Patiwnt notes, history taking systematic screwing if patients to arrive at impression. Examination guide on assessment of patient normal anatomy and physiology by review of the body systems, central nervous system, Gastrointestinal , Cardiopulmonary , Genitourinary and Muskuloskeleal system review and examination

1. History & Examination in
Obstetrics & Gynaecology
BSc. Clinical Medicine
Dr Kenneth Chanda
BScHB, MBChB, MMed (MMOG)-[UNZA]
First version: 22-10-17
Latest version: 23-10-17

2. General Aspects of History Taking
• Respect
• Privacy
• Confidentiality
• Information should:
 Flow in a logical & chronological sequence in a paragraph
format
 Not simply translate the patient’s words into Medical English
Language
 Form a provisional diagnosis
 Plan the examination, investigations & treatment accordingly

3. Key points
• Introduce yourself with a friendly greeting
• Give your name and status
• Explain what you would like to do and gain
her consent
• Ensure the patient is comfortable and warm
• Maintain good eye contact & listen attentively
• Facilitate verbal & non verbal communication
• Do not do vaginal or breast examination alone
• Record your findings

4. Terminology
• Gravidity: Total number of present and
previous pregnancies
• Parity: Previous pregnancies beyond period of
viability (28 weeks) regardless of outcome
 Miscarriages, terminations and ectopic pregnancies as a
subscript plus
 A multiple pregnancy is counted as one
• Delivery: >28weeks
 Term Delivery: 37 completed weeks and above
 Preterm: < 37 completed weeks
• Miscarriage/Abortion: <28weeks

5. Terminology (Cont’d)
• 5 or more births are called grand multipara
• Nullipara –never completed pregnancy beyond
viability. May or not have aborted previously
• Nulligavida-not and never been pregnant
• Primipara-one who has delivered one viable
child
• Primigravida-one who is pregnant for the first
time

6. Terminology (Cont’d)
• Multigravida-one who has previously been
pregnant. May have aborted or have delivered
a viable baby
• Multipara-one who has delivered two or more
children
• A parturient –woman in labour
• Puerpera –a woman who has just given birth

7. Practical Examples
• A woman who is not pregnant and has a term single
live birth, one miscarriage and one termination
P1+2
• A woman who is pregnant with singleton pregnancy
and has had two previous pregnancies resulting in a
premature live birth and term stillbirth
• A woman who has a singleton pregnancy and has had
live twins at term and previous ectopic
• A woman who is not pregnant but had a twin
pregnancy resulting in live preterm births

8. Gestation Age (GA) and Expected
Date of Delivery (EDD)
• Assumptions made using Nagaele rule
Regular 28 day cycle not using contraceptives
Ovulation occurs 14days before start of next
menses
• Two methods for getting EDD:
 Add 7days and 9months to the date of the 1st day of
last menstrual period
 Add 7days, subtract 3months and add 1year to the
date of the 1st day of last menstrual period

9. Gestation Age (GA) and Expected
Date of Delivery (EDD) [Cont’d]
• Gestational age in weeks is calculated using
LMP or EDD as references
• Example: if a client has her LMP of 12th august
2017 and she is seen or clerked 25th October
• EDD will be 19th may 2018 2018
• Gestational age is (Two methods):
 Count number of days from LMP to clerking date (25
Oct 2017)
-19(August)+30(September)+25(October)=74/7=104D

10. Gestation Age (GA) and Expected
Date of Delivery (EDD) [Cont’d]
Or divide the days of each month by 7 then
adding the results
-Add the remainders (days), divide by 7 and
add to the weeks
August 12th-31st=19days =2W5D
September 1st-30th=30 days =4W2D
October 1st-25th=25 days =3W4D
Remainders 5+2+4 =11/7 = 1W4D
GA= 2W+4W+3+1W+4D =10W4D

11. History Taking Format
1. Vital statistics
2. Presenting complaint
3. History of presenting complaint
4. Systemic enquiry
5. History of present pregnancy
6. Past reproductive history
7. Past medical and surgical history
8. Drug history
9. Family history
10. Social history

12. History taking: Vital Statistics
• Name/Age
• Address
• Gravidity & Parity
• Gestational Age
• Marital status
• Religion
• Referral center
• Reasons for referral
• Date of clerking

13. Presenting Complaint
• Main complaints (Symptoms) in order of
occurrence
• 1st symptom(s) written or reported first
• Duration of the complaints (duration of
symptom)
• Time of onset of symptom to time of patient
presentation
• If no complaint enquire on:
-sleep, appetite, bowel habit and urination

14. History of Presenting Complaint
• Elicit the evolution of the disease
• Progression of symptoms
• Appearances of new symptoms
• Spontaneous remissions and exacerbations
• Onset: acute or insidious
• Volume, colour and consistency of fluids
• Location, progression, relieving, aggravating,
associated factors, location, course, severity,
duration etc.
• Any treatment received

15. Systemic Enquiry
• Nervous: headache, dizziness, blurred vision, fever,
convulsion
• CVS: orthopnea, palpitation, leg swelling
paroxysmal nocturnal dyspnea
• Respiratory: cough, dyspnea tachypnea, chest pain,
sputum, anosmia
• Digestive: vomiting, dysphagia, abdominal pain,
diarrhoea, jaundice, haematochezia, melenae
• Urinary: incontinence, dysuria, frequency, urgency,
retention, haematuria, loin pain

16. Systemic Enquiry (Cont’d)
• Reproductive: bleeding PV relationship to menses
(menorrhagia, dymenorrhoea, metrorrhagia,
oligomenoorhea and polymenorrhea) and sex
(postcoital bleeding), dysmenorrhea, abnormal
vaginal discharge, vulva ulcers, papules or pustules,
sexual dysfunction (dyspareunia/apareunia, frigidity,
premature orgasm, nyphomania), rare sexual
deversion (homo, bi or transexuality), infertility
• Musculoskeletal: joint pain, joint stiffness, joint
swelling, muscle and bone deformity , pain or
atrophy

17. History of Present Pregnancy
• Menstrual History
Last normal menstrual period (LNMP)
Any subsequent bleed
Brief details of cycle frequency, duration and
quantity of loss
Recent contraception history, especially
hormonal, and recent history of breast-feeding
Calculate EDD using Naegle's Rule and estimate
the current gestation

18. History of Present Pregnancy (Cont’d)
• Booking
 When, where and how pregnancy and gestational age
confirmed - e.g. by examination, pregnancy test,
ultrasound scan.
 Date of quickening – fetal movements 'first felt or
perceived.
• Antenatal Findings
 No. of clinic visits, date of last visit, significant
abnormal findings, and details of antenatal hospital
admissions
 Note complications in different trimesters

19. Past Reproductive History
• Obstetric history-relate only to multigravida
• Record previous obstetric events chronologically
• Give year of delivery, abortions or
ectopic pregnancy, significant antenatal
complications, delivery methods, birth weight or
gestational age, and present condition of infant or
cause death.

20. Other Aspects of History
• Past medical and surgical history - Including
gynaecological conditions not mentioned
above.
• Drug history- Present medication and allergies
• Family History- Multiple pregnancies,
cardiovascular disease, diabetes, TB, sickle cell etc.
• Social History - Accommodation, family
support at home, financial support.

21. Summary of History
• Summarise significant positive findings before
proceeding to findings of examination
• Name, age, parity, main problems and risk
factors
• Do not repeat the entire history

22. 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

23. Examination (Cont’d)
– Tongue,teeth,gums and tonsils:evidences of
malnutrition from glossitisand stomatitis
– Neck neck veins,thyroid gland or lymph nodes
– Oedema of legs: check medial malleolus and
anterior surface of lower 1/3 tibia.varicosities
– Pulse
– B.P mufflin of sound (Korotkov4) rather than
diappearance of sound(5) is the best
representation of diastolic pressure in pregnancy
– Breast : mandatory-check for changes of
pregnancy and nature of nipples

24. Obstetric examination
• Symphyseal-fundal Height (SFH) - This
should be recorded with the bladder empty
• Presentation - Can be determined' after 28
weeks if the patient is not obese
• Fundal palpation - Palpate the fundus with
both hands for the other fetal pole
• Lateral palpation - detect lie and liquor
• Auscultation -fetal stethoscope (Pinard) over
the anterior shoulder of the fetus

25. Pelvic Examination
• You may suggest to the examiner that you
would want to perform a pelvic exam, and then
proceed if given permission
• Never do one without permission
• The same applies to a speculum examination.
• Speculum examination is not a routine part of
the obstetric examination

26. 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

27. 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

28. History and Examination in
Gynaecology (Cont’d)
• Systemic enquiry
• Menstrual history
First day of Last Menstrual Period (LMP)
Last normal Menstrual period (LNMP) if
different
Contraception in the past year
Date and result of last cervical (Pap) smear.
(Date of Menarche, and Menopause if
appropriate).

29. History and Examination in
Gynaecology (Cont’d)
• Menstrual history (Cont’d)
Number of pads used or presence of clots
Are periods painful
Intermenstrual bleeding
Postcoital bleeding
Vaginal discharge
Premenstrual tension
If postmenopausal,any postmenopausal
bleeding?

30. History and Examination in
Gynaecology (Cont’d)
• Past reproductive history
 Number of viable pregnancies of 28 weeks gestation
and above
 Include details of abortions and ectopic pregnancies
• Past medical and surgical history
• Drug history: allergies; smoking and alcohol
• Family history
• Social history
• A short summary of history

31. 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

32. Gynaecological Examination
(Cont’d)
• Breast and axillary exam
–As screening test for cancer of the breast
• Abdominal exam
–Inspection
–Palpation
–Percussion
–ascultation

33. Gynaecological Examination
(Cont’d)
• Vaginal examination
–Frightening
–Ask for chaperone,privacy,explain intention
and ask for permission.
–Use lubricating jelly
–Speculum should be warmed