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 alpation of pregnant abdomen: P Four maneuvers 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

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 Pelvic diameters: Anterio-posterior Transverse Right Side Left side Pelvic diameters: Anterio-posterior Transverse Oblique

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 Examination 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 Amniotic fluid Auscultation: FETAL HEART

Fetal skull s

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 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: Free head Descent & engagement Descent & Flexion Internal rotation Extension External rotation Restitution 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

Demonstration