History Taking and Physical

Examination in OBGY
Samuel Bezabih
Yekatit 2008
DB
 Identification

• Name (use initials when reporting for wider audience)

• Age *
• Occupation, Marital Status**
• Religion
• Address

* adolescents (< 18 ) and the elderly gravida (> 35) are at

particular risk for adverse pregnancy outcome
**Information on marital status and occupation help assess the socioeconomic
status of the pregnant woman. Low socioeconomic status is associated with
several poor pregnanacy outcomes Eg preterm labor, PROM, low birth weight,
anemia, Pre-eclampasia, Eclampsia

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 Chief Complaint

• Most pregnant women come for routine ANC

– May have minor routine complaints eg abdominal
discomfort, morning sickness, back pain, leg pain,
urinary frequency and urgency,
– Some complaints may mark a serious problem and
warrant
– Eg- vaginal bleeding, ↓fetal movement, headache, headache,
visual disturbance leakage of liquor,

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 History of Present Pregnancy (HPP)

• HPP is the most important part of obstetric history and is

composed of
1.Summary of reproductive performance
Gravidity-refers to all previous pregnancies i.e. term, preterm,
live birth, stillbirth, abortion, ectopic pregnancy, molar
pregnancy
Primigravidity (1st pregnancy) is associated with increased risk of PIH, labor
abnormalities, CPD and obstructed labor
Parity- all previous pregnancies that have reached fetal
viablity and delivered dead or alive ( i.e. at or beyond
28 weeks of gestational age for Ethiopia and UK , 28
weeks according to other western countries)

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 HPP
• Parity- all previous pregnancies that have
reached fetal viablity and delivered dead or
alive ( i.e. at or beyond 28 weeks of
gestational age for Ethiopia and UK , 28 weeks
according to other western countries)
– Primipara- 01 previous delivery
– Multipara- > 02 previous deliveries
– Grand multipara - > 5 previous deliveries

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 HPP
2. Last normal menstrual Period (LNMP), Expected Date of
Delivery (EDD) and Gestational age (GA)
LNMP- 1st day of last menses
For LNMP to be reliable,
• It should be regular ( cycle length vary among idividuals
ranging b/n 21 to 35 days)
• It Should be similar to previous cycles in volume and
duration of flow
• If the woman was on OCPs it should be discontinued for at
least 03 months ahead of LMP
• Lactating women should have 03 regular cycles before LMP

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 HPP
Expected Date Of Delivery (EDD)- 280 days after LMP
EDD calculation
• Naegel’s Rule
– Subtract 03 months from LNMP and add 07days
– Eg If LNMP is February 12 then EDD will be on November 19
• Calculation according to the Ethiopian calendar ( 12
months of 30 days and pagume 5days/ 6 days with
each leap year)
– LMP+ 9mths + 10days- if EDD doesn’t cross a year
– LMP+ 9mths + 5 days- if EDD crosses a year and pagume is 05
days
– LMP + 09 mths + 04 days- if EDD crosses a year and pagume
is 6 days
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 HPP

Gestational age
• GA is calculated in completed weeks
– Preterm pregnanacy- GA below 37completed wks
– Early Term pregnancy: 37 – 38 6/7 Week
– Full Term Pregnancy: 39- 41 6/7
– Post-term pregnancy: > 42 weeks
• GA calculation is based on the assumption a
28 day regular cycle length- ovulation on the
14th day

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 HPP

In addition to LMP other methods are used to estimate GA

• Early US  before 20 weeks
– Ultrasonography may be considered to confirm menstrual
dates if there is a GA agreement
• within 1 week by CRL obtained in the 1st trimester or
• within 10 days by an average of multiple fetal biometric
measurements (eg,CRL, BPD, HC, AC,FL) obtained in the 2nd (up to 20
weeks GA) . ACOG-2008
• Quakening date –
– around the 17th week for multipara ( experience from previous
pregnancies)
– Around the 19th week for primipara
• Fundal height at umbilicus~20 weeks
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 HPP

• ANC
• if no ANC or delayed start – reason
• Details of ANC
– Prepregnancy weight /BMI and weight at booking and
on subsequent visits
– Blood pressure recordings
– Lab investigation results
• Blood group, Rh, hemoglobin level
• UA for bacteruria, infection and hCG
• RVI,
• RPR/ VDRL test
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• HBsAg SAMUEL BEZABIH 10
 HPP

• Health education about nutrition, sanitation,

labor, breast feeding and contraception
• Iron supplementation, malaria prophylaxis, TT
immunization,
• Any drug use- prescription, over-the-counter
or herbal medications
• Significant symptoms of illness early in
pregnancy like excessive nausea and vomiting,
Vaginal bleeding

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 HPP

• Detailed discussion of the presenting complaint

• Always ask about the common danger signs of
pregnancy
– Head ache (severe, persistent, not responsive for
analgesia)
– Visual disturbance
– Epigastric/ RUQ pain
– Vaginal bleeding
– Leakage of liquor per vagina
– Fetal movement status

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 HPP
• Positive and negative statements directed at
possible DDx to the presenting complaint
NB: Relevant informations should be switched from other
sections ( past ob Hx, Medical and surgical hx , family hx etc. )
to the HPP.

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 Nutritional Hx

• Detailed enquiry whether the woman takes

adequate amount of carbohydrates, fat,
proteins , minerals and vitamins
• Look for any food restrictions for cultural
reasons or taboos

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 Past obstetric History

• Detailed chronological documentation of all

previous pregnancies i.e. year, gestation length,
labor duration, presentation, fetal outcome
( weight, alive/ dead), mode of delivery
• Any antepartum, intrapartum or postpartum
complications
– Eg APH, PPH, IUGR, PROM, Malpresentations,
macrosomia, congenital anomalies, molar pregnancy,
GDM, Hypertensive disorder
NB- most of these complications have a significant
recurrence risk
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 Gynecologic History

• Menstrual history
– Age at menarchae
– Regular, irregular ,intermenstrual bleeding/
spotting
– Amount and duration of flow
– Discomfort during menses (Dysmenorrhoea)
– Premenstrual symptoms (cyclic affective and
somatic symptoms in the luteal phase)
• Contraception use history

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 Past medical and surgical History

• Episodes of acute/ chronic illnesses, duration,

treatment outcome , followup , current status
• Such chronic illnesses as DM, HTN, Thyroid disease
( thyrotoxicosis and hypothyroidism), cardiac and renal
disease that affect pregnancy outcome need to be
integrated with the HPP
• Hx of blood transfusion-
– possibility of minor blood group incompatibility and Rh isoimmunization
• STI Hx and treatment
• Hx of pelvic surgery
– Eg –myomectomy, hysterectomy, metroplasty- cause uterine scarring
and may dehisce during pregnancy and labor
• Hx of surgery involving other organ systems
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 Personal and Family History
• Place of birth and bringing up
• Education, occupation, income
• Habit of smoking, alcohol , caffein or illicit drug use
• siblings-
– Number of sisters and brothers
– Alive
– Dead – cause of death
• Parents
– Age
– Health status
– If deceased- age when dying and cause of death
• Family history of chronic illnesses ( eg DM, Hypertension Epilepsy
etc.) or any hereditary disease
• Family history of twining
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 Review of System (Functional enquiry)

• Detailed orderly search for any symptoms

pertaining to each organ system

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 Physical Examination
• General Appearance
– Comfortable, in CRD, acutely/ chronically sick
looking,
– body habitus ( obese, malnourished), stature
( extremely short?), skeletal deformities
– Facial features- chloasma of pregnancy, puffy face
NB. some of the above descriptions can be placed at
the respective systemic examinations

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 PE-Vital Signs
BP
– Measured in the left lateral ( usually for inpatients) or
sitting positions
– The right arm should be used consistently, in a
roughly horizontal position at heart level.
– For DBP, both phases ( IV-muffling and V-
disappearance of sound) should be recorded.
PR, RR, T0 are taken the same way as in any
medical patient-
NB- physiologic changes caused by pregnancy should be
taken into account while interprating results
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 PE

• HEENT
– look for chloasma, Cnjunctival pallor, icteric sclera
– Hair distribution
– Buccal mucosa- wet or dry ?
– Gingival hypertrophy, gingivitis?
– Oral thrush?
• LGS-
– Breast (engorgement, areolar pigmentation ,montgomery
tubercles….), thyroid and all accessible LN areas are examined
• Chest
• CVS
– PMI displacement lateral to the MCL, S3 and systolic murmurs <
Grade III are usual non pathologic findings
– Look for varicose veins in the
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 Physical Examination
• Abdomen
Exposure
– The patient should be supine with a comfortable
pillow, the arms lie by her sides
– The abdomen should be exposed from just below
breasts to the symphisis pubis just below the
pubic hairline ( not to miss pfannenstel scar)
NB- the woman is often asked to expose the
abdomen by herself
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 PE-Abdomen

Inspection
• Grossly distended abdomen?
• Protuberence- central or localized tone area
• Movemnt of abdomen with respiration
• Flank fullness
• Uterine dextrorotation ( abdomen tilted more to the right)
• Black line (linea Nigra) more prominent in the midline b/n umbilicus and
and symphysis pubis.
• Striae gravidarum- stretch marks due to disruption of collagen fibers of
dermis ( breasts and thighs can also be involved)
– NEW- purplish, few
– Old (straie albicantes)- whitish, multiple
• Umbilicus-flat, inverted, everted?
• Scar- location, size and thickness
• distended veins and ascitis portal hypertension
•02/03/2023
Abdominal wall edema with peau-d-orange
SAMUEL BEZABIH appearance  part of ana sarca24
 PE-Abdomen

Superficial palpation
• In each quadrant –
– areas of rigidity, tenderness, abd wall masses
– Location of appendix base in advanced
pregnancies at higher level than McBurneys point
( pushed up by the gravid uterus)
– Diffuse tenderness and rigidity / generalized
peritonitis chorioamnionitis abruptio placentae,
ruptured appendicitis, perforated PUD

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 PE-Abdomen
Deep Palpation
• Detection of hepatomegally and
splenomegally

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 PE- Abdomen
Obstetric Palpations (Leopold’s maneuvers)
• Four sequential maneuvers Performed on the
gravid uterus i.e. the fundal, lateral, pelvic
palpations and the Pawlik’s grip.
NB
• before 28 weeks of gestation fundal height
determination is the only palpation possible as the
fetus is too small to determine lie or presentation
• Fetal heart beat can be ascultated from 20th week
of gestation

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 PE- Abdomen
1- Fundal Palpation
Objectives:Determination of Height of fundus
( Gestational Age) and what occupies the
fundus
• Abdominal assymetry need to be corrected
first ( if dextro or levorotation is there) and the
bladder should be empty before starting
examination
A.Fundal Height determination-
– two methods ie Tape measurement of symphysis
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fundal height (SFH) in cms or Finger method
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 PE- Abdomen
I.SFH tape measurement (tape measurement)
• In the midline along the linea nigra traversing
the umbilicus
• The fundal height in cm accurately matches to
the gestational age b/n 18- 34 weeks
• More reliable method than the finger method

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 PE-Abdomen
II. Finger method
– Fundus just palpable at Spubis  12 weeks
– Midway b/ Spubis and umbilicus 16 weeks
– At Umbilicus 20 weeks
– Generally 1 finger above umbilicus represents 2
weeks
– At Xyphisternum 38 weeks/term
– 36 week by finger is comparale to 40 weeks of GA
due to decrease in fundal height after engagement

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 PE- Abdomen
NB
• a fundal height to GA discripancy of upto 02 weeks is
acceptable.
• A positive or negative discripancy of more than 02 week
mandates further investigation to identify the possible
underlying cause.
• The commonest cause of both +ve and –ve discrepancies
(large for date and small for date respectively) is wrong dating
• Other possible causes
– +ve Discrepancy multiple gestation, polyhydramnios,
macrosomia, GTD, leiomyoma, ovarian tumor,
– -ve discripancy IUGR, oligohydramnios, PROM, transverse lie,
IUFD, missed abortion
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 PE- Abdomen
B- determining what occupies the fundus
• Palpate and ballot the fundal area with both
hands
– Head hard, round, ballotable structure
– Breech soft,bulky, irregular, non ballotable

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 PE- Abdomen
2- Lateral Palpation
Objective- determination of fetal lie and identification of the
side of the back
Lie orientation of the fetal longtudinal axis with respevt to
that of the mother ie longtudinal, Transverse or Oblique
Lateral palpation is performed alternatively on both sidesusing
one hand to stabilize the uterus.
The back feels like hard, straight/ flat structure while the
extremities on the opposite side feel like multiple nodular
parts
Fetal heart beat can be easily auscultated on the side of the
back

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 PE- Abdomen
3- pelvic palpation
Objectives- identification of fetal presentation and attitude ( if cephalic)
 Cephalic prominence
The examiner faces the patient's feet and places a hand on either side of
the uterus, just above the pelvic inlet. When pressure is exerted in the
direction of the inlet, one hand can descend farther than the other. The
part of the fetus that prevents the deep descent of one hand is called
the cephalic prominence.
Presentation can be Cephalic , breech or shoulder
Attitude-
• flexed-the cephalic prominence is on the same side as the small parts.
• Extended,-the cephalic prominence is on the same side as the back.
• military
Desscent- from 5/5 ( floating) to 0/5
Engagement-
02/03/2023 minimum of 2/5 descent
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Desscent- b/n 5/5 ( floating) and 0/5
Engagement- minimum of 2/5 descent

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 PE- Abdomen
4- Pawlik’s Grip
Objective- identification what fetal part lies in the lower
segment ( presentation) and its mobility
• A single examining hand is placed just above the symphysis.
• The fetal part that overrides the symphysis is grasped
between the thumb and third finger. If the head is
unengaged, it is readily recognized as a round, hard object
that frequently can be displaced upward. After engagement,
the back of the head or a shoulder is felt as a relatively
fixed, knoblike part.
• In breech presentations, the irregular, nodular breech is felt
in direct continuity with the fetal back
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 PE- Abdomen
• Abdominal Findings in multiple gestation
– multiple fetal poles
– 2 fetal heart beats at 2 sites , a difference of > 10
bpm, FHR auscultated simultaneously by two
examiners ie for twin pregnancy

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 PE- GUS

Inspection
• Look for Normal development of the external genitals(The
Vulva)-
– Mons pubis (Veneris), Labia majora and minora, urethra, Skene
(paraurethral) Glands,Vestibule, Bartholins (Great vestibular) glands,
The Hymen, Fossa Navicularis
• Hair distribution-
– Normal findings-I
• Inverted triangle pattern with a base over the mons Pubis. The labia majora are
also covered
– Extension of hair to the abdomen is abnormal for females ( Hirsuitism)
• Look for skin lesions( warts), discharge (vaginal or
urethral),Scars, Swelling and Prolapse ( descent with or without
exertion)
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 PE-GUS

Speculum Examination
• Speculum Types
– Bivalved ( Pederson’s, Cusco’s, Grave’s
– Univalved (Sims ,Auvard)

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 Sims Speculum

Grave’s Speculum

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 PE- GUS
Speculum Examination
• Position- dorso lithilomy
• Warm and lubricate the speculum ( clean speculum for most
gynecologic examinations)
• Insert the speculum with the transverse diameter of the blades
anteroposteriorly and guide the blades through the introitus in a
downward motion with the tips pointing toward the rectum
• Then turn the blades so that their transverse axis is along with
the transverse axis of the vagina
• Open the blades after full length insertion of the speculum- the
cervix should be visible b/n the blades

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 PE- GUS

Speculum Examination
• Inspect the vagina and Cervix
– Vagina
• Discharge , inflammation (erythema), Mass (eg Gatner’s cyst)
– Cervix-
• External OS ( shape, discharge from), SCJ, Nabothian cysts,
Lesions (polyp, ulceration, nodularity, inflammation), bleeding
NB-
– Cervical Ca screening ( Cytology via Pap smear or visual
methods via VIA / VILI) can be performed if indicated
and possible.
– Discharge specimen is SAMUEL
02/03/2023
taken for wet mount and KOH test
BEZABIH 44
 PE- GUS, Pelvic Examination

Bimanual Examination -palpation of the uterus and the adnexa.

• Gloved and lubricated index and middle fingers of the dominant hand
are inserted deeply into the vagina so that they rest beneath the cervix
in the posterior fornix.
• The opposite hand is placed on the patient's abdomen above the pubic
symphysis. The flat of the fingers are used for palpation.
• The vaginal hand then elevates the uterus by pressing up on the cervix
and delivering the uterus to the abdominal hand so that the uterus may
be placed between the two hands,
• Both adnexa are also examined in the same way through the lateral
fornices
• Bimanual Examination helps identify
– Position ( often anteverted and anteflexed) , size, shape, consistency, and
mobility of the uterus
– Whether the adnexa are papable or not
–02/03/2023 SAMUEL BEZABIH
The presence or absence of uterine or adnexal masses
45
 Bimanual examination of
Bimanual examination of the the Adnexa
Uterus

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 PE- GUS, Pelvic Examination

Notice the following while performing Bimanual Exam-

ሀ Cervix
• Excitation / motion tenderness –
– Move the cervix gently to each side with one finger.
– Pain points at a tuboovarian mass (ectopic, abscess) or
inflammation.
• Consistency
– A normal cervix is firm (tip of nose) but not hard,
– in pregnancy it is softer with a firmer core.
– In cervical cancer the cervix can be hard, broad, with an
irregular surface.

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 PE- GUS, Pelvic Examination

ለ.Uterus
• Axis/ position
– Anteverted- anteflexed (most common), retroverted or straight
• Size
– Enlarged size pregnancy, leiomyoma, sarcoma etc
– A large tubo-ovarian mass can be mistaken for an enlarged
uterus. Uterne mass moves with the cervix but not adnexal
masses
• Consistency
– Normally firm , A gravid uterus is soft, uterine fibroids are hard or
at least firm; advanced uterine or cervical malignancy is often
hard but endometrium carcinoma can present as a soft enlarged
uterus as well.
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 PE- GUS- Pelvic Examiation

ሐ - Adnexa
• Mass
– Ovaries normally impalpable unless the woman is too slim
– Normal tubes are impalpable too even in slim women
– Adnexal masses can arise from ovarian cysts, solid benign tumors,
ovarian malignancy, hydrosalpinx, ectopic pregnancy, tubo-ovarian
abscess or rarely tubal malignancy.
• Tenderness
– pain in the adnexa can point to adnexitis or pelvic inflammatory
disease (PID) (most often bilateral), ectopic pregnancy (unilateral) or
ovarian cysts or hydrosalpinx (uni- or bilateral).
• Mobility –
– benign ovarian tumors such as a dermoid or ovarian cysts can be
freely moved
– TOA in frozen pelvis,advanced malignant ovarian tumors - immobile
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 Rectovaginal examination

• The rectovaginal palpation is not necessary in every

patient
• Often done in cases when there is suspicion of
malignancy, endometriosis or any process located in the
pouch of Douglas.
• It helps to assess the structures between the vagina and
rectum. Eg Rectovaginal septum,Uterosacral ligaments
• Mass, thickenig, tenderness of these structures may be
caused by malignancy, inflammation or endometriosis
• Retroverted uterus can also be examined ( size, shape,
consistency) through the RV route

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 Rectal Examination

• In virgins, a vaginal examination is avoided.

• Instead a well-lubricated finger inserted into the rectum can be used for a
bimanual assessment of the pelvic structures.
• Today, practically all gynaecologists prefer ultrasonic scanning to rectal
examination, which, apart from being unpleasant, is not that accurate.
• A rectal examination is a very useful additional examination whenever there is any
palpable pathology in the pouch of Douglas. It often allows the ovaries to be more
easily identified. In parametritis and endometriosis, the uterosacral ligaments are
often thickened, nodular and tender. It confirms the swelling to be anterior to the
rectum, and if the rectum is adherent to that swelling. This is important in case of
carcinoma of the cervix to determine the extent of its posterior spread.
• A rectal examination is mandatory in women having rectal symptoms. This should
begin by inspecting the anus in a good light, when lesions like fissures, fistula-in-
ano, polyps and piles may come to light. Introduction of a well-lubricated
proctoscope to inspect the rectum and anal canal helps to complete the
examination. Ultrasound today has reduced the importance of rectal examination
except in cancer cervix and pelvic endometriosis.
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