Obstetrics & Gynecology PE Flashcards
Obstetric Examination
Introduction
- privacy to undress
- offer chaperone
- empty bladder
- position: slight left lateral tilt (pillow under right hip)
- explain steps
- consent
GA: pallor, jaundice
VS: BP, pulse, temp; weight, height, BMI
Face: periorbital & generalized facial edema, melasma, pallor, jaundice
Abdomen:
Inspection: scars, fetal movements, linea nigra, striae gravidarum
Palpation: Leopold’s Maneuver
- Fetal lie
- Presentation
- Position
- Engagement
1. Fundal grip: fundal height
2. Lateral grip: fetal lie
3. Pelvic grip: presentation
4. Degree of descent: engagement
-Assess for fetal movements
- Assess fetal heart rate (Normal: 110 - 160 bpm)
Genital examination
- chaperone, explain steps, consent
Inspection: discharge, bleeding, lesions, rashes
Speculum exam
Vaginal exam: Bishop score
- Dilation
- Effacement
- Consistency
- Position
- Head station
Lower limb exam
- edema, clonus, hyperreflexia
Urine dipstick: proteinuria, UTI
Regular Obstetric Examination
Your next patient is a 36 weeks pregnant lady who has come for her regular obstetric examination. This is her first pregnancy and it has been uneventful. Antenatal screenings have been done and are normal. She has done her sweet drink test which has been normal. Urine dipstick has been done and is normal.
Tasks:
1. Explain your physical examination to the medical student
2. Explain what instruments you will be using
3. Interpret and correlate the following findings during your explanation
- BP 130/80
- FH: 36cm, SFH 37cm, cephalic presentation, fetal head: 4/5 above pelvic brim
- FHR 130 bpm
- Fetal movement: FMF
- Arm circumference 34cm
Introduction
- privacy to undress
- offer chaperone
- empty bladder
- position: slight left lateral tilt (pillow under right hip)
- explain steps
- consent
GA: pallor, jaundice
VS: BP - In this case, a BP of 130/80 is still okay
, pulse, temp; weight, height, BMI
Hands: CRT, pale palmar crease
Face: periorbital & generalized facial edema, melasma, pallor, jaundice
Abdomen:
Inspection: scars, fetal movements, linea nigra, striae gravidarum
Palpation: Leopold’s Maneuver
- Fetal lie
- Presentation
- Position
- Engagement
1. Fundal grip: fundal height
- The current pregnancy is at 36 weeks AOG, and the reported SFH is 37cm, so this is normal
- Because I have a cephalic presentation on the chart, that means that the head is in the pelvis and the buttocks will be felt in the pelvis
2. Lateral grip: fetal lie
- Because I have a cephalic presentation, I expect the lie to be most likely longitudinal
3. Pelvic grip: presentation
- Since this is a cephalic presentation, I expect to feel a hard round mass in the pelvis
4. Degree of descent: engagement
- In this case we have a cephalic presentation, so if you feel the head completely, it is 5/5 or no engagement
- If you can’t feel the head, it is 0/5, or fully engaged
- In this case, engagement is at 4/5, which means engagement has started, we’re not able to feel the head completely but still able to feel the forehead and occiput easily
-Assess for fetal movements
- Assess fetal heart rate (Normal: 110 - 160 bpm)
- In our case, the FHR is 130bpm, so there is no concern
Genital examination
- chaperone, explain steps, consent
Inspection: discharge, bleeding, lesions, rashes
Speculum exam
Vaginal exam: Bishop score
- Dilation
- Effacement
- Consistency
- Position
- Head station
Lower limb exam
- edema, clonus, hyperreflexia
Urine dipstick: proteinuria, UTI
Preeclampsia Examination
Your next patient is a 36 week pregnant lady who has presented to the ED. Her blood pressure is 155/90, she has 3+ protein on her urine dipstick. Her fundal heigh is 35cm, longitudinal lie and head is 4/5 palpable.
Tasks:
1. Explain the instruments you will be using in this examination
2. Explain the physical examination
3. Explain your diagnosis with reasons
Request further investigations
Hemodynamic Stability
Introduction:
- introduce yourself
- explain steps: looking & feeling the stomach, listen with Doppler ultrasound, look at the private parts, looking at the lower limbs
- use measuring tape, Doppler ultrasound, pen torch, ophthalmoscope, speculum, reflex hammer
- privacy to undress, cloth to cover herself
- empty the bladder
- get consent
- position: left lateral tilt
- wash hands before starting examination
Flagging:
I am concerned about preeclampsia because I have high blood pressure and proteinuria. I will be looking for key features of preeclampsia: papilledema, hyperreflexia, clonus, and abdominal examination mainly looking for tenderness
GA: LOC, pallor, jaundice, rash, edema
VS: BP on both arms, PR and rhythm, RR, O2 sat
Hands: ecchymosis
Face: pallor, jaundice, periorbital & facial edema
Eye: fundoscopy for papilledema, VA, pupils
Neck: JVP at 45 degrees
Chest:
- CVS: visible apex best, displaced apex beat, auscultate for gallop rhythm & murmurs
- Respi: asymmetrical chest movements, bibasal crepitation for pulmonary edema
Abdomen: RUQ for liver tenderness, uterus for tenderness
Leopolds:
- Fetal lie
- Presentation
- Position
- Engagement
1. Fundal grip: fundal height
2. Lateral grip: fetal lie
3. Pelvic grip: presentation
4. Degree of descent: engagement
-Assess for fetal movements
- Assess fetal heart rate (Normal: 110 - 160 bpm)
Neurological Exam & Lower limb: edema, knee reflex looking for hyperreflexia, clonus
Genital Exam:
- chaperone, explain steps, consent
Inspection: discharge, bleeding, lesions, rashes
Speculum exam
Vaginal exam: Bishop score
- Dilation
- Effacement
- Consistency
- Position
- Head station
Investigations
- FBE with platelets
- UEC (urea, electrolyte, creatinine), eGFR
- Liver function: liver enzymes
- Urine ACR (albumin-creatinine-ratio): quantitative amount of leaking protein
<2.5 normal
2.25 microalbuminuria
>2.5 macroalbuminuria
32 week pregnant lady that comes to you with leakage of fluid.
Task:
1. Explain the OB examination to the medical student
2. Explain the CTG
Introduction
- privacy to undress
- offer chaperone
- empty bladder
- position: slight left lateral tilt (pillow under right hip)
- explain steps
- consent
GA: pallor, jaundice
VS: BP, pulse, temp; weight, height, BMI
Face: periorbital & generalized facial edema, melasma, pallor, jaundice
Abdomen:
Inspection: scars, fetal movements, linea nigra, striae gravidarum
Palpation: Leopold’s Maneuver
- Fetal lie
- Presentation
- Position
- Engagement
1. Fundal grip: fundal height
2. Lateral grip: fetal lie
3. Pelvic grip: presentation
4. Degree of descent: engagement
-Assess for fetal movements
- Assess fetal heart rate (Normal: 110 - 160 bpm)
Genital examination
- chaperone, explain steps, consent
Inspection: discharge, bleeding, lesions, rashes
Sterile Speculum exam
- Inspect: if dilated or not, fluid leaking, pooling of liquid in the vaginal vault, if see umbilical cord or presenting part
- If suspecting PROM, do a Valsalva maneuver, look for pooling of liquid outside of the cervix
- If you see fluid, take a sample and swab and send to lab to check if it is amniotic fluid. Also check for microscopy and culture
25 year old pregnant lady, with GA of 41 weeks. This is her 1st pregnancy. All antenatal have been done and are normal. Baby is kicking and moving normally. OB registrar has decided to go for an induction of labor. She has had intermittent abdominal pain since yesterday.
Task:
1. Explain physical examination to medical student
2. Explain what you are looking for with reasons
3. At 6 minutes, CTG will be given. Interpret it to medical student
Introduction
- privacy to undress
- offer chaperone
- empty bladder
- position: slight left lateral tilt (pillow under right hip)
- explain steps
- consent
GA: pallor, jaundice
VS: BP, pulse, temp; weight, height, BMI
Face: periorbital & generalized facial edema, melasma, pallor, jaundice
Abdomen:
Inspection: scars, fetal movements, linea nigra, striae gravidarum
Palpation: Leopold’s Maneuver
- Fetal lie
- Presentation
- Position
- Engagement
1. Fundal grip: fundal height
2. Lateral grip: fetal lie
3. Pelvic grip: presentation
4. Degree of descent: engagement
-Assess for fetal movements
- Assess fetal heart rate (Normal: 110 - 160 bpm)
Genital examination
- chaperone, explain steps, consent
Inspection: discharge, bleeding, lesions, rashes
Speculum exam
Vaginal exam: Bishop score
- Dilation
- Effacement
- Consistency
- Position
- Head station
- All of these factors will calculate a Bishop score that will give us a score between 0 - 13. It predicts the success of induction of labor. If it is less than 6, it means the cervix is not ready (can do techniques for ripening of cervix)
CTG Interpretation
Start from 28 weeks AOG
Descriptors:
- Baseline FHR (normal 110 - 160 bpm)
- Variability (normal 6 - 25 bpm)
- Accelerations (normal at least 2 within 20 minutes)
- Decelerations (normal: absent or early)
Early: head compression
Late: hypoxia
Variable
CST Interpretation:
Positive (abnormal): has late decelerations following >50 percent of contractions
Negative (normal): no late decelerations or significant variable decelerations
Unsatisfactory: fewer than 3 contractions in 10 minutes & is not positive
Reactive test (from 32 weeks to term): there are 2 or more FHR accelerations reaching a peak of at least 15 bpm above the baseline, lasting for at least 15 seconds in a 20 minute period
if non-reactive NST, get another tracing for 20 minutes
Breast Examination
Your next patient is a 28 year old lady who presents to you concerned of a breast lump.
Task:
1. Explain PE to medical student
- Introduce yourself
- Explain steps: I’ll be looking and feeling the breasts and armpits
- Exposure: Need to remove the shirt and bra, I’ll give you privacy to undress, cloth to cover yourself
- Position: both in a sitting and lying position
- Offer chaperone
- Stop signal: if at any point of the examination you feel uncomfortable, you can stop me
- Get consent
- Wash hands before starting examination
Inspection: sitting position
- asymmetry, visible masses, redness, rash, dimpling, nipple retraction/ulceration, nipple discharge
Check findings in 5 positions:
1. neutral on lap
2. hands on waist and push
3. hands behind head and push elbow back
4. lean forward
5. raise arms above head and lower slowly to see tethering of nipple/skin
Palpation: lying position & repeat while sitting
- hand of examined side under the head
- examine systematically in spiral or vertical method
Lump characteristics:
- site (quadrant, clock)
- consistency
- border
- surface
- tenderness
- mobility
Benign: smooth, mobile, regular borders and surface
Malignant: hard, stony, irregular borders
Lymph node palpation
- Axillary (CLIPS)
- supraclavicular
27 year old lady has come to you for a cervical screening
Task:
1. Explain the procedure to the medical student
Before CST:
-Not on her period
-Best time: 2 weeks after LMP
-No vaginal creams, douches, intercourse in the last 48 hours
On the day:
- Introduce yourself
- Explain steps: I will be looking at the private parts, inserting a speculum in the vagina, taking a sample with a brush
- Exposure: remove pants and underwear
- Give her privacy to undress, sheet to cover herself
- Offer chaperone
- Stop signal
- Position: lie down on her back, bend the knees and spread the legs
- Empty the bladder
- Get consent
- Wash hands and start examination
Prepare:
- Speculum: choose correct size
- Broom
- Thinprep liquid cytology: check the expiry date
- Warm water as a lubricant
Procedure:
Inspection: discharge, bleeding, rash
Speculum:
- Warn the patient that you are inserting
- Insert the speculum at a 45 degree downward angle, holding it in a vertical position
○ Once inside, rotate the speculum into a horizontal position
○ Open blades and make sure I can see cervix
○ If you visualize the transformation zone, which is the junction of the endo and ectocervix, you will use the broom, if not, use the spatula and brush
§ In a premenopausal lady, without any history of treatments, we are most likely going to see the transformation zone
○ When you’re using the broom, the long bristles take a sample from the endocervix and the short bristles take a sample from the ectocervix
§ You will need to do 5 full 360 degree rotations
§ Remove and rinse vigorously in the liquid in the bottle
§ Don’t leave the head of the broom in the vial
§ Tighten the cap, write the patient’s name on the bottle
○ For a postmenopausal lady or post-treatment young lady and you cannot visualize the transformation zone, we use the spatula and brush
§ Spatula takes a sample from the ectocervix, do 1 full 360 degree rotation
§ Brush takes a sample from the endocervix, do a quarter to half a turn
Post-procedure:
- It’s possible to have some spotting
- Advice:
○ CST every 5 years from age 25
○ New cervical screening guidelines of Australia:
§ Screen for HPV: if positive, reflex cytology is done (if negative, no cytology)
□ Main risk factor for cervical cancer
□ It is a sexually transmitted infection
□ More than 100 strains, worried about high risk ones for cancer HPV 16 &18
