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Obstetric _ Gynaecology History _ Clinical Examination

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Obstetric _ Gynaecology History _ Clinical Examination Powered By Docstoc
					    Practical issues, History taking & Clinical
               examination in O&G




            Hervinder Kaur
Consultant Obstetrician & Gynaecologist, UHCW
Obstetric & Gynaecology Lead for Warwick
          Medical School
                               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….

 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 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
•Gynaecology

1. Menstural disorder
2. Endometriosis
3. Prolapse
4. Incontinence
5. Infertility
6. Postmenopausal bleeding
7. Early pregnancy complication
                               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 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

 Consent, explanation & beware of
  supine hypotension

 General examination
  -Colour
  -Hand, eyes & mouth
  -Presence of oedema
  -BP & Urine
  -CVS & Respiratory system
  examination
    Abdominal Examination


 Inspection: abdominal scars
              striae gravidarum
              linea nigra
              oedema
                     Abdominal palpation
P 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
                   Lie of Fetus

                                    Lie: relationship of long.
                                    axis of fetus to long.axis
                                    of uterus e.g longitudinal,
                                    transverse, oblique




Longitudinal lie




                   Transverse lie
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

Right
                            Left
Side
                            side

        Pelvic diameters:
        Anterio-posterior
        Transverse
        Oblique
                       Abdominal Examination
                        1. Left Occipito- anterior
 Position: Relation
of denominator          2. Left Occipito- posterior
(occiput/ sacrum) of
presenting part to
the quadrants of
pelvis e.g
LOA,LOP
       Abdominal Examination
                    G




                        Engagement: Widest
                        diameter of head below the
                        pelvic brim.
  Amniotic fluid
                        No. of 5th head palpable
 Auscultation:         above the pelvic brim e.g
  FETAL HEART           4/5th , 3/5th
    Fetal skull
s
                                   Bregma

                                                       Occiput



                          Mentum




 Parts of fetal skull:     Presenting diameters:
a) Occipital bone          g) Face presentation
b) Posterior fontanella       Submento-bregmatic
c) Saggital suture         h) Deflexed OP
d) Frontal bone                Occipito-frontal
e) Anterior fontanelle     i) Brow presentation
f) Parietal bone              Occipito-mental
                           j) Normal vertex
                              Sub-occipito bregmatic
                               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 Examination

s


             Station -3


             Station +3




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


1. Free head
2. Descent &
   engagement
3. Descent & Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Restitution
8. Delivery of shoulder
         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

 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 History

 Previous Gynaecological & Obstetric History:

             PID/STI
             Endometriosis
             Previous miscarriages / preg<24 wks
             Ectopic pregnancy
             Pregnancies>24 wks & outcome
                   History cont….

 Medical
 Surgical

 Family history- Fibroids, endometriosis,
  cancers, DVT/PE

 Medications
 Allergies

 Social History
                                        Examination
 General- Conjunctiva, pulse

 Abdomen:
- Inspection- distension of abdomen
              mass
              previous scar
- Palpation- tenderness
             mass( size, consistency)
             ascites
             lymph nodes
- Percussion
- Auscultation
                               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)


 Examination of pregnant abdomen

 Examination of non-pregnant abdomen

 Speculum(Cusco’s speculum)
  examination
Demonstratio
           n

				
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