Terminology and history taking in obstetrics

1. History taking and physical
examination in
Obstetrics/Gynaecology
PRESENTED BY: SIAMANI BRIAN
(CURTESY: Prof Bellington Vwalika
Consultant Obstetrician/Gynaecologist –
UTH, LUSAKA)
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2. History taking
 Vital statistics
– Name
– Address
– Date of first exam
– Marital status
– Religion
– Age-above 30 at first pregnancy is elderly
primigravida
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3. Importance of LMP
 Last menstrual period useful in calculating
EDD
– Affected by : diseases, drugs
 Menstrual history : cycle, duration, amount
of blood flow and first day of L.M.P
– Calculation of EDD done according to Naegele`s
formula by adding 9 calendar months from LMP
and then add 7 days to fist day of LMP
alternatively subtract 3 calendar months and 7
days
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Naegele's rule is a standard way of calculating the due date for a pregnancy.
The rule estimates the expected date of delivery (EDD) by adding one year,
subtracting three months, and adding seven days to the first day of a
woman's last menstrual period (LMP). The result is approximately 280 days
(40 weeks) from the start of the last menstrual period. Another method is by
adding 9 months and 7 days to the first day of the last menstrual period.

4. Importance of LMP
 Normal cycle length is 28+/- 7days
with a flow not exceeding 7 days
 Menstrual questions
– How often and duration of menses(4/28
means bleeding lasts 4 days and occurs
every 28 days)
– Regular or irregular
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5.  Occupation of woman-help interpret
symptoms due to fatigue or occupational
hazards
 Occupation of husband –idea about social-
economic status is assessed+ problems eg
anaemia ,PE,prematurity,advice,
 Period of gestation in weeks from LNMP
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6.  Complaints
– Genesis,mode of onset,progress and
duration
– If no complaint inquire on
sleep,appetite,bowel habit and urination
 History of present pregnancy-note
complications in different trimesters
– Hyperemesis and threatened abortion in
first trimester, features of UTI in second
– Anaemia,toxaemia and APH in the third 6

7. – Number of antenatal visits
– Medication or radiation exposure early
– Medical –surgical events during
pregnancy are inquired
 Obstetric history-relate only to
multigravida
– Record previous obstetric events
chronologically
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8. No Year and date Pregnancy
events
Labour
events
Methods of delivery pueperium Baby
Wt and sex
Condition at birth
Duratio of BF
immun
1 1983
January
Abortion at 8/52 MVA Uneventiful
2 1987
April
Well covere
antenatally –
uneventiful
Uneventiful SVD Uneventiful boy, wt,BF8/12
3 1991
june
-d-o -do- -do- -do- Girl average
weight,
cried at birth
Breastfed 6/12
Both babies fully
immunised
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9.  Obstetric history summed up as:
– No. of living children…….Boys…..Girls…..Health
status of the baby……immunisation….last
issue…..
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10.  Past medical history-relevant history of past
illnesses,HIV and HAART
 Past surgical history –previous surgery-
general or gynaecological if any is to be
inquired
 Family history –HTN,DM,PTB,blood
dyscrasia,twinning,hereditary disease
 Personal history-contraceptive prior to
pregnancy,smoking,alcohol,BT,immunization
,anti-D,pap smear 10

11. Examination
 General:
– build;:obese/average/thin
– Nutrition:good/average /poor
– Height;short stature likely to have a small
pelvis
– Weight-preferably with same machine
– Pallor-lower palpebra conjunctiva,
dorsum of tongue and nail beds
– Jaundice:bulbar conjunctiva,undersurface
of the tongue.hard palate and skin 11

12. – Tongue, teeth, gums and tonsils: evidences of
malnutrition from glossitis and stomatitis
– Neck veins, thyroid gland or lymph nodes
– Oedema of legs: check medial malleolus and
anterior surface of lower 1/3 tibia. Varicosities
– Causes of oedema in pregnancy
 Physiological
 PE
 Anaemia and hypoproteinaemia
 Cardiac failure
 Nephrotic syndrome
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13. – Pulse
– B.P muffling of sound (Korotkov4) rather
than disappearance of sound(5) is the
best representation of diastolic pressure
in pregnancy
– Breast : mandatory-check for changes of
pregnancy and nature of nipples
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14. Obstetric examination
– Abdominal-tone of muscles,scars
,hernia,skin condition.Fundus of uterus is
just palpable above symphysis pubis at
12 weeks
– Correlate HOF to dates
– Vaginal ;unless contraindicated may be
done for:
 Diagnose pregnancy
 Corroborate uterine size to period of
amennorrhoea
 Exclude pelvic pathology
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15. Steps in vaginal exam
 Lithotomy
 Empty bladder
 Sterile glove
 Inspection –separate labia
 Speculum exam
 Bimanual exam
– Cervix-consistency,direction,pathology
– Uterus-size,shape,position,consistency
– Adnexae-mass felt through the fornix
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16. History and examination
in gynaecology
 Personal details
– Name,age ,occupation,marital status
 Presenting complaint
– How long the problem is
– How much it affects her
– If pain what worsens and alleviates,where it
is,its nature
– Has she asked for opinion before and what has
been done
– Allow to talk initially without direct questions
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17. Specific questions
 Start with those relevant to to
complaint
– Eg if a menstrual problem ,appropriate
questions concern menstruation
 Menstrual questions
– How often and duration of menses(4/28
means bleeding lasts 4 days and occurs
every 28 days)
– Regular or irregular 17

18. – Number of pads used or presence of clots
– Are periods painful
– Intermenstrual bleeding?
– Postcoital bleeding?
– Vaginal discharge
– Premenstrual tension
– LMP
– If postmenopausal,any postmenopausal
bleeding?
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19.  Sexual /contraceptive questions
– Sexually active?
– Is it painful? if so, superficial or deep?
– What contraceptive is the patient using
now or in the past
 Cervical smear questions
– When last smear
– Ever had abnormal smear? If so what
was done 19

20.  Uterine/prolapse questions
– Any frequency,nocturia,urgency or
enuresis
– Does she leak urine? if so ,how severe it
is and with what is it associated(eg
coughing or urgency)
– Any dysuria or haematuria?
– Any dragging sensation or feel mass in or
at the vagina
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21. Other history
 Ever been pregnant if no go to PMH,if yes
ask details about previous pregnancies in
chronological order
 Of deliveries ask when,weight,mode of
delivery how they are now
 Any major complications in labour or
pregnancy
 Past medical history-ask any particulary
gynae operations,DM,lung and heart
disease,HTN,jaudice,previous admissions 21

22.  Systemic review
 Drugs-any regular medication,preconceptual
folic acid
 Family history-eg breast,ovarian
cancer,DM,HTN,heart disease
 Personal/social history –does she
smoke?alcohol?married?accommodation
 Allergy ask specifically about penincillin
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23. Gynaecological
examination
 Seek the effects(eg secondary spread of
malignancy,thyroid,menstrual
disturbances)of gynaecological problems
 Assess general health and incidental disease
,particulary if anaesthesia is needed
 General
appearance,weight,temp,BP,pulse,anaemia
lymph nodes
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24.  Breast and axillary exam
– As screening test for cancer of the breast
 Abdominal exam
– Inspection
– Palpation
– Percussion
– auscultation
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25.  Vaginal examination
– Frightening
– Ask for chaperone,privacy,explain
intention and ask for permission.
– Use lubricating jelly
– Speculum should be warmed
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26. Outline
 Female
– Preparation for the exam
– External genital exam
– Speculum exam
– Bimanual exam
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27. Detailed Procedural
Instructions
Prior to examination
– Prepare all required equipment, supplies
– Ensure that equipment is in good working
condition
– Explain the procedure while participant is dressed
– Answer any questions patient may have
– review previous exam records if availabe
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28. Patient Preparation
 Explain the procedure thoroughly
 Provide emotional support
 Observe body language for signs of
discomfort
 Ask participant to avoid douching prior
to procedure
 Ask participant to empty bowels and
bladder prior to procedure 28

29. General
Assess the following:
– Hands, palms, forearms
– Mouth, hair
– Skin
– Lower abdomen
– Pubic region for lice and nits hair distribution
– Buttocks
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30. General (cont’d)
Assess the following:
– Inguinal lymph nodes
– Inspection and palpation of external
genitals
– Buttocks & thighs
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31. Examination of the
External Genitalia
Examine and palpate the following looking for
ulcerations, discharge or other signs of
infection:
 Labia majora
 Labia minora
 Clitoris
 Urethral orifice
 Introitus
 Para urethral glands (Skene’s glands)
 Milk Urethra
 Bartholin’s glands 31

32. Female External genitalia
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33. Internal Examination
Speculum exam
 Use lubricating jelly or than water
 Warm speculum
 Explain the procedure
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34. Speculum insertion
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35. Internal Examination:
Speculum Exam
Examine the following looking for
ulcerations, colour changes, discharge or
other signs of infection:
 Cervix
– State of cervix
– Size and shape of cervical os
– Other
 Erythema, ectopy, Nabothian cysts, ulceration
– Mucopurulernt discharge
 Vaginal walls and mucosa
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36. Internal Examination:
Speculum Exam
Examine the following looking for
ulcerations, colour changes, discharge or
other signs of infection:
 Cervix
 Vaginal walls and mucosa
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37. Internal Examination:
Bimanual
Palpate the internal organs to assess for
tenderness and abnormalities in size and
shape:
 Lubrication of fingers may be used
 Palpate the cervix and determine the
position
 Palpate the uterus
 Palpate the adnexae & ovaries
 The pouch of douglas –palpate uterosacral
ligaments
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38. Uterine size
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39. Adnexal palpation
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40.  Cuscoe`s speculum allows inspection
of the cervix and vaginal walls
 Sims` speculum allows better
inspection of the vaginal walls and
specifically prolapse
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41. End
Any questions?
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