?
o Do you have sex with men, women or both?
Partner
o Regular or casual?
type of relationship and duration
o Male or female partner? Similar symptoms?

OBSTETRICS AND GYNAECOLOGY


Partner risk assessment
Ethnicity, IDU, Sex workers?
o How many sexual partners have you had
in last 12 months? Male/Female/Both?
o Any sex worker/overseas local contact?
Travel?
o Are you happy with your relationship?
Protection from Pregnancy
o Are you using any form of protection or
contraception?
o Condom
% of times used
When is it put on/taken off?
When did you last have sex
without one?
o Contraceptive devices or medications?
o Are you concerned about getting
pregnant/your partner pregnant?*
o When did you last have unprotected sex?
Protection from STI's
o Have you or your partners ever had an STI?
When? Diagnosis? Treatment?
Partner?
o Ever been screened for HIV or other STIs?
Would you like to be screened?
o Have you or your partners ever injected
drugs?
o Vaccinations? Hep B, HPV, Hep A (for MSM
only)
Is there anything about your current sex life you
are concerned about?
Have you ever been sexually abused or the subject
of domestic violence?
Gynaecological History
Contraception
o Type of contraceptive being taken and
why?
o Are you happy with your current
contraception?
o Planning on having a family in the future?
o COCP
Type/brand, dose
Variation in times taken.
Frequency of missed pills
S/E's and physiological impacts
STIs (5th P of the 5 P's of Sexual History)
o Gonorrhoea, Chlamydia, Syphilis, HIV,
Herpes, HPV, Hepatitis
PIDs
o Salpingitis, endometritis
o

Richard Shaw

Others
o UTIs, Vaginitis, Vulval Dermatitis, Fibroids
etc
Pap Smears
o Last pap smear results
Past Medical/Surgical History
Any surgeries? Gynaecological/Pelvic or otherwise?
Ever required a blood transfusion?
Weight gain/loss?, thyroid disease, epilepsy
DVT, ID-DM, Lung and Heart Disease, H/T,
Jaundice
Medications and Allergies
Drugs
o Prescribed drugs?
o Over the counter drugs?
o Herbs/supplements?
OCP/HRT
Allergies/Drug Allergies
o Penicillin? Latex?
Family History
Any conditions that run in the family?
o Endometriosis, PCOS,
cervical/ovarian/breast/colon cancer
o DM, DVT, H/T, Heart and Lung disease
o Twins in the family?
Timing of menopause in family members if
relevant
Osteoporosis, hirsutism etc as relevant
Psychosocial History
Drugs
o Smoking, Alcohol, Recreational Drugs
Home Supports
o Is there anyone at home to support you?
o Where do you live and what type of
accommodation is it?
o Childcare arrangements?
o Plans for breastfeeding?
Relationship
o Stability?
Education/Employment/Financial WHACS
ADLs and other activities
o Sleep, appetite, micturition, defecation
Exercise/Diet/Community Activities/Other

OBSTETRICS AND GYNAECOLOGY

Richard Shaw

Obstetric and Gynaecological Examinations


Gynaecological Examination

Explain why you want to perform this examination.


Explain what this examination will involve.
Questions to ask beforehand:
o Have you ever had this examination done before?
o Are you currently pregnant?

Can't use brush or combi


o Are you currently on your period?

Makes PV examination difficult


o Have you had any children? Were they vaginal
births?

Alters method of speculum insertion


Would you like someone else to be in the room during the
examination? A chaperone.
Ideally would also ask patient to empty bladder and
bowels beforehand more comfortable examination.
Ensure all equipment is present before starting:
o Speculum
o KY Jelly
o Swabs/Cervical Samplers

Broom and Brush (or Combi)

Brush/Combi not for pregnant women


o Slides and Fixation Spray

Appropriate details must be written on


slide in pencil before beginning
o Lighting
o Gloves

Position and Exposure

Allow patient to undress and put on gown in privacy and


ensure there are plenty of sheets.
Patient supine with legs apart, ankles together and knees
bent (frog-legged position).
Perineum should be brightly illuminated with a lamp.

General Inspection

Mentally alert and orientated


Respiratory distress and/or anxiety

Abdomen (ideally full abdominal examination)


Inspection

Skin quality

Abdominal distension and masses

Scars and Striae

Palpation
Is there pain anywhere in your abdomen? Palpate this area last.

Light Palpation

Deep Palpation

Liver

Spleen
Put on gloves, and re-explain to patient what you intend to do.

Pelvis
Inspection

Pubic hair distribution

Normal anatomy features


o Labia majora
o Labia minora
o Vaginal and urethral openings discharges?

Blood discharge

Menses, cancer, miscarriage,


cervical polyp or erosion

Purulent discharge

Vaginitis, cervicitis,
endometritis, retained
tampon

Physiological discharge

If discharge present, inspect/describe


it, swab it and seal in container.
o Clitoral shape and size

Skin lesions
o Features of thrush or trichomoniasis

Leukoplakia

Redness

Swelling

Excoriation
o Ulceration
o Rashes
o Warts
o Scars
o Sinus openings

Vaginal atrophy (elderly)


Palpation

External genitalia
o Tenderness,
o Lumps and bumps

Bartholin cyst or Abscess

Separate labia and palpate


in posterior part of L. majora

Cough Test
o Stress incontinence
o Cystocoele bulge from anterior
o Rectocoele blge from posterior
o Uterine Prolapse

Cervix (tell patient what you intend to do)


o Put KY Jelly on right index and middle finger
o Separate labia with thumb and forefinger of left
hand and insert right fingers into vagina

OBSTETRICS AND GYNAECOLOGY


o
o

o
o

Position (which way cervix is pointing)

Post (normal), ant or central


Consistency/Surface(nose in nulliparous)

Hard, soft or lumpy

Nabothian cysts
Size, Shape, Mobility
Tenderness

Tactile tenderness

Excitation tenderness

Tender when moved around


External Os

Dilatation/effacement

Fornices
o Anterior, posterior and lateral
Uterus
o Fingers in vagina are kept high up and rotated
to face upwards while left hand presses/rocks
above symphysis (perpendicular to linea alba)
o Fundal height
o Tenderness

Period Pain

Adenomyosis
o Position

Angle between cervix and vagina

Anteversion

Most women, where the


uterus lies on top of the
bladder, pointing
posteroinferiorly

Axial

Uterine lumen is parallel to


vaginal lumen

Retroversion

Majority of uterus lies in


uterorectal pouch rather
than overlying the bladder
o Flexion

Angle between uterine lumen and


cervical canal

Retroflexion

Distal uterus is in normal


position (cervix pointing
posteroinferiorly) but the
body is bent backwards
occupying uterorectal pouch

Anteflexion

Distal portion of uterus is in


normal position but fundus
points anteriorly and
inferiorly. Normal position
o Size

Conveyed as a gravid uterus in weeks


of pregnancy (e.g. 18 week uterus)

Normal size is approximately a fist


o Shape/Surface

Smooth and enlarged

Pregnancy

o
o

Richard Shaw

Adenomyosis

Submucous fibroids

Knobbly

Fibroids
Consistency

Soft pregnancy

Hard fibroids
Mobility

due to adhesions
Masses

Uterine masses move with cervix and


adnexal masses do not

Adnexa
o Turn fingers laterally to each side in turn and
bimanually palpate with left hand
o Attempt to feel for

Fallopian tubes

Broad ligament

Adnexal masses or tenderness


o Ask about tenderness/pain
Withdraw fingers and observe glove for any discharge (+/- smell for
distinctly pungent odour)

Speculum Examination

Warm speculum with warm water during abdominal


examination check temperature on skin

KY jelly can be used but may interfere with some cytology


examinations

Hold speculum with gun grip (handle facing up) and stand
on the right side of the patient - touch speculum to
fourchette (talk to patient the whole way through)

Spread labia with left hand and insert speculum


o Nulliparous - bills parallel to labia
o Multiparous - maybe perpendicular to labia

Turn handle towards ceiling with insertion


o Resistance before complete insertion reached
flexion of vagina as it passes through the pelvic
diaphragm angle speculum more posteriorly

(Warn patient) Open speculum with left hand, visualise


the cervix and lock nut with right hand
Inspection

Vagina

Cervix
o Parity

Nulliparous dot or circle

Multiparous curved line


Pap Smear

Important to get cells samples from


o External cervix (preferably transformation zone)
o Endocervical cells

Remember Pap smear ideal at detected precancerous cells


and cervical cancer detecting sensitivity is only 50%

Do not use brush or combi on a pregnant women


o May rupture the fetal membranes and cause
miscarriage or premature birth

OBSTETRICS AND GYNAECOLOGY

Ensure appropriate details have been written on slide in


pencil beforehand.
With each device:
o Rotate through 360 at the squamous-columnar
junction (transitional zone)
o Remove and sweep across slide twice (one swipe
on each side) (brush roll)
o Fix slide with fixant spray
o If available, put the brush into a thin prep or
short prep container also good when there is
bleeding or discharge
Speculum removal
o Loosen nut
o Keep bill open initially to prevent closure over
the cervix
o Once again rotate the bills back to parallel with
the labia when exiting the introitus

Obstetric Examination
General Inspection

Distress of mother?

Obese

BMI (e.g. height and weight)


BP, HR, Temp.
UA
FHR/CTG

Fetal Movements

Has the baby been moving normally?


o Starts at 18-20 weeks in nulliparous women and
15-17 weeks in multiparous women.

Movements reduce after 36 weeks but should still be


investigated maternal kick chart
Abdominal

Inspection
o Striae
o Linea alba
o Scars

Palpation
o Fundal height (need to know gestation from Hx)

Fundus to pubic symphysis

Most important is increasing height on


serial measurement (until engagement)

12/52 fundus just palpable above


pubic symphysis

20/52 fundus at umbilicus

General rule fundal height is


gestation in weeks from LMP

20-36 weeks +/- 2cm

36-40 weeks +/- 3cm

40 weeks +/- 4cm


o Lie

Relation of fetal long axis to maternal


long axis

Richard Shaw

Left occipito-anterior is most common


position and lie
Longitudinal, Oblique (fetal head in
iliac fossa, usually due to full bladder)
or Transverse

Presentation (Palpable after 26 weeks)


o Fetal part occupying lower segment/pelvis
o Cephalic

Further subdivided by attitude


relationship of fetal head to spine
flexed (best), neutral, extended
o Breech (4%)
Engagement
o "fifths palpable" fraction out of 5
o The fetal head can be palpated bimanually

Both hands placed on imaginary line


between the two ASIS with fingers
pointed inferiorly and medially

Then "ballot" the head between hands


o Usually palpable after 37 weeks
Amniotic Fluid
o "Ballot" the amnion between hands and feel
how tense it is (hands like oven mits)
o Abnormality suspected use USS
o Excess fluid polyhydramnios
o Insufficient fluid oligohydramnios
Uterine Irritability
o Same technique as amniotic fluid palpation but
fingers spread sensitivity to uterine
contractions often an abnormal finding
o Intrauterine growth restriction
Fetal Heart Sounds
o Using Dopper device/Pinar stethoscope
o Like a horse galloping and not the "whooshing"
noise of placental blood flow
o Palpate maternal radial pulse to confirm that
HR found is different to maternal HR
o Fetal HR may undergo decelerations in:

Squeezing of cord

Hypoxia

Cephalic pressure during labour


o Best found over anterior shoulder of fetus

OBSTETRICS AND GYNAECOLOGY

Speculum Examination
Vaginal Examination

Dilatation

Effacement

Position
o Occiput in relation to maternal pelvis
o Assists with finding best location to listen for
fetal heart sounds (over anterior shoulder)

Station
o Level of presenting part in relation to maternal
ischial spines

Bishops Score
o <7 not favourable
o > or = 7 favourable

Richard Shaw

OBSTETRICS AND GYNAECOLOGY


In Addition

Cardiovascular Examination

Respiratory Examination

Breast Examination

Lymph Nodes Examination

Skin Examination
o Oedema
o Spider angioma
o Striae
o Linea nigra

Other examinations as directed by the history


o Oedema of legs
o Reflexes
o Clonus
o Signs of anaemia

Post Partum Assessment


Initial Questioning

What day post partum?

Mode of delivery:
o Caesarean
o Vaginal
o Instrumental

Any perineal trauma sustained at birth?

Passing urine?

Bowels/flatus?

Lochia (PV discharge)


o Blood, mucus, placental tissue
Breasts

Breast or bottle feeding?

Tenderness/redness/cracked nipples?

Educate on mastitis
Antenatal Card

Blood pressure - need BP check with GP

Abnormal LFTs - need repeat

Diabetes - need 75g GTT at 6/52

Ensure appropriate follow-up on discharge

Blood Group
o Does she need anti-D?

Rubella Immunity
o Does she need MMR?
Pap Smear

If not done in past 2 years, need to see GP at 6 weeks


Contraception

Ask about plans

Give options if unsure

Arrange if concerned about patient following up (e.g.


young, multiple unplanned pregnancies)

Can start hormonal contraception ~3-6 weeks post


partum
Examination

BP

Fundus
o Should be firm and below umbilicus
o Perineum if suturing

If 3rd/4th degree tearing, need


referral to pelvic floor clinic
Anything else relevant on history (e.g. complaint of sore
calf muscles)

Richard Shaw