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1. Basic Skills
Ob/Gyn
Wang juanWang juan

2. Some definitions
Fetal lie: refers to the relationship of the long
axis of the fetus to the long axis of the centralized
uterus or maternal spine.
Longitudinal lie Transverse lieLongitudinal lie

3. Presentation: the part of the fetus which
occupies the lower pole of the uterus. Cephalic,
podalic, shoulder ， breech, and others.
Some definitions
Shoulder CephalicBreech

4. Some definitions
Denominator: the arbitrary bony fixed point
on the presenting part. Occiput in vertex, sacrum
in breech, and acromion in shoulder.
Position: the denominator to the different
quadrants of the maternal pelvis.
Or the relationship between maternal pelvis and
point of fetal presentation.

5. 研究背景

6. Obstetrical abdominal
examination
Preliminaries: patient evacuates the
bladder, lies in supine position with the
thighs slightly flexed. The examiner stands
on the right side of patient.

7. Obstetrical abdominal
examination
Inspection:
 The uterine ovoid is longitudinal or
transverse or oblique
 Undue enlargement of uterus
 Any incisional scar mark on the abdomen

8. Obstetrical examination
Palpation: height of uterus (SFH)
GA(weeks
)
Approximate SFH
12 2-3 fingerbreadth above sym.
16 Midway between sym. and Umb.
20 1 fingerbreadth under umb.
24 1 fingerbreadth above umb.
28 3 fingerbreadth above umb.
32 Midway between umb. and
xiphoid
36 2 fingerbreadth under xiphoid

9. Obstetrical examination
The height of uterus is more than the period
of amenorrhea
Mistaken date of LMP
Twins
Polyhydramnios
Big baby
Pelvic tumors – ovarian or fibroid
Hydatidiform mole

10. Obstetrical examination
The height of uterus is less than the
period of amenorrhea
Mistaken date of LMP
FGR
oligohydramnios
Intrauterine fetal death

11. Obstetrical grips
(Leopold maneuvers)
Fundal grip (First maneuver)
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
Broad, soft and irregular mass
Smooth, hard and globular mass

12. Obstetrical grips
(Leopold maneuvers)
Lateral and umbilical grip (Second maneuver)
The hands are to be placed flat on either side
of the umbilicus to palpate the sides and the
front of uterus to find out the position of
back, limbs and the anterior shoulder
Smooth curved and resistant feel
Small knob like irregular parts

13. First and Second maneuver

14. Obstetrical grips
(Leopold maneuvers)
third maneuver
The over stretched thumb and four fingers of the
right hand are placed over the lower pole of the
uterus
The ulnar boarder of the palm on the upper boarder
of the symphysis pubis.
The presenting part is grasped distinctly, if not
engaged, the mobility from side to side is tested.

15. Obstetrical grips
(Leopold maneuvers)
fourth maneuver
The examiner faces the mother's feet and, with the
tips of the first three fingers of each hand, exerts
deep pressure in the direction of the axis of the
pelvic inlet. In many instances, when the head has
descended into the pelvis, the anterior shoulder may
be differentiated readily by the third maneuver
The engagement is ascertained noting the presence
or absence of the sincipital or occipital poles or
whether there is convergence or divergence of the
finger tips during palpation.

16. Third and fourth maneuver

17. Engagement
When the greatest horizontal plane, the biparietal, has
passed the plane of the pelvic brim, the head is said to be
engaged.
Divergence of fingers
Engaged head
Convergence of fingers
Not engaged head

18. Obstetrical examination
Auscultation
The fetal heart sounds are best audible through the
back
The maximum intensity of the FHS is below the
umbilicus in cephalic presentation and around the
umbilicus in breech.
In occipital-anterior position, the FHS is located in
the spino-umbilical line of the same side.

19. Location of the FHS in different
presentation of positon of fetus

20. Gynecological examination
Preparation
Introduce self to patient
Explain purpose of examination
Patient’s bladder emptied, in lithotomy position, arms
at sides or across chest, not overhead
Check material and equipment: vaginal speculum,
lubricant, cervical scraper, gloves, light source.
Explain in advance each step of the examination and
tell the patient what she might feel.
Avoid any unexpected or sudden movement.

21. External examination
Inspect and palpate
the mons pubis,
labium majus,
urethral meatus,
perineum, anus
Hair distribution,
clitoris hypertrophy,
lesions, redness,
pigment loss, scars,
tumors, bartholin’s
gland, hemorrhoids.

22. Speculum examination
Insert speculum
Hold speculum at 45-degree angle from the
vertical.
 Open labia with opposite hand and introduce
speculum into vagina.
Insert blades gently and slowly into the vagina
along the posterior wall, rotating at full
insertion so that handle is vertical
 Open speculum slowly, exposing cervix.
Tighten screw to hold in open position.

23. Speculum examination

24. Speculum examination
Inspect the cervix for color, discharge,
erythema, erosion, ulceration, scars and mass.

25. Pap smear
The longer end of the scraper is inserted into the external os. The
scraper is rotated 360°while scraping off cells from the external
os.

26. Inspect the vaginal walls
The patient is told that the speculum
will be withdrawed.
As the speculum is slowly withdrawn
and closed, the vaginal walls are
inspected for mass, laceration,
leukoplasia.

27. Bimanual palpation
Bimanual palpation is used to palpate
the uterus and adnexa.
The examiner’s fingers are placed in
patient’s vagina and on the lower
abdomen. The pelvic structures are
palpated between the hands.
In general, the right hand is inserted into
the vagina and the left hand palpates the
abdomen.

28. Bimanual palpation
The patient is told that the internal examination
will begin.
The physician should be positioned between the
patient’s legs.
The labia is separated, the lubricated right index
and middle fingers are introduced into the vagina
vertically. A downward pressure toward the
perineum is applied. The fourth and fifth fingers
are flexed and the thumb is extended.
The area around the clitoris should not be
touched.

29. Bimanual palpation
The vaginal walls are palpated for nodules,
scarring and induration.
The right hand is rotated 90° clockwise so that
the palm is facing upward. The left hand is
placed on the abdomen approximately 1/3 of
the way to umbilicus from symphysis pubis.
The right hand (vaginal) pushes the pelvic
organs up out of the pelvis and stabilizes them
which they are palpated by the left (abdominal)
hand.
It is the abdominal, not the vaginal, hand that
performs the palpation.

30. Bimanual palpation
Cervix and uterus
The cervix is palpated for consistency.
Assess cervical motion tenderness (lifting pain) by gently
moving cervix back and forth.
Fingers inserted deeply to posterior fornix beneath cervix
Flat of fingers of opposite hand on abdomen above pubes
Uterus elevated by vaginal hand to identify the following
palpatory findings: position, size, mobility, consistency,
shape, and tenderness.
A retroverted uterus is not easily felt by bimanual
palpation

31. Bimanual palpation

32. Bimanual palpation

33. Bimanual palpation

34. Bimanual palpation
Technique of adnexal exam
Vaginal fingers in lateral fornix
Put abdominal hand just inside pubic
arch and above pubic hairline on the
same side and attempt to palpate the
ovary, check for pelvic mass.
Only palpable 50% of time in
reproductive age

35. Bimanual palpation

36. Rectovaginal Examination
 Remove fingers from vagina.
 Reglove and apply lubricant to index and middle fingers.
 Alert patient that the rectovaginal exam will begin.
 Ask patient to bear down as finger is inserted into
rectum (anal sphincter relaxation technique).
 Insert middle finger into rectum and index finger into
vagina.
 Repeat the palpation and characterization of the cervix,
uterus, and ovaries from this posterior position.
 Palpate rectovaginal septum between fingers using a
scissor-like movement.
 Remove fingers smoothly.

37. Rectovaginal Examination

39. Electronic Fetal Monitoring
• Detect fetal hypoxia i.e reduce and avoid
harm to the fetus and improve fetal and baby
outcome.
• Severe acidosis may result in FHR changes.
• Could occur in Normal physiological
response in labor.

40. EFM- Interpretation
Consider :
Intrapartum/antepartum trace.
Stage of labour.
Gestation.
Fetal presentation, Malpresentation.
Any augmentation, Medications
Direct or indirect monitoring

41. Basic Features of FH Trace

42. Basic Features
Baseline FHR - Mean level of FHR when
this is stable, excluding Accelerations and
Decelerations (120-160 bpm)
-Tachycardia
-Bradycardia
• Baseline Variability-5 bpm or greater than
or equal to 5bpm, between contractions
-Normal
-Non-reassuring-Less than 5 bpm or less
but less than 30 min
-Abnormal-less than 5 bpm for 90 min or
more.

43. Baseline variability

44. Baseline variability
The minor fluctuations on baseline FHR
at 3-5 cycles p/m produces Baseline
variability.
Examine 1min segment and estimate
highest peak and lowest trough.
Normal is more than or equal to 5 bpm.

45. EFM-Accelerations
Accelerations- transient increase in FHR
of 15 bpm or more lasting for 15 sec.
Absence of accelerations on an otherwise
normal CTG(cardiotocogram) remains
unclear.
Presence of FHR Accelerations have
Good outcome.

46. EFM Decelerations
Decelerations
transient slowing of
FHR below the
baseline level of
more than 15 bpm
and lasting for 15 sec.
Or more.

47. Electronic Fetal Monitoring
a) Early Decelerations
Head compression
Begins on the onset of contraction
and returns to baseline as the
contraction ends.
Should not be disregarded if they
appear early in labor or Antenatal.

48. Fig Early Decelerations

49. b) Late Decelerations
Uniform periodic slowing of FHR with
the on set of the contractions .
Repetitive late decels increases risk of
Umbilical artery acidosis and Apgar
score of less than 7 at 5 mins and
Increased risk of CP(cerebral palsy).
Electronic Fetal Monitoring

50. Electronic Fetal Monitoring
b) Late Decelerations (Fig 4)
• Due to acute and chronic feto-placental
vascular insufficiency
• Occurs after the peak and past the length of
uterine contraction, often with slow return
to the baseline.
• Are precipitated by hypoxemia
• Associated with respiratory and metabolic
acidosis
• Common in patients with PIH, DM, IUGR
or other form of placental insufficiency.

51. Fig Late Decelerations

52. Late Decelerations
Reduces Baseline variability together
with Late Decelerations or Variable
Decelerations is associated with
increased risk of CP.

53. EFM- Variable Decelerations
Variable intermittent periodic slowing of FHR
with rapid onset recovery and isolation.
They can resemble other types of deceleration
in timing and shape.
Atypical VD are associated with an increased
risk of umbilical artery acidosis and Apgar
score less than 7 at 5 min
Additional components:
Loss of 1 degree or 2 degree rise in baseline
Rate
Slow return to baseline FHR after and end of
contraction.
Prolonged secondary rise in Base FHR
Biphasic deceleration
Loss of variability during deceleration
Continuation of base line at a lower level.

54. Electronic Fetal Monitoring
c) Variable Deceleration (Vagal activity) (Fig 5)
Inconsistent in configuration,
No uniform temporal r-ship to the onset of
contraction, are variable and occur in isolation.
Worrisome when Rule of 60 is exceeded (i.e.
decrease of 60 bpm,or rate of 60 bpm and longer
than 60 sec)
Caused by cord compression of the umbilical cord
Often associated with Oligohydramnios with or
without PROM
Can cause short lived RDS if they MILD
Acidosis if prolonged and Recurrent.

55. Fig Variable Decelerations

56. EFM Prolonged deceleration
Prolonged Deceleration (Fig 6)
Drop in FHR of 30 bpm or More lasting
for at least 2 min
Is pathological when crosses 2
contractions i.e 3 mins.
Reduction in O2 transfer to placenta.
Associated with poor neonatal outcome.

57. EFM- Prolonged Decelerations
CAUSES
Cord prolapse.
Maternal hypertension
Uterine Hypertonia
Followed by a VE or ARM or SROM
with High PP

58. Fig Prolonged Deceleration

59. EFM - Prolonged Deceleration
Maternal position
IV fluids
V.E to exclude cord prolapse
Assess BP
FBS(fetal blood sampling) if cx dilated
and well applied PP
Mx Depending on the clinical situation