OBGYN History & Examination Flashcards
What are the steps to the abdominal examination of a pregnant woman?
Introduction
Inspection
Palpation
Auscultation
What are the important steps in the introduction when doing an obstetric/gynaecological examination?
Introduce self
Wash hands
Explain procedure
Obtain consent
Offer chaperone
Expose pt to appropriate level with a covering sheet
Position pt comfortably and appropriately
Why might the bed need to be adjusted for a pregnant patient, and how might we need to adjust it?
Lying flat in pregnancy can be difficult, and can cause blood pressure problems.
The head of the bed can be tilted up to 15 degrees.
What equipment do we need to prepare when examining a pregnant woman?
Covering sheet
Measuring tape
Pinnard or doppler stethoscope
BP cuff
What do we look for on inspection of the pregnant abdomen?
Distension (in keeping with pregnancy)
Striae
Scars
Linea nigra
What is the first thing we should palpate in a pregnant abdo examination?
The fundus, so we can measure the symphyseal-fundal height.
How is symphyseal-fundal height measured?
- Find fundus with the side of your hand at the top of the pregnant belly (below the xiphisternum)
- Place the measuring tape upside down at the top of the fundus, then run it down to the pubic symphysis to measure the fundal height.
What are the 4 steps of the pregnant abdo palpation?
- Palpate the fundus
- Palpate the sides with ballotting motion
- Palpate the apex with C-shaped hands
- Palpate to check for engagement with fingertips
What are you looking for when you palpate the sides of the pregnant abdomen?
Shapes and feelings suggesting where the back, head, and limbs are located.
How does the back of the foetus feel when you palpate it?
Smooth, broad, and consistent
How do the limbs of the foetus feel on palpation?
Knob-like structures
How does the head of the foetus feel on palpation?
Hard, rounded, and mobile.
How does the bottom of the foetus feel on palpation?
Soft, non-mobile, and irregular
What 5 things do we describe after examining the pregnant abdomen?
- Symphyseal-fundal height
- Lie of the foetus
- Presentation of foetus
- If foetus is engaged
- Foetal Heart Rate
What re the elements ofa gynaecological history? (Aside from general hx taking elements)
Menstrual hx - age of menarche or menopause, cycle length and duration, last menstrual period.
Contraception
Prior vaginal/pelvic infections of surgery
Be age appropriate
How should we take the obstetric element of a history?
Go chronologically: Number of pregnancies Each pregnancy outcome Gestational ages Pregnancy-related complications Birth-relatedcomplications
When a pregnant woman presents, what are the 4 key aspects of a history that you must ask?
Have they experienced any:
- Change in foetal movements
- PV bleeding
- Tightening (beginning of labour)
- Membrane ruptures
What do we need to know about a current pregnancy?
Gestational age (LMP if early pregnancy) EDD If scans up to date Singleton/multiple If there has been any screening done Folate use around conception
What do we need to know about previous pregnancies?
How many, and how many of them were carried to term. Gestation Mode of delivery Birth weight Complications If any assisted reproductive techniques used Any terminations or miscarriages Ectopics Medical complications during pregnancy
What is gravidity?
The total number of pregnancies, regardless of the outcome
What is parity?
Total number of pregnancies carried over 24 weeks (threshold of viability)
What does G3 P2+1 mean?
3 total pregnancies
2 were delivered, and 1 was a miscarriage
What does G3 P2 mean?
Patient is currently pregnant and has had 2 previous deliveries
How many scans are routine for a pregnancy?
2 - at 12 weeks and 20 weeks
What are the 2 routine scans for?
12 weeks for viability and dating
20 weeks for abnormalities
What are the broad categories of PMH questions you need to ask in an obstetric hx?
Medical hx
Pelvic surgery
Abdominal surgery
Mental health conditions
What medical co-morbidities are common in women of child-bearing age?
Asthma CF Epilepsy HTN Congenital heart disease Diabetes T1 or T2 Autoimmune diseases Haemoglobinopathies BBVs
Why might mental health be an important question to ask about?
Nearly 25% of deaths 6-12 months post-partum were due to psychiatric issues.
This may be due to established mental health problems, or new onset.
Why is drug history very relevant in an obstetric history?
The mother may be on a teratogenic drug, such as some epilepsy medications.
Illiit drugs and alcohol use are also important due to teratogenic effects.
What elements of a social history are important in obstetrics?
If pregnancy was planned or unplanned (may be source of anxiety).
Current on previous occupation, and arrangements for going back to work.
Home circumstances
Financial circumstances
Smoking
Domestic abuse
In an obstetric history, what do we need to know about the mothers blood group?
Why is this important?
If she is Rhesus positive or negative.
If she is Rhesus negative, she will need anti-IgG before and after birth to protect the baby from haemolytic disease of the newborn.
What is a good format for emergency history taking?
SAMPLE
Signs/symptoms Allergies Medication Past illness/Pregnancy Last oral intake Events leading up to current clinical picture
Catchy, huh?
What gynae complaints might someone come to you with?
PV bleeding Abdominal/Pelvic pain Vaginal discharge Menstrual changes/complaints Dyspareunia Vulval itching/anogenital skin changes Infertility
When a pt complains of vaginal discharge, what do we want to know?
Colour
Consistency
Amount
Smell
Like the obstetric history, past medical hx is an important element. What do we need to ask about?
Pregnancies Cervical smears Surgical hx Gynae problem hx Sexual hx inc. STIs
A drug hx in gynaecology should include specific enquiries about what?
Contraception
HRT
Recent antibiotic use
A family hx in gynaecology should include specific enquiries about what?
Breast/ovarian/endometrial cancer
Diabetes
Bleeding disorders
A social hx in gynaecology should include specific enquiries about what?
Weight Occupation Home situation Smoking Alcohol Diet and exercise
How should a obstetric or gynae history be finished?
Systems review!
Urinary, bowel, neuro symptoms, fever, fatigue, weight loss, abdominal distension
What does a bimanual examination involve?
Inspection and palpation of the abdomen and groin
External examination of the vulva
Palpation of internal structures of vagina with fingers using gloves and lubricant, while pushing down with other hand on the fundus.
What is important to not do when taking a sexual history?
Don’t assume anything e.g. sexuality, what they mean by “sex”, if they identify as one thing but practice another etc.
What presenting complaints might lead you into a sexual history?
- Vaginal bleeding
- Abdominal or pelvic pain
- Vaginal discharge
- Dyspareunia
- Vulval itching
- Anogenital skin changes
- Infertility
- In men - Testicular/scrotal pain/itching/discharge, dysuria
How should you take a sexual history of a presenting complaint?
Like anything else, SQITARS, any previous occurences, menstrual history, is it cyclical etc.
What patterns of vaginal bleeding might a pt report?
- Intermenstrual
- Post-coital
- Post-menopausal
What do we need to know about vaginal discharge?
- Colour
- Consistency
- Amount
- Smell
What patterns of dyspareunia do patients report?
Deep or superficial
What other symptoms might a patient report in a sexual history?
- Anal discharge
- Fever
- Urinary symptoms
- Joint pain
- Eye symptoms
What do you need to ask about sexual partners?
- Are they in a relationship currently? Is it a sexual relationship?
- How many sexual partners do they currently have?
- How many have they had in the last 3 months?
What do we need to know about contraception?
- Is it barrier or not?
- How frequently is it used?
- How do they use it (technique)?
- Any problems with it they have faced recently?
What do we need to ask about the nature of sexual relationships/contact?
- Was it consensual
- Was it regular or one off?
- Was it casual?
- Was it paid?
What past medical history is important in a sexual history?
- Previous STIs
- Previous STI screens
- Cervical smears
- Previous gynae problems
- Surgical history (pelvic/abdo)
- Pregnancies
- Other medical conditions
What drug history is important in a sexual history?
- Contraception, including non-drug forms (i.e. barrier)
- HRT
- Recent abx
- Allergies
What social history is important in a sexual history?
Smoking
Alcohol
Recreational drug use
IVDU
What risk factors are important to ask about when thinking about blood-borne virus risk?
- HIV positive sexual partner
- MSM/sexual contact with bisexual/homosexual man
- Intercourse with someone from a high prevalence area of HIV
- IVDU in pt or partner
- Paid or paying for sex
- Blood transfusion/tattoo/piercing in high risk environment
What is a speculum?
A plastic or metal device that is used to look inside the vagina and observe the cervix.
How should you introduce a speculum examination?
- Introduce self
- Wash hands
- Explain procedure
- Reassure pt
- Obtain verbal consent
- Offer a chaperone (don’t do it without one)
How should the pt prepare for a speculum examination?
Empty bladder (for comfort) Remove clothes from waist down and cover with a sheet
How should the doctor prepare for a speculum examination?
Prepare loves, lubricant, and speculum, as well as swabs/smear, and Pipelle biopsy as appropriate.
Wash hands.
What are the steps to a speculum examinaton?
Introduce Prepare Abdo examination External examination Speculum examination Bimanual alongside as needed Swabs etc as needed
What do we look for on the abdomen as part of the speculum examination?
Scars and ascites
Palpate for masses or tenderness
Inguinal lymphadenopathy
What do we look for in the external part of the speculum examination?
- Any skin abnormalities
- Discharge
- Bleeding
- Swelling of vulva
- Changes associated with childirth
- Abnormal secondary sexual characteristics
- Cough -> incontinence or prolapse
- Palpate for any reported swellings
How do we do the speculum part of a speculum examination?
- Lubricate speculum and warn patient
- Part labia with left hand
- Hold speculum like a syringe to keep the blades together
- Insert vertically, then rotate 90 degrees
- Slowly open blades and adjust to visualise cervix
Once a speculum is in, what do we look for on the cervix?
- Discharge
- Ectropion
- Growths
- Inflammation
- Bleeding
- Polyps
Once a speculum is in, what do we look for on the vaginal walls?
- Erosions
- Ulceration
- Growths
- Inflammation
- Bleeding
- Polyps
How do you remove a speculum?
Undo the screw to allow the blades to close (leave open slightly to not pinch the vaginal walls), rotating back 90 degrees and gently remove
What order should swabs be done in?
- Hi-vaginal charcoal swab
- Endocervical charcoal swab
- Endocervical chlamydia swab
How should an endocervical swab be taken?
- Pass cytobrush through vagina into endocervical canal
- Turn brush 360 degrees 5 times
- Introduce brush to specimen pot and move brush to dislodge cells into the liquid.
When is the ideal time to take a smear?
Mid-cycle
