History and Examination Flashcards
What is asked about in previous obstetric history?
Any carried beyond 24 weeks
Gestation - preterm
Mode - spontaneous vaginal, assisted vaginal or caesarean
Gender
Birth weight - SGA
Complications e.g. pre-eclampsia, gestational HTN, gestational diabetes, obstetric anal sphincter injury (3/4th degree tears) post partum haemorrhage
Assisted reproductive therapies e.g. ovulation induction with clomiphene, IVF
Care providers - just midwife, obstetric input
What is asked about for pregnancies not beyond 24 weeks?
Gestation
Miscarriages - spontaneous, medical management, surgical management e.g. evacuation of retained products of conception
Terminations - medical or surgical
Identified causes of miscarriage or stillbirth e.g. abnormal parental karyotype, fetal anomaly
Ectopic pregnancy - site and management e.g. methotrexate injection, laparotomy, laparoscopy, salpingectomy
What is gravidity?
Total number of pregnancies, regardless of outcome
What is parity?
Total number of pregnancies carried over the threshold of viability (24+0)
If patient is currently pregnant, one previous delivery and one previous miscarriage what is the G and P?
G3 P1+1 (+1 is pregnancy not carried to 24+0)
What is Naegele’s rule?
Assumes gestational age of 280 days at childbirth
EDD by adding a year, subtracting 3 months, and adding 7 days to origin of gestational age
Approx 280 days from LMP
Date of LMP + 7 days + 9 calendar months
What is asked about in history of current pregnancy?
Gestational age of pregnancy
Use of folate prior to conception and currently
Agreed EDD
Singleton or multiple
Uptake and results of Down’s screening
What is noted at 18-20 week scan?
Fetal anomalies
Placenta position - is it clear of the internal os
Amniotic fluid index - oligohydroamnios, normal or polyhydramnios
Estimated fetal weight
What is it important to note in PMH?
Usual questions
Abdominal or pelvic surgery
Mental health conditions
Asthma, CF Epilepsy HTN - older women Congenital heart disease Diabetes Systemic autoimmune disease Haemoglobinopathies BBVs HIV, Hep
What are the mental health red flags in an obstetric history?
Recent significant changes in mental state or emergence of new symptoms
New thoughts or acts of violent self harm
New and persistent expressions of incompetency as a mother, or estrangement from the infant
What should be asked about in drug history?
Allergies and intolerances
Enquire about drugs taken around conception and first 12 weeks
Drugs currently taken, including herbal or complementary therapies
Illicit drugs, alcohol, smoking
400ug folic acid per day for first 12 weeks
What do you need to ask about in an obstetric history?
Current gestation Previous pregnancies Presenting problem Current pregnancy Hx Gynae Hx PMH Family Hx Drug and Social Hx
How would you explore the patients presenting complaint?
As with any other Hx
Review symptoms - bleeding, spotting, discharge, abdomen pain, pruritus, headache, reduced fetal movements
What do you want to find out about the current pregnancy?
When they were booked (first antenatal visit) Results of scans and screening What scans they have had Fetal movements Fetal growth Hospital admissions? Planned mode of delivery
What are the key questions for an emergency gynaecological focused history?
SAMPLE
Signs/symptoms Allergies Medication Past illness/pregnancy Last oral intake Events leading to current clinical picture
What common gynaecological symptoms should be explored?
Vaginal bleeding - intermenstrual, post coital, post menopausal
Abdominal or pelvic pain
Vaginal discharge - colour, consistency, amount, smell
Menstrual history
Frequency - avg 28 days
<24 frequent, >38 infreq
Duration - 5 days
>8 prolonged, <4.5 shortened
Vol - avg 40ml
>80 heavy, <5 light
Date of LMP
Dyspareunia
Vulval itching
Anogenital changes
Infertility
What should be asked in PMH in gynaecological history?
Pregnancies births, miscarriages, abortions, ectopics Means of delivery Age of child, birth weight Complications
Cervical smear
Date, result, treatment
Surgical history
esp pelvic or abdo
Previous gynaecological problems
Previous sexually transmitted infections
What should be asked in Mx history in gynaecological history?
Contraception
Type, brand, correct use, previous contraception history
HRT Duration Cyclical or continuous Combined or oestrogen only Method of delivery
Recent abx use
Other medications, OTC
Known allergies
What is important to note in FH in a gynaecological history?
Breast, ovarian, endometrial cancer
e.g. BRCA 1/2
Diabetes
Bleeding disorders
What is important to note in SH in a gynaecological history?
Weight
Rapid weight loss - oligo or amenorrhoea
Obesity; changes, or increase risk of endometrial cancer
Occupation
Industrial exposures
Home situation
Smoking and alcohol intake
Diet and exercise
What are common symptoms to explore in a sexual history?
Vaginal bleeding Abdo/pelvic pain Vaginal discharge Dyspareunia Vulval itching Anogenital skin changes Infertility
Menstrual history
What should be asked about sexual contact in a sexual history?
Current relationship; how long, sexual relationship
Contraception; type, consistency, problems e.g. condom split
Timing of last sexual contact
Partners in last 3 months
Number, genders, known infections
For each sexual partner: Male or female Relationship - regular, casual, paid etc Was it consensual When last had sex Type of sex - oral, anal, vaginal Condoms/contraception Did condom break/fall off Did partner have any symptoms of STI Partner's details e.g. name, region, age for contact tracing
What should be asked in PMH for sexual history?
Previous STIs, including partners Previous STI screens and HIV tests Cervical smears - date, result, treatments Previous gynaecological problems Surgical history Pregnancies Other medical conditions
What should be asked about in DH for sexual history?
Contraception Medications affecting contraception considered Type and brand name Correct use Previous contraception Hormone replacement therapy Recent abx use Allergies
What are positive risk factors to look out for when assessing BBV risk?
Sexual contact with HIV positive partner
Engaging in sexual activities with bisexual/homosexual men MSM
Engaging in sexual activities with someone from an area of high HIV prevalence
IV drug use
Paying/being paid for sex
Receiving blood transfusions/tattoos/piercings in environments when sterile equipment cannot be guaranteed
What are the steps of a bimanual examination?
Pelvic examination of female genital organs
Introduction, chaperone, consent
Patient should have empty bladder
Remove clothing from waist down and sanitary protection
Any abdominal inspection and palpation performed before asking patient to lie on back with legs apart
Abdominal inspection for scars, ascites
Palpate for masses and tenderness, inguinal lymphadenopathy
External examination for
Deficiency - childbirth
Abnormal hair distribution, cliteromegaly
Skin abnormalities
Discharge - colour, consistency
Bleeding
Swellings of vulva e.g. tumours, cysts
Cough for any incontinence or prolapse
Palpate labia majora
Bimanual examination
Complete examination, thank patient, summarise findings
Further investigations; pelvic ultrasound, bloods depending on history and findings
What are the steps in a bimanual examination?
Lubricate right index finger and middle finger
Insert fingers into vagina, enter with palm facing sideways then rotate so palm is facing upwards
Move along posterior wall of vagina and locate cervix
Feel for smoothness, clots, mobility and firmness
Place fingers in the posterior fornix, to lift the uterus whilst pushing fundus down by putting hand on symphysis pubis
Assess uterus size (normal size of plum)
Determine if anteverted or retroverted
Note tenderness, mobility and shape
Place fingers in lateral fornix, and then press lateral to umbilicus to feel for any adnexal tenderness or masses.
Repeat on other side.
Move cervix from side to side, check for cervical tenderness.
Remove fingers gently, inspect for discharge or blood.
What are the steps in an obstetric examination?
Introduce self etc.
Measure patient’s heigh and weight
Ensure empty bladder
Expose from xiphisternum to pubic symphysis
Lie in supine position with head of bed raised to 15 degrees
Will need measuring tape, pinnard stethoscope/doppler transducer, US gel
General inspection
Wellbeing
Hands - radial pulse
Head and neck - melasma, conjunctival pallor, jaundice, oedema
Legs and calves - calf swelling, oedema, varicose veins
Abdominal inspection Distension compatible with pregnancy Fetal movement (>24) Surgical scars Skin changes in pregnancy - linea nigra, striae gravidarum (stretch marks) striae albicans (old silvery white striae)
Palpation
Fundal height - medial edge of left hand press on xiphisternum to locate fundus
Measure from here to PS in cm and inches, distance should be similar to gestational age
Assess lie
Place hands on either side of top of uterus, apply pressure
Move hands and palpate down abdomen
One side will feel fuller and firmer - back
Presentation
Palpate lower uterus
Firm and round means cephalic, soft/non round is breech
Breech can sometimes palpate head in upper uterus
Ballot head pushing from one side to other
Liquor volume
Palpate and ballot
Engagement
If presenting part has entered bony pelvis - note how much of head is palpable; engagement measured in 1/5s
Fetal auscultation
Location back of fetus to listen for heart
Place instrument towards where between fetal scapulae are
Use of hand held doppler only after 16 weeks
Feel mothers HR at same time
Measure fetal HR for one min - should be 110-160bpm
Complete examination Palpate ankles Test for hyperreflexia (pre-eclampsia) Wash hands, summarise Perform BP and urine dipstick
How do you perform a speculum examination?
Introduce self, explain, consent and chaperone
Patient should have empty bladder, remove clothing
Prepare gloves, lubricant, speculum, +/- smear, swabs, pipelle biopsy
Abdominal examination
Inspect for scars, ascites
Palpate masses, tenderness
Palpate groin for inguinal lymphadenopathy
External examination Inspect external genitalia Deficiency - childbirth Hair distribution, cliteromegaly Skin abnormalities - lesions, warts, erythema Discharge - colour, consistency Bleeding Swelling of vulva
Speculum Examination
Part labia, insert with screw facing sideways, blades vertical, then rotate
Slowly open, use light to inspect cervix
Look for abnormal discharge Erosions Ulcerations Growths Inflammation Bleeding Polyps Ectropion
Swabs taken if needed
Remove speculum - unscrew, rotate back
