History and physical

examination in Obstetrics
and Gynecology
Dr. Tibebu MD
Introduction- OBGYN
• Obstetrics -
Is a specialty of medicine concerned with care of women
during pregnancy, parturition and puerperium
including the physiological and pathological function of
female reproductive tract.
Gynecology-
A medical specialty deals with disease of female genital
organs as well as endocrinology and reproductive
physiology of the female
A health care for women
History and physical examination-importance

Appropriate history and physical examination learning

• Embody time-honored skills of healing and patient
care
• Deepens your relationships with patients, focuses
your assessment, and sets the direction of your
clinical reasoning
• Shape the image of the unique human being
entrusted to your care.
 Part One
Obstetrics history and physical examination
Identification
• Name, Age (<18yrs, >35yrs are high risk) and sex
• Marital status (unmarried & unsupported are high risk)
• Address, Occupation and Religion
• Source of the history
• Date of admission
• Ward, bed number
Chief complaint-
 The one or more symptoms or concerns causing the patient to seek care
• Come for routine ANC follow up
• Nausea and vomiting, Vaginal bleeding
• Leakage of liquor/fluid per vagina
• Decreased/absent fetal movement
• Abdominal pain/pushing down pain
• Headache, RUQ or epigastric pain, blurring of vision, convulsion
• Failure to control urine Etc….
History of present pregnancy
Should include the following information:
• Gravidity – all previous pregnancies– term/preterm live births & still
births, abortions, ectopic pregnancy or molar pregnancy
• Parity– all pregnancies that have extended beyond fetal viability
whether the fetus is delivered alive or dead
≥28 weeks – UK and Ethiopia
≥20 weeks –WHO, USA
• Abortion(s)- termination of pregnancy before the age of viability.
Mention the LNMP- the 1st day of the last normal…..
To be considered reliable:
 Menstrual cycle should have been regular for at least 3
cycles if non-lactating and no contraceptive use
 D/c OCP at least 3 months prior to the LNMP and saw 3
regular cycles
Discontinue injectable /implanon contraceptive 6 months
prior to the LNMP and saw at least 3 regular cycles
 If lactating should have seen 3 regular cycles
HPP- cont.
• Calculate the EDD/EDC- 40 weeks or 280 days after LMP
• If using Gregorian calendar:
Naegele’s rule: LMP – 3 months + 7 days + 1 year
• If using Ethiopian calendar:
LMP + 9 months + 10 days if pagume is not passed or
(+ 5 days if pagume is 5 days or
+ 4 days if pagume is 6 ) & if pagume is passed
– only 5% of pregnant women delivered on this day.
HPP- cont.
• Calculate the gestational age in completed weeks and days- by
subtracting the LNMP from the date of contact/examination
• Mention dating by using early U/S (done before 22weeks) or fundal
height measurement taken before 20 weeks. If yes calculate GA.
• Has the patient had a confirmatory urine pregnancy test, and when? If
no other milestones.
HPP- cont.
• Quickening: 1st time the mother felt fetal movement(date/month, not the
month of pregnancy) for primi 18-20wks and for multi 16-18wks. It is used
for dating.The last two usually used to ascertain fetal maturity.
• Examples
• A primigravid lady whose LNMP was Miazia 5, 2014. currently she came
for routine 2nd ANC follow up. She had also U/S done on ginbot 4, 2014
showing GA of 9weeks.
A- what is the GA today?
B- when will be EDC?
C-what is the current GA calculated from the early U/S
History of present pregnancy cont.…
• Document ANC status in detail (when, where & what was done or
counseled at each visit) or if not followed the reason should be sought
• Elaborate the chief complaint
• Any complaint during present pregnancy-eventful or uneventful
• Ask for danger signs: vaginal bleeding, leakage of liquor,
abdominal/ pushing down pain, decreased or absent fetal
movement etc.
• Other negative or positive statements e.g in HDP
 Past Obstetric History
• Document all previous pregnancies in chronological order and
include date of gestation, length of gestation, birth weight,
fetal outcome, length of labor, fetal presentation, mode of
delivery, complications which occurred ante, intra and post
partum.
• Most obstetric & gynecologic problems are recurrent e.g. APH,
PPH,PROM, DM, C/S, EP & abortion.
Past obstetric history- summary.
Past Gynecologic History

• Contraception: use or need for any form of contraception, type and

duration
• Sexual history: including history of STIs. Assess risk of HIV/AIDS
• History of gynecologic operations: history of FGC, history of
gynecologic surgery e.g. prior uterine surgery- hysterectomy,
metroplasty, D&C, E&C, MVA
• Menstrual history: age at menarche, interval between periods,
duration of flow, amount and character of flow, degree of discomfort.
Past medical and surgical history
• Medical disorders may affect the outcome of
pregnancy and physiological changes of pregnancy
may aggravate the medical disorders e.g. DM, HTN,
thyrotoxicosis, or hypothyroidism.
• Previous blood transfusion may relate to HDNB
• Hypersensitivity to drugs
• History of maternal infection during pregnancy e.g.
STI, rubella, etc
Personal, family and social history
• Early child hood history: number of siblings, whether parents
and siblings are alive or dead.
• Educational status:
• Habits –smoking, alcohol and drug use may have a deleterious
effect on pregnancy e.g. FAS
• Occupation and family income: low socioeconomic status is
associated with pregnancy complications like pre-eclampsia, PTL,
PROM, etc
• Family history- DM, HTN, TB, Twinning, hereditary diseases and
chromosomal anomalies, allergies, mental disorders run in family
Review of systems
• Review all the systems
• HEENT, LGS, RS, CVS, GIS, GUS, MSIs and CNS
Physical Examination-obstetric part
• Should be conducted in the environment that is aesthetically pleasing
to the patient.
• A female assistant (chaperon) should be present.
• Adequate gowning and draping to avoid embarrassment.
• Warm instruments, reassurance and adequate lighting to avoid
discomfort.
• Should be conducted thoroughly and systematically.
PHYSICAL EXAMINATION cont’…
• General appearance
• Vital signs-PR(10-15b/m), RR (1-4b/m), BP, T0, weight, height, BMI
Method of taking blood pressure:
1. should be measured in a sitting position or 30 degree left lateral tilt
to avoid hypotension
2. The right upper arm must be used consistently and at the level of
the heart
3. It should be taken after 5-10 minutes of rest.
4. Appropriate blood pressure cuff with arm size should be used
5. The woman should not use tobacco or caffeine within 30 minutes of
the measurement
6. the mercury sphygmomanometer should be used if possible
HEENT
emphasize on conjunctiva, gingiva- epulis gravidarum or pyogenic
granulomas,
• LGS- LN, thyroid, breast
• Chest/RS examination-same as non pregnant
P/E-cardiovascular system
• Generally, it is the same as non pregnant women
• Some variations inherent to physiologic changes of
pregnancy include-
• PMI may shift to the left outward to the 4 th ICS
• S3 gallop may be heard normally
• Functional systolic murmurs ≤ grade III may be heard
normally
 P/E-Abdominal examination
• Exposure-from the xymph sternum-Symphysis pubis
• Positioning–semi-siting, bed should be 30 degree elevated
• Inspection
symmetry, scars, striae gravidarum, linea nigra, umbilicus, distended
veins, visible fetal movements, flank fullness and hernial sites
• Palpation
Superficial palpation
look for rigidity, tenderness, superficial mass, wall defect, look for
organomegally.
Abdominal examination cont…
Obstetric palpation (Leopold’s maneuvers)
• Fundal palpation-1st -fundal height, what occupies fundus
• Lateral palpation-2nd -Lie, side of the back (FHB)
• Pelvic palpation-3rd-Presentation, Descent of presenting part,
Attitude of the fetal head
• Pawlik’s grip-4th -Presentation, Descent of fetal head-
obsolate
1st Leopold-Symphysis fundal height
measurement
• Correct for dextrorotation and use different methods:
Finger method
 below the umbilicus one finger corresponds with 1 week of gestation
 above the umbilicus one finger corresponds with 2 weeks of gestation
Tape method – at 18-34 weeks of gestation its accuracy is ± 2 weeks of
the actual GA
Land mark method –At the symphysis pubis-12 weeks, at the umbilicus-
20 weeks and the xiphisternum-36 weeks.
1st Leopold- what occupies the fundus
• The uterine fundus can be occupied by
 Soft irregular bulky mass -the breech
 Hard, round ballotable mass- the head
No palpable mass- transverse lie
2nd Leopold manuever
3rd–pelvic palpation: It has three purposes:

A. Presentation – cephalic, breech etc.

B. Descent – using the 5th rule
• 5/5 – floating, 3-4/5 – fixed and 2/5 - engaged
C. Attitude-
Cephalic prominence on the side of the back – extended
Cephalic prominence opposite to the side of the back - flexed
3rd leopold maneuver –pelvic palpation
Abdominal examination cont…
Percussion
shifting dullness, flank dullness, fluid thrill- ascites, poly
hydramnios, hemoperitoneum
Auscultation
• FHB (Dee Lee/ pinard sthetoscope-20wk
• Doppler U/S-10wk , more on the side of the back.
FW estimation by Johnson formula
(Fh-11 or 12)155 +/- 375gram
Genitourinary system
• Urinary system-CVA or suprapubic tenderness
• Pelvic assessment-done at two times during pregnancy
unless otherwise indicated due to complications and in labor
1. early – during the 1st trimester-To diagnose pregnancy, to
date pregnancy and to diagnose pelvic problems.
2. late – above 37 weeks
A. pelvic assessment to diagnose contracted pelvis
B. to assess the Bishop’s score
MSS & INT. system
• look for edema – pretibial, pedal and ankle (dependent)
80% of pregnant women have such edema
• Other areas to look for pathological (non-dependent edema)
• Facial edema
• Tightening of rings
• Sacral edema
• Abdominal wall edema
Physical examination continued..
• CNS: Reflexes, Consciousness, Gross neurologic deficit
• Summary
• DDX
• Assessment
• Investigation
• Treatment plan
THANK YOU!
II. GYNECOLOGY
History
• Identification: same as obstetrics
• Chief complaint: Gynecologic patients may present with any of the
following complaints;
• Cessation of menses
• Vaginal bleeding
• Vaginal discharge
• Lower abdominal pain
• Pain during intercourse
Chief compliant cont…
• Pain during menstruation
• Mass protruding through introits
• Ulcer over the external genitalia
• Urinary incontinence
• Abdominal distension
• Hirsuitism-abnormal hair growth pattern
• Sexual assault
History of present illness:
• Reproductive history: parity, abortions, molar and
ectopic pregnancy
• Each complaint should be discussed in detail
Examples:
• Abnormal uterine bleeding:
Describe clearly onset, duration of flow, amount and
relations of AUB with menstrual cycle and LMP
History of present illness cont…
• Vaginal discharge:
Color, odor, amount, viscosity
Timing in relation to the menstrual cycle
Association with bleeding – may indicate malignancy
Itching may indicate infection
 History of present illness cont…
• Abdominal pain: PQRST
o Location (position), Quality, Radiation, Severity and Timing –
intermittent, constant of the pain.
o Relation of the pain to the menstrual cycle should also be stated
 contraceptive, sexual and menstrual history should be included
if pertinent
 positive and negative statements pertinent to the presenting
complaint
Gynecologic patient- history cont…
• Gynecologic history: as in obstetrics
• Past obstetric history: as in obstetrics
• Past medical and surgical history: as in obstetrics
• Systemic review:
Physical examination
• General appearance
• Vital signs-as in obstetrics
Weight-
Height-in postmenopausal patients loss of height from
osteoporosis and vertebral fractures
BMI
obesity is a risk factor for end. Ca, ovarian ca, amenorrhea
Breast examination
• Inspection:
Symmetry, dimpling, peau’d’ orange, nipple retraction,
ulceration, eczematous nipple lesions should be
documented
• Palpation:
All four quadrants & axillary tail -Detailed description of a
mass
nipples for discharge
axillary, supraclavicular and cervical lymph nodes
Abdominal examination

Inspection-as usual as is done for other patients

Palpation-superficial and deep palpation
Abdominal mass description
• size in weeks of pregnant uterus
• pelvic or abdominal: one can go below the mass into the
pelvic cavity or not?
• consistency: firm, hard, cystic, soft
• mobility: fixation may indicate malignancy
• tenderness
• surface contour :smooth, irregular, nodular
 Pelvic examination
 Materials
• Table with stirrups
• Light source
• Sterile speculum
• Slides & cotton tipped applicators
• Lubricants and
• disposable gloves
Code of practice for pelvic examination
• Chaperone should be available
• Explanation and consent
• Respect and protect patients confidential
information
• No personal comments given
• Gloves on both hands
• Gentleness and fast
Pelvic examination cont…
• Have 4 components
• examination of external genitalia
• speculum examination
• digital vaginal examination
• bimanual pelvic examination
1.Examination of the external genitalia
• Pubic hair – pattern-Masculine – diamond shaped vs
Feminine- inverted triangle and Infected hair follicles
• Skin of vulva, Mons pubis and perineal area, inspected for
dermatitis or discoloration; ulcers or swellings
• Labia majora and minora– ulcers, swellings or tumors as
condylomaaccuminata, evidence of FGC
• Palpate and milk the urethral orifice
• Comment on the hymen- weither raptured or not
1.Examination of the external genitalia cont..
unruptured: annular, septate, imperforate (pathological)
ruptured: after birth of many children=carunculae
myrtiformis, very important in sexual assault examination
• Discharge or bleeding from the introitus
• Check perineal support
open the labia with two fingers and ask patient to strain to
see perineal descent and pelvic organ prolaps
2.Speculum examination
• Several types-
 Sim’s speculum,
 bivalve speculum(Cuscos)- Graves, Pederson’s, Huffman’s
• Choice of several size depending on age & parity
• Dampened with warm water but not lubricants
• Examination-explain findings of inspection
Speculum examination-Vagina
• Color: pink, whitened,inflammed
• Congenital anomalies like vaginal septa
• Rughe folds-formed, flattened
• Fornices- formed, flattened, bulging
• Discharge: color, amount
• Scars, lacerations and length
Speculum examination -Cervix
• Color :pink, bluish
• Cervical os : pinpointed vs slitlike
• Any lesion- erosions/lacerations/ulcer, , scars, mass,
nabothian cysts
• Concomitantly procedures can be done.eg,
 Papannicolau’s smear should be taken at this time from
exocervix and endocervix
 Punch biopsy
Digital vaginal examination

• Vagina
masses, tenderness, or stenosis
• vagina fornices
formed, obliterated, bulging esp.(cul-de-sac) & its tenderness
• Cervix
o consistency like tip of nose normally, firm to hard in malignancy
o Excitation (motion tenderness)
o Effacement, position, dilatation-partrution
Bimanual pelvic examination

• Delineate the uterus and adenexa between the two finger in

the vagina and the flat of the other hand on the lower
abdominal wall.
• Examination Under Ansthesia may be required in obese
patients.
• Cervix -3-4cm sized, smooth surface and closed ex.os
• Uterus -9cm length, 7cm width, 2cm depth, 70-90gm in
weight non-tender and firm organ and mobile.
Bimanual pelvic examination-uterus
• Position
anteverted anteflexed normally, in relation to vagina and
cervix respectively
retroverted and retroflexed in 20% of cases- may indicate
pathology
There may be fixation due to ca, inflammation
• Adnexae
refers to the tubes, ovaries, broad ligament and
parametria
Ovaries- 3cmx2cmx1cm in size; Tubes- 7mm at its
greater diameter
may be palpable in thin women with soft abdominal
wall
Slightly tender normally
should not be palpable in postmenopausal women
• Rectal examination
in virgin
to assess involvement of rectal mucosa; parametrial and
pelvic side wall in ca staging.
Normally parametrium is not palpable or is free, become
indurated in malignant infiltration or infection
Rectovaginal examination

• Performed with index finger in the vagina and middle finger

in the rectum and assess the structures in between.
• It helps to examine the rectovaginal septum or uterosacral
ligaments for nodularity or infiltration in cases of malignancy
and endometriosis
• Also helps to differenciate rectocele from enterocele.
P/E cont….
• GUS, MS &INT.S and CNS as in obstetrics

__________ // ___________
THANK YOU