Gynaecological Case Taking, Bimanual examination, Vaginal Digital examination, Yoni sparshan parikshan

Gynaecological Case Taking
Pelvic Examination
Digital & Bimanual
DR. RAMVEER SHARMA
M.D. Ayu.(PT&SR)
PROF.& H.O.D.
Prasuti Tantra & Stree Roga Dep't.
M.M.M .Govt. Ayu. College UDAIPUR
Mob. 9414757932
Email. ramveersharma1960@gmail.com
DR. RAMVEER SHARMA
Digital & Bimanual Examination

Digital Examination
1. Position of the patient –
According to the examination purpose and place.
2. Wash and gloved both hands.
3. Lubricate the index, middle finger of right hand with
colourless jelly.
 In virgins – intact hymen – Examination withheld or under
general anesthesia.
DR. RAMVEER SHARMA

The clitoris- abnormality, enlargement, ulcer, carcinoma etc.
should be noted.
The labia majora – any swelling = Bartholinitis / cyst.
To palpate the Bartholin's glands - palpation finger placed
internally and the thumb externally.
DR. RAMVEER SHARMA

DR. RAMVEER SHARMA

METHOD:-
a. The labia majora are gently parted by index finger and thumb
of the left hand.
b. The urethra is now pressed from above down – is there any
discharge ?
c. The gloved index finger of the right hand is the inserted gently
– in to the vagina.
d. Avoiding the urethral meatus – exerting sustained pressure on
the perineal body – until the perineal musculature relaxed .
DR. RAMVEER SHARMA

Watch:-
a. The face of the patient for any sign of discomfort, tenderness.
b. By vaginal finger, a rigid hymeneal ring will be felt.
c. Test the perineal integrity .
d. Full length of the finger is than introduced – until cervix is
palpated.
e. At this stage second finger can be inserted to improve
quality of examination.
DR. RAMVEER SHARMA

Assess:- and feel -
 The vaginal walls for any deformity.
 The tone of lavator ani muscles.
 The condition of the vaginal upper part.
 In front, -The urethra, bladder and behind,- the rectum.
DR. RAMVEER SHARMA

BIMANNUAL EXAMINATION:-
 Method :-
 The Left Hand-is placed on the – above the symphysis
pubis, below umbilicus in mid line.
 This hand provides gentle directional pressure to bring the
pelvic viscera towards the examiners fingers in the vagina.
 Right Hand - Index and middle fingers inserted deep in
side the vagina.
 While right thumb is kept abducted,
 Little and ring fingers being kept flexed.
DR. RAMVEER SHARMA

Asked to patient for -
 Relax her abdomen ,
 Breath deeply by open her mouth,
 Abduct her thighs and- breathing down effort as in
defecation.
DR. RAMVEER SHARMA

1) The Cervix :-
 Size:- About 1 inch - Portio vaginalis ( Normal)
 More than 1 inch - Elongation (Cervical Ectropion),
 Short than normal – Infantile uterus.
 Absence – Cervical atrophy.
Shape:- Conical - in Nulliparous,
 Cylindrical - in parous,
 Barrel - in Cervicitis or missed cervical abortion.
 Bulky irregular - Hypertrophy / Growth.
DR. RAMVEER SHARMA

Station of the External Os :-
 At the level of Ischial spine - Normal,
 Below the level - Elongation of the Cervix / Uterine prolapse.
 High to the level - Any growth in the body or in the pouch of
Douglas.
DR. RAMVEER SHARMA

Stature:-
 Firm, (like tip of the nose) - Normal in nonpregnant,
 Soft (like lower lip) - During pregnancy or in fibroid.
 Hard and friable - Carcinoma or growths.
Surface:-
Along all it lips, smooth - Normal,
Furrowed/ rough and velvety - Erosion.
Ulcerated -Tubercular or syphilitic ulcer,
Ulcerated and cauliflower growth - Carcinoma of the cervix.
DR. RAMVEER SHARMA

Direction :-
 Anteverted - Anterior lip felt first then external os then after
posterior lip.
Cervix felt down wards and back wards.
 Retroverted - Posterior lip or external os felt first ,
Cervix pointed forwards.
External Os :- Closed - Normally.
 Opened - Cervical incompetency, Abortion, before labour.
 Shape – Round - Nulliparous
 Slit or tilted lacerated - Parous.
DR. RAMVEER SHARMA

Mobility :-
 The cervix is mobile 1-2 cm in all directions.
 Mild discomfort by move - Normal.
 Tenderness on move - Pelvic inflammation.
 Excitation/ extreme pain - Ectopic pregnancy.
 Immobile - Parametric metastasis, or parametric adhesions.
 Bleed to touch - Carcinoma or Cervical Vascular erosion.
DR. RAMVEER SHARMA

2) The Body:-
Method of palpate:-
 The vaginal fingers are placed in the anterior fornix.
 The left hand fingers placed flat on the hypogestrium.
Position:-
 75% A.V. Uterus - Uterus would be felt as a firm organ
between the vaginal and abdominal fingers.
 25% R.V. Uterus - If does not felt by above procedure, put
vaginal fingers in posterior fornix and palpate by manually.
DR. RAMVEER SHARMA

Size:-
 Normally it about 3 inch,
 But it variant in different conditions.
 Small - Hypoplastic uterus.
 Enlarge, bulky - Pregnancy, Tumours, Fibroma, Myoma,
Carcinoma,
 Absent - Agenesis or hysterectomy.
DR. RAMVEER SHARMA

Shape :-
 Like an inverted electric bulb - Normal
 Narrow at the Tip - Unicornuate Uterus.
 Furrow at Fundus - Bicornuate Uterus,
 Globular - Early Pregnancy,
 Pyriform - Late Pregnancy.
Surface:-
 Smooth - Normal
 Bossed - Multiple fibroid.
DR. RAMVEER SHARMA

Position:- A.V. / R.V.
 Displaced - Tumours of body, Fluid, Blood or Pus collection.
Consistency:-
 Firm - Normal in non pregnant,
 Firm with Enlarged - Fibroid, Endometriosis.
 Soft - Pregnancy, Carcinoma, Pyometra.
Relation with Cervix :- Anteflaxed / Retro flexed.
DR. RAMVEER SHARMA

Mobility:-
 Moving it freely forward and backward - Normal.
 Restrict movement - Inflammation, Neoplastic adhesions.
 Movement with tumour,
 Immobile - Adhesion or Metastasis with Perimetrium.
DR. RAMVEER SHARMA

The Appendages:-
Feel with vaginal fingers - In both lateral fornix,
 No felt - Normal,
 Felt - Abnormal,
 Tube felt with tenderness - Salpingitis, Hydro, Haemo, Pyo,
Salphinx.
 Ovaries felt - Enlarged, Oophoritis, PCOD, Carcinoma,
Prolapsed ovary.
 Enlarged lymph nodes on lateral pelvic wall - In Pregnancy
or chronic PID.
DR. RAMVEER SHARMA

PELVIC EXAMINATION DURING PREGNANCY
Mandatory –
Maintain proper aseptic and antiseptic precautions.
a) To diagnose the early pregnancy – Jacamar's signs,
Osiander's sign.
 The cervix - Soft like lower lip - Pregnancy + Ve.
 Lower segment - Soft , Hagar’s sign is + Ve.
 Uterus - Enlarged , Pyriform and Soft as per period of M.A.
Up to 12 week - Felt pelvic organ.
DR. RAMVEER SHARMA

CLINICAL PRLVIMETRY :-
To assessed the size and shape of the pelvis.
Method:- Assess the Normal pelvis by -
 Fornix is depressed by vaginal fingers,
 The curve of the sacrum is traced -1) From below to upward
2) Side by side.
1. The sacrum shows a concave curve both longitudinally &
transversely.
DR. RAMVEER SHARMA

2. Attempt to reach the sacral promontory -
It should can not be reached.
3. Sacrosciatic notch –
Placing fingers on sacrospinous ligament - accommodate 2
fingers.
4. Ischial spines are felt on the lateral pelvic wall on the both
side - Transverse distance between them - assessed.
5. Assess the side walls of the pelvis - Should be strait
without undue projection of ischial spines.
DR. RAMVEER SHARMA

Pelvic Curve Assessment
Pubic Curve-
 Method - Fingers are placed against the back of the
symphysis pubis,
a. Palpate and assess the anterior portion of the brim with
curve, it should be wide.
b. Supra Pubic Angle- Assessed by pushing up the palmer
aspect of the vaginal fingers against the symphysis pubis,
normally it accommodates two fingers.
DR. RAMVEER SHARMA

Diagonal Conjugate :-
 It measured when sacral promontory can be palpated.
 Measured by pelvimeter or caliper, on withdrawn of fingers from
vagina.
 Measure from the tip of the middle finger to crease of
Metacarpo -Phalangeal joint of the thumb.
T.D.O.(Transverse Diameter Of Outlet) measured by -
 Pressing the knuckles of four fingers between ischial tubrositis,
 Normal T.D.O. easily accommodates four knuckles in front of
anus.
DR. RAMVEER SHARMA

Clinical Pelvimetery
DR. RAMVEER SHARMA

Cephalo-pelvic Disproportion
(Muller Kerr Method)
a. Right hand – index and middle fingers are placed in the
vagina,
b. Right thumb is pressed on the anterior surface of the
Symphysis pubis.
c. Left palm per abdomen – pushed the non engaged fetal
head to wards pelvis.
d. The descend head in to the pelvic cavity is assessed – by
internal fingers.
DR. RAMVEER SHARMA

Cephalo-pelvic Disproportion
e. The thumb externally estimate the degree of overlapping of
the head on the symphysis pubis.
DR. RAMVEER SHARMA

Bishop’s Score Determination During Labour
CERVICAL 0 1 2 3 Score
Dilation Closed 1-2 CM. 3-4 CM. > 5 CM 3
Effacement 0 - 30% 40- 50 % 60-70 % > 80% 3
Consistency FIRM MEDIUM SOFT - 2
Station of Head -3 -2 -1 TO -0 +1 To +2 3
Occipital Position Posterior Lateral Anterior - 2
DR. RAMVEER SHARMA
Results:-
Score = > 9 means successful. 7 – 9 Wait for.
< 5 means unfavorable.

Assess –
a. The presence or absence of amniotic membranes and state of
fluid.
b.The level of the presenting part.
c. The pulsation of umbilical cord especially if the membranes
are ruptured.
d.The degree of the moulding of the fetal head or presence of
caput succedaneum.
DR. RAMVEER SHARMA

 Softness of lower segment
DR. RAMVEER SHARMA

Monthly Uterine Growth
DR. RAMVEER SHARMA

Monthly Fundal Height
DR. RAMVEER SHARMA

Gynaecological Case Taking, Bimanual examination, Vaginal Digital examination, Yoni sparshan parikshan

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