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) Downs 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 Side Left 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 (Cuscos & Sims)

- 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(Cuscos speculum) examination

Demonstratio n