Transcript Obstetric & Gynaecology History & Clinical Examination

Practical issues, History taking & Clinical
examination in O&G
Hervinder Kaur
Consultant Obstetrician & Gynaecologist, UHCW
Obstetric & Gynaecology Lead for Warwick
Medical School
LEARNING OBJECTIVES
 To develop the basic clinical skills of history taking, clinical
examination and case presentation in O & G.
 To obtain knowledge of the common clinical problems in O & G.







ANC :
Booking visit :
History taking
Investigations ( booking bloods & scan)
Down’s syndrome screening
Health promotion advice- smoking, alcohol, drug abuse
& diet
Management plan
High/Low risk pregnancy?
LEARNING OBJECTIVES CONT….
 Examination of pregnant women
 Pre eclampsia, IUGR, Large for dates , polyhydramnios,
breech/ transverse lie, twins , previous caesarean, grand
multiparous , Obesity & placenta previa
 Medical disorder- Diabetes , thyroid problems, essential
HTN, Cardiac, renal, drug misuse, Hepatitis/HIV.
 Pre-operative counselling for C-section





Emergency Obstetric Admissions
Abdominal pain
Preterm labour/ SROM
Ante/postpartum bleeding
Pre eclampsia/ Eclampsia
Obstetric Day Assessment Unit
•Antenatal fetal assessment- CTG, USS (growth/liquor/doppler)
•Maternal assessment-BP/urine, blood test (PET, GTT)
Labour Ward
•Induction of labour
•Management/Complications of labour
•Normal deliveries
•Fetal Monitoring in labour
•Pain relief in labour
•Instrumental deliveries & Caesarean sectionelective/emergency
•Twins
•Preterm labour
•HDU care- PPH, Severe pre eclampsia/eclampsia
EPAU
•Early pregnancy scan
•Miscarriage
•Ectopic pregnancy
•Molar pregnancy
GOPD
•History taking
•Gynaecological examination-abdomen, pelvis (speculum,
digital bimanual)
•Investigation & management of menstural abnormalities
•Investigation & management of pelvic pain/endometriosis
•Diagnosis & management of menopause
•Urogynae clinic-Management of prolapse
& incontinence
•Infertility clinic- Management of male & female infertility
•Oncology –Management/follow-up of gynae cancer
& management of abnormal smear (colposcopy clinic)
GUM clinic
•Obtain sexual lifestyle history
•Understand relevance of confidentiality and
being non-judgmental.
•Genital examination and swabs from couple
•STD- diagnosis & treatment
•Pre/post test counselling for HIV
Community
•Home visits - Postnatal examination
(caesarean scar, perineal tears)
•Pre eclapmsia surveillance
•Community midwife ANC
PORTFOLIO CASES
 Obstetrics:
1.
2.
3.
4.
5.
6.
7.
8.
A normal pregnancy delivery and puerperium
Antepartum/postpartum haemorrhage
An abnormality of fetal growth and development
Pre-eclampsia
Medical disease complicating pregnancy
Multiple pregnancy
Abnormal labour
A third stage abnormality
•Gynaecology
1. Menstural disorder
2. Endometriosis
3. Prolapse
4. Incontinence
5. Infertility
6. Postmenopausal bleeding
7. Early pregnancy complication
Obstetric History




Age
Gravidity
Parity- (Preg>24 wks)+(Preg< 24wks)
LMP; menstural cycle; conceived on pill; EDD
 History of this pregnacy :
- Presenting complaints- when did they occur &
how long they lasted, any investigation or
treatment already ?
- Low/high risk pregnancy?
- Any problems in antenatal care so far ?
- Fetal movements
Obstetric History

-
Previous pregnancy:
Previous miscarriages
Gestation & mode of delivery
Length of labour & complications
Third stage complications
Postnatal problems
 Medical & surgical history
 Drug history & allergies
 Family history- hereditary disorders, HTN,DM, twins or
congenital malformation
 Social history- smoking, alcohol, drug misuse,
occupation, housing & marital status
Examination
 Consent, explanation & beware of
supine hypotension
 General examination
-Colour
-Hand, eyes & mouth
-Presence of oedema
-BP & Urine
-CVS & Respiratory system
examination
Abdominal Examination
 Inspection: abdominal scars
striae gravidarum
linea nigra
oedema
Abdominal palpation
P alpation of pregnant abdomen:
1. Examination of uterine
fundus
Symphysio- fundal
height(cm)
2. Fetal back
3. Presenting part e.g
vertex, breech
4. Engagement of
presenting part
Four maneuvers
of leopold
Lie of Fetus
Lie: relationship of long.
axis of fetus to long.axis
of uterus e.g longitudinal,
transverse, oblique
Longitudinal lie
Transverse lie
Presentation of fetus
Presentation:
presenting part of fetus
occupying the lower pole
of uterus i.e ceph(vertex),
breech,face,brow or
shoulder
Female bony pelvis
Right
Left
Side
side
Pelvic diameters:
Anterio-posterior
Transverse
Oblique
Abdominal Examination
Position: Relation
of denominator
(occiput/ sacrum) of
presenting part to
the quadrants of
pelvis e.g
LOA,LOP
1. Left Occipito- anterior
2. Left Occipito- posterior
Abdominal Examination
G
Amniotic fluid
 Auscultation:
FETAL HEART
Engagement: Widest
diameter of head below the
pelvic brim.
No. of 5th head palpable
above the pelvic brim e.g
4/5th , 3/5th
Fetal skull
s
Bregma
Occiput
Mentum
Parts of fetal skull:
a) Occipital bone
b) Posterior fontanella
c) Saggital suture
d) Frontal bone
e) Anterior fontanelle
f) Parietal bone
Presenting diameters:
g) Face presentation
Submento-bregmatic
h) Deflexed OP
Occipito-frontal
i) Brow presentation
Occipito-mental
j) Normal vertex
Sub-occipito bregmatic
Vaginal Examination
 Vulva & vagina
 Cervix-dilatation ,effacement, position & consistency
 Presenting part i.e Vertex
 Station-cm in relation to the ischial spine
 Caput-swelling on the scalp superficial to periosteum of
cranium ,as a result of venous congestion, on the part of
head most in advance
 Moulding- Overriding of the bones of skull
 Membranes & Liquor
Vaginal Examination
s
Station -3
Station +3
Station- position of presenting part
(PP) in cm in relation to the ischial
spine
Mechanism of labour
LOA position:
1. Free head
2. Descent &
engagement
3. Descent & Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Restitution
8. Delivery of shoulder
Useful website for medical
illustration
 Nucleus Medical Media
Normal vaginal delivery anim002
Normal vaginal birth ANC00030
Delivery ANC00037
Birth station of presentation ANC00038
Change in cervix during pregnancy S15551477
Gynaecological History
 Age, Gravidity, Parity, LMP
 Contraception
 Last cervical smear
 Presenting complaints:
Nature & duration
Relation to menstrual cycle
Bowel symptoms
Urinary symptoms
Vaginal discharge
Vaginal bleeding
Gynaecological History
 Previous Gynaecological & Obstetric History:
PID/STI
Endometriosis
Previous miscarriages / preg<24 wks
Ectopic pregnancy
Pregnancies>24 wks & outcome
History cont….
 Medical
 Surgical
 Family history- Fibroids, endometriosis,
cancers, DVT/PE
 Medications
 Allergies
 Social History
 General- Conjunctiva, pulse
 Abdomen:
- Inspection- distension of abdomen
mass
previous scar
- Palpation- tenderness
mass( size, consistency)
ascites
lymph nodes
- Percussion
- Auscultation
Examination
Vaginal Examination
 Vulva
 Speculum (Cusco’s & Sim’s)
- vagina (atrophy, mass, trauma, prolapse)
- cervix (ectropion, polyp, growth, contact bleeding,
- uterine prolapse
 Bimanual pelvic exam. – uterine/ adenexal masses
tenderness
Competencies (Mandatory)
 Examination of pregnant abdomen
 Examination of non-pregnant abdomen
 Speculum(Cusco’s speculum)
examination
Demonstratio
n