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Practical issues, History taking & Clinical examination in O&G . Hervinder Kaur Consultant Obstetrician & Gynaecologist, UHCW Obstetric & Gynaecology Lead for Warwick Medical School. LEARNING OBJECTIVES.

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practical issues history taking clinical examination in o g

Practical issues, History taking & Clinical examination in O&G

Hervinder Kaur

Consultant Obstetrician & Gynaecologist, UHCW

Obstetric & Gynaecology Lead for Warwick Medical School

learning objectives
LEARNING OBJECTIVES
  • To develop the basic clinical skills of history taking, clinical examination and case presentation in O & G.
  • To obtain knowledge of the common clinical problems in O & G.

ANC :

  • Booking visit :
  • History taking
  • Investigations ( booking bloods & scan)
  • Down’s syndrome screening
  • Health promotion advice- smoking, alcohol, drug abuse & diet
  • Management plan
  • High/Low risk pregnancy?
learning objectives cont
LEARNING OBJECTIVES CONT….
  • Examination of pregnant women
  • Pre eclampsia, IUGR, Large for dates , polyhydramnios, breech/ transverse lie, twins , previous caesarean, grand multiparous , Obesity & placenta previa
  • Medical disorder- Diabetes , thyroid problems, essential HTN, Cardiac, renal, drug misuse, Hepatitis/HIV.
  • Pre-operative counselling for C-section
  • Emergency Obstetric Admissions
  • Abdominal pain
  • Preterm labour/ SROM
  • Ante/postpartum bleeding
  • Pre eclampsia/ Eclampsia
slide4

Obstetric Day Assessment Unit

  • Antenatal fetal assessment- CTG, USS (growth/liquor/doppler)
  • Maternal assessment-BP/urine, blood test (PET, GTT)

Labour Ward

  • Induction of labour
  • Management/Complications of labour
  • Normal deliveries
  • Fetal Monitoring in labour
  • Pain relief in labour
  • Instrumental deliveries & Caesarean section- elective/emergency
  • Twins
  • Preterm labour
  • HDU care- PPH, Severe pre eclampsia/eclampsia
slide5

EPAU

  • Early pregnancy scan
  • Miscarriage
  • Ectopic pregnancy
  • Molar pregnancy

GOPD

  • History taking
  • Gynaecological examination-abdomen, pelvis (speculum, digital bimanual)
  • Investigation & management of menstural abnormalities
  • Investigation & management of pelvic pain/endometriosis
slide6

Diagnosis & management of menopause

  • Urogynae clinic-Management of prolapse

& incontinence

  • Infertility clinic- Management of male & female infertility
  • Oncology –Management/follow-up of gynae cancer

& management of abnormal smear (colposcopy clinic)

GUM clinic

  • Obtain sexual lifestyle history
  • Understand relevance of confidentiality and

being non-judgmental.

  • Genital examination and swabs from couple
  • STD- diagnosis & treatment
  • Pre/post test counselling for HIV
slide7

Community

  • Home visits - Postnatal examination

(caesarean scar, perineal tears)

  • Pre eclapmsia surveillance
  • Community midwife ANC
portfolio cases
PORTFOLIO CASES
  • Obstetrics:

1. A normal pregnancy delivery and puerperium

2. Antepartum/postpartum haemorrhage

3. An abnormality of fetal growth and development

4. Pre-eclampsia

5. Medical disease complicating pregnancy

6. Multiple pregnancy

7. Abnormal labour

8. A third stage abnormality

slide9

Gynaecology

1. Menstural disorder

2. Endometriosis

3. Prolapse

4. Incontinence

5. Infertility

6. Postmenopausal bleeding

7. Early pregnancy complication

obstetric history
Obstetric History
  • Age
  • Gravidity
  • Parity- (Preg>24 wks)+(Preg< 24wks)
  • LMP; menstural cycle; conceived on pill; EDD
  • History of this pregnacy :
  • Presenting complaints- when did they occur & how long they lasted, any investigation or treatment already ?
  • Low/high risk pregnancy?
  • Any problems in antenatal care so far ?
  • Fetal movements
obstetric history11
Obstetric History
  • Previous pregnancy:

- Previous miscarriages

- Gestation & mode of delivery

- Length of labour & complications

- Third stage complications

- Postnatal problems

  • Medical & surgical history
  • Drug history & allergies
  • Family history- hereditary disorders, HTN,DM, twins or congenital malformation
  • Social history- smoking, alcohol, drug misuse, occupation, housing & marital status
examination
Examination
  • Consent, explanation & beware of supine hypotension
  • General examination

-Colour

-Hand, eyes & mouth

-Presence of oedema

-BP & Urine

-CVS & Respiratory system examination

abdominal examination
Abdominal Examination

Inspection: abdominal scars

striae gravidarum

linea nigra

oedema

abdominal palpation
Abdominal palpation

alpation of pregnant abdomen:

P

  • Examination of uterine fundus

Symphysio- fundal height(cm)

  • Fetal back
  • Presenting part e.g vertex, breech

4. Engagement of presenting part

Four maneuvers

of leopold

slide15

Lie of Fetus

Lie: relationship of long.

axis of fetus to long.axis

of uterus e.g longitudinal,

transverse, oblique

Longitudinal lie

Transverse lie

slide16

Presentation of fetus

Presentation:

presenting part of fetus

occupying the lower pole

of uterus i.e ceph(vertex),

breech,face,brow or

shoulder

female bony pelvis
Female bony pelvis

Right

Side

Left

side

Pelvic diameters:

Anterio-posterior

Transverse

Oblique

abdominal examination18
Abdominal Examination

Left Occipito- anterior

Left Occipito- posterior

Position: Relation of denominator (occiput/ sacrum) of presenting part to the quadrants of pelvis e.g

LOA,LOP

abdominal examination19
Abdominal Examination

G

Amniotic fluid

  • Auscultation: FETAL HEART

Engagement: Widest diameter of head below the pelvic brim.

No. of 5th head palpable above the pelvic brim e.g 4/5th , 3/5th

slide21

Bregma

Occiput

Mentum

Presenting diameters:

g) Face presentation

Submento-bregmatic

h) Deflexed OP

Occipito-frontal

i) Brow presentation

Occipito-mental

j) Normal vertex

Sub-occipito bregmatic

  • Parts of fetal skull:
  • Occipital bone
  • Posterior fontanella
  • Saggital suture
  • Frontal bone
  • Anterior fontanelle
  • Parietal bone
vaginal examination
Vaginal Examination
  • Vulva & vagina
  • Cervix-dilatation ,effacement, position & consistency
  • Presenting part i.e Vertex
  • Station-cm in relation to the ischial spine
  • Caput-swelling on the scalp superficial to periosteum of cranium ,as a result of venous congestion, on the part of head most in advance
  • Moulding- Overriding of the bones of skull
  • Membranes & Liquor
vaginal examination23
Vaginal Examination

s

Station -3

Station +3

Station- position of presenting part (PP) in cm in relation to the ischial spine

mechanism of labour
Mechanism of labour

LOA position:

Free head

Descent & engagement

Descent & Flexion

Internal rotation

Extension

External rotation

Restitution

Delivery of shoulder

useful website for medical illustration
Useful website for medical illustration
  • Nucleus Medical Media

Normal vaginal delivery anim002

Normal vaginal birth ANC00030

Delivery ANC00037

Birth station of presentation ANC00038

Change in cervix during pregnancy S15551477

gynaecological history
Gynaecological History
  • Age, Gravidity, Parity, LMP
  • Contraception
  • Last cervical smear
  • Presenting complaints: Nature & duration

Relation to menstrual cycle

Bowel symptoms

Urinary symptoms

Vaginal discharge

Vaginal bleeding

gynaecological history27
Gynaecological History
  • Previous Gynaecological & Obstetric History:

PID/STI

Endometriosis

Previous miscarriages / preg<24 wks

Ectopic pregnancy

Pregnancies>24 wks & outcome

history cont
History cont….
  • Medical
  • Surgical
  • Family history- Fibroids, endometriosis, cancers, DVT/PE
  • Medications
  • Allergies
  • Social History
examination29
Examination
  • General- Conjunctiva, pulse
  • Abdomen:
  • Inspection- distension of abdomen

mass

previous scar

  • Palpation- tenderness

mass( size, consistency)

ascites

lymph nodes

  • Percussion
  • Auscultation
vaginal examination30
Vaginal Examination
  • Vulva
  • Speculum (Cusco’s & Sim’s)

- vagina (atrophy, mass, trauma, prolapse)

- cervix (ectropion, polyp, growth, contact bleeding,

- uterine prolapse

  • Bimanual pelvic exam. – uterine/ adenexal masses tenderness
competencies mandatory
Competencies (Mandatory)
  • Examination of pregnant abdomen
  • Examination of non-pregnant abdomen
  • Speculum(Cusco’s speculum) examination