Assessment of Obstetrics and Gynecologic System

Angela G. Sison-Aguilar MD
Clinical Associate Professor Department of Obstetrics and Gynecology UP PGH

The obstetric patient

History
Obstetric examination Physical examination

Laboratory tests
Clinic and home based maternal record

Definition of prenatal care

A planned program of medical

evaluation and management, observation and education of the pregnant woman directed toward making pregnancy, labor, delivery and the postpartum recovery, a safe and satisfying experience. (WHO)

Goals
To provide opportunities for the

physician and the patient to become better acquainted To allow the physician to learn something about the patients attitude toward pregnancy and labor

Goals
To instruct the patient and her husband

in the optimal care of herself and the coming baby To prepare the patient and her husband in a prepared childbirth program

Definitions
Primipara - delivered viable baby once

Multipara - delivered viable baby twice or

more Nulligravida - never been pregnant Primigravida - pregnant once Multigravida - pregnant twice or more Parturient - woman in labor Puerpera - woman who had just given birth

Estimating Date of Pregnancy

Nageles Rule

average of 280 days-40 weeks (37 to 42 weeks) minus 3 months plus seven days from Last Normal Menstrual Period 16-20 weeks 20 to 30 weeks - equivalent to centimeters

Timing from Quickening

Timing from Fundic Height

Initial Comprehensive Evaluation

Goals: To define health status of mother and fetus To determine gestational age of fetus To initiate a plan for continuing obstetric care To define those at risk for complications and to minimize that risk whenever possible

Obstetric history
History obtained

unhurriedly in a private setting to establish good rapport

Initial Comprehensive Evaluation

past medical history
family history menstrual history

Menarche or age of onset of periods Establish regularity of cycle and interval Duration Amount Associated symptoms, i.e. dysmenorrhea

Initial Comprehensive Evaluation

Contraceptive history

Oral contraceptive pills or injectables Intrauterine device nature, type of deliveries, size and sex of baby, weight, where delivered, postpartum course

Obstetric history

Initial Comprehensive Evaluation

History: history of present pregnancy

previous prenatal care symptoms infections fetal movement dietary history emotional well-being

Examining the pregnant patient

Initial Comprehensive Evaluation

Physical Examination: eyes, ears, nose, throat lungs and heart abdomen extremities weight and blood pressure breast exam

Initial Comprehensive Evaluation

Physical Examination: abdominal exam:

Leopolds maneuver - fetal lie, position fundic height size estimate fetal heart tones

The Leopolds Maneuver

Diagnosis of fetal presentation and

position Descibed by Leopold and Sporlin in 1894

Features
Examiner stands at side of bed and

faces patient in first 3 maneuvers Examiner reverses position and faces patients feet in last maneuver

Features
Difficult if not impossible to perform:

patient is obese placenta is anteriorly implanted large amount of amniotic fluid

Confusing to interpret in multiple

gestation

First Maneuver

First Maneuver
Outline contour of uterus
Ascertain how fundus approximates

xiphoid cartilage Examiner gently palpates fundus with tips of fingers to define which fetal pole is present Breech large nodular body Head hard, round, movable, ballottable

Second Manuever

Second Manuever
Palms placed on either side of

abdomen and gentle but deep pressure is exerted Back is hard resistant structure Fetal extremities numerous small irregular and mobile Note if back anterior, posterior, transverse and will determine lie

Third Maneuver

Third Maneuver
Thumb and fingers grasp lower portion

of abdomen just above symphysis pubis If presenting part not engaged, movable body felt: head or breech Confirms findings of first maneuver

Fourth Maneuver

Fourth Maneuver
Examiner faces mothers feet
Tips of first three fingers of each hand

exerts deep pressure in direction of axis of pelvic inlet Cephalic prominence is determined if one hand arrested in higher position

Fourth Maneuver
Determining fetal attitude

Cephalic prominence same side as small partshead flexed Cephalic prominence same side as backhead extended

Fourth Maneuver
Engagement determined:

Space between presenting part and symphysis pubisfloating (hands converge) No spaceengaged (hands diverge)

Cephalic prominence readily palpabe

means no descent has occurred

Uses
Performed in latter half of pregnancy

and during and in between contractions of labor Cephalopelvic disproportion gauged from overriding of symphysis pubis by fetal head Estimate size of fetus and best area to auscultate Twin gestation: determine

Accuracy
Sensitivity 88%
Specificity 94% Positive predictive value 74%

Negative predictive value 97%

Initial Comprehensive Evaluation

Physical Examination: pelvic exam

external lesions - infection bleeding from cancer, inflammation, polyp Papanicolau (Pap) smear Pelvimetry Confirmation and station of presenting part Consistency, effacement and dilatation of cervix

Subsequent Prenatal Care

Maternal evaluation

BP Weight
underweight

- 28 to 40 lbs normal - 25 to 35 lbs overweight - 15 - 25 lbs

Symptoms headache, altered vision, abdominal pain, nausea and vomiting, bleeding, fluid from vagina and dysurus fundic height, abdominal exam vaginal exam (1st visit and at term-37 weeks)

Subsequent Prenatal Care

Fetal evaluation

Heart rate Size Amount of amniotic fluid Presenting part and station Fetal activity Ultrasound - not routine, recommended for high risk patients

Prenatal tests

Initial Comprehensive Evaluation

Laboratory Examination: CBC blood type, Rh syphilis, rubella, hepatitis B virus urinalysis glucose challenge test for diabetes

Ultrasound screening

Not currently recommended for low risk pregnancies

Ultrasound screening

First trimester ultrasound

Intra

or extrauterine location of sac Embryo identification Aging based on crown rump length at 11 to 14 weeks Fetal heart motion Fetal number Uterus and adnexal evaluation

Ultrasound screening

Second and third trimester

Congenital

anomaly scan Featl number Presentation Fetal heart motion Placental location Amniotic fluid volume Gestational age Gender identification (after 16 weeks) Evaluation of maternal pelvic masses

Prenatal Instructions
Inform patient of any problems
Discuss management Begin education on diet, relaxation and

sleep, bowel habits, exercise, bathing, recreation, intercourse, smoking, alcohol Explain future visits Discuss economic aspects

Clinic and home based record

Clinic and home based record

WHO Goal 2000

Worldwide prenatal care statistics

80 - 90% of pregnant women at least one prenatal visit in the first trimester

The gynecologic evaluation

History
Physical exam Pelvic exam

Ancillary tests

Gynecologic history
Family history

Pelvic malignancy: ovarian, breast Myoma, endometriosis Recurrent abortion and infertility Bleeding conditions

Gynecologic history
Gynecologic surgery
Obstetric history Menstrual history

Contraceptive history
Last Pap smear/mammography results Personal/Social/Sexual history

Physical exam

Effective Examination
Fully cooperative,

informed and relaxed patient Allay anxiety Discuss objectives and techniques beforehand Proceed in slow, deliberate and reassuring manner

Effective Examination
Have patient urinate to empty her

bladder before the examination not only for patients comfort but to optimize palpation of pelvic organs Have head elevated 20 degrees and use comfortably padded table with clean stirrups

The Examining Table

Effective Examination
Explain each step in

advance Ensure comfortable positioning in examining table Do not leave patient waiting in lithotomy position with her feet in stirrups

Effective Examination
Most patients desire

adequate draping before and during pelvic examination to minimize exposure

Effective Examination
Presence of a

female chaperone is prudent at all times regardless of gender of examiner

Effective Examination
Be gentle in the course of the

examination Distract patients attention or formally elicit relaxation rather than applying more intensive pressure Give the patient the opportunity to slow or stop the examination whenever she desires DO NOT RUSH!

Inspecting External Genitalia

Inspecting External Genitalia

Inspecting External Genitalia

Inspecting External Genitalia

Inspecting External Genitalia

Inspecting External Genitalia

Examining the vagina

Technique

Inspection of vagina is done during withdrawl of speculum after inspection of cervix and after taking pap smear. Release the thumb screw first. Slowly remove the speculum, controlling the degree the blades are opened. Close the blades as the speculum emerges from the introitus. During withdrawal, inspect the vaginal mucosa

Examining the vagina

Inspect Vaginal mucosa for

Color Inflammation Ulcers Discharge Masses.

Pelvic exam
Speculum technique To prepare for an adequate examination, the patient should be given an opportunity to empty her bladder and should be draped

appropriately. The examiner should use warm gloved hands and a warm speculum. Each step of the examination should be explained in advance to the patient. Always do pelvic exam chaperoned.

Performing a Pap Smear

Performing a Pap Smear

Appropriate Speculum Size

Graves Pedersens Virginal

Nasal speculum for

pediatric patients

Performing a Pap Smear

Parts of a Speculum

Other Types of Speculum

Inserting the Speculum

Warm the speculum with water, light

bulb or examining hand Exert pressure on inside of thigh to inform patient the examination is to start so as not to startle patient

Performing a Pap Smear

Inserting a Speculum

Pelvic exam
Speculum technique

With your other hand, introduce the closed speculum past your fingers at a 45o angle downward. The blades should be held up obliquely and the pressure exerted towards the posterior vaginal wall, avoiding the more sensitive anterior wall and urethra.

Inserting a Speculum

Pelvic exam
Speculum technique

After the speculum has entered the vagina, remove your fingers from the introitus. Rotate the blades of the speculum into a horizontal position. Open the blades after full insertion and maneuver the speculum gently so that the cervix comes into full view.

Inserting a Speculum

Inserting a Speculum

Inserting a Speculum

Performing a Pap Smear

Inserting a Speculum

Pelvic exam
Cervix Note the color of the cervix Describe the mucous membrane Position of Cervix Cervical os Appearnce and location Mucous membrane note the nature of discharge. Normal:

Cervical os is small and round in nulliparous and slit like after child birth. The cervix is covered by smooth pink epithelium.

Performing a Pap Smear

Obtaining Pap smear

With the blades open, secure the

speculum by tightening the thumb screw. Take three specimens: Endocervical swab:

Insert a cotton applicator stick (wire brush may also be used for endocervical specimens) into the os of the cervix. Roll the stick gently between the thumb and index finger. Remove and smear a labelled glass slide.

Performing a Pap Smear

Obtaining Pap smear

Cervical scrape: Place the longer end of a cervical spatula into the os of the cervix and press gently, turn and scrape. Smear a second labelled

glass slide. Any bleeding of the cervix during this procedure should be noted.
Posterior fornix:

Roll a cotton applicator stick on the floor of the vagina posterior to the cervix. Smear a third labelled glass slide.

Performing a Pap Smear

Performing a Pap Smear

Performing a Pap Smear

Performing a Pap Smear

Performing a Pap Smear

Performing a Pap Smear

Performing a Pap Smear

Performing a Pap Smear

Transferring smear to slide

Separate slides
Two portion

technique:

Upper half and lower half Right half and left half
V X N

Three portion

technique:

V Exo Endo Endo Exo - V

Transferring to Slide

Transferring to Slide

Transferring to Slide

Fixing the Slide

Dip slide in 90% alcohol
Spray slide with alcohol-containing hair

spray

Fixing the Slide

Bimanual Examination
Gently insert lubricated index and

middle fingers of the gloved hand into the vagina and palpate using abdominal counterpressure with the opposite hand.

Bimanual Examination

Bimanual Examination
Specifically note the size, shape and

consistency, and mobility of the cervix, uterine corpus, ovaries and tubes Assess for tenderness elicited by compression or motion Examine vaginal walls for submucosal nodularity that could not be seen earlier on speculum examination

Bimanual Examination

Palpating vagina and cervix

Palpate vagina and Cervix

Technique
Introduce

the middle and index fingers of your gloved and lubricated hand into the vagina. The thumb should be abducted and the ring and little fingers flexed into the palm.

Feel: Identify the cervix, noting its position, shape, consistency, regularity, mobility and tenderness.

Palpating uterus
Palpate uterus via bimanual exam

Technique
Place

your other hand midway between the umbilicus and the symphysis pubis and press downward toward the pelvic hand. Using the palmar surface of your fingers, palpate for the uterine fundus while gently pushing the cervix anteriorly with the pelvic hand.

Palpating uterus
Feel the uterus Normal uterus

and note

Size Position Consistency Mobility Tenderness

is the size of a small orange. When enlarged often described in size corresponding to weeks of Pregnancy Upside down Pear shaped firm smooth surface anteverted (80%) and anteflexed. freely movable. not tender

Bimanual Examination

Palpating adnexae
Normal Adnexa
Ovary

2x2 cms Almond shaped slightly tender to palpation very mobile

Rectovaginal Examination
Examine the rectovaginal septum, cul

de sac of Douglas, uterosacral ligaments, anal canal, anal sphincter and the rectum Look for evidence of neoplasm, endometriosis or infection

Rectovaginal Examination

Ancillary tests
Pap smear
Mammography Ultrasound

Ancillary tests
Screening for infection

Swab culture and serology Candida, Gardnerella, Trichomonas, Chlamydia, Gonorrhea, Syphilis Hepatitis B, HSV, HPV, HIV

Ancillary tests
Screening for

malignancy

Biopsy: Vulvar Vaginal Endocervical Endometrial Colposcopy

Ancillary tests
Screening for endocrine/fertility

disorders

Hormonal tests Hysterosalpingography Laparoscopy

Urodynamic evaluation

Thank you!