Practical issues, History taking & Clinical examination in O&G

1. Practical issues, History taking & Clinical examination in O&G Hervinder Kaur Consultant Obstetrician & Gynaecologist, UHCW Obstetric & Gynaecology Lead for Warwick Medical School

2. 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?

3. 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

4. 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

5. 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

6. 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

7. Community • Home visits - Postnatal examination (caesarean scar, perineal tears) • Pre eclapmsia surveillance • Community midwife ANC

8. 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

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

10. 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

11. 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

12. Examination • Consent, explanation & beware of supine hypotension • General examination -Colour -Hand, eyes & mouth -Presence of oedema -BP & Urine -CVS & Respiratory system examination

13. Abdominal Examination Inspection: abdominal scars striae gravidarum linea nigra oedema

14. Abdominal palpation alpation of pregnant abdomen: P • 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

15. Lie of Fetus Lie: relationship of long. axis of fetus to long.axis of uterus e.g longitudinal, transverse, oblique Longitudinal lie Transverse lie

16. Presentation of fetus Presentation: presenting part of fetus occupying the lower pole of uterus i.e ceph(vertex), breech,face,brow or shoulder

17. Female bony pelvis Right Side Left side Pelvic diameters: Anterio-posterior Transverse Oblique

18. 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

19. Abdominal Examination G Amniotic fluid • Auscultation: FETAL HEART Engagement: Widest diameter of head below the pelvic brim. No. of 5th head palpable above the pelvic brim e.g 4/5th , 3/5th

20. Fetal skull s

21. 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

22. 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

23. Vaginal Examination s Station -3 Station +3 Station- position of presenting part (PP) in cm in relation to the ischial spine

24. Mechanism of labour LOA position: Free head Descent & engagement Descent & Flexion Internal rotation Extension External rotation Restitution Delivery of shoulder

25. 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

26. 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

27. Gynaecological History • Previous Gynaecological & Obstetric History: PID/STI Endometriosis Previous miscarriages / preg<24 wks Ectopic pregnancy Pregnancies>24 wks & outcome

28. History cont…. • Medical • Surgical • Family history- Fibroids, endometriosis, cancers, DVT/PE • Medications • Allergies • Social History

29. Examination • General- Conjunctiva, pulse • Abdomen: • Inspection- distension of abdomen mass previous scar • Palpation- tenderness mass( size, consistency) ascites lymph nodes • Percussion • Auscultation

30. 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

31. Competencies (Mandatory) • Examination of pregnant abdomen • Examination of non-pregnant abdomen • Speculum(Cusco’s speculum) examination

32. Demonstration