when cycle length is 28 days and ovulation on the 14th day.
(more than three beats of clonus).
01 history and examination dr isameldin
Dr. Isameldin Elamin MD DOWH MBBS
Obstetrics & Gynaecology department
By the end of this lecture the student should
be able to:
Take a detailed obstetric and gynaecological
Describe how to conduct obstetrical and
Describe how to conduct digital and speculum
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History in Obstetrics and gynaecology:
History taking needs to:
Build a good rapport with the woman.
Closed room with adequate facilities and
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At a booking visit, the history.
must be thorough and meticulously
Ask yourself what you need to achieve.
Ask why the patient has attended. (May be
Make sure that the patient is comfortable.
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Polite when talking to the patient.
Appearance is suitable before you enter the
Tell why you have come to see them.
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Duration of marriage.
Name of the husband.
Age of husband.
Make a note of ethnic background.
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Details of the presenting problem.
Reason for attendance if no complaints.
Write in the patient's own words.
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Arrange in order of occurrence.
1-vomiting / today.
2-abdominal pain / 2days.
3-fatigue / 3days.
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Gush of fluid per vaginum.
Blurring of vision.
Edema of hands or face.
Diminished or absent fetal movements.
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last menstrual period (LMP) or estimated
date of delivery (EDD)
Pregnancy duration is 280 days (40 weeks).
Add 9 month and 7days (14 Arabic) to
calculate EDD. (Naegele`s rule need 28 day
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Dates can be calculated from ultrasound before
20 weeks by:
The crown–rump length is used up until 13
weeks 6 days.
Head circumference from 14 to 20 weeks.
After 20 weeks, variability of growth makes
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Accurate EDD is important because:
Serum screening for down’s syndrome.
Induction of labour for post-dates pregnancy.
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What action has been taken?
Is there a plan for the rest of the
What are the patient’s main concerns?
Have there been any other problems in
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What scans have been performed?
Were any problems identified?
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Gravida – G:
is the total number of pregnancies regardless
of how they ended.
Parity – P:
is the number of live births at any gestation or
stillbirths after 24 weeks.
In terms of parity, twins count as two.
(Ten teacher s,19th edition).
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Parity is the number of pregnancy reaching
viability, so In terms of parity, twins count as
G2P1A0L2.(twins in first pregnancy)
So we consider this in our college.
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Occupation, partner’s occupation.
Who is available to help at home?
Are there any housing problems?
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All medication including over-the-counter
Any regular medications.
What problems do they cause?
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The history should be summarized in one to two
MRS X 34 years old teacher G5P3A1 GA 37
weeks with previous C/S known hypertensive
admitted for control of BP.
G_ p_ +_
Any chronic condition.
Cause of admission.
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Principles of infection reduction.
Remove any wrist watches or rings with
Bare arms from the elbow down.
Wash hands or use gel before and after any
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Maternal weight and height:
Calculate body mass index BMI. [Weight
Risk for BMI <20 >30.
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Hypertension diagnosed >140/90 mmHg on
two separate occasions at least 4 hours
Measured woman seated or semi-recumbent.
Use an appropriately sized cuff.
Use Korotkoff v, (disappearance of sounds).
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Women presenting for a routine visit there is
little benefit in a full formal physical
Inspect when enter for gait height etc.
Eye, tongue, Teeth palm etc.
Neck, Thyroid often palpable.
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In asymptomatic women with no cardiac history is
Flow murmurs can be heard in approximately 80 per
cent of women at the end of the first trimester.
Formal breast examination is not necessary.
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Shape of the uterus
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Palpation: (deep and superficial)
Symphysis–fundal height measurement.
Measure SFH and plot on an SFH chart.
In late third trimester SFH the fundal height is
2 cm less than the number of weeks.
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Fetal lie, presentation and engagement.
Palpate to count the number of fetal poles.
For multiple pregnancy.
Lie: longitudinal, oblique or transverse
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is the part of the fetus in the lower pole of the
uterus overlying the pelvic brim (cephalic,
The lie of the fetus:
is the relation of the long axis of the fetus to the
uterus (could be longitudinal, oblique or
transverse. Only longitudinal lie is normal)
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is the posture of the fetus (flexion, deflexion,
the position of the fetal presenting part in the
maternal pelvis in relation to the denominator.
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Occiput in vertex presentation
Sacrum in breech presentation
Mentum in face presentation
(e.g. Occipitoanterior, sacroposterior).
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is the relation of the presenting part to the ischial
spine. If the presenting part is at the level of
ischial spine, station =0
the descent of the biparietal diameter through
pelvic brim. If the head is at the level of ischial
spine the head must be engaged.
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Palpate the fundus (to determine if it contains
breech or head)
By gentle pressure If breech:
soft consistency, indefinite, outline
If head, it is hard, smooth, well defined,
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Mobility to differentiate between head and
move your fingertips over the fetal mass to
If moves freely between fingertips it is the head
If can’t move independent from the body it is the the
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2nd pelvic grip for engagement
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Using a two-hand, and watching the woman’s
face, gently feel for the presenting part.
The head is generally much firmer than the
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Assess for engagement.
5/5th palpable means head not engaged.
1/5th or 2/5th palpable means head engaged.
The fetal position:
Occipito-posterior, lateral or anterior.
Position is Important when labour begins.
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Fetal heart beat by hand-held device or
Best position is over the fetal shoulder.
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Digital or speculum.
Female chaperone should be present.
It is necessary in:
Excessive or offensive discharge.
To perform a cervical smear.
To confirm rupture of membranes.
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To assess the cervix.
It provide information about:
Dilation of cervix.
Station of presenting part.
Consistency of cervix..
Length of cervix. (Effacement).
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Introduce two fingers into the vagina.
Bishop score can be calculated.
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Oedema of the extremities.
Assess reflexes in pre-eclampsia.
Fundoscopy in hypertension and in
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Gynaecological History And Examination
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Same like in obstetrics History.
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(Patient’s own words).
History of presenting complaint e.g:
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Age of menarche.
Duration of period and length of cycle. (5/28).
First day of the last period LMP.
Pattern of bleeding: regular or irregular.
Amount of blood loss.
Any inter-menstrual or post-coital bleeding.
Any pain relating to the period.
Any medication taken.
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Site, nature, severity.
Aggravating or relieving factors.
Relationship to menstrual cycle and
Association with bowel or bladder functions.
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Amount, colour, odour, presence of blood
Relationship to the menstrual cycle
History of sexually transmitted diseases
Vaginal dryness (post-menopausal).
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The type of contraception.
Availability of husband.
Frequency of intercourse.
Difficulties or pain during intercourse.
Post coital bleeding.
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Menopause (where relevant).
Date of last period.
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Previous gynaecological history.
Previous gynaecological treatments or surgery.
Previous obstetric history:
Number of children.
Number of miscarriages.
All details of pregnancy out comes.
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Previous medical history.
Enquiry of other systems.(Systemic
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Patient’s consent should be taken.
Chaperone should be present,
Watch patient walking into the
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Examining the hands and mucous
membranes The supraclavicular area for
Virchow's node (Troissier’s sign).
The thyroid gland.
The chest and breasts.
A general neurological assessment.
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Empty the bladder.
Patient should be comfortable.
Cover patient with a sheet.
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The contour of the abdomen.
Distension or mass.
Laparoscopy scars .
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Superficial and deep.
Area of pain should be examined at the end of
Palpate 4 quadrant of abdomen.
Palpate for masses.(deep) the liver, spleen and kidneys.
Mass can not palpate below it, it is pelvic in origin.
Look for signs of peritoneum, i.e. Guarding and rebound
Examined for inguinal hernias and lymph nodes.
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Percussion is particularly useful if free fluid is
Look for :
Dullness in the flanks.
A fluid thrill.
Aware full bladder is dull due to urinary retention.
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Auscultate for bowel sounds in:
Postoperative patient with ileus.
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Obtain verbal consent.
Female chaperone should be present.
Empty the bladder.
inspect the external genitalia and surrounding skin.
Sign of stress incontinence.
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Using a bi-valve or Cusco's speculum.
Has a retaining screw.
Used for smear or swab.
A Sim’s speculum.
Used for prolapse.
Warm the speculum.
Use water as lubricant for smear.
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Done to assess the pelvic organs.
Part labia with left hand.
Insert one or two fingers of the right hand
into the vagina.
Place the left hand on the abdomen.
Palpate the fundus of the uterus.
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Place the tips of the fingers in the lateral fornix.
Palpate for adenexa (tubes and ovaries).
Pushing down with the fingers of the abdominal
Swelling or tenderness.
Palpate the posterior fornix. (Endometriosis).
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Can be used in:
Adults who have never had sex.
Less sensitive than a vaginal.
Can detect a pelvic mass.
Recto vaginal examination may be useful.
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Pass this information to others in a clear and
Summarize positive findings.
Busy ward round.
Be aware of sensitive information.
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Gynaecology by ten teachers 19 editions.
Obstetrics by ten teachers 19 editions.
Oxford hand book of obstetrics and
1-history template obstetric page 14.
2-history template of gynaecology page2.
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