History and examination in obs and gynae Flashcards
How does a Gynae History vary from a normal history?
Same at start, PC, PMH, DH, SH, FH, SE ….
Additional info;
- Sexual History
- Obstetric History
Summarise;
- I saw Ms X a 34 yr old para 1+2 who presented with….
What 7 things are important to never forget in an Gynaecology history?
- LMP (Last menstrual period)
- Cycle (Regularity, duration and degree of bleeding)
- Intermenstrual or Post Coital bleeding?
- Sexually Active?
- Contraception (or HRT?)
- Last smear (and result of it!)
- Vaginal Discharge?
What are the 4 common conditions you will see?
- Menorrhagia
- Prolapse
- Pelvic Pain
- Early pregnancy bleeding
What is Menorrhagia and what questions would you ask?
Menorrhagia is heavy or irregular periods
Questions;
- How do you know how heavy?
- How many pads do you use a day
- What kind of pad/tampon (heavy flow, light flow)
- Getting up during night to change pad?
- Flooding during day ?
- Ask how do they interfere with your life?
- Anemia? (ask if anaemic and do FBC to see as well)
What questions would you ask about Prolapse?
- Is it anally or vaginally? (Rectocele or Cystocele)
- How much has prolapsed ? (Procidentia)
- Do you have heavy/dragging feeling?
- Stress incontinence (cant cough, laugh dance and leak)
- Urge incontinence - When bladder fills you need to go
- Retention
What questions would you ask for Pelvic Pain?
- what bring it on, in relation to period, before after?
- Painful on sex?
- Pain on outside or inside?
- Pain on urination
What is Menorrhagia and what questions would you ask for Early Pregnancy Bleeding?
What is Procidentia?
Procidentia - cervix and uterus comes outside vagina, needs to be packed
What 5 steps are involved in a Gynae Examination?
- Chaperone ! (Intimate)
- General
- Abdominal (Could miss massive abdominal/pelvic pass if don’t do and also gets patient used to you touching them and relaxes them so do abdo first)
- Pelvic Vaginal exam (Bimanual)
- Speculum (Cuscos/Sims)
What 5 things do you look for on a Vaginal Examination?
- Position of uterus
- Size of uterus
- Mobility of uterus
- Adnexal masses (what size, walnut, grapefruit?)
- Tenderness/Cervical excitation ? (If wiggling cervix and becomes tender = excitation)
Important to be honest and say what you feel, you might be given a patient with a hysterectomy !
What tools do we use for our vaginal examination ?
- Cusco Speculum (metal)
- Lucy’s (Sims) Speculum (M shaped)
Important to only pull out Cusco’s when closed !
What questions should you include in an Obstetric History ?
- Parity (forget Grava)
- Gestation? Expected date of delivery?
Gynae history;
- LMP (Last menstrual period)
- Cycle (Regularity, duration and degree of bleeding)
- Intermenstrual or Post Coital bleeding?
- Sexually Active?
- Contraception (or HRT?)
- Last smear (and result of it!)
- Vaginal Discharge?
POH - Past Obstetric History
PMH, DH, FH (Genetic History?), SH - other children?, SE, Summarise
Need to know if child is at risk, we all have this responsibility and support the family. Als domestic abuse which accelerates when pregnant
What is Parity (and Gravida) and how do you work it out?
Para = Number of times that a woman has given birth to a foetus with a gestational age of 24 weeks or more.
Told not to worry about Gravida but…
Gravida = Number of times a woman has been pregnant
If a woman was pregnant 3 times and had 1 delivery at term, 1 early TOP and 1 earl miscarriage then she would be (Gravida 3) Para 1+2
Add numbers together get how many pregnancies, 1st number how many given birth to, 2nd number how many lost/terminated
What questions should you ask in Past Obstetric History?
- All previous pregnancies and outcomes
- Date of them
- Type of delivery
- Live Birth or Still Birth?
- Weight and sex of baby (think diabetes?)
- Any problems encountered during pregnancy or delivery
What should you cover in an Obstetric Examination?
- General examination including BP
- Abdominal Exam
- Fundal Height
- Urine
Not complete without BP and urine test must offer this in an obstetric exam !!!
How do you measure the fundal height and what is important to remember when doing this?
DO NOT LIE PREGNANT WOMAN FLAT! On tilt or sitting up. It puts the weight of your uterus on your spine and back muscles. In the second and third trimesters, lying on your back may compress a major blood vessel that takes blood to your uterus, making you feel dizzy and possibly reducing blood flow to your fetus.
How to assess;
- Have the mother semi recumbent with an empty bladder
- General obsevation (stretch marks, look unwell, rashes?)
Palpate funds with 2 hands;
- Need to be firm but gentle and looking at patients face to see if sore).
- Find top of bump and work way down and find hard shelf where uterus starts, don’t look at cm, face down and find symphysis (lower than you think)
- Secure tape measurement down at top of fundus
- Measure to top of symphysis pubis
- Measure along longitudinal axis of measurement
Final notes;
- Fundal height is important in women not on scanning paths
- Don’t redo it!
What are the 6 different ways a foetus can lie?
3 Main Ways;
- Longitudinal
- Transverse (C-section)
- Oblique (C-section)
Longitudinal;
- Cephalic (Yey!)
- Breech (Bum first)
Transverse;
- Backdown (Sleeping)
- Backup (More likely to prolapse cord, nothing there to plug cervix, have to get over baby to pull out) (WAP)
Oblique;
- Head RIF (Right Inferior)
- Breech (Bum first)
What is Fifth’s Palpable?
You will be asked about this!!!
5th palpable is used to assess how much of the foetal head is engaged - Engaged when widest part head past pelvic inlet
When only 2/5 of the head is palpable abdominally then the widest part has descended into the pelvis and the head is engaged
Pubic bone is marker! If you can feel foetal head 5 fingers above pubic symphysis then 5/5ths palpable, 4 fingers, 4/5ths and so on…
Examples;
- If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged).
- A little hiding behind pubic symphysis, cant feel or get behind head then 4/5th palpable
- If you are not able to feel the head at all abdominally, it is zero fifths palpable (i.e. fully engaged).
How do we listen for the foetal heart?
Want to listen over the baby’s anterior right shoulder with doppler, need to locate by palpation then listen.
If hearing a fast woosh woosh sounds most likely placenta hearing and if lowers will be maternal pulse (hold maternal pulse during to differentiate)
Foetal Heart is heard and the rate is… (normal 110-160bpm)
