HISTORY TAKING AND PHYSICAL

EXAMINATION

OBS/GYN

Dr Matovelo Dismas
CUHAS/BMC
 Objectives
• At the end of this course;
– a student will be able to take a thorough
gynaecological/ obstetric history.
– the student will demonstrate ability to perform
physical examination by using simulated model
and role play.

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 Overview
Taking obs/ gyn history can at first be difficult as
you are asking very personal questions, which
sometimes patients are uncomfortable to talk
about

Fear of embarrassment (both yourself and the

patient) however should not stop you from asking
necessary questions

The more histories that you take, the easier it

becomes and more at ease

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Obstetric History
 Introduction
Name

Age
Occupation-This would give us an idea of the social class of the
patient

Gravidity: Number of pregnancies regardless of how they ended

Parity: Number of deliveries

Gestation Age-Preferably in weeks

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 Last Normal Menstrual Period, LNMP-First day
of the last menstruation
EDD-Expected date of delivery by:-
Naegele’s rule
• EDD= LNMP + 7days – 3 months (or + 9
months) for regular 28 days cycle
Ultrasound-BPD,AC,FL
Gestational wheel
??FH
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 Chief complaints
Chief Complaint(s)-Duration

It is important to ask as open a question as

possible in this part of the history and to ensure
the complaint is understood

Problem must be listed in priority if there are

multiple problems and explained adequately
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 History of Presenting Illnesses
May have the following structure:-
 Onset
 Rate of progression
 Severity
 Aggravating Factors
 Relieving factors
 Associated factors
 Explore the causes and R/O other possible causes
 Explore possible complications
 Treatment used & diagnostic investigations
done/planned and the results
 Fetal status –fetal movements, draining etc
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 Review of systems
• This will uncover seemingly (to the patient)
unrelated aspects of her health
– Cardiovascular
– Respiratory
– CNS
– GIT
– GUS
– ENT
– Musculoskeletal

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 Index Pregnancy
Gestation age at booking
Number of check up attended- where?
eventful?
Enquire for:-
Physical-Bwt, Ht, BP
Investigations done- HB, ABO, Rh, VDRL, HIV
Preventive/Treatment measures-TT
vaccination, IPT-SP, deworming, Iron supp,
Folic acid
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 Past Obstetric History
• Previous pregnancy (first to last)
• Mode of delivery-SVD, Induction of labor, CS
• Alive or Dead?
• Term of pregnancy-pre, term, post
• Termination- ie abortion
• Place of delivery
• Complication-mother?(before, during and after
delivery)Child ?
• Singleton? Twins?
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Past Gynaecological History

Menstrual

Contraception

Gynaecological Diseases

Gynaecological Surgeries
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 Past Medical /Surgical History
History of:-
HD, epilepsy, HTN, DM, Thyroid disorder,
TIA
Surgery-anaesthetic complication
History of any drug reactions
Allergies
Blood Transfusions
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 Family/Social History
• Marital status
• Working or not
• Partner’s occupation
• Smoking: how long? No. of cigarettes/day
• Alcohol: how much?
• Explore similar familial illnesses
– Hypertension
– DM
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 Summary
• Should be short and precise, could
include:-
Name, age, gravidity, parity, gestation
age
Main complaints
Positive findings and important negative
features

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Gynaecological History
• Introduction
–Name, Age, Occupation, Parity
• Chief Complaints
–It is important to ask as open a
question as possible in this part of the
history and to ensure the complaint is
understood

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 History of Presenting illness
This will vary depending on the main complaints
Example:-
Discharge:
Duration
Amount
Smell
Itchiness
Colour
Rash
Any symptoms in partner
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Vaginal bleeding
Duration
Amount-?No of pads/day, ?Soaked
Associated with contact or not
Symptoms of complication
Dizziness, Headache, Awareness of heartbeats,
easy fatigue on exertion

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Pain
Duration
Location
Type of pain
Aggravating or alleviating factors
Relation to the cycle- ie during
menstruation

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 Review of other systems
• Other systems will be reviewed as explained
earlier

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 Menstrual History
Menarche
Cycle length and Period
Regularity
Bleeding between periods
Bleeding after intercourse
Any postmenopausal bleeding
Nature of periods
• Heavy
• Clots
• Flooding

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 Contraceptive History
Previous methods
what
when stopped
why stopped
Current method
what
when started
any side effects
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 Past Gynaecological History
Gynecological symptoms
Pv discharge, LAP, PV bleeding

Gynecological diagnoses
Myoma, Ovarian Masses

Gynecological surgery
Myomectomy/Hysterectomy

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• Past Obstetric History
• Past Medical/Surgical
• Family and Social History
• Summary

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PHYSICAL EXAMINATION IN
OBS/GYN
 General examination
This will be done from head to toe

Appearance: ill/well, obese/thin,

anxious/ depressed, Pallor, Jaundice,
Cyanosis, Edema

Vitals:- Temp, PR, RR, BP

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 Systemic examination
Start with the affected system first
Its important to be systematic,
observe the following trend
Inspection
Palpation
Percussion
Auscultation
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 Respiratory System
Inspection:-Appearance of the chest,
movement, respiratory rate
Palpation:-Lymph nodes, area of tenderness,
trachea position, chest expansion
Percussion:- Normal-Resonance but could be
stony dullness, hyperresonance
Auscultation:-Breath sounds have intensity and
quality.
The intensity (loudness) may be normal, increased or
decreased.
Normal quality breaths sound is described as
vesicular
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 Cardiovascular system
Inspection:-Pallor, Cyanosis, finger clubbing,
coldness of extremities, and edema

Palpation:-Arterial Pulse, jugular venous pulse,

Blood pressure, chest wall-apical impulse

Auscultation:-
– Heart sounds (1st and 2nd )
• ??3rd and 4th
– Heart murmurs
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 Abdominal Examination
Inspection:-
Shape-normal contour, Scaphoid?, distended?
• Generalized distention:-may be due to 5Fs-Fat, Fluid, Flatus,
Faeces and Foetus
Umbilicus, Movement of the abdomen (ie in
peritonitis the movement is absent), skin and
abdominal surface
Palpation:-Sequence of palpation is needed-
suggested from left iliac region, superficial/Deep
Palpate for:-lt kidney, spleen, rt kidney, liver, aorta,
groin and external genitalia
Mass:-Site, Size, Shape, Surface, Edges, Consistency
and Mobility
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 Percussion:- Light percussion is needed and
tympanic note is heard throughout except over
the liver where it is dull
?Shifting dullness

Auscultation:-
Listening for bowel sounds and/or sometimes aortic
bruits
The stethoscope should be placed at one site
preferably just to the right of the umbilicus
Normal, Increased or Absent
Normal bowel sound are heard as low or medium
pitched gurgles interspersed with an occasional high
pitched noise

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 In Obstetrics…
• Abdominal examination can be conducted
systematically employing the four maneuvers
described by Leopold
• The mother should be supine and comfortably
positioned with her abdomen bared
• These maneuvers may be difficult to perform and
interpret if:-
– the patient is obese
– if there is excessive amniotic fluid
– if the placenta is anteriorly implanted

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 First Leopold Maneuver
AIM:- To determine
what is in the fundus &
fundal height
–Face the patient’s head
–Use both hands to
palpate the fundus
–A mass is felt – is it
head or buttocks?

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 Consider:-
Consistency
– the head is harder than the buttocks
Shape
– the head is round
Mobility
– the head moves independent of the trunk
– the breech moves with the trunk

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 Second Leopold Maneuver
AIM:- To locate the lie and back of the fetus in
relation to the right or left side of the mother

• Face the patient’s head

• Use the palms of both hands, one on either side
of the abdomen, so that one hand steadies the
uterus while the other palpates using a slight
circular motion from the top of the uterus to the
lower segment, feeling for fetal outline
• Palpate the other side, reversing the functions of
the hands
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 2nd Cont…
Consider:-
• The back will feel
smooth and hard
• The knees and elbows
will have numerous
angular nodulations

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 Third Leopold Maneuver
AIM:- To determine what is lying in the pelvic inlet
and to its mobility i.e the presenting part

• Important because the findings aid in diagnosing

– presentation
– position
– engagement

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 3rd Cont…
• Face the patient’s head
• Gently grasp the lower portion of
the abdomen just above the
symphysis pubis, using the thumb
and fingers of one hand
• If the presenting part is
unengaged:-
– a moveable body will be noted
which may be gently ballotted

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 Fourth Leopold Maneuver
AIM:- To locate the cephalic
prominence to assist in diagnosing
descent into the pelvis i.e
engagement

• Face the patient’s feet

• The fingers of both hands are moved
gently down the sides of the uterus
toward the pubis
• The cephalic prominence is located
on the side where the greatest
resistance is felt
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 Consider:-
If the prominence is located on the
opposite side from the fetal back, the
head is said to be well flexed
If the prominence is located on the
same side as the back, the head is
said to be extended (face
presentation)
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 Pelvic Assessment
Seek consent before assessment
Explain to the woman what you are going to do
Bladder must be empty
Inspect External Genitalia
Labia majora, Labia minora, Clitoris
Look for ulcers, inflammation, growths or swellings
Inspect urethral orifice for discharge
Check for any Vaginal discharge/leakage/bleeding

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 Speculum Examination
This is an essential part of
gynaecological examination:-

Cusco’s speculum-for
displaying the cervix

Sims speculum- to display

vaginal wall

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 Digital Exam
Use lubricant
Left hand spreads labia insert right hand
Palpate vaginal walls, growth, cyst,
Then examine fornices check for
obliteration or swelling.
Cervix is examined next noting direction,
size and shape, surface smooth/irregular,
size of external os, and growths or
ulcerations
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 Cont…
Bimanual: -
Right inserted and left
pushing on abdomen;
to feel uterus
Determine size,
mobility, and
surrounding structure

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 Summary

At the end; it’s important to give summary

of the positive findings and important
negatives from General and Systemic
Examination

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 References
Hutchison's Clinical Methods 21st Edition

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