Examinations

Question 1

Overall generic order of pregnant bump examination

Answer 1

-History
-Exposure and positioning
-Look
-Feel
-Listen

Question 2

Importance of positioning

Answer 2

-Lie the patient down a little but not too flat to avoid:
=Gravid uterus (lies on inferior vena cava)
=Aortocaval compression
=Reduced venous return to the heart
=Starling’s Law???!?
=Reduced stroke volume

Depends on indication for exam, consider tilt for >20 weeks

Question 3

Inspection of bump

Answer 3

-Abdomen appears distended consistent with gestation
-Signs of pregnancy:
=Linea nigra (line in middle)
=Striae gravidarum (Latin stretch marks)
=Scars of: Previous caesarean section,
Renal transplant, Previous midline incision (obstetric implications)

-Palmar erythema, spider naevi, oedema, pallor, jaundice, scratch marks, melasma

Question 4

Palpation of bump

Answer 4

-Fundus (top of uterus)
-With edge of hand moving down from xiphisternum (flat of hand, Umbi=20 weeks)
=Symphysio-fundal height (fundus to bony bit of pelvis/ top of pubic symphysis)
=Measuring tape
=cm = weeks of gestation (after 20/40)
=+/- a 3 cm, trend more important: plot on chart

-Lie: axis of baby relative to maternal spine (uncomfortable)
=Longitudinal (wanted)
=Transverse
=Oblique (head in iliac fossa/ diagonal)
-Position: where is the baby’s back on? =feel around watching face, assess liquor, either side feel

-Presentation
=Cephalic/ breech
=Ballot the head (ballotable) or breech
=Pawlick’s manoeuvre (tender)

-Engagement
=How much of the presenting part (ideally head!) can you feel abdominally
=Talked about in fifths i.e. 2/5 palpable = 3/5 engaged (36 weeks onwards)

Question 5

How does the baby’s position affect birth?

Answer 5

-Cephalic = head first
-Breech = bum first
-Footling breech = feet first
-Compound = more than one bit at once
-Cord = scary and bad

Question 6

Auscultation/listening in bump

Answer 6

-Doppler (or Pinard if you’re feeling retro)
-Over anterior shoulder
-Normal foetal heart rate of between 110 – 160bpm with accelerations and no audible decelerations

=Where is baby back- check which side has more resistance

Question 7

Vaginal examinations during labour

Answer 7

-Consent and chaperone
-Vulva and vagina (lichen sclerosis, varicose veins)

-Cervix
=Position (posterior/ anterior)
=Consistency (soft and hard)
=Dilatation
=Effacement

-Station of presenting part relative to ischial spines
=Above = too high to consider forceps
=At or below = consider instrumental

-Position
-Caput (squishiness)
-Moulding (overlapping structures)

Question 8

Overall generic order of gynae examination

Answer 8

-History and hand washing
-Exposure and positioning
-Look
-Abdominal exam (targeted)
-Bimanual
-Speculum

Question 9

Exposure and positioning of gynae exam

Answer 9

-Lying reasonably flat
-Bottom half all off
-Ankles up towards bum
-Keeping feet together, flop knees out to the side
=Like you’re doing yoga
=If at any point, you feel like it’s too much you just have to ask me to stop and I will – because you’re the boss

Question 10

Gynae inspection

Answer 10

-External inspection of vulva
=Skin (atrophic?)
=Labial architecture (lichen sclerosis)
=Rash
=Excoriations
=Scars
=Lumps/bumps
=Blood staining

Question 11

Describe bimanual examination

Answer 11

-Part labia with non-dominant hand, approaching on RHS
-Lubricating gel
-Single digit first - then 2 fingers (posterior fornix, other hand above pubic symphysis)
-Cervix (like the end of your nose)
=Consistency
=Excitation/ tenderness (free fluid in pelvis)
-Uterus (ballot)
=Size (slightly weird fruit system); multifibroid, nodular, tenderness
=Consistency
=Anteversion/retroversion
=Mobility
-Adnexal masses (ballot, corners)
=Tenderness, masses, left fornix/ LIF + right fornix/ RIF

Question 12

Describe the speculum examination

Answer 12

-Lubricating gel
-Part labia with non-dominant hand
-Insert it side-e-ways
-Aim for sacrum/posterior fornix (angle of vagina from horizontal= 60 degrees down)
-Put it all the way in before you open it!
-Press handles together
-Voila – cervix! Anterior
-Reverse manoeuvres to bring it back out

=Get them to sit on their fists
=Finger of a glove with end chopped off helps with lax vaginal walls
=Having a good assistant = priceless (vocal anaesthetic!)
=If she asks you to stop – stop
=If you’re not sure – ask a friendly registrar
=More tentative usually = more uncomfortable

Question 13

Bimanual examination findings

Answer 13

-Mobility: Uterus fixed/ immobile and examination uncomfortable
=Adhesions
=Endometriosis
=Infection
=Surgery
=Malignancy

-Regularity: asymmetrical (fibroids)