Part 1

Obstetrics

Introduction

Obstetric history and physical examination The obstetric history 4 Physical examination 6 Reporting your history and examination findings 9

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History-taking and physical examination are essential skills for good clinical practice. Competence in this area requires a sound clinical knowledge in order to direct questions that will help to shape the presentation appropriately. The basic framework to history-taking and physical examination can be readily acquired but the best result can only be achieved by improving these skills by practice and better knowledge.

The obstetric history The obstetric history is both a synopsis of a woman’s background risk as well as an account of the progress of her index pregnancy. A carefully taken history provides a clinical guide to the physical examination to follow. Further physical signs which are not routinely elicited in a pregnant woman may become necessary if the history warrants it. It is useful to have a template for taking the obstetric history. This allows the history to be taken and presented in a logical sequence and avoids inadvertent omission of important details. The following is a guide to taking an obstetric history.

Current pregnancy In presenting an obstetric case, it is appropriate to begin with a summary of the details to follow. This is especially so if the history that is to follow is complicated. It allows the listener to focus on the clinical issues in the pregnancy. The summary is best constructed by having some organisation in history taking and is given below; Personal and pregnancy details.

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A polite introduction of you followed by permission to take the history and examination is vital. Start with the enquiry of her name, age, gravidity (i.e. number of pregnancies including the current one) and parity (i.e. number of births beyond 24 weeks gestation). The expected date of delivery (EDD) can be calculated from the last menstrual period (LMP) by Naegele’s rule (add one year and seven days to the LMP and subtract 3 months). Inquire about her health and that of her fetus (e.g. after 20 weeks inquire about fetal movements). This should be followed by details of the current problems if there are any. A chronological and concise account of the events in pregnancy is best obtained by enquiring about her pregnancy in the first, second and third trimester. If she was in the postnatal period details of labour and delivery are relevant. This inquiry should include details of laboratory tests and ultrasound scans. The date pregnancy was confirmed by a pregnancy test, results of the routine antenatal blood tests and the date and details of the first scan (dating or nuchal translucency scan) are important. Subsequent antenatal check ups and tests done including subsequent scans should be noted. The details of the results may be asked from the woman and if necessary can be cross checked against the notes. There should be an organisational logic of history taking. At times it may be necessary to revisit an area of the history as the story unfolds further or during or after clinical examination.

Obstetric history and physical examination

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Menstrual history – State the last menstrual period (LMP) and any details that may influence the validity of her EDD as calculated from the LMP, such as long cycles irregular periods or recent use of the combined oral contraceptive pill. Past obstetric history – Outcome of previous pregnancies and any significant antenatal, intra or postpartum events may have influence in the management of the current pregnancy. Previous maternal complications, mode of delivery, birth weights and the life and health of babies may be relevant. Past gynaecological history – Details of contraceptive history, previous surgical procedures and cervical smears should be noted. Past medical/surgical history – Some medical conditions may have a significant impact on the course of the pregnancy. Heart disease, epilepsy, bronchial asthma, thyroid disorders, insulin-dependent diabetes mellitus and other medical conditions or the medications they take for these conditions may have significant impact on the pregnancy. Alternatively pregnancy may have an impact on the medical condition. The condition may remain the same or get better or worse. These may be incorporated under “current pregnancy” if it is of concern in this pregnancy. Outcome of joint consultations should be known and if it has not been done, arrangements need to be made for looking after the mother in a multidisciplinary clinic or with the relevant physician. Drug history – History of allergies should be highlighted and any use/abuse of drugs during pregnancy should be noted. Arrangements may have to be made to wean off the drug. Family/social history – History of hereditary illnesses or congenital defects is important and may be of concern to the couple. Appropriate counselling and investigations may have to be organised. This will be a good opportunity to discuss about stopping to smoke or to reduce excessive alcohol intake. Relevant social aspects such as childcare arrangements and plans for breastfeeding and contraception can be discussed at this point. Final summary – This should include the salient details that will impact on the investigations to be carried out and the proposed plan of management.

It may be necessary to vary this template to suit different clinical situations. In a woman who has experienced many problems during her pregnancy, it may be better to provide details of each problem separately rather than a chronological account of the pregnancy.

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Physical examination 6

Many aspects of the obstetric physical examination are unique. There are several necessary techniques and skills, which are not required in other specialities.

General examination The assessment should begin with a general examination. This is intended to provide the clinician with an overview of the woman’s condition upon which more specific examinations can be directed. The general examination should include the woman’s height and weight. From these, the body mass index (BMI) can be calculated as follows: BMI = weight (kg) Height2 (m) Some antenatal and perinatal complications are associated with a BMI < 20 or > 25. The thyroid gland and breasts should be examined at a booking visit and auscultation of the heart sounds and lungs is essential. For many women, the obstetric booking visit will be their first visit to a doctor in many years. Hence, it is not unusual for asymptomatic conditions such as a cardiac murmur from valvular heart disease, breast lumps or goitre to be detected at these visits. These conditions may have significant implications on the course of her pregnancy and, indeed, subsequent health. More detailed examinations are indicated when a sign is detected (e.g. multinodular of the goitre, bruit over the mass, ophthalmic signs, tremors etc.) or in specific situations, for example examination of the eyes with an ophthalmoscope to look for retinopathy in a diabetic or hypertensive woman. The measurement of maternal blood pressure is of great importance in pregnancy. It is not appropriate to measure this in the supine position as pressure from a gravid uterus on the inferior vena cava impedes venous return resulting in a falsely low blood pressure. This is often referred to as the supine hypotension syndrome. The correct position is ‘semi recumbent’ – a 45° tilt. When auscultating the brachial artery in measuring the diastolic blood pressure, the value at which the sounds disappear (Korotkoff V) is currently accepted as it gives the closest reading to the direct arterial blood pressure measurement. An appropriate size cuff should be utilised with a larger cuff for those with a larger upper arm circumference – the smaller cuff in these women would give a falsely high reading.

Abdominal examination The fundamental steps in abdominal examination, namely inspection, palpation and auscultation apply to the pregnant woman and occasionally the art of percussion to elicit fluid thrill when polyhydramnios is suspected. The specific manoeuvres and techniques vary in an obstetric examination. The clinician may be guided by the preceding history and general examination to conduct this more specific part of the physical examination. For instance, a history of abdominal pain should prompt a careful palpation for uterine contractions (suggestive of labour) or localised tenderness (associated with red degeneration of a fibroid, accident of an adnexal mass, dehiscence of a previous scar or rarely placental abruption).

Obstetric history and physical examination Inspection

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Note the distension of the abdomen that may indirectly indicate the shape and size of the uterus. Any asymmetry of the abdomen and fetal movements should be recorded. It is important to note any surgical scars, particularly a low transverse Pfannenstiel incision that may be obscured by pubic hair and a laparoscopic scar within the umbilicus. The scars observed should be correlated to previous surgical and gynaecological history. Cutaneous signs of pregnancy such as linea nigra (dark pigmented line stretching from just below the xiphi sternum through the umbilicus to the supra-pubic area) or striae gravidarum (recent striae are purplish in colour) are often present though they are of no clinical significance. Old striae (striae albicans) are silvery-white and are evidence of previous parity. The umbilicus may be flat with the surface or everted due to increased intraabdominal pressure. Superficial veins may be seen denoting alternate paths of venous drainage due to pressure on the inferior venacava by the gravid uterus.

Palpation

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Uterine size – The uterine size is objectively measured and expressed as fundo-symphyseal height. First the highest point of the fundus of the uterus should be palpated. One should bear in mind that the uterus may be displaced to the left or right of the midline. Use the ulnar border of the left hand and move it downwards from below the xiphi sternum and from below each subcostal margin until the fundus is located. Once the highest point of the uterine fundus is identified the fundo-symphysial height (SFH) can be measured with a tape measure. The upper margin of the bony pubic symphysis is located by palpating downwards in the midline starting from few centimetres above the pubic hair margin. The SFH in centimetres ± 2 cm should approximate the gestation of the pregnancy in weeks from 20 until 36 weeks gestation. From 36 to 40 weeks this could be +/− 3 cm and at 40 weeks it is +/− 4 cm. The decrease in height is due to reduction in the amniotic fluid volume and descent of the fetal head. On the contrary the increase in size may be due to further growth of the fetus, increase of amniotic fluid and non descent of the fetal head. It is important at this stage that the number of fetuses is determined. Palpation of a larger uterus than that expected for that gestation, two heads, three poles, multiple fetal parts, excessive amniotic fluid, and auscultation of two fetal heart rates with a difference of greater than 10 beats per minute suggests the presence of multiple pregnancies. Presentation – Presentation is the part of the fetus that overlies the pelvic brim and is of importance especially after 37 weeks gestation when the majority of women go into labour. This is determined by placing both hands on either side of the lower pole of the uterus while facing the woman’s feet. Approximate the hands firmly but gently towards the midline to ascertain the presenting part. A hard rounded presenting part suggests a cephalic presentation while a broader, soft object suggests breech presentation. In cephalic presentation, it is usual to report the number of fifths of the head palpable. This is a rough approximation of how many finger breadths are necessary to cover the head above the pelvic brim. As this step is performed it is important to look at the woman’s face as

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Physical examination (continued ) 8

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palpation of the fetal head may be tender. The clinician should detect any signs of discomfort from her facial expression and be gentle with the palpation. Paulik’s grip is a one-handed technique to feel for the presenting part. The cupped right hand is used to grasp the lower pole of the uterus and it is possible to feel the hard rounded fetal head in nearly 95% of pregnancies at term. It can cause discomfort and is not a necessary part of the examination if the head can be palpated with ease by the two hands. If the hands on the sides of the head converge above the pelvic brim then the head is not engaged as more of the head is above whilst if the hands diverge then it is suggestive of engagement i.e. more than half the head has descended below the pelvic brim. Lie of the fetus and location of the fetal back – Lie of the fetus describes the relationship of the longitudinal axis of the fetus to the longitudinal axis of the uterus. This is best done by facing the woman and placing one hand on each side of the uterus and applying gentle pressure when one should be able to perceive the resistance of the firm fetal back and on the opposite side it may be possible to feel the fetal limbs. This can be confirmed by alternately palpating with one hand while using the opposite hand to steady the fetus. If the presentation is cephalic or breech (the buttocks of the fetus) it has to be a longitudinal lie as the lower pole of the longitudinal lie of the uterus is occupied by one pole of the longitudinal axis of the fetus. If no presenting part was palpable in the lower pole and if the head or a breech was in one of the iliac fossa then it is an oblique lie and if the longitudinal axis of the fetus straddles right across the horizontal axis of the uterus then it is a transverse lie. Once the fetal lie is determined the anterior shoulder should be palpated as the fetal heart sounds are best heard over this area. A shallow groove palpable between the presenting part and the rest of the fetus helps to identify the prominent anterior shoulder in most cases. Estimation of fetal weight and quantity of amniotic fluid – Assessing fetal weight can be difficult but it is important to determine whether the fetus is small, average or big. It is usually assessed by placing one hand over each pole of the fetus and by guessing the approximate weight. With experience and by checking the guessed weight to the actual weight after delivery the clinician is able to improve his/her performance although many a times the error would exceed more than 10% especially with the very small and the very large fetuses. The ease with which the fetal parts are palpable, ballotment of the fetal parts and the ‘cystic’ feeling for the fluid in the uterus should give some idea of the amniotic fluid.

Auscultation The fetal stethoscope or an electronic device like the Doptone can be placed over the anterior shoulder and the fetal heart can be heard. The rate can be determined by auscultation over one minute.

Percussion Percussion is generally not used in an obstetric examination. If the quantity of amniotic fluid is felt to be excessive (shining, stretched abdomen with difficulty in feeling fetal parts) then the sign of ballotment is useful to identify the head. Fluid thrill may be elicited by tapping in the mid point of the uterus on one side and trying to feel it with the hand placed on the opposite side at the same level. The passage of surface vibrations should be damped by an assistant or patient keeping the ulnar border of the hand firmly in the midline on the abdominal wall.

Obstetric history and physical examination Vaginal examination Vaginal speculum and digital examinations are not a routine part of the obstetric physical examination but are performed when indicated e.g. A speculum examination to confirm leaking amniotic fluid in cases of pre-labour rupture of membranes, or to carry out inspection and take swabs in cases with abnormal vaginal discharge.

Reporting your history and examination findings A concise, clear and logical sequence of reporting the history and examination findings is essential to ensure that that the rest of the medical team and the patient can understand the clinical condition. It should form the basis for further investigations if needed and to help plan effective management. A summary of the history should be followed by a summary of the examination findings. The general examination findings should be reported first, emphasising any aspects that may influence management. Abdominal findings should be reported in the order that they were elicited using the appropriate terminology (e.g. lie, presentation, engagement).

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Part 2

Gynaecology

Introduction

History and physical examination of the gynaecological patient Current history 446 Past medical, family, and social history 446 Physical examination 448 Summary of the clinical problem 450

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It is best to have an outline on which the gynaecological history can be taken and presented. This avoids inadvertent omission of important details and allows for a systematic and concise presentation of the facts. Please be polite, introduce yourself (your name & designation) to the patient and the purpose of your discussion. A suggested outline is as follows:

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Name, age and parity Detailed history of present complaint - One should be able to establish the presenting complaints. A brief history relevant to the presenting complaints must be taken. There must be some organisational logic in history taking.

e.g. Abnormal menstrual loss – Distinguish between a regular or irregular pattern of bleeding. Attempt to quantify amount of loss by indicating the number of sanitary pads used in a day, presence of blood clots and the need to use two pads at one time (‘flooding’). The social impact of the heavy periods such as absence from work during menses due to associated pain, weakness or flooding is important.

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e.g. Pelvic pain – Establish the duration, site and nature of pain and possible relationship with the time in the menstrual cycle. Aggravating and relieving factors. Radiation of the pain and associated symptoms e.g. vomiting, fever, dysuria. e.g. Vaginal discharge – Describe odour, colour, consistency, amount and presence of blood. Relationship to the period and associated itching or irritation is relevant.

Past medical, family, and social history This is an inquiry into the reproductive history that includes past obstetric, gynaecological, menstrual, contraceptive and smear histories. This should be followed by past medical and surgical history. Family and social history should not be forgotten. Menstrual history Menarche (age when periods began) Cycle (interval between the first days of two consecutive periods) Duration of period State first day of the last menstrual period (L.M.P.) Past Obstetric history - Describe outcomes and details of previous pregnancies. If there were many pregnancies, it is appropriate to summarise, e.g. 5 previous full term spontaneous vaginal deliveries. Operative deliveries and any important issue such as miscarriage and fetal loss should be noted. Past Gynaecological history - Details of gynaecological history other than the presenting complaint should include details of previous cervical smears, previous gynaecological problems and any surgery (e.g. pelvic inflammatory disease or endometriosis).

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History and physical examination

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Contraceptive history – The methods used, duration of use, acceptance, current method, side effects and plan for the future. Past Medical and Surgical history - Past medical and surgical history may have some bearing to the current problem or its management. Drug allergies - This is vital information and should be prominently displayed in the notes. Failure to do so may cause severe illness or death of the patient. Social history - This should include the impact of the present problem on the patient’s life. Smoking, drinking, drug abuse and living conditions may be relevant to the current problem or to the management planned.

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Physical examination This should always start with the general examination of the patient followed by cardiovascular and respiratory systems. The gynaecological examination encompasses both an abdominal as well as a vaginal pelvic examination that includes bimanual palpation. A bimanual examination should be preceded by inspection of the vulva, vagina and cervix using a speculum. In specific circumstances, a rectal examination may be indicated.

Abdominal examination The fundamental steps in an abdominal examination should be followed, i.e. inspection, palpation and percussion. Auscultation may be relevant especially in cases of acute abdomen and post-operative examinations.

Inspection Abdominal distension, if any, should be noted and if present look for visible evidence of masses. If surgical scars are present they should be correlated to the past history.

Palpation

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Guarding, tenderness and rebound tenderness are important signs to elicit in any one presenting with an acute abdomen. After performing a routine light palpation of the whole abdomen with the right hand, it is important to switch to the left hand and feel for pelvic masses. This is an important difference between gynaecological and surgical examination that allows the clinician to detect any masses that may rise out of the pelvis.

Percussion/auscultation Percussion is useful to distinguish between a solid mass (dull) and distended bowel (tympanic). In the presence of a vague mass on palpation in an obese individual or when one is tensing the abdominal wall percussion is useful to identify the possibility of the mass and also in defining the borders of a mass. It is useful to demonstrate ascites or collection of blood. Shifting dullness and fluid thrill need to be demonstrated appropriate to the situation.

The pelvic examination The pelvic or vaginal examination is the most challenging part of the gynaecological physical examination. It is a potential source of embarrassment to the woman and should be conducted in a sensitive manner in privacy accompanied by a suitable chaperon. Exposure should be in a manner needed to carry out the examination. The abdomen should be covered up to and just below the knees. It should be performed gently, otherwise it can be uncomfortable. A well performed pelvic examination gives good information about the genital tract and pelvic organs. It is thus an indispensable part of the gynaecological assessment and is to the gynaecologist the equivalent of a rectal examination to the surgeon.

Position The pelvic examination can be performed in the dorsal, lithotomy or Sim’s position. Sim’s position is a modification of the left lateral position and is ideal for examination of a woman with utero-vaginal prolapse or vesico-vaginal fistulae. The lithotomy position, in which both thighs are abducted and feet suspended from lithotomy poles is usually adopted when performing vaginal surgery. The dorsal position is most commonly used for routine outpatient gynaecological examinations such as when obtaining a cervical smear.

History and physical examination Technique The steps in performing a pelvic examination are: Inspection of the external genitalia Speculum examination of the vagina and cervix Bimanual examination of the uterus and adnexae.

Inspection Inspect the vulva and external genitalia. It is useful to imagine a series of circles surrounding the vaginal introitus and then to describe your findings from the outermost to the innermost circle. For example, one could begin with describing the mons pubis and pubic hair distribution, the labia majora and minora, the clitoris, urethral meatus and vaginal introitus.

Speculum examination Two vaginal speculae are commonly used – the Sim’s (duck-billed) speculum and Cusco’s or bivalve speculum. Sim’s speculum is used in the Sim’s position and is most useful for the examination of utero-vaginal prolapse. Cusco’s speculum is most frequently used and is described below. The labia minora are parted with the index and middle fingers of the left hand to obtain a good view of the introitus. A well-lubricated and warm bivalve speculum is held in the right hand with the main body of the speculum in the palm and the closed blades projecting between the index and middle fingers. This grasp is intended to keep the blades opposed and prevent inadvertent opening of the speculum while it is being inserted. In the lithotomy position, the speculum is usually inserted with the handle inferior while in the dorsal position, the handle should be superior. The speculum is advanced gently along with gentle pressure on the posterior wall of the vagina to open the potential space. Take note that the axis of the vagina is directed slightly towards the rectum. Open the speculum only when it can not be advanced further. The cervix may be visualised. If it cannot be seen, the speculum is either above or below the cervix as the blades are in the anterior or posterior fornix of the vagina. It will then be necessary to close the speculum, withdraw it slightly, change its direction and advance it before opening it again. The vaginal skin is rugose and that over the cervix is smooth, usually there is mucus close to the cervical os, there will be a convex anterior vaginal fornix or a concave posterior fornix – one or more of these features may come into view that may help to change the direction of the speculum. Removal of the speculum requires as much care as insertion. It is essential that the blades are held open as the speculum is withdrawn until the ends of the blades are distal to the cervix. Otherwise, closing the blades on the cervix will cause pain. The speculum must be completely closed as the ends of the blades come out through the introitus.

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Digital examination

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The digital bimanual examination helps to identify the pelvic organs. The bladder should be emptied prior to this examination. The index and middle fingers of the right hand are inserted into the vagina with the palmar aspect facing upwards. Feel the consistency of the cervix. The left hand is placed on the abdomen and bimanual palpation commenced. The purpose of bimanual palpation is to bring the abdominal wall close to the pelvic organs by pressing on the appropriate place on the abdominal wall and also by shifting the pelvic organs or masses towards that hand. One should feel these organs or masses between the vaginal and abdominal hands. First, the uterus is felt with the vaginal fingers placed on the cervix and the hand on the lower midline above the uterine fundus. Then, the adnexae can be palpated between the vaginal fingers placed in the lateral fornices and the abdominal hand over the respective iliac fossa. An anteverted uterus is easily palpated bimanually but a retroverted one may not be. Retroverted uteri can be assessed by feeling the body of the uterus with the vaginal fingers via the vaginal wall of the posterior fornix. If a pelvic mass is discovered, its size, consistency and mobility are determined. Uterine masses may be felt to move with the cervix when the uterus is shifted upwards while adnexal masses will not. If adnexal masses are suspected there should be a line of separation between the uterus and the mass and the mass should be felt distinctly from the uterus. However, pedunculated masses from the uterus may give the impression of an adnexal mass and an adnexal mass adherent to the uterus may give the impression of a uterine mass. The consistency of the mass may be of help to distinguish the origin in some cases. An ultrasound examination may be necessary to define it better.

Summary of the clinical problem At the end of history taking and examination the clinical problem should be summarised in a manner that would provide the important differential diagnosis or some pointers towards the investigations needed to derive at the diagnosis. The summary should include salient points from the past medical, surgical, obstetric and gynaecological history that may influence the treatment. This summary should be explained to the patient and the information provided should be understood by her in order for her to decide whether to proceed with the investigations and/or to accept the treatment. This should also form the basis for a reply to her Family practitioner.

History and physical examination

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