Clinical methods in obstetrics and gynecology.ppt

Lecture notes

1. Clinical methods in obstetrics
and gynecology

JULIA MUTETI

2. Initial Assessment and
Communication
•There is need to ascertain the patient's
general health status, social, and familial
situation .
•The physician should avoid being
judgmental, particularly with respect to
questions about sexual practices and
sexual orientation.
•Good communication is essential to
patient assessment and treatment.

3. Cont’
•The foundation of communication is based
on key skills: empathy, attentive listening,
expert knowledge, and rapport.
•For physician/patient communication to be
effective, the patient must feel that she is
able to discuss her problems fully.
•The intimate and highly personal nature of
many gynecologic conditions requires
particular sensitivity to evoke an honest
response.

4. Cont’
•After a dialogue has been established, the patient
assessment proceeds with obtaining a complete history
and performing a physical examination.
•Both of these aspects of the assessment rely on good
patient/ physician interchange and attention to details.
•At the completion of the physical examination, the
patient should be informed of the findings.
•When the results of the examination are normal, the
patient can be reassured accordingly. When there is a
possible abnormality, the patient should be informed
immediately; this discussion should take place after the
examination with the patient clothed.

5. History
•The components are like any other medical
patient but with emphasis on obs/gyn issues
•Format similar for both obstetric and
gynecological patient
•Components:-
-Personal information
- Presenting complaint(s)
- History of presenting illness
- Obstetric and gynecological history
- Past medical/surgical history
- Family and social history
- Systemic Inquiry

6. Personal Information
•Name
•Age
•Sex
•Residence
•Marital status
•Religion
•Occupation
•Next of kin
•Informant

7. Presenting complaints
•Main reason(s) why the client/patient is
seeking attention
•Listed/presented in chronological order
•Use patients/clients own words
•Referred or patients admitted through clinic
may not give a typical presenting complaint

8. History of presenting complaints
•Specifies the chronological order of events
and symptoms up to the time of interview
•Gives details of every symptom/complaint
including associated factors e.g. Pain
include location, onset, radiation, intensity,
character, associated and relieving factors
• Includes all tests done and treatments
given plus their outcomes as reported by
the patient

9. Obstetric history
•Past obstetric history- is one of the most important
areas for establishing risk in the current pregnancy
- parity
- details of each pregnancy-outcome, year, place
of delivery, mode, duration of labour, gest age,
weight, sex, complications

•Present obstetric
- LMP, EDD, period of amenorrhea
- ANC attendance
- disorders encountered

10. Gynecological history
•Menstrual history-LNMP
- menarche, duration of flow, cycle
length, quantity, regularity, dysmenorrhea.
•Sexual history – coitarche, sex partners,
disorders, post coital bleeding,dyspareunia
•Contraceptive history-type ,duration, any
complications, reasons for discontinuing
•STI’s exposure-include
treatments/complications
•Reproductive tract cancers screening – pap
smear, VIA, VILI, scans, mammogram

11. Note:
•Gynecological history usually comes first in
a gynecological patient
•PMHx may precede Ob/Gy history in case
of a medical disorder in pregnancy

12. Past medical and surgical history
•Relevant medical disorders-
systemic ,metabolic or endocrinal should
be enquired
•Past surgical history includes general,
obstetrical or gynecological surgery
•The nature of the operation, anesthetic
complications if any
•Current treatments not related to the p/c.
•Any known allergies

13. Family and social history
•Personal history- Position in the family,
Occupation, marital status
•Socio-economic history-view the daily
habits, diet
•Familial illnesses-hereditary disorders
•Chronic illnesses –Tubercular affection of
any family member

14. Systemic inquiry
•Targets all other systems not dealt with in
the HPI
•Ensures that other symptoms that may
not have been considered important are
captured
•Looks at a patient as a whole rather than
as a system

15. Note:
•A summary of the history should be made
immediately after the systemic inquiry

16. Physical examination
•A physical examination requires a
cooperative patient and a quiet, warm and
well-lit room, equipped and a couch
• Adequate privacy should be ensured
•Begins with appropriate positioning
•A chaperone or another health worker
should preferably be present when
invasive examination is to be done

17. Components
•General examination
•Systemic examination
- Inspection
- Palpation
- Percussion
- Auscultation

18. General examination
•All components important
•General appearance/condition
-Does the patient look healthy,unwell, well
groomed or unkept
-intelligence ,mental status, expression, gait
- nutritional status
- hydration status
- pallor
- jaundice
- edema, cyanosis
•Vital signs

19. Systemic examination
•Systems considered:
- CVS, RS, Per Abdomen, CNS,
Musculoskeletal
•Examination begins with the system with
most positive findings
•All positive and negative findings on per
abdominal exam should be given.
•All systems examined in every patient

20. Abdominal Examination
INSPECTION
•Distension – presence/absence, degree,
symmetry
•Movement with respiration
•Status and position of umbilicus
•Presence/absence of linear nigra, striae
gravidarum
•Surgical incisions, other scars
•Distended superficial vessels, herniae

21. Abdominal exam
PALPATION
•Superficial palpation – obvious masses,
tenderness, temperature
•Deep palpation – looks for specific organ
enlargement, describes the various
characteristics of masses present.
•Uterine enlargement due to pregnancy
described by Leopold maneuver

22. LEOPOLD MANEUVER
• Fundal height -Fundal grip- determine
fundal contents/approximate duration of
pregnancy in terms of weeks of gestation
•The palpation is done facing the patients
face, the ulnar border of the left hand is
placed on the upper most level of the
fundus and an approx. duration of
pregnancy is ascertained
•Conditions where the height may not
correspond with period of amenorrhea

23. Cont’
More than period of amenorrhoea
1.Mistaken date of the last menstrual period
2.Twin pregnancy
3.Polyhydramnios
4.Big baby
5.Pelvic tumors
6.Hydatidiform mole
7.Concealed accidental hemorrhage
Less than Gestational period
1.Mistaken date of the last menstrual period
2.Scanty liquor
3.Fetal growth retardation
4.Intrauterine fetal death

24. Cont’
•Fundal grip-The whole of the fundal area
is palpated using both hands laid flat on it
to find out which pole of the fetus is lying
in the fundus ( breech, head)
•If broad, soft consistency/ irregular mass -
breech
•If hard, smooth, well defined - head

25. Cont’
•Move your fingertips over the fetal mass to
determine mobility and size
•If can’t move independent from the body-
breech
•If moves freely between fingertips - head
•In Transverse Lie, neither of the fetal poles
are palpated in the fundal area

27. • lie of fetus -lateral grip– relationship of
long axis of fetus to that of the mother,
direction of fetal back
•Done facing the patient’s face
•Hands are placed on each side of the
umbilicus. The fetal back will palpate as
smooth curved, firm, flat and linear. The
fetal extremities are palpable by their
varying contour and movements. The
purpose of this maneuver is to determine
whether the fetal back is left or right.

29. • Presenting part- Pawlik's grip– portion
of fetus lower most in uterus adjacent to
the pelvic inlet
•Done facing towards the patient’s face
•Grasp the lower poles of the uterus
between fingers and thumbs and comment
of the size, flexion and mobility of the
head.In transverse lie pawlik’s is empty
•Engagement –Pelvic grip– whether or not
a portion of presenting part gone below the
level of the inlet. During labor, descent
should then be determined

30. •Four fingers of both the hands are placed
on either sides of the midline in the lower
pole of the uterus and parallel to the
inquinal ligament
•The fingers are pressed downwards and
backwards in a manner of approximation
of fingers tips to palpate the part
occupying the lower pole of the uterus
(presentation)
•If it is head,note the precise presenting
area, attitude, and engagement

32. Auscultation
Fetal Heart
•Along the fetal back .in vertex or breech the
convex portion of the back is in contact with
the uterine wall.
•The maximum intensity of the F.H.S is
below the umbilicus in cephalic and around
the umbilicus in breech

33. Percussion and Auscultation
•Percussion has little role in obstetrics –
delineation of indistinct masses or uterus
•Auscultation looks for presence and
characteristics of the fetal heart – rate,
regularity, loudness/clarity
•Maternal bowel sounds may also be
looked for in some instances

34. Pelvic examination
•The pelvic examination is usually performed
with the patient in the dorsal lithotomy
position
•The patient is instructed to empty her
bladder. She is placed in the lithotomy
position and draped properly.
•The examiner is gloved,. The pelvic area is
illuminated well, and the examiner faces the
patient.

36. Vaginal examination
•Inspection of the external genitalia –
 Abnormality of superficial structures (external genitalia)
Abnormal discharge /bleeding
Masses/growths
Warts
Injuries
Skin colour change
FGM

37. Bimanual Exam
•The pelvic organs can be outlined by
bimanual palpation
•Clean vulva
•The examiner places one hand on the lower
abdominal wall and the index and the
middle fingers of the other hand is
introduced gently into the vagina(lubricated)
at the posterior aspect near the perineum

38. Bimanual exam cont,
•Test the strength of the perineum by
pressing downward on the perineum and
asking the patient to bear down
•Advance the fingers along the posterior
wall until the cervix is encountered.
•Palpate and note
Open or closed, irregularity, growth,
consistency, mobility, tenderness

39. Bimanual Exam cont,
•Press the abdominal hand, which is
resting on the infraumbilical area.very
gently downward, sweeping the pelvic
structures toward the palpating vaginal
fingers
•Coordinate the activity of the two hands to
evaluate the body of the uterus for
- Position

40. Bimanual Exam cont,
-Architecture, size, shape,symmetry
-Consistency
-Mobility
-Tenderness
-Position-Anteverted,retroverted,mid
potition
Place the vaginal fingers in the right lateral
fornix and the infrabdominal hand on the
right lower quadrant

41. Cont,
•Manipulate the abdominal hand gently
downward toward the vaginal fingers to
outline the adnexa
•Palpate the vaginal walls to detect any
abnormality, rugae
•Test for anterior /posterior vaginal wall
weakness
•Palpate for Bartholin's gland
abnormality(abscess/cyst).made with
finger placed internally and thumb placed
externally

44. Speculum Examination
•Ask patient to relax and reassure her
throughout the procedure
•Speculum of appropriate size and shape
•Lubricate and warm the speculum with
warm water
•Place two fingers just inside or at the
introitus and gently separate the labia to
visualize the introitus

45. Speculum exam cont,
•Introduce the closed speculum horizontally
into the vagina and slight pressure exerted
towards the posterior vaginal wall
•Open the blades after full insertion and
maneuver the speculum so that the cervix
comes into full view
•Under good light inspect the cervix-
colour,position,smoothness,discharge,prenc
e of a mass,friable

46. Cont,
•Obtain specimen of discharge for
microscopic exam, c/s, pap smear
•Inspect the vaginal mucosa by gently rotating
the speculum several degrees in both
directions after loosening the screws, while
beginning to withdraw the closed speculum
•Leave client clean
•Place speculum in decontamination sol

47. BREAST EXAM
•The client lie supine with her arm over the head on the
side you are examing
•Four quadrants with tail extending into the axilla –
Examine all areas and tail of the breast and lymph nodes
which drain the breast
•Most of breast cancers occur in the upper outer quadrant
of the breast
•Use the pad of your middle three fingers to compress
and mobilize the breast gently against the underlying
chest wall .make spiral motions or parallel lines to
consistency cover all the breast tissue

48. Cont’
•Start at the top-outermost edge
•While palpating the breast note
 Any tenderness
Masses (lumps)
Increased temperature
Dimpling of the skin-suspicious for cancer
•Gently palpate the areola and Nipple for masses
or any abnormal discharge
•Gently palpate the axilla for enlarged or tender
nodes
•Repeat this for the other breast

49. •Essential definitions that you
should know to understand the
physical examination findings

50. The Presentation
•Fetal presentation; whichever
portion of the fetus is deepest in the
birth canal and is felt on vaginal
examination is referred to as the
presenting part; this determines fetal
presentation

51. Cont’
•Presentation can be;
1.Cephalic (occiput, sinciput, brow, face, or
chin [mentum]).
2.Breech (frank, complete, or footling [single
or double]).
3.Shoulder, or compound (hand/arm
presenting same time as vertex [head] or
hand presenting same time as breech).

53. Fetal Lie
•Fetus assumes a lie (comparison of
the fetal long axis to the long axis of
the woman) that is; transverse,
longitudinal, or oblique.

54. •In a longitudinal lie (99% of all births),
the fetal head will present (cephalic
presentation) or the buttocks or feet
will present (breech presentation).
•In a transverse lie, the shoulder
presents.
•In an oblique lie, the fetus is in an
angle off the transverse lie

56. Fetal Attitude
•Fetal posture- fetus assumes a
characteristic posture in later pregnancy to
accommodate to the uterine cavity.
•The fetal head is flexed, back is rounded,
and extremities are flexed. Flexed head
allows smallest diameter of fetal head
(occiput) to present and pass through the
birth canal

57. •The attitude: is the posture of the fetus
(flexion, deflexion, extension)

58. Fetal Position
•Fetal position; designation of
landmark of fetal presenting part
(occiput, mentum, sacrum, scapula)
to right or left, and anterior, posterior,
or transverse portion of the woman's
pelvis

59. Cont’
•For example, a fetus presenting by the
vertex with occiput on the left anterior part
of the woman's pelvis would have
presentation and position described as
LOA, or left occiput anterior.
•The first and third letters relate to the
pelvis, and the second letter relates to the
fetus

61. Station and Engagement
•Station: is the relation of the presenting
part to the ischial spine. If the presenting
part is at the level of ischial spine, station
=0
•Engagement: the descent of the biparietal
diameter through pelvic brim. If the head is
at the level of ischial spine the head must
be engaged.

63. Fundal Height
•It is estimated by centimeters from
upper border of the fundus to the
pubis symphasis by taping measure.
The height of the fundus correlates
well with the gestational age
especially during the weeks of
pregnancy.