History and examination Flashcards
What information must you always get when taking an obs/gynae history?
Last menstrual period
Cycle
Contraception/sexually active
Last smear test and result
If your patient tells you that they don’t use contraception but they are sexually active what should you do?
Ask if they are planning a pregnancy
If not, advise of importance of contraception
It may be that their partner has had a vasectomy or that they use condoms or withdrawal methods
If a female presents with Menorrhagia (heavy flow), what questions could you ask to determine the heaviness of flow or the impact on their QOL?
Do they soak through 1 or 2 sanitary pads every 1-2 hours for several consecutive hours?
Do they need to use double sanitary protection? + specific products used
Do they experience flooding (soaking through all protection without warning)?
Do they need to change bed clothes during the night? or get up in the middle of the night to change product?
Length of flooding? >7days considered abnormal
Passing of clots?
Restriction of daily activities?
Enquire about anaemia - fatigue, SOB
Ask about pain or irregular or intermenstrual bleeding
Why does prolapse of the bladder/retcum/uterus or cervix occur?
Weakness of ligaments/muscles of the pelvic floor
What are risk factors associated with Prolapse? (4) - these should be asked about as part of the history
Vaginal delivery
Chronic constipation
Persistent cough
Heavy lifting
What are some common conditions that women present with to obs/gynae clinic?
Menorrhagia
Prolapse
Pelvic pain
Early pregnancy bleeding
How do females often describe prolapse symptoms?
Sensation of something coming down or that they feel like they are sitting on a ball. They may feel a bulge in their vagina.
Due to gravity, these symptoms tend to get worse as the day goes on.
When a patient presents with early pregnancy bleeding it is important to ask about…
LMP
Cycle
Contraception
Planned pregnancy?
Amount of bleeding and how long it’s been going on for?
Pain and site/type and timing of pain
What might be the cause of early pregnancy bleeding?
Missed, threatened or incomplete miscarriage
Ectopic pregnancy - can be associated with massive intra-abdominal bleeding
Why is it important to ask about shoulder tip pain if you suspect an ectopic pregnancy?
Blood may irritate the diaphragm and cause shoulder tip pain due to same innervation
What is involved in a typical gynae examination?
General
Abdominal
PV - vaginal (bimanual)
Speculum – Cuscos (cervix) /Sims (ant/post vaginal wall)
What things are you looking for during a vaginal examination?
Position of uterus – axial, anteverted or retroverted
Size of uterus
Mobility of uterus
Adnexal masses
Tenderness/cervical excitation (pain from moving cervix side to side)
80% of uteruses are of which position?
Anteverted
What can cause cervical excitation?
Ectopic pregnancy
Pelvic infection
What is parity?
Indicates the number of pregnancies reaching viable gestational age. 2 numbers:
1st number = number of pregnancies that have ended after 24 weeks regardless of whether the child was born alive or was stillborn.
2nd number = number of pregnancies that have ended before 24 weeks (terminations, miscarriages and ectopics)
So if someone gives birth to a baby full term and no other pregnancies then the will be para 1+0
If they’ve had a still born female infant at 26 weeks and a live born at 32 weeks and had an ectopic they will be para 2+1
3 miscarriages or 2 terminations and an ectopic = para 0+3
What do you want to find out about a woman’s past obstetric history?
All previous pregnancies and outcomes
Dates of delivery and type of delivery
Live born or still born
Weight and sex of baby
Any problems encountered during pregnancy/delivery/postnatally
Types of delivery (3)
Spontaneous vaginal
Forceps - assisted vaginal
C-section - elective or emergency
What does an obstetric examination involve?
General examination including BP
Abdominal examination
Foetal Heart
Urine
What is foetal lie?
Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother.
There are 3 main types of foetal lie which include:
Longitudinal lie: the head and buttocks are palpable at each end of the uterus.
Oblique lie: the head and buttocks are palpable in one of the iliac fossae.
Transverse lie: the fetus is lying directly across the uterus.
When is a foetus considered ‘engaged’?
When more than 50% of the presenting part (usually the head) has descended into the pelvis.
The fetal head is divided into fifths when assessing engagement:
If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged).
When only 2/5 of the head is palpable abdominally then the widest part has descended into the pelvis and the head is “engaged”
Where do you best hear the foetal heart?
Over the anterior shoulder. (Between the shoulders on the foetal back)
If the baby is in a longitudinal lie with a cephalic presentation (head down, legs at top) then listen suprapubically in the midline
What is a normal foetal heart rate?
110-160 bpm
In an exam you are asked to perform an obstetric abdominal exam. What is necessary to complete this examination that you should state at the end?
BP and urinalysis
Why should you never lie a pregnant woman flat/supine?
In the supine position the pressure of the gravid uterus on the inferior vena cava causes a reduction in venous return to the heart with a possible 25% reduction in cardiac output
