1. History & Physical Examination(H&P) in OB/GYN
DR.Rayan G. Albarakati, MBBS, SB-OB
Assistant Professor OB/GYN
Head Of Obstetrics & Gynecology

2. Introduction Why the H&P? What's special about OBGYN patients?
What's the difference in the OB/GYN H&P from the medical and surgical one ?

3. The doctor should always:
Knock before entering the patient’s room.
Identify himself or herself.
Meet the patient initially when she is fully dressed, if possible.
Address the patient courteously and respectfully.
Respect the patient’s privacy and modesty.
Ensure cleanliness, good grooming, and good manners in all patient encounters.
Beware that a casual & familiar approach is not acceptable to all patients.
Maintain the privacy of the patient’s medical info. & records.
Be mindful and respectful of any cultural preferences.

4. Obstetric History

5. A complete history must be recorded at the time of:
The prepregnancy evaluation
At the initial antenatal visit
First encounter.

6. we start by documenting the patient identification including:
Age
Gravidity
Parity ( G __ P__ + __ )
Abortions
last menstrual cycle (LMP)
gestational age (GA) in weeks, Term , preterm, post date
Expected date of confinement (EDC) or Expected date of delivery (EDD)
Any significant medical illness

7. CHIEF COMPLAIN In addition to any complain, you have to comment on:
1. Abdominal pain
2. Per vaginal loss
3. Fetal movement (after the age of viability)

8. HISTORY OF PRESENT ILLNESS
Details about the chief complain
Details about current pregnancy

9. PREVIOUS PREGNANCIES Each prior pregnancy should be reviewed in chronologic order and the following information recorded:
1. Date of delivery
2. Location of delivery
3. Duration of gestation in weeks
4. Type of delivery (spont./induction/vaginal/instrumental /operative)
5. Duration of labor in hours.
6. Type of anesthesia. Any complications of anesthesia should be noted.
7. Maternal complications
8. Newborn weight.
9. Newborn gender.
10. Fetal and neonatal complications

10. MENSTRUAL HISTORY
A good menstrual history is essential because it is the determinant for establishing the EDC.
Nägele’s rule for establishing the EDC is to add 9 months and 7 days to the first day of the last normal menstrual period
You will ask about:
Menarche, Regularity, duration, interval between cycles, amount of bleeding, associated symptoms( pain, mood disturbance), inter-menstrual bleeding
Note the terms: oligo menorrhea, hypo menorrhea, menorrhagia, poly menorrhea, Amenorrhea, menometrorrhagia

11. Obstetric wheel

12. CONTRACEPTIVE HISTORY
Oral contraceptives use and time of discontinuation
Intrauterine devices(IUDs), can cause early pregnancy loss, infection, and premature delivery.

13. GYNECOLOGICAL HISTORY
Hx of Gynecological diseases, e.g fibroids, polycyctic ovarian syndrome (PCOS), ovarian cyst, pelvic inflammatory disease, etc.
Hx of infertility
Sexual Hx

14. MEDICAL HISTORY
In addition to common disorders, such as diabetes mellitus, hypertension, and renal disease, which are known to affect pregnancy outcome, all serious medical conditions should be recorded.

15. SURGICAL HISTORY
Each surgical procedure should be recorded chronologically, including:
date
hospital
complications.
Trauma must also be listed (e.g., a fractured pelvis may result in diminished pelvic capacity).

16. SOCIAL HISTORY
Habits such as smoking, alcohol use, and other substance abuse.
The patient’s contact or exposure to domesticated animals
The patient’s type of work and lifestyle may affect the pregnancy.

17. DRUG HISTORY
FAMILY HISTORY
MEDICATION HISTORY
BLOOD TRANSFUSION AND ALLERGIES
VACCINATION HISTORY
SYSTEMIC REVIEW

18. Obstetric Physical Examination

19. GENERAL PHYSICAL EXAMINATION
This procedure must be systematic, thorough and performed as early as possible in the prenatal period.
A complete physical examination provides an opportunity to detect previously unrecognized abnormalities.
Normal baseline levels must also be established, (Wt., BP, and cardiac status).

20. ABDOMINAL EXAMINATION
Inspection
Fundal height
Leopold's Maneuvers:
First maneuver: Fundal Grip
Second maneuver: lateral Grip
Third maneuver: Pawlick's Grip
Fourth maneuver: Pelvic Grip

21. PELVIC EXAMINATION
(1) inspection of the external genitalia, vagina, and cervix.
(2) collection of cytological specimens
(3) Palpation of the cervix, uterus, and adnexa.
(4) Rectal and rectovaginal.
(5) Cervix assessment.
(6) Clinical pelvimetry
Note: In cervix digital examination, you comment on:
Dilatation
Effacement
Position
Consistency
Membrane status
Liquor

22. Cervix appearance at speculum exam

23. Bimanual examination for adnexal assessment
Bimanual Eamination for uterus assessment

24. Clinical Pelvimetry
Assessing the diagonal conjugate

25. SYMPTOMS & SYMPTOMS OF PREGNANCY
SIGNS
Amenorrhea
Urinary frequency
Breast engorgement
Nausea & Vomitting
Tiredness
Easy fatigability
Discoloration and cyanosis of the vulva, vagina, and cervix (Chadwick’s sign)
pigmentation of the midline of the lower abdomen (linea nigra)
Pigmentation under the eyes (chloasma or the mask of pregnancy)
Early uterine changes (Piskacek’s sign , Hegar’s sign), round globular fundus
Quickening

26. Gynecologic History

27. MENSTRUAL HISTORY Age at menarche interval between periods
duration of menses
character of the flow (scant, normal, heavy, usually without clots).
Any intermenstrual bleeding (metrorrhagia).
The date of onset of the LMP and the date of the previous one
Menstrual cramps (dysmenorrhea);
Midcycle pain ( mittelschmerz ) and a midcycle increase in vaginal secretions

28. CONTRACEPTIVE HISTORY
The type and duration of each contraceptive method, along with any complications.
These may include:
amenorrhea or thromboembolic disease with oral contraceptives
dysmenorrhea, heavy bleeding (menorrhagia), or pelvic infection with the intrauterine device
contraceptive failure with the diaphragm, contraceptive sponge, or contraceptive cream.

29. OBSTETRIC HISTORY
Each pregnancy and delivery and any associated complications should be listed sequentially with relevant details and dates.

30. SEXUAL HISTORY
The health of, and current relationship with, the husband or partner(s) may provide insight into the present complaints.
Inquiry should be made regarding any pain (dyspareunia), bleeding, or dysuria associated with sexual intercourse.
Sexual satisfaction (should be discussed tactfully).

31. PAST HISTORY
Any significant past medical or surgical history should be recorded, as should the patient’s family history.
Family History
Drug & Allergy Hx
Immunization Hx
Blood transfusion Hx

32. Gynecologic Physical Examination

33. General Examination
Vital signs
Head & Neck
Breast
Abdominal
Pelvic examination including Pap smear & bimanual rectal examination

34. Tanner scale Hair distribution
Tanner I no pubic hair at all Tanner II small amount of long, downy hair with slight pigmentation Tanner III hair becomes more coarse and curly, and begins to extend laterally Tanner IV adult-like hair quality, extending across pubis but sparing medial thighs Tanner V hair extends to medial surface of the thighs [15+]

35. Tanner scale Tanner Breast
I  No glandular tissue: areola follows the skin contours of the chest II  Breast bud forms,small area of surrounding glandular tissue; areola begins to widen III  Breast more elevated,extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast IV  Increased breast size and elevation; areola projecting from the V  Breast reaches final adult size; areola returns to contour with a projecting central papilla.

36. Tanner scale stage of females

37. Diagram of Vulva and anatomical structures

38. Different sizes of the Bi-valved vaginal Speculum

39. Bimanual rectal exam to assess the recto vaginal septum

40. THANK YOU