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 Four maneuvers
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 Pelvic diameters: Anterio-posterior Transverse
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 ExaminationG
Engagement: Widest diameter of head below the pelvic brim.
No. of 5th head palpable above the pelvic brim e.g 4/5th , 3/5th
Amniotic fluid
Auscultation: FETAL HEART

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 S

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