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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
Hervinder Kaur Consultant Obstetrician & Gynaecologist, UHCW Obstetric & Gynaecology Lead for Warwick Medical School
LEARNING OBJECTIVESLEARNING 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?
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
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
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
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
•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
Community•Home visits - Postnatal examination (caesarean scar, perineal tears)•Pre eclapmsia surveillance•Community midwife ANC
PORTFOLIO CASESPORTFOLIO CASES
Obstetrics:
1. A normal pregnancy delivery and puerperium2. Antepartum/postpartum haemorrhage 3. An abnormality of fetal growth and development4. Pre-eclampsia5. Medical disease complicating pregnancy6. Multiple pregnancy7. Abnormal labour 8. A third stage abnormality
Obstetrics:
1. A normal pregnancy delivery and puerperium2. Antepartum/postpartum haemorrhage 3. An abnormality of fetal growth and development4. Pre-eclampsia5. Medical disease complicating pregnancy6. Multiple pregnancy7. Abnormal labour 8. A third stage abnormality
•Gynaecology
1. Menstural disorder 2. Endometriosis 3. Prolapse 4. Incontinence 5. Infertility 6. Postmenopausal bleeding 7. Early pregnancy complication
Obstetric HistoryObstetric 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
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 HistoryObstetric 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
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
Consent, explanation & beware of supine hypotension
General examination -Colour -Hand, eyes & mouth -Presence of oedema -BP & Urine -CVS & Respiratory system
examination
Abdominal ExaminationAbdominal Examination
Inspection: abdominal scars striae gravidarum linea nigra oedema
Inspection: abdominal scars striae gravidarum linea nigra oedema
Abdominal palpationAbdominal palpation alpation of pregnant abdomen:
1. Examination of uterine fundus
Symphysio- fundal
height(cm)
2. Fetal back
3. Presenting part e.g vertex, breech
4. Engagement of presenting part
Four maneuvers of leopold
P
Lie of Fetus
Longitudinal lie
Transverse lie
Lie: relationship of long. axis of fetus to long.axis of uterus e.g longitudinal,transverse, oblique
Presentation of fetus
Presentation: presenting part of fetus occupying the lower poleof uterus i.e ceph(vertex),breech,face,brow orshoulder
Female bony pelvisFemale bony pelvis
Pelvic diameters: Anterio-posterior Transverse Oblique
Right
Side
Left
side
Abdominal ExaminationAbdominal Examination
Position: Relation of denominator (occiput/ sacrum) of presenting part to the quadrants of pelvis e.g
LOA,LOP
Position: Relation of denominator (occiput/ sacrum) of presenting part to the quadrants of pelvis e.g
LOA,LOP
1. Left Occipito- anterior
2. Left Occipito- posterior
Abdominal Examination
Abdominal Examination
Amniotic fluid
Auscultation: FETAL HEART
Amniotic fluid
Auscultation: FETAL HEART
G
Engagement: Widest diameter of head below the pelvic brim.
No. of 5th head palpable above the pelvic brim e.g 4/5th , 3/5th
Fetal skullFetal skull
s
Parts of fetal skull:a) Occipital boneb) Posterior fontanellac) Saggital sutured) Frontal bonee) Anterior fontanellef) Parietal bone
Presenting diameters: g) Face presentation Submento-bregmatich) Deflexed OP Occipito-frontali) Brow presentation Occipito-mentalj) Normal vertex Sub-occipito bregmatic
Bregma
Mentum
Occiput
Vaginal ExaminationVaginal 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
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 ExaminationVaginal Examination
Station -3
Station +3
s
Station- position of presenting part (PP) in cm in relation to the ischial spine
Mechanism of labourMechanism of labour
1. Free head2. Descent &
engagement3. Descent & Flexion 4. Internal rotation5. Extension6. External rotation7. Restitution8. Delivery of shoulder
LOA position:
Useful website for medical illustration
Useful website for medical illustration
Nucleus Medical Media
Normal vaginal delivery anim002Normal vaginal birth ANC00030Delivery ANC00037Birth station of presentation ANC00038Change in cervix during pregnancy
S15551477
Nucleus Medical Media
Normal vaginal delivery anim002Normal vaginal birth ANC00030Delivery ANC00037Birth station of presentation ANC00038Change in cervix during pregnancy
S15551477
Gynaecological HistoryGynaecological 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
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 HistoryGynaecological History
Previous Gynaecological & Obstetric History:
PID/STIEndometriosisPrevious miscarriages / preg<24 wksEctopic pregnancyPregnancies>24 wks & outcome
Previous Gynaecological & Obstetric History:
PID/STIEndometriosisPrevious miscarriages / preg<24 wksEctopic pregnancyPregnancies>24 wks & outcome
History cont…. History cont….
Medical Surgical
Family history- Fibroids, endometriosis, cancers, DVT/PE
Medications Allergies
Social History
Medical Surgical
Family history- Fibroids, endometriosis, cancers, DVT/PE
Medications Allergies
Social History
ExaminationExamination General- Conjunctiva, pulse
Abdomen:- Inspection- distension of abdomen mass previous scar- Palpation- tenderness mass( size, consistency) ascites lymph nodes- Percussion - Auscultation
General- Conjunctiva, pulse
Abdomen:- Inspection- distension of abdomen mass previous scar- Palpation- tenderness mass( size, consistency) ascites lymph nodes- Percussion - Auscultation
Vaginal ExaminationVaginal 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
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
Examination of pregnant abdomen
Examination of non-pregnant abdomen
Speculum(Cusco’s speculum) examination
DemonstrationDemonstration