Practical issues, History taking &

Clinical examination in O&G

Practical issues, History taking &

Clinical examination in O&G

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

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

LEARNING OBJECTIVESLEARNING 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?

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….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

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 section- elective/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 CASESPORTFOLIO CASES

Obstetrics:

1. A normal pregnancy delivery and puerperium2. Antepartum/postpartum haemorrhage 3. An abnormality of fetal growth and development4. Pre-eclampsia5. Medical disease complicating pregnancy6. Multiple pregnancy7. Abnormal labour 8. A third stage abnormality

Obstetrics:

1. A normal pregnancy delivery and puerperium2. Antepartum/postpartum haemorrhage 3. An abnormality of fetal growth and development4. Pre-eclampsia5. Medical disease complicating pregnancy6. Multiple pregnancy7. Abnormal labour 8. A third stage abnormality

•Gynaecology

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

Obstetric HistoryObstetric 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

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 HistoryObstetric 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

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 Examination

Consent, explanation & beware of supine hypotension

General examination -Colour -Hand, eyes & mouth -Presence of oedema -BP & Urine -CVS & Respiratory system

examination

Consent, explanation & beware of supine hypotension

General examination -Colour -Hand, eyes & mouth -Presence of oedema -BP & Urine -CVS & Respiratory system

examination

Abdominal ExaminationAbdominal Examination

Inspection: abdominal scars striae gravidarum linea nigra oedema

Inspection: abdominal scars striae gravidarum linea nigra oedema

Abdominal palpationAbdominal palpation 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

P

Lie of Fetus

Longitudinal lie

Transverse lie

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

Presentation of fetus

Presentation: presenting part of fetus occupying the lower poleof uterus i.e ceph(vertex),breech,face,brow orshoulder

Female bony pelvisFemale bony pelvis

Pelvic diameters: Anterio-posterior Transverse Oblique

Right

Side

Left

side

Abdominal ExaminationAbdominal Examination

Position: Relation of denominator (occiput/ sacrum) of presenting part to the quadrants of pelvis e.g

LOA,LOP

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

Abdominal Examination

Amniotic fluid

Auscultation: FETAL HEART

Amniotic fluid

Auscultation: FETAL HEART

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

Fetal skullFetal skull

s

Parts of fetal skull:a) Occipital boneb) Posterior fontanellac) Saggital sutured) Frontal bonee) Anterior fontanellef) Parietal bone

Presenting diameters: g) Face presentation Submento-bregmatich) Deflexed OP Occipito-frontali) Brow presentation Occipito-mentalj) Normal vertex Sub-occipito bregmatic

Bregma

Mentum

Occiput

Vaginal ExaminationVaginal 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

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 ExaminationVaginal Examination

Station -3

Station +3

s

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

Mechanism of labourMechanism of labour

1. Free head2. Descent &

engagement3. Descent & Flexion 4. Internal rotation5. Extension6. External rotation7. Restitution8. Delivery of shoulder

LOA position:

Useful website for medical illustration

Useful website for medical illustration

Nucleus Medical Media

Normal vaginal delivery anim002Normal vaginal birth ANC00030Delivery ANC00037Birth station of presentation ANC00038Change in cervix during pregnancy

S15551477

Nucleus Medical Media

Normal vaginal delivery anim002Normal vaginal birth ANC00030Delivery ANC00037Birth station of presentation ANC00038Change in cervix during pregnancy

S15551477

Gynaecological HistoryGynaecological 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

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 HistoryGynaecological History

Previous Gynaecological & Obstetric History:

PID/STIEndometriosisPrevious miscarriages / preg<24 wksEctopic pregnancyPregnancies>24 wks & outcome

Previous Gynaecological & Obstetric History:

PID/STIEndometriosisPrevious miscarriages / preg<24 wksEctopic pregnancyPregnancies>24 wks & outcome

History cont…. History cont….

Medical Surgical

Family history- Fibroids, endometriosis, cancers, DVT/PE

Medications Allergies

Social History

Medical Surgical

Family history- Fibroids, endometriosis, cancers, DVT/PE

Medications Allergies

Social History

ExaminationExamination General- Conjunctiva, pulse

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

General- Conjunctiva, pulse

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

Vaginal ExaminationVaginal 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

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) Competencies (Mandatory)

Examination of pregnant abdomen

Examination of non-pregnant abdomen

Speculum(Cusco’s speculum) examination

Examination of pregnant abdomen

Examination of non-pregnant abdomen

Speculum(Cusco’s speculum) examination

DemonstrationDemonstration