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Medical File in Gynecology Presentation.pptx
1. Female pelvis in relation to child birth.
Medical File
in
Gynecology. Evaluation in gynecology
Loredana Toma
MD, PhD student
UMF „Gr T Popa” Iasi, 2021
2. Contents
➜ I. Describe the structure of the female pelvis (bones,
ligaments, joints)
➜ II. Identify types of pelvis
➜ III. Describe pelvis diameters and landmarks
➜ IV. Draw and label female pelvis
➜ V. Medical file in gynecology
➜ VI. Evaluation in gynecology
3. The female pelvis
➜ The female pelvis is the bonny
compartment which supports the
vertebrae column, and its articulation
with the lower limbs, it permits a
person to sit and kneel
It forms a bonny passage through which the
fetus passes during labour
It comprises of four bones:
• Two innominate or unnamed bones
• One sacrum
• One coccyx
4. The female pelvis
➜ Is made up of three bones:
Illium, Ischium and the Pubis
The illium
Is the large flared-out part; when the hand is
placed on the hip it rests on the iliac crest,
which is the upper border
At the front of the iliac crest can be felt a bony
prominence known as the anterior superior iliac
spine
Below is the anterior inferior iliac spine
There are two similar points at the other end of
the crest, posterior superior and posterior
inferior iliac spines.
5. The female pelvis
• The ischium •
Is the thick lower part which has a large
prominence known as the ischial
tuberosity, on which the body rests when
sitting
Behind and a little above the tuberosity is
an inward projection known as, the ischial
spine
During labor the station of the fetal head
is estimated In relation to the ischial
spines
6. The female pelvis
➜ The pubic bone
This bone forms the anterior
part
It has a body and two oar-like
projections, the superior ramus
and the inferior ramus
The two pubic bones meet at
the symphisis pubis and the two
inferior rami form the pubic
arch, merging into a similar
ramus on the ischium
The space enclosed by the body
of the pubic bone, the rami and
the ischium is called the
obturator foramen
7. The female pelvis
➜ The ischium contains a
deep cup to receive the
head of femur, called
acetabulum
On the lower boarder of
the innominate bone are
found two curves
One extends from the
posterior inferior iliac
spine up to the ischial
spine and is called
greater sciatic notch
The other lies between
the ischial spine and
ischial tuberosity and is
the lesser sciatic notch
8. The female pelvis
➜ The sacrum
• Is a wedge-shaped bone consisting of five fused
vertebrae.
• The upper border of the first sacral vertebra juts
forward and is known as sacral promontory
• The anterior surface of the sacrum is concave and
is referred to as the hollow of the sacrum.
• Laterally the sacrum extends into a wing or ala.
Four pairs of holes or foramina pierce the sacrum
and, through these, nerves from the cauda equina
emerge to supply the pelvic organs
• The posterior surface is roughened to receive
attachment of muscles
The coccyx
• Is a vestigial tail which consist of
four fussed vertebral forming a
small triangular bone
• The coccyx articulates with the fifth
sacral vertebra to form the
sacrococcygeal joint
• During birth the coccyx is usually
forced backwards to allow more
room for the fetus to pass
9. Pelvic joints
➜ There are four pelvic joints:
➜ • One symphisis pubis
➜ • Two sacro iliac joints
➜ • One sacrococcygeal joint
➜ • The pelvic joints are not very mobile in non pregnant woman, but
during pregnancy the endocrine activity causes the ligaments of
the joints to soften which allows the joints to soften and stretch
during labour
10. The symphysis pubis
➜ It is formed at the junction of the
two pubic bones, which are united
by a pad of cartilage
➜ It widens during the last months of
pregnancy and, because of its
increased mobility may cause the
pregnant woman pain as she walks
11. Sacroiliac joints
• These are the strongest
joint in the body
• They join the sacrum to the
ilium and thus connect the
spine to the pelvis
• During pregnancy much
stress is placed on these
joints and multipara often
complain of backache during
pregnancy and for few
weeks following delivery
12. Sacrococcygeal joint
• This joint is formed where the base of
the coccyx articulates with the tip of the
sacrum
• The joint allows the coccyx to move
backwards during birth, thus widening
the outlet of the pelvis
13. Pelvic ligaments
➜ Each of the pelvic joints is held together by
ligaments:
• Interpubic ligaments at the symphysis pubis
• Sacroiliac ligament,
• Sacrococcygeal ligaments
➜ The other two ligaments important in midwifery
are:
➜ - Sacrotuberous ligaments :- from the sacrum to
the ischial tuberosity
➜ - Sacrospinous ligament: - from the sacrum to the
ischial spine
14. The pelvic floor. Functions
➜ The pelvic floor is formed by the soft tissues that fill the
outlet of the pelvis
➜ Functions
The pelvic floor supports the weight of the abdominal and
pelvic organs
Its muscles are responsible for the voluntary control of
micturation and defecation and play an important role in
sexual intercourse
During child birth it allows the passive movements of the
fetus through the birth canal
15. Muscle layers
➜ The superficial layer which is composed of five muscles:
➜ - The external anal sphincter encircles the anus and is
attached behind by a few fibers to the coccyx
➜ - The transverse perineal muscles pass from the
ischial tuberosity to the centre of the perineum
➜ - The bulbocavernosus muscles pass from the
perineum forward around the vagina to the copra
cavernosa of the clitoris just under the pubic arch
➜ - The ischial cavernosa muscles pass from the ischial
tuberosities along the pubic arch to the copra
cavernosa.
➜ - The membranous sphincter of the urethra is
composed of muscle fibres passing above and below
the urethra and attached to the pubic bone
16. Muscle layers
➜ The deep layer
➜ This layer is composed of three pairs
of muscles which together are
known as levator ani muscles
➜ - Each levator ani muscle (left and
right) consist of the following:
The pubococcygeus muscle from
the pubis to the coccyx
The iliococcygeal muscle from the
fascia covering the obturator intenus
muscle to the coccyx
The ischiococcygeus muscle from
the ischial spine to the coccyx
17. Diameters of pelvis
➜ The true pelvis
• It is the bonny canal through which
the fetus must pass during birth. It
has a brim, cavity and outlet
➜ The pelvic brim
• The brim is round except where the
sacral promontory projects into it
• The promontory and wings of sacrum
form its posterior boarder, the iliac
bones its lateral boarders and the
pubic bone its anterior boarder
18. The landmarks of the brim
➜ Sacral promontory
➜ Sacral ala or wing
➜ Sacro iliac joint
➜ Iliopectineal line
➜ Iliopectineal eminence
➜ Superior ramus of the pubic bone
➜ Upper inner boarder of the body of pubic bone
➜ Upper inner boarder of the symphysis pubis
➜ Diameters of the brim
➜ - Three diameters are measured
19. The landmarks of the brim
➜ The anteroposterior diameter
It is a line from the sacral
promontory to the upper boarder of
the symphysis pubis
When the line is taken to the upper
boarder of the symphysis pubis it is
called the anatomical conjugate and
is measured 12 cm;
When it is taken to the posterior
boarder of the upper surface 1.25 cm
lower is called obstetrical conjugate
and measures 11 cm, it represent the
available space for the passage of
the fetus
20. The landmarks of the brim
➜ The diagonal conjugate is
measured from the lower
boarder of the symphysis pubis
to the sacral promontory it may
be estimated on vaginal
examination as part of pelvic
assessment and should measure
12-13 cm
21. The landmarks of the brim
➜ The Oblique diameter
- It is a line from one sacroiliac
joint to the iliopectineal eminence
on the opposite side and measures
12 cm
- There are two diameters left and
right oblique diameters each takes
its name from the sacroiliac joint
from which it arises
22. The landmarks of the brim
The transverse diameter
➜ • It is a line between the
points further apart on the
iliopectineal line and measures
13 cm.
➜ • Another diameter is
measured, the sacrocotyloid
diameter from the sacral
promontory to the iliopectineal
eminence on each side and
measures 9- 9.5 cm
➜ It is only important in posterior
positions of the occiput
23. The pelvic cavity
➜ • The cavity extends from the
brim above to the cavity below
➜ The anterior wall is formed by the
pubic bone and the symphysis
pubis and is 4 cm long
➜ The posterior wall is formed by
the curve of sacrum and is 12 cm
long
➜ Its lateral walls are the sides of
the pelvis
➜
• The cavity is circular in shape its
diameters cannot be measured
but are considered to be 12 cm
24. The outlet
➜ Two outlets are described, the anatomical and
obstetrical
➜ The anatomical outlet is formed by the lower
border of the pelvic bones and the sacrotuberous
ligaments
➜ The obstetrical outlet is the space between the
narrow pelvic strait and the anatomical outlet
➜ The narrow pelvis strait lies between the
sacrococcygeal joint, the two ischial spines and the
lower boarder of symphysis pubis
➜ - There are three diameters
25. The outlet
➜ The anteroposterior diameter
➜ • It is a line from the lower boarder of the symphysis pubis
to the sacrococcygeal joint
• It measures 13 cm
• The coccyx may be deflected backwards during labour
• The dimeter indicates the space available during delivery.
The oblique diameter
• Between the obturator foramen and the sacrospinous
ligaments there are no fixed points the measurement is
taken to be 12 cm
➜ The transverse diameter
• This is a line between the two ischial spines and measures
10-11 cm it is the narrowest diameter in the pelvis
26. The false pelvis
➜ The false pelvis is the part
situated above the brim
➜ It is formed by the upper
flared-out part of the iliac
bones and protects the
abdominal organs
27. Types of the pelvis
➜ There are four types of pelvis
➜ - Pelvises are classified
according to shape of the brim
➜ - Much important is the
individual woman’s pelvic
capacity and whether it is
adequate for the passage of
the child she is carrying
28. Gynaecoid pelvis
➜ Gynaecoid pelvis
➜ - It is the ideal pelvis for child bearing
➜ - Its main features are rounded brim, straight
side walls, and shallow cavity with broad well
curved sacrum, blunt ischial spines, wide sciatic
notch and a pubic arch of 90 degrees.
➜ - It is found in women with average size and
height with shoe size of 4 or larger.
➜ All diameters are reduced but are in proportion
➜ It is normally found in women of small stature
less than 1.5 m in height with small hands and
feet
29. The andoroid pelvis
➜ - It resembles the male pelvis
➜ - Its brim is heart shaped with a narrow fore pelvis
➜ - It is a funnel shape with a deep cavity and straight
sacrum
➜ - The ischial spines are prominent and the sciatic
notch is straight
➜ The sub pubic angle is less than 90 degrees, it is
found in heavily built women
➜ • The heart shaped brim favors posterior position of
the occiput and is the least suited for child bearing
30. The anthropoid pelvis
➜ - It has a long oval brim in which the
anteroposterior diameter is long than the
transverse
➜ - The sacrum is long and deeply concave
➜ - The ischial spines are not prominent,
the sciatic notch and sub pubic angle are
very wide
➜ - It is found in women who are tall with
narrow shoulders
➜ - Labour does not usually present any
difficulties
31. The platypeloid pelvis
➜ This flat pelvis has a kidney-shaped brim
in which anteroposterior diameter is
reduced and the transverse increased
➜ - The sacrum is straight and the cavity is
shallow
• The ischial spines are blunt and the
sciatic notch and sub pubic angle are wide
• The head must engage with the sagittal
suture in the transverse diameter but
usually descends without difficulty
33. Gynecologic Hystory taking
➜ Respect, confidentiality and privacy can
help the diagnosis
➜ Try to understand the patient
➜ Try to gain the trust of the patient
33
34. Personal and social data
Name of the
patient
Age
Occupation
Residence
Level of
education
Marital status.
Single or married
Duration of
marriage
Husband*s name
and age
Occupation
Blood grouping
Consanguinity
Special habits:
• Smoking
• Drug abuse
• Alcohol intake
• Domestic pets
34
35. Presenting problem
HISTORY OF PRESENTING
ILLNESS
Should be focus on the
presenting problem or
complaint
Menstrual problems
Pain
Subfertility
Urinary incontenence, etc.
PRESENTING PROBLEM
Allow the patient to
describe this in her own
words as it is important to
understand what it is that
the patient perceives to be
the problem
35
36. Relevant Questions..
Abnormal menstrual
loss
• Regular or iregular
• Amount of blood
loss – no. of pads,
presence of clots,
flooding, absence
from school or
work due to
associated pain,
weakness or
flooding
Vaginal discharge
• Odour, color,
consistency,
amount &
presence of
blood
• Relation to the
period
• Associated
itching or
irritation
Pelvic pain
• Duration, nature
& site
• Relation to the
menstrual cycle
• Aggrevating or
relieving factors
• Radiation &
associated
synptoms
• Dysparunea
36
37. Menstrual history
Menarche, cycle, duration of the period
Last menstrual period (LMP)
Intermenstrual bleeding (IMB)
Postcoital bleeding (PCB)
Volume of blood loss
Pattern of bleeding: regular or irregular and
length of cycle
Pain relating to the period, its severity and
timing of onset
Medication taken during the period
38. Pelvic pain
• site of pain, its nature
and severity
• anything that aggravates
or relieves the pain-
specifically enquire
about relationship to
menstrual cycle and
intercourse
Vaginal discharge
• amount, colour, odour,
presence of blood
• relationship to the
menstrual cycle
• history of sexually
transmitted diseases
(STDs) or recent tests
• vaginal dryness (post-
menopausal)
38
41. Menopause (where relevant)
Past gynecological history
Previous gynecological problems and its treatments (PID,
endometriosis)
Gynecological operation (D&C, myomectomy.. etc.), date and
complications
Type of anesthesia used and complucations
Date of last period
any post-menopausal bleeding
any menopausal symptoms
41
42. 42
Past Obstetrical History
Number of children with ages and birth
weight
Any complications during pregnancy,
delivery or puerperium
Number of miscarriages and gestation at
which they occurred, their management
and complication
43. Past medical and surgical history
Hypertension
Blood transfusion
Diabetes
Any surgical operation,
date and complication
Asthma
Type of anesthesia used
and complication (s)
Hospitalization
43
46. Complaint…
main complaint (1 or 2 in
maximum)
in the patient`s own words
Duration of the complaint
History of current
illness
Analysis of the complaint +
symptoms
46
Onset, course, severity, duration
What increases / decreases the symptom
Associated symptoms
Other symptoms to prove / disprove the
provisional diagnosis
Investigation done (date, place & results)
Treatment received (details & response)
Any complications
50. Systemic review 50
A systemic review of all other organs especially:
URINARY SYSTEM
~ frequency – no of times per day
~ Nocturia – need to pass urine during the night
~ Dysuria – discomfort on passing urine
~ Urgency – strong desire to pass urine which can not
be ignored
~ Incontenece – involuntary leaking of urine
Provocation factors – coughing, laughing, running, etc.
51. Examination
General examination – general appereance
of the patient – gait, BMI, vital signs, face,
hands
Head and neck –examine the thyroid gland
Cardiovascular system
Respiratory system
Breast examination
Lower limp for oedema and varicose veins
52. Abdominal examination
Inspection – abdominal distension, shape,
asymmetry, masses, scars, hernia, dilated veins
Palpation:
~ superficial palpation for: tenderness, rigidity,
guarding
~ deep palpation for: organomegaly (liver, spleen,
kidneys), deep palpation for any masses and if
present determine if arising from the pelvis (can I
get below the mass?)
53. Abdominal examination
Percussion:
~ dull if the mass is solid, tympanitic if
distended bowel, shifting dullness and fluid
thrill in case of ascites
Auscultation:
~ usually used postoperatively to detect
bowel sounds
53
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64
65. Timeline
65
DEC
NOV
OCT
SEP
AUG
JUL
JUN
MAY
APR
MAR
FEB
JAN
Blue is the colour of the
clear sky and the deep
sea
Red is the colour of
danger and courage
Black is the color of
ebony and of outer
space
Yellow is the color of
gold, butter and ripe
lemons
White is the color of
milk and fresh snow
Blue is the colour of the
clear sky and the deep
sea
Yellow is the color of
gold, butter and ripe
lemons
White is the color of
milk and fresh snow
Blue is the colour of the
clear sky and the deep
sea
Red is the colour of
danger and courage
Black is the color of
ebony and of outer
space
Yellow is the color
of gold, butter and
ripe lemons
66. Roadmap
66
1 3 5
6
4
2
Blue is the colour of the
clear sky and the deep
sea
Red is the colour of
danger and courage
Black is the color of
ebony and of outer
space
Yellow is the color of
gold, butter and ripe
lemons
White is the color of
milk and fresh snow
Blue is the colour of the
clear sky and the deep
sea
68. SWOT Analysis
68
STRENGTHS
Blue is the colour of the clear
sky and the deep sea
WEAKNESSES
Yellow is the color of gold,
butter and ripe lemons
Black is the color of ebony and
of outer space
OPPORTUNITIES
White is the color of milk and
fresh snow
THREATS
69. Business Model Canvas
69
Key Activities
Insert your content
Key Resources
Insert your content
Value Propositions
Insert your content
Customer Relationships
Insert your content
Channels
Insert your content
Customer Segments
Insert your content
Key Partners
Insert your content
Cost Structure
Insert your content
Revenue Streams
Insert your content
70. Team Presentation
70
Imani Jackson
JOB TITLE
Blue is the colour of the clear
sky and the deep sea
Marcos Galán
JOB TITLE
Blue is the colour of the clear
sky and the deep sea
Ixchel Valdía
JOB TITLE
Blue is the colour of the clear
sky and the deep sea
Nils Årud
JOB TITLE
Blue is the colour of the clear
sky and the deep sea
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