Practical issues, History taking & Clinical examination in O&G

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Practical issues, History
taking Clinical examination in OG

• Hervinder Kaur
• Consultant Obstetrician Gynaecologist, UHCW
• Obstetric Gynaecology Lead for Warwick
  Medical School

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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?

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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

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• 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 section-
  elective/emergency
• Twins
• Preterm labour
• HDU care- PPH, Severe pre eclampsia/eclampsia

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• 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

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• 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

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• Community
• Home visits - Postnatal examination
• (caesarean scar, perineal
  tears)
• Pre eclapmsia surveillance
• Community midwife ANC

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PORTFOLIO CASES

• Obstetrics
• 1. A normal pregnancy delivery and puerperium
• 2. Antepartum/postpartum haemorrhage
• 3. An abnormality of fetal growth and development
• 4. Pre-eclampsia
• 5. Medical disease complicating pregnancy
• 6. Multiple pregnancy
• 7. Abnormal labour
• 8. A third stage abnormality

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• Gynaecology
• 1. Menstural disorder
• 2. Endometriosis
• 3. Prolapse
• 4. Incontinence
• 5. Infertility
• 6. Postmenopausal bleeding
• 7. Early pregnancy complication

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Obstetric History

• Age
• Gravidity
• Parity- (Preggt24 wks)(Preglt 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

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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

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Examination

• Consent, explanation beware of supine
  hypotension
• General examination
• -Colour
• -Hand, eyes mouth
• -Presence of oedema
• -BP Urine
• -CVS Respiratory system examination

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Abdominal Examination

• Inspection abdominal scars
• striae gravidarum
• linea nigra
• oedema

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Abdominal palpation
alpation of pregnant abdomen
P

• Examination of uterine fundus
• Symphysio- fundal height(cm)
• Fetal back
• Presenting part e.g vertex, breech
• 4. Engagement of presenting part

Four maneuvers of leopold
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Lie of Fetus

• Lie relationship of long.
• axis of fetus to long.axis
• of uterus e.g longitudinal,
• transverse, oblique

Longitudinal lie
Transverse lie
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Presentation of fetus
Presentation presenting part of fetus
occupying the lower pole of uterus i.e
ceph(vertex), breech,face,brow or shoulder
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Female bony pelvis
Right Side
Left side
Pelvic diameters Anterio-posterior
Transverse Oblique
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Abdominal Examination

• Left Occipito- anterior
• Left Occipito- posterior

• Position Relation of denominator
  (occiput/ sacrum) of presenting part to the
  quadrants of pelvis e.g
• LOA,LOP

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Abdominal Examination


G
Engagement Widest diameter of head below the
pelvic brim. No. of 5th head palpable above
the pelvic brim e.g 4/5th , 3/5th

• Amniotic fluid
• Auscultation FETAL HEART

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Fetal skull
s



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Bregma
Occiput
Mentum
Presenting diameters g) Face presentation
Submento-bregmatic h) Deflexed OP
Occipito-frontal i) Brow presentation
Occipito-mental j) Normal vertex Sub-occipito
bregmatic

• Parts of fetal skull
• Occipital bone
• Posterior fontanella
• Saggital suture
• Frontal bone
• Anterior fontanelle
• Parietal bone

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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

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Vaginal Examination


s

Station -3
Station 3
Station- position of presenting part (PP) in cm
in relation to the ischial spine
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Mechanism of labour
LOA position

• Free head
• Descent engagement
• Descent Flexion
• Internal rotation
• Extension
• External rotation
• Restitution
• Delivery of shoulder

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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

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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

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Gynaecological History

• Previous Gynaecological Obstetric History
• PID/STI
• Endometriosis
• Previous miscarriages / preglt24 wks
• Ectopic pregnancy
• Pregnanciesgt24 wks outcome

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History cont.

• Medical
• Surgical
• Family history- Fibroids, endometriosis, cancers,
  DVT/PE
• Medications
• Allergies
• Social History

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Examination

• General- Conjunctiva, pulse
• Abdomen
• Inspection- distension of abdomen
• mass
• previous scar
• Palpation- tenderness
• mass( size, consistency)
• ascites
• lymph nodes
• Percussion
• Auscultation

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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

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Competencies (Mandatory)

• Examination of pregnant abdomen
• Examination of non-pregnant abdomen
• Speculum(Cuscos speculum) examination

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Demonstration