History Taking and
Physical
Examination in
Obstetrics and
Gynaecology
By
Dr Rukiyat Adeola Abdus-salam
Objectives
Learn how to interact with patients and gain
patients’ confidence
Learn Patient’s assessment:
Thorough clerkship
Identify the patient’s problems and
prioritize
Make Diagnosis
Institute Appropriate interventions
Prognosis and follow up
Biodata
Also known as sociodemographic characteristics
Name
Age
Sex
Contact Address and telephone Number
Level of education
Occupation
Marital status
Religion (e.g. Jehovah Witness, catholic)
Gynaecological History
Menstrual history:
Age at Menarche
Ketamania – duration of flow/cycle length
E.g 4-5 days/ 28-30days cycle
Regular or irregular
Dysmenorrhea
Primary or secondary
Menorrhagia
Reproductive history
Parity – deliveries & miscarriages
If pregnant include gravidity
LMP – last normal menstrual period
Last Confinement
Contraceptive History – types used, duration
of use, when discontinued
Presenting Complaints
Arranged in Chronological Order
Pay attention to important symptoms
Common presenting complaints in OBGYN
Lower abdominal pain
Irregular menstrual flow
Mass in the abdomen/swelling
Inability to achieve pregnancy
Leakage of urine/urinary symptoms
Sexual history
Bleeding par Vagina (Pregnant or non-pregnant)
Amenorrhoea /Caesation of menses
Drainage of liquor
Labour pains
History of Presenting
Complaints
Details of the complaints
Risk factors elucidated
Factors that may affect management elucidated
Prognostic factors elucidated
Using 5 Cs:
Complaint, course of the symptom, cause –
aetiology and differentials, complications
and associated factors, care so far –
evaluation, investigation and interventions
Review of Systems:
All systems are reviewed to elucidate
missing information
History of Presenting
Complaints
Specific questions on common complaints
Masses (site, mode of onset, pain, weight loss)
Pain (type, location, radiation, associated
factors)
Bleeding (relation to menses, coitus, amount)
Vaginal Discharge
Coitus (frequency, pain, bleeding, number of
partners)
Pregnancy loss (number, gestational age
pattern)
Obstetric history
History of index pregnancy:
Booking, clinical parameters, blood group, Hb
genotype, investigation
Pregnancy events
Past obstetric history
All pregnancies – Year, Duration, Course and
outcome of pregnancy, Breastfeeding,
Status of child
ANC
Labour & Puerperium
Pregnancy loss
Gynaecological history
Specific gynae interventions,
Surgery
Others
Past Medical History
Usually risk factors are explored
Allows to explore missed information
Chronic Medical conditions and treatment
Operations
Surgeries, admissions, drugs and blood
transfusion
Investigations done eg Infertility
Family and Social history
Medical history in the family - Relevant
family history: diabetes, hypertension,
genetic disorders
Familial diseases e.g. Ca Ovary and Breast
Cancer
Similar history in relations
Relevant social/financial support for VVF
patients and adolescents
Drinking –alcohol, etc
Smoking
Family social history – size, type, Family
setting (Mono/polygamous union)
Partner’s occupation
Drug and Allergy history
Drug use
Known allergies – drugs, environmental
Examination
Counsel
Consent/partner’s
Chaperone - Must have a FEMALE
CHAPERON
Privacy
Comfortable setting, couch and illumination
No contraindication
Physical Examination
General Examination
Gait, appearance
Pallor, jaundice, febrile, lymphadenopathy
Height/Weight/BMI
Thyroid gland
Breasts
Lumps
Nipple discharge (galactorrhoea, bloody
discharge)
Physical Examination
Respiratory system
Cardiovascular system
Pulse rate, Blood pressure
Abdomen
Distension, linea nigra, striae,
umbilicus
Consistency e.g soft
Tenderness
Organomegaly
Masses ( shape, size, tenderness,
consistency, ascites)
Gravid uterus
Vaginal Examination
Must have a FEMALE CHAPERON
Trolley (Gloves, specula – Cusco's or Sims, vaginal retractor,
sponge holding forceps, spatula, light source, lubricant, swabs)
External genitalia
Inspection (part the labia)
Hair distribution
Clitoris/hood
Labia majora/minora
Urethra
Vaginal introitus/hymen
Request to cough/bear down ( stress incontinence and
prolapse)
Vaginal Examination
Possible abnormalities of external genitalia
Atrophy
Hypertrophy
Cyst
Warts
Excoriations
Ulceration (benign/malignant)
Bartholin’s cyst
Speculum examination
Useful for taking swabs/pap smears prior to digital
examination
Reveals source of discharge – vaginal/cervical,
bleeding - vaginal/cervical, lacerations, lesions in
vagina, cervix
Bivalve Cusco’s speculum: patient in dorsal
position
Sim’s speculum: patient in left lateral position
Nulliparous cervix – pin hole
Multiparous cervix – patulous
Pregnant cervix -
Digital (Bimanual) Examination
Index + Middle fingers
Vagina (length, width, mucosa, scarring, stenosis, growth,
ulcers/discontinuity)
Cervix
Consistency
Pregnant cervix – soft
Non-pregnant cervix –firm
Dilatation
Position
Cervical excitation tenderness
PID
Ectopic pregnancy
Digital (Bimanual)
Examination
Uterus
Define position (Anteverted, retroverted)
Size (in weeks), bulky when > 12 weeks size
Surface and regularity
Consistency
Mobility
Tenderness
Adnexa
Masses
Tenderness
Rectal examination (prolapse and cervical cancer, not
sexually active)
Obstetric Examination
Examination of the Abdomen
General – note size, shape, & contour, masses,
visible peristaltic waves, prominent veins,
herniation.
Palpation
Tenderness, rigidity, masses, hernias, liver,
spleen, kidneys, other masses.
Height of fundus;
Lie, Presentation and position of the fetus (in
advanced pregnancies);
Auscultation – Fetal heart sounds. 21
HEIGHT OF FUNDUS ON ABDOMINAL
WALL
As pregnancy progresses,
the size of the uterus
should be evaluated at each
pre-natal visit to determine
whether or not growth is
adequate.
This is carried out by using
a fixed reference point- the
superior ramus of the pubis
or umbilicus from which to
measure the fundus.
The fundal height is
measured (in cm) above the
symphysis with a flexible
tape. 22
EXAMINATION OF THE FETUS
(in advanced pregnancy)
Determine the:
LIE
PRESENTATION
POSITION
ATTITUDE
Refers to the relation of the different parts of the fetus
to one another.
Normally, the head, back and limbs of the fetus are
flexed.
ENGAGEMENT
23
Descent of the fetal head into the pelvic cavity such
that both parietal bones are at or below the ischial
ABOMINAL PALPATION OF THE
FETAL HEAD FOR ENGAGEMENT
By abdominal palpation,
assess descent in terms of
fetal head palpable above the
symphysis pubis
A head that is entirely above
the symphysis pubis is five-
fifths (5/5) palpable (Figs. A &
B).
A head that is two-fifths (2/5)
or less above the symphysis
pubis is engaged (Figs. C & D).
24
The Quality of clerking is directly
proportional to the depth of knowledge
on the condition
Obstetric conditions
Normal pregnancy
Antepartum haemorrhage
Postpartum haemorrhage
Hypertensive disorders of pregnancy
Diabetes mellitus in pregnancy
Premature rupture of membrane
Cervical incontinence
Intrauterine fetal death
Gynaecological Conditions
Infertility
Abortions
Uterine Fibroids
Ovarian mass
Abnormal uterine bleeding
Abnormal vaginal discharge
Pelvic inflammatory disease
Ectopic pregnancy
Careful history taking and
examination in women
The Complaints may be psychosomatic.
Symptoms of serious disease may be undisclosed
or distorted.
Women tend to postpone seeking for help for
health-related conditions.
Hidden conditions – Assault, GBV – spousal abuse,
induced/unsafe abortion,
Medicolegal – assault, abuse
Litigation – in OBGYN
Thank you
