History Taking and Physical Examination in Obstetrics

and Gynaecology

DR.MACHEKU GODWIN,MD.

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 A;HISTORY TAKING IN OBSI.
I.INTRODUCTION

• Name
• Age
• Nationality
• Occupation
• Gravidity and parity
• LMP
• EDD

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 I.INTRODUCTION cont…
• Naegle’s rule:
• EDD= LMP + 7d – 3 mths (or + 9 mths)
Pregnancy wheel may be used
How many weeks pregnant now(GA)
• (gravida#, para#, +abortions)
delivery of twins or triplets is considered one parity; eg. 2 sets of
twins is para2, although she has 4 children.
Any delivery ≥28weeks is para.
• When first fetal movements were felt(quickening, in a primi
gravida around 18-20/52, in multipara 16-18/52

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 2.Chief complaint.
• Chief complaint, and present pregnancy
• Admitted through OPD/self refferal/reffered
on the date complaining of eg. Morning
sickness, bleeding PV, abdominal pain…
• Duration of the complain.

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 3.AMPLIFICATIO-῾῾ado᾽᾽
• Detailed history of the present complaint:
• Eg;
– Abnormal pv bleeding:pattern, regular/ irregular
,Amount of loss,# of pads or tampons used,passage of
clots or flooding,any pain with the loss.
– Abdominal pain:
Site, Nature, Aggravating and relieving factors,
associated SS
– Vaginal discharge:
Amount, color, odor, blood, rash, pain

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 4;ANC Hx-index pregnancy.
• Booking?GA?
• Vitals-BP,PR.
• Oedema-limbs.
• Immunization?deworming?IPT?
• PMTCT?
• IBP?
• Body wt etc.

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 5.POH
•Obstetric history:-each pregnacy even abortions,ectopic
etc.
•Birth-Year,FTND (full term normal delivery); vaginal/C-
section
Born home/hospital,Male/female baby
•Weight (healthy at 2.8-3.6 kg, >4kg is macrosomic- DM or
genetic. Macrosomic babies suffer risk during vaginal
delivery more chances of injuring the clavicles. C-section is
preferred, but not routine)
•PP complications,Breast fed,Baby alive and well.
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 POH cont…
• Ex. 1989, FTND, in hospital, male baby, 3.5 kg, no PP
complications, breast fed
• Complicated birth:
Year?39/40,C.S for C.S for APH, female baby alive
3kg, post op normal, breast fed.
• Abortion:
Ex. 1990, abortion at 10/52, evac, no post op
complications
Ex.2: 1992, abortion at 22/52, D&E, no post op
complications
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 6.PMH
• Past medical & surgical history:
Especially surgeries on the uterus;
myomectomy removal of fibroids.
Hx of abdominal surgery may cause adhesions.
• History of chronic diseases, e.g ,HTN, DM
,epilepsy, twins, TB
• Drug and allergy history:
OCP,Teratogenic drugs; phenytoin, cytotoxic
drugs, tetracycline, chloramphenicol
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 7.FSHx
• Family history:
HTN,DM,epilepsy,twins,TB,Malformations

• Social history:

House wife/ working mother,Smoking,Drinking

Husband’s profession

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 SUMMARY

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 Physical examination of OBS.
• Physical examination of OBS
• 1.General:
Appearance: ill/well, obese/thin, anxious/
depressed
Pallor, Jaundice,Cyanosis,Edema.
Vital signs:
Pulse, BP,Temp,RR
Urine dip stick for protein and sugar

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 Abdominal exam

1-Inspection ;
shape & size
 asymmetry
surgical scars (pfannensteil incision)
cutaneous signs of pregnancy (linea
nigra, striae gravidarum, striae albicans.)

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 Abdominal exam
2-Palpation
• Uterine size symphysis fundal Ht = GA in wks
-at 13-14 wks just palpable
-20-22 wks at the umbilicus
• No of fetuses
• Presentation the part of the fetus that overlays the pelvic brim.
• Cephalic presentation  no of fifths palpable
• Lie of the fetus longitudinal axis of the uterus to the longitudinal
axis of the fetus
• EFWt
LEOPOLD maneuvers  4 grips

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 Abdominal exam
3-Ascultation fetal heart at 13-14 wks
4-Percussion polyhydramnious ballotment

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 Pelvic assessment

• Check ischial spines if prominent or not

• Diagonal conjugate distance from lower border
of the symphysis pubis to the sacral promontery
(pelvic inlet)
• Shape of the sacrum
• Side walls of the pelvis
• Distance between the two sacral promonteries

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 LEOPOLD maneuvers -4 grips.
• Fundal height:
from S.pubis uptil the fundus. If by calculation 36 and measure 26 it
means there is either a miscalculation of the EDD, or a problem
with the fetus as IUGR. Also if the opposite, the calculation, it may
suggest a macrosomic baby, twin pregnancy, polyhydramnios,
hydropis fetalis.
• Fundal grip:
to see whether the head or the buttocks are occupying the fundus.
Cephalic presentation-when the head is down and the buttocks
occupy the fundus.
Breech presentation-is when the head occupies the fundus. This is
significant esp in a primigravida where C-section is preferred.

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 Cont…
• Lateral grip:- assess how the baby is lying; whether
transverse, oblique or longitudinal, the latter being the only
ideal position for delivery.
• It also tells whether the baby’s back is on the right or left.
• 75% of baby’s backs are on the left probably b/c of the liver
on the right. This is necessary to find the site to auscultate
for the baby’s heart beat.
• First pelvic grip:
The only position with the back to the patient
Insert the fingers into the pelvis to see what part of the baby
occupies the pelvis

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 Cont…
• Second pelvic grip:
Move the part left and right , if mobile, then it
is not in the pelvic brim, so no engagement
has occurred yet.
• If immobile it means that the BPD (biparietal
diameter) of the baby is in the pelvic brim; i.e
engagement occurred.

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 Uss in obstretics
• ULTRA SOUND:
Useful but not available every where
- measures the BPD
- measures the femoral length
this is accurate in the first 16 weeks. After 16
weeks it has a +/- 2 weeks accuracy,±3wks in
3rd trimester.

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 GYNECOLOGIC HISTORY
• 1-General information
Name, age & parity
• 2-Present complaint
• 3-Hx of present complaint
Ask relevant questions examples:
Abnormal menstrual loss
regular or irregular
Amount of blood loss no. of pads, presence of clots,
flooding, absence from school or work due to associated
pain, weakness or flooding

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 GYNECOLOGIC HISTORY
 Vaginaldischarge
odour, color, consistency, amount & presence of blood
relation to the period
associated itching or irritation
Pelvic pain
 duration, nature & site
relation to the menstrual cycle
aggrevating or relieving factors
radiation & associated symptoms eg. Vomitting, fever,
dysurea
dysparunea
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 GYNECOLOGIC HISTORY
4-MENSTRUAL HX
- Menarche,-Cycle, duration of the period
- LMP, Volume of blood loss
-Menstrual molimina Discomfort, irritability,
depression, pelvic pain
-Menopause/ HRT

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 GYNECOLOGIC HISTORY
5-PAST OB HX
Outcome & details of previous pregnancies if
many summarize
6-Past medical & surgical Hx,-
Medications,Allergies
7-Family&Social Hx impact of the current
problem on social life-alcohol use,inherited
disease in family etc.
8-Summary
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GYNECOLOGIC PHYSICAL EXAMINATION
• General exam.
• Abdominal exam
1-Inspection distension  masses
surgical scars
2-Palpation guarding , tenderness, masses
3-Percussion /ascultation to distiguish solid masses from
bowel, ascites
• Pelvic exam
1-Inspection of the external genitalia
2-Speculum exam
3-Digital exam
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 Inspection&palpation
• Inspection:
size and shape:
midline fullness indicates ovarian or uterine mass. Fullness of
flanks suggests ascites (confirm by fluid thrill and shifting
dullness), iliac fossa masses usually ovarian or bowel.
• Palpation:
Rigidity or guarding
Mass: position, size, shape, edges, mobility, consistency, fluid
thrill if cystic,Malignant tumors usually fixed. Mobile tumors
usually benign, but may be fixed by adhesions.

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 Percusion&auscultation
• Percussion:
Dull masses are in contact with the abdominal wall,
while resonant suggest being behind the bowel

Auscultation:
Bowel sounds, absent in ileus.

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 PELVIC EXAMINATION-gyn
• PELVIC EXAMINATION:

Bladder must be empty

• Normal anatomy
Vulva, Labia majora, labia minora,Clitoris
Look for ulcers, inflammation, growths or swellings
Inspect urethral orifice for discharge ( if present
spread on thin film), redness or growth
• Speculum to assess vagina: Sims speculum, Cusco

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 PELVIC EXAMINATION
• Digital: use lubricant, left hand spreads labia insert right
hand: palpate vaginal walls, growth, cyst, .
• 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
• Bimanual: right inserted and left pushing on abdomen; to
feel uterus . Determine size, mobility, and surrounding
structure. Only abnormal fallopian tubes are palpable.
Ovaries may be felt as small mobile oval structures that
are sensitive to pressure.

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 PELVIC EXAMINATION
• Positions:
- Left lateral
- Sims Semi-prone: good for external genitalia, Cervix and
anterior vaginal wall, exposing the vaginal end of the
vesicovagianl fistula
- Dorsal: good for vulva, bimanual, most frequently use
- Lithotomy: best position for under anesthesia
examination

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 END!!

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