ADAMA UNIVERSITY, ASSELA SCHOOL OF MEDICAL SCIENCES, DEPARTMENT OF

OBSTETRICS AND GYNECOLOGY FORMAT FOR HISTORY AND PHYSICAL EXAMINATION IN

OBSTETRICS AND GYNACOLOGY

 OBSTETRICS
History components

1. Identification - Emphasize on
 Name
 Age-<18yrs and >35yrs are high risk groups.
 Marital status-Unmarried and unsupported are high risk
 Address
 Religion
 Occupation
 Source of information
 Mode of arrival
 Date of admission, ward, bed number

2. Chief complaint - Patient may have come for scheduled ANC follow up or

- May have a specific complaint e.g nausea and vomiting, vaginal bleeding etc.

3. History of present pregnancy - should include the following information

o Gravidity - all previous pregnancies-term live births, still births, abortions, ectopic
pregnancy or Hydatidiform mole.
o Parity - pregnancies that have extended beyond fetal viability whether the fetus is
delivered alive or dead.
 >28 weeks-UK and Ethiopia
 >20 weeks WHO
o Abortion(s)
o LNMP – 1st day of last normal menstrual period

To be considered as reliable:

Menstrual cycle should have been regular

No use of OCP for at least 3 months prior to LNMP or 3 regular cycles.
If lactating should have seen at least 3 regular cycles.
o Calculate the EDD - 40 weeks or 280 days after LMP -5% of pregnant women deliverer on
this day.
 Term pregnancy : 37-42 completed weeks.
Preterm pregnancy : <37 completed weeks.
Post term pregnancy : >42 completed weeks.

Neagele’s rule – G.C LNMP - 3 months +7 days or

- E.C LMP + 9 months +10 days or

- If pagume is passed -
_3 months +5 days if pagume is 5 or 4 days if pagume is 6

_ Used assuming 28dys regular cycle

Calculate gestational age in completed weeks and days.

o Quickening - 1st time the mother felt movement

- Used to date the pregnancy if LMP is unknown.
 Primigravida -1 8-20 weeks.
 Multigravida – 16-18 weeks.
o ANC status should be document and if not followed the reason should be sought
o Elaborate the chief complaint
o Any complaints during the present pregnancy – eventful or un eventful
o Ask for danger signs:
 Vaginal bleeding
 Leakage of liquor
 Abdominal pain etc.
o Fetal movements - decreased or increased? Useful to assess fetal well being.
o Other negative and positive statement according to the patient’s complaints e.g Headache,
blurring of vision, epigastric pain or convulsion in hypertensive disorders of pregnancy etc.

4. Past obstetrics history – document all previous pregnancy in chronological order.

Year of Ante Length of Length of Mode of Birth Postpartum Child

gestation partum gestation labor delivery outcome complications alive or
not

Important because most obstetric problems are recurrent and have a chance of recurring in the
current pregnancy e.g. APH, PPH, PROM, DM, C\S, Ectopic pregnancy and abortion.

5. Gynecologic history

 Contraception – use or need for any form of contraception, type and duration, side effects
  Sexual history – including history of STD, Assess risk or HIV\AIDS, age at first intercourse,
Hx of MSP, pain during intercourse.
 History of gynecologic operations including
 History of female genital cutting
 History of previous gynecologic surgery – e.g. prior uterine surgery (hysterotomy,
metroplasty, D&C, MVA, E&C).
 Menstrual history: Age at menarche, interval between periods, duration of flow, amount
and character of flow, degree of discomfort.

Normal menstrual cycles

 1-8 days of flow\ 5 days on average

 21-35 days cycle length\28 days on average.
 10-80 ml(50ml on average amount of blood flow
 dark non-clotting blood - Clotting of menstrual blood, increased number of pads used and
anemia indicate pathology.

6. Past medical and surgical history –

 Medical disorder may affect the outcome of pregnancy and the physiological change of
pregnancy may aggravate the medical disorder.E.g. Diabetes mellitus, Hypertension,
Thyrotoxicosis [hyper or Hypothyroidism).
 Previous blood transfusion – may be related to hemolytic disease of the new born.
 Hypersensitivity to drugs.
 History of maternal infection during pregnancy- e.g. STD, rubella etc.

7. Personal and social history

 Early childhood history

 Education
 Habits- smoking, alcohol and drug use may have a deleterious effect on pregnancy. E.g. fetal
alcohol syndrome.
 Occupation and family income – Low socio economic status is associated with pregnancy
complication e.g. pre-eclampsia, preterm labor, PROM. Etc.

8. Family history

 Number of siblings, whether parents and siblings are alive or not. If dead reason for death
should be mentioned to uncover familial reasons.
 Family history of Diabetes mellitus, hypertension, tuberculosis, twinning, hereditary
diseases, chromosomal anomalies, allergies, and mental disorders-run in families.

9. Review of systems
Physical examination
Should be conducted –

 In an environment that is aesthetically pleasing to the patient.

 A female assistant (chaperone) should be present whenever possible.
 Adequate gowning and draping to avoid embarrassment.
 Warm instruments, reassurance and adequate lighting.
 General physical examination covering all the systems should be conducted thoroughly.
a. General appearance
b. Vital signs
 Blood pressure - should be measured in the sitting position or 30 degree left lateral tilt to
avoid supine hypotension syndrome due to venacaval compression.
 Pulse – 10-15 beats\minute increase in pulse rate during pregnancy.
 RR – 1-4 breaths\minute increase during pregnancy
 Weight – ideal body weight found by using Broca’s formula: Height in cms – 100
20% above or below this is the normal range, weight gain >1kg/wk is abnormal.
 Height < 150 cms is a risk for contracted pelvis (CPD)
c. HEENT EXAMINATION– emphasize on conjunctiva, sclera, and teeth
d. LGS
o Glands- Thyroid
o Breast - detailed examination
o Nipple retraction- should be treated during pregnancy so that it will not interfere
with breastfeeding.
e. Chest – same as non pregnant.
f. CVS
- PMI may be deviated to the left.
- S3 gallop may be heard normally.
- Functional systolic murmur < III/VI grade may be heard.
g. Abdomen

Inspection

 Distention – symmetrical/asymmetrical – tilted to the right or tilted to the left, site of

distention, uniformity, shape and movement.
 Linea nigra – midline hyperpigmentation due to increased MSH during pregnancy.
 Striae gravidarum – purplish marks on the abdomen due to the distention – New striae
gravidarum or old striae gravidarum (striae albicantes).
 Umbilicus – flat, inverted or everted.
  Scar: non surgical or surgical – sub umbilical midline or pfannensteil –suprapubic
transverse scar.
 Distended veins.
 Flank – full or not
 Visible fetal movement.
 Pulsatile mass.

Palpation

Superficial palpation

-look for rigidity, tenderness, superficial mass, characteristic mass, abdominal wall defect.

Deep palpation

 Look for mass, and organomegally.

 Characterize mass (size, origin, consistency, mobility, tenderness and contour).

Obstetric palpation

1st - Fundal palpation – has two purposes: 1) Determination of fundal height and

2) What occupied the fundus.

A. Fundal height measurement – after correcting for dextrorotation.

There are two methods or measuring the fundal height.

I- Finger meathod - below the umbilicus – 1 finger = 1 wk and above the umbilicus – finger = two
wks.

 Uterus at symphysis – 12 weeks.

 At the umbilicus – 20 weeks.
 At xiphistermum – 38 weeks.
 Mid way between symphysis and umbilicus – 16 weeks
 Mid way between umbilicus and xiphisternum – 28 weeks.

II- Tape measurement – symphysis-fundal height measurement in centimeter with tape meter.

- At 18-34 week of gestation is accurate to +2 weeks of actual gestational age,

-McDonald rule and Johnson formula for GA and fetal weight estimation.

B – What occupies the fundus

-Soft irregular bulky mass – the breech

 -Hard round ballottable mass – head

2nd – Lateral palpation- has two purposes: 1) To know the Lie

2) Side of the back.

a. Lie - the longitudinal axis or the fetus In relation to the longitudinal axis of the mother.

Longitudinal lie, transverse lie, oblique lie

b. Side of the back – to auscultate the fetal FHR on that side. FHR can be auscultated at 20
weeds by
using the Dee Lee\pinard sthettoscope or aat 10-12 weeks using Doppler.

3rd pelvic palpation – it has three purposes. These are to know:

1. Presentation – part of the fetus that occupies the lower uterine segment. Eg cephalic,
breech, shoulder.
2. Attitude – relationship of the fetal head to the fetal trunk.
Cephalic prominence on the side of the back…extended attitude
Cephalic prominence on opposite side of the back…flexed attitude
Flexed is normal, extended or military are abnormal attitudes.
3. Descent – level of fetal presenting part to maternal bony pelvis; measured by palpating
fetal shoulder in terms of fingers: 5/5 – floating, 4/5 – fixed, 2/5 – engaged

4th - Pawlik’ grip – it has two purposes

1. To know the presentation & 2. Check for engagement

Percussion - shifting dullness and fluid thrill as in ascites and polyhydraminos

Auscultation – FHB first heard at 20wks – on the side of the back

- Below the umbilicus in cephalic presentation

- Ubove the umbilicus in breech presentation
- At the flanks in OP position
c. GUS –
 CVA and suprapubic tenderness
 Pelvic assessment – done at two times in pregnancy unless otherwise contraindicated and
also in labor
1. During pregnancy
a. First trimester – to diagnose pregnancy, to date pregnancy, to diagnose pelvic problems
like ovarian cyst, vaginal and uterine anomalies
b. Late in pregnancy – for soft tissue assessment
 - For pelvic assessment
- To assess the Bishop score before induction
2. In labor – to evaluate the cervical effacement, dilatation, station, presentation, position,
membrane status, caput or molding

d. Musculoskeletal system – Extremities :

 look for dependent edema – pretibial and pedal
80% of pregnant women experience it
 Non dependent edema…facial edema, tightening around fingers, sacral edema,abdominal
wall edema…as seen preeclamsia
e. Integumentary system – emphasize on skin chnges in pregnancy
f. CNS – consciousness, reflexes, gross neurological defects

SUMMERY

ASSESSMENT

DIFFERENTIAL DIAGNOSIS

TREATMENT PLAN
  GYNECOLOGY
HISTORY

1. IDENTIFICATION……Same as in Obstetrics
2. Chief complaint……Same as in Obstetrics
Common presenting complaints include
- Vaginal bleeding
- Vaginal discharge
- Lower abdominal pain
- Failure to conceive
- Absence of mensus
- Pain during intercourse
- Pain during mensus
- Abdominal swelling
- Mass per vaginum etc.
- Force sexual intercourse
3. History of present illness
 Reproductive history – Gravidity, parity, abortions
 Each complaint should be discussed in detail
- Where exactly is it occurring
- Date and time of onset
- Abating or getting worse
- Duration when they occur
Examples,
 Abnormal uterine bleeding – Describe clearly onset, duration of flow, amount – indicated
by number of pads used, clotting of menstrual blood. Describe relation of AUB to menstrual
cycle & LNMP.
LMNP should be included in the HPI.
Menstrual history in detail can be included in the HPI or elsewhere if not pertinent
to the present complaints.
 Vaginal discharge
- Color, odor, amount, viscosity.
- Timing in relation to menstureal cycle.
- Associated with abnormal vaginal bleeding – may indicate malignancy.
- Itching – indicate infection.
 Abdominal pain – PQRST
- Location
- Quality
- Radiation
- Severity
- Timing – intermittent constant, etc especially relationship to menstrual cycle. Pain during
menstruation could be primary or secondary dysmenorrhea.
 Contraceptive history, sexual history and menstrual history should be included in the HPI if
pertinent to the present complaints otherwise can be included in the past gynecologic
history
 Negative – positive statements-pertinent to the presenting complaints should be discussed
in detail.
 Menustral history – age at menarch, interval between periods, duration of flow, amount
and character of flow, degree of discomfort and age at menopause.
4. Past Gynecologic history – as in obstetrics
5. Past obstetric history – as in obstetrics
6. Past medical and surgical history - as in obstetrics
7. Personal and social history- as in obstetrics
8. Family history - as in obstetrics
9. Systemic review
Physical examination
a. General appearance
b. Vital signs - as in obstetrics
Weight – obesity is a risk factor for certain gynecologic illnesses –endometrial ca, ovarian
ca, ammenorrea
Height – especially important in post menopausal pts to document loss of height from
osteoporosis and vertebral fractures
c. Breast examination
Inspection – with pts hands pressing on her hips and arms above the head respectively
Symmetry, dimpling peau’d orange, nipple retraction, ulceration and eczematous
nipple lesion should be documented.
Palpation – all four quadrants, axillary tail, nipple area for discharge. Axillary,
supraclvicular and cervical lymph nodes with detailed descriptions of a mass.
d. Respiratory system
e. CVS
f. ABDOMINAL EXAMINATION
INSPECTION – SAME as in any patient
Auscultation – bruits over masses and bowel sounds
Palpation - superficial or deep
Abdominal mass – describe:size, origin, consistency, mobility, tenderness and contour
Size –in weeks of pregnant uterus size.
12wks at the symphysis pubis
20wks at umbilicus
38wks at xiphesternum
- In centimetre
 Origin – Pelvic –abdominal mass arising from the pelvis or an abdominal mass –
differentioated by identifying if one can go below the mass in to the pelvi cavity or not?
 Concistency – firm, hard, soft or cystic.
 Mobility – fixation may indicate adhesions or malignancy.
 Tenderness.
 Surface contour – smooth, irregular or nodular
- Check for Organomegally – liver, spleen, kidneys.

Percussion

- Shifting dullness, fluid thrill to detact ascitis.

 - Differentiation of a large ovarian tumor verses ascities.
Large ovarian tumor has central dullness with tympanicity at the flanks as opposed to
ascites with central tympanicity.

G. pelvic examination – has four components

a. examination of external genitalia

b. speculum examination

c. digital vaginal examination

d. bimanual pelvic examination

a. Examination of external genitalia – inspection and palpation

Pubic hair- pattern – masculine – diamond shaped

- Feminine – inverted triangle.

 Skin of vulva, mons pubis and perineal area inspectes for dermatitis or discoloration e.g.
whitish discoloration on vulvar dystrophies.
o Ulcer or swelling E.g. sebacius cycts or tumors
 Labia majora and minora – ulcers, swelling or tumors such as condyloma accuminata could
be found.
 Evidence of FGM – scarring etc.
 Urethral orifice – should be of the same color as surrounding.
o Milk for discharge
o Urethral caruncle or tumor if any
 Area of Bartholin’s glad – at 5&7 o’clock position
 Inspection and palpation for sweeling and tenderness
 Discharge or bleeding from the introitus – should be noted.
 Hymen – unruptured – many forms – annular, septate
 Imperforate – pathological
 Ruptured – especially after the birth of many children carunculae myformis.
 Examination important in case of sexual assault.
 Check perineal support – open the labila with 2 finger and ask patient to strain to
document genital prolapsed.

b.Speculum examination

-speculum – dampening with warm water but not lubricants

 - Types - Cuscos (Graves) bivalve speculum.

-Sims speculum

-Choice of several size depending on age etc.

The following should be documented.

Vagina

 Color – pink, whitened,inflamed.

 Congenital anomalities like vaginal septa.
 Rugae folds – formed, flattened.
 Fornices - formed, flattened, bulging especially posterior fornix
 Discharge – color, amount
 Scars, lacerations

Cervix –

 Color – pink, bluish

 Os – nulliparous – pinpointed.
o Multiparous – sit like
 Erosins, scars, lacerations, ulcer, mass, nabothinan cycts
 Effacement, dilation, bleeding from Os or from the surface
 Any mass detacted on the cervix.
 Papannicolau’s smear should be taken from the exocervix.

c. Digital vaginal examination – note the following. The patient should have voided just prior to
examination to avoid difficulty in examining the uterus and adnexal by the distended bladder.

- Vaginal masses, tenderness or stenosis

- Fornices – formed or obliterated
- Bulging especially posterior fornix (cul-de-sac)
- Tenderness

Cervix – consistency – Tip of nose – normal

Firm to hard in malignancies.

Excitation (motion tenderness)

 Effacement, position nad dilatation

d.Bimanual pelvic examination

- To delineate the uterus and adnexal between the 2 fingers in the vagina and the flat of the
other hand on the lower abdominal wall.
- EUA may be required in obese patients.
- Note the following.

a. Cervix -3-4 cms in diameter, round, tip of the nose consistency

-External Os usually closed

- Smooth surface normally

- Can be moved 2-4 cms in any direction without discomfort.

b. Uterus – Dimensions of normal uterus

9 cms length

7 cms width

2 cms depth

= 70-90 grams

Assess the following regarding the uterus

Position – anterverted – normally

- anteflexd – body of the uterus flexed at the cervix

- Retroverted and retroflexed in 20% of the cases

- may indicate pathology

Tenderness – normally non – tender organ

Mobility – mobile in all directions normally.
Fixation – may be due to cancer \neoplasia or inflammation
Size – in pregnant uterus size
Surface contour – smooth normally

c.Adnexae – refer to the – Tubes, ovaries, broad ligament and parametria

 - ovaries – 3cm *2cm*1cm in size.
- May be palpable in thin women with soft abdominal walls.
- Tender normally
- Tubes diameter = 7 mms at its greatest diameter
- Description of adnexal mass = similar to uterine mass

Summary

Assessment

Differential diagnosis

Investigations

Treatment plan