OBSTETRICS AND GYNAECOLOGY
Richard Shaw
Obstetric and Gynaecological History Formalities Wash Hands
Menstrual History Cycle Typical cycle length o o Regularity of cycles → 21-35d Bleeding 1st day of LMP and duration of menses → o 3-7d Flow o No. pads/tampons used in a day →4/5 Ever needed to double-up? >80mL/period = heavy Any flooding or clots? Post-coital or intermenstrual bleeding? Menarche/Menopause ?ranges?
Introduction - name, age, consent, confidentiality History of Presenting Complaint
Open Questioning →SOCRATES and specific differential questioning. Associated Symptoms o screen for bladder/bowel issues, vaginal or other orifice discharges screen for depression (sadness etc) Current Pregnancy Duration o LMP and EDD from USS Nägele's Rule: +1 yr, +7d, -3m How/When did you find out? Symptoms o Abnormal Per vaginal bleeding, pain/cramps, dyspareunia Normal Fatigue, nausea, vomiting, urinary frequency, breast tenderness, constipation, fluid retention, backache, weight gain, cravings, fetal movements after 20w Antenatal Care (See (See Antenatal Visit o Specifics) USS 18w morphology scan Vaccinations MMR Varicella Screening Test Antenatal blood tests Nuchal Translucency CVS Amniocentesis Partner o Do you have a partner? Are they the father? Was the pregnancy planned? Was it conceived naturally? Plans for the future? Risk Factor Questioning Specific risk factors to help DDx Smoking, Alcohol, IDU etc
Associated Symptoms Primary vs Secondary Dysmenorrhoea o (timing) PMS o Obstetric History
Gravidity and Parity (= births >20/52) When were these pregnancies? o Gestations (TermPremAbort Living /GxPx systems) o Fetal Outcomes o Ectopics, miscarriages (gestation at miscarriage) , terminations, normal birth Length of labour o Induced or spontaneous Delivery types and fetal presentations o Sex and birthweight of babies o Complications (ante, peri, postnatally) o Bleeding, infection, other? Sexual History
Initial framing question - why and consent. Are you sexually active? No → have you ever been sexually active? o Yes →How long have you been sexually o active for? When did you last have a sexual encounter with someone? Practices Oral, Anal, Vaginal? o Who does what? Insertive/Receptive, o Ejaculation? Do you have sex with men, women or both? o Partner o
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Regular or casual? type of relationship and duration Male or female partner? Similar symptoms?
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OBSTETRICS AND GYNAECOLOGY
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Partner risk assessment Ethnicity, IDU, Sex workers? How many sexual partners have you had in last 12 months? Male/Female/Both? Any sex worker/overseas local contact? Travel? Are you happy with your relationship?
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Protection from Pregnancy Are you using any form of protection or o contraception? Condom o % of times used When is it put on/taken off? When did you last have sex without one? Contraceptive devices or medications? o Are you concerned about getting o pregnant/your partner pregnant?* When did you last have unprotected sex? o
Protection from STI's Have you or your partners ever had an STI? o When? Diagnosis? Treatment? Partner? Ever been screened for HIV or other STIs? o Would you like to be screened? Have you or your partners ever injected o drugs? Vaccinations? Hep B, HPV, Hep A (for MSM o only)
UTIs, Vaginitis, Vulval Dermatitis, Fibroids etc Pap Smears Last pap smear results o Past Medical/Surgical History
Any surgeries? Gynaecological/Pelvic or otherwise?
Ever required a blood transfusion?
Weight gain/loss?, thyroid disease, epilepsy
DVT, ID-DM, Lung and Heart Disease, H/T, Jaundice Medications and Allergies Drugs Prescribed drugs? o Over the counter drugs? o Herbs/supplements? o OCP/HRT
Allergies/Drug Allergies Penicillin? Latex? o Family History
Is there anything about your current sex life you are concerned about?
Have you ever been sexually abused or the subject of domestic violence? Gynaecological History
Contraception Type of contraceptive being taken and o why? Are you happy with your current o contraception? Planning on having a family in the future? o COCP o Type/brand, dose Variation in times taken. Frequency of missed pills S/E's and physiological impacts STIs (5th P of the 5 P's of Sexual History) Gonorrhoea, Chlamydia, Syphilis, HIV, o Herpes, HPV, Hepatitis
Osteoporosis, hirsutism etc as relevant Psychosocial History
PIDs o
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Salpingitis, endometritis
Drugs Smoking, Alcohol, Recreational Drugs Home Supports Is there anyone at home to support you? o Where do you live and what type of o accommodation is it? Childcare arrangements? o Plans for breastfeeding? o o
Any conditions that run in the family? Endometriosis, PCOS, o cervical/ovarian/breast/colon cancer DM, DVT, H/T, Heart and Lung disease o Twins in the family? o Timing of menopause in family members if relevant
Others o
Richard Shaw
Relationship Stability? o Education/Employment/Financial → WHACS ADLs and other activities Sleep, appetite, micturition, defecation o Exercise/Diet/Community Activities/Other
OBSTETRICS AND GYNAECOLOGY
Richard Shaw
Obstetric and Gynaecological Examinations Gynaecological Examination
Explain why you want to perform this examination.
Explain what this examination will involve.
Questions to ask beforehand: Have you ever had this examination done before? o Are you currently pregnant? o Can't use brush or combi Are you currently on your period? o Makes PV examination difficult Have you had any children? Were they vaginal o births? Alters method of speculum insertion
Would you like someone else to be in the room during the examination? A chaperone.
Palpation Is there pain anywhere in your abdomen? Palpate this area last.
Light Palpation
Deep Palpation
Liver
Spleen
Put on gloves, and re-explain to patient what you intend to do.
Pelvis Inspection
Ideally would also ask patient to empty bladder and bowels beforehand → more comfortable examination.
Pubic hair distribution Normal anatomy features Labia majora o Labia minora o Vaginal and urethral openings → discharges? o Blood discharge
Ensure all equipment is present before s tarting: Speculum o KY Jelly o Swabs/Cervical Samplers o Broom and Brush (or Combi) Brush/Combi not for pregnant women Slides and Fixation Spray o Appropriate details must be written on slide in pencil before beginning Lighting o Gloves o
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Position and Exposure
Patient supine with legs apart, ankles together and knees bent (frog-legged position).
Perineum should be brightly illuminated with a lamp.
General Inspection Mentally alert and orientated
Respiratory distress and/or anxiety
Abdomen (ideally full abdominal examination)
Vaginal atrophy (elderly) Palpation
Inspection
Skin quality
Abdominal distension and masses
Scars and Striae
External genitalia Tenderness, o Lumps and bumps o Bartholin cyst or Abscess
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Skin lesions Features of thrush or trichomoniasis o Leukoplakia Redness Swelling Excoriation Ulceration o Rashes o Warts o Scars o Sinus openings o
Allow patient to undress and put on gown in privacy and ensure there are plenty of sheets.
Vaginitis, cervicitis, endometritis, retained tampon Physiological discharge If discharge present, inspect/describe it, swab it and seal in container. Clitoral shape and size
Menses, cancer, miscarriage, cervical polyp or erosion Purulent discharge
Separate labia and palpate in posterior part of L. majora
Cough Test Stress incontinence o Cystocoele → bulge from anterior o Rectocoele → blge from posterior o Uterine Prolapse o Cervix (tell patient what you intend to do) Put KY Jelly on right index and middle finger o Separate labia with thumb and forefinger of left o hand and insert right fingers into vagina
OBSTETRICS AND GYNAECOLOGY
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Position (which way cervix is pointing) Post (normal), ant or central Consistency/Surface(nose in nulliparous) Hard, soft or lumpy Nabothian cysts Size, Shape, Mobility Tenderness Tactile tenderness Excitation tenderness
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External Os Dilatation/effacement
Fornices o
Uterus o
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Fingers in vagina are kept high up and rotated to face upwards while left hand presses/rocks above symphysis (perpendicular to linea alba) Fundal height Tenderness Period Pain Adenomyosis Position Angle between cervix and vagina Anteversion
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Most women, where the uterus lies on top of the bladder, pointing posteroinferiorly
Axial
Uterine lumen is parallel to vaginal lumen Retroversion
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Majority of uterus lies in uterorectal pouch rather than overlying the bladder
Angle between uterine lumen and cervical canal Retroflexion Distal uterus is in normal position (cervix pointing posteroinferiorly) but the body is bent backwards occupying uterorectal pouch Anteflexion
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Distal portion of uterus is in normal position but fundus points anteriorly and inferiorly. Normal position
Speculum Examination
Conveyed as a gravid uterus in weeks of pregnancy (e.g. 18 week uterus) Normal size is approximately a fist Shape/Surface Smooth and enlarged
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Pregnancy
Warm speculum with warm water during abdominal examination → check temperature on skin KY jelly can be used but may interfere with some cytology examinations Hold speculum with gun grip (handle facing up) and stand on the right side of the patient - touch speculum to fourchette (talk to patient the whole way through) Spread labia with left h and and insert speculum Nulliparous - bills parallel to labia o Multiparous - maybe perpendicular to labia o Turn handle towards ceiling with insertion Resistance before complete insertion → reached o flexion of vagina as it passes through the pelvic diaphragm → angle speculum more posteriorly
(Warn patient) Open speculum with left hand, visualise the cervix and lock nut with right h and Inspection
Vagina
Cervix o
Parity
Nulliparous → dot or circle Multiparous → curved line
Pap Smear
Size
Adnexa
Turn fingers laterally to each side in turn and bimanually palpate with left hand Attempt to feel for o Fallopian tubes Broad ligament Adnexal masses or tenderness Ask about tenderness/pain o Withdraw fingers and observe glove for any discharge (+/- smell for distinctly pungent odour)
Flexion
Consistency Soft → pregnanc y Hard → fibroids Mobility ↓ due to adhesions Masses Uterine masses move with cervix and adnexal masses do not
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Fibroids
Anterior, posterior and lateral
Submucous fibroids
Tender when moved around
Knobbly
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Adenomyosis
Richard Shaw
Important to get cells samples from External cervix (preferably transformation zone) o Endocervical cells o Remember Pap smear ideal at detected precancerous cells and cervical cancer detecting sensitivity is only 50% Do not use brush or combi on a pregnant women May rupture the fetal membranes and cause o miscarriage or premature birth
OBSTETRICS AND GYNAECOLOGY
Ensure appropriate details have been written on slide in pencil beforehand.
With each device: Rotate through 360° at the squamous-columnar o junction (transitional zone) Remove and sweep across slide twice (one swipe o on each side) (brush → roll) Fix slide with fixant spray o If available, put the brush into a thin prep or o short prep container → also good when there is bleeding or discharge Speculum removal Loosen nut o Keep bill open initially to prevent closure over o the cervix Once again rotate the bills back to parallel with o the labia when exiting the introitus
Obstetric Examination Distress of mother?
Obese
BMI (e.g. height and weight)
BP, HR, Temp.
UA
FHR/CTG
Left occipito-anterior is most common position and lie Longitudinal, Oblique (fetal head in iliac fossa, usually due to full bladder) or Transverse
Presentation (Palpable after 26 weeks) Fetal part occupying lower segment/pelvis o Cephalic o Further subdivided by attitude → rel ationship of fetal head to spine → flexed (best), neutral, extended Breech (4%) o
General Inspection
Richard Shaw
Engagement "fifths palpable" → fraction out of 5 o The fetal head can be palpated bimanually o Both hands placed on imaginary line between the two ASIS with fingers pointed inferiorly and medially Then "ballot" the head between hands Usually palpable after 37 weeks o
Fetal Movements
Has the baby been moving normally? Starts at 18-20 weeks in nulliparous women and o 15-17 weeks in multiparous women. Movements reduce after 36 weeks but should still be investigated → maternal kick chart
Abdominal
Inspection Striae o Linea alba o Scars o
20-36 weeks +/- 2cm
36-40 weeks +/- 3cm
40 weeks +/- 4cm
Lie
Uterine Irritability Same technique as amniotic fluid palpation but o contractions → often an abnormal finding
Palpation Fundal height (need to know gestation from Hx) o Fundus to pubic symphysis Most important is increasing height on serial measurement (until engagement) 12/52 → fundus just palpable above pubic symphysis 20/52 → fundus at umbilicus General rule → fundal heig ht is gestation in weeks from LMP
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Amniotic Fluid "Ballot" the amnion between hands and feel o how tense it is (hands like oven mits) Abnormality suspected → use USS o o Excess fluid → polyhydramnios o Insufficient fluid → oligohydramnios
fingers spread → ↑ sensitivity to uterine
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Relation of fetal long axis to maternal long axis
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Intrauterine growth restriction
Fetal Heart Sounds Using Dopper device/Pinar stethoscope o Like a horse galloping and not the "whooshing" o noise of placental blood flow Palpate maternal radial pulse to confirm that o HR found is different to maternal HR Fetal HR may undergo decelerations in: o Squeezing of cord Hypoxia Cephalic pressure during labour Best found over anterior shoulder of fetus o
OBSTETRICS AND GYNAECOLOGY
Speculum Examination Vaginal Examination
Dilatation
Effacement
Position o o
Station o
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Occiput in relation to maternal pelvis Assists with finding best location to listen for fetal heart sounds (over anterior shoulder) Level of presenting part in relation to maternal ischial spines
Bishops Score <7 → not favourable o > or = 7 → favourable o
Richard Shaw
OBSTETRICS AND GYNAECOLOGY
In Addition
Cardiovascular Examination
Respiratory Examination
Breast Examination
Lymph Nodes Examination
Skin Examination Oedema o Spider angioma o Striae o Linea nigra o Other examinations as directed by the history Oedema of legs o Reflexes o Clonus o Signs of anaemia o
Post Partum Assessment Initial Questioning
What day post partum? Mode of delivery: Caesarean o Vaginal o Instrumental o
Any perineal trauma sustained at birth?
Passing urine?
Bowels/flatus?
Lochia (PV discharge) Blood, mucus, placental tissue o
Breasts
Breast or bottle feeding?
Tenderness/redness/cracked nipples?
Educate on mastitis Antenatal Card
Blood pressure - need BP check with GP
Abnormal LFTs - need repeat
Diabetes - need 75g GTT at 6/52
Ensure appropriate follow-up on discharge
Blood Group Does she need anti-D? o
Rubella Immunity Does she need MMR? o Pap Smear
If not done in past 2 years, need to see GP at 6 weeks Contraception
Ask about plans
Give options if unsure
Arrange if concerned about patient following up (e.g. young, multiple unplanned pregnancies)
Can start hormonal contraception ~3-6 weeks post partum Examination
BP
Fundus o o
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Should be firm and below umbilicus Perineum if suturing
Richard Shaw
If 3rd/4th degree tearing, need referral to pelvic floor clinic
Anything else relevant on history (e.g. complaint of sore calf muscles)
