BAHIR DAR UNIVERSITY

COLLEGE OF MEDICINE & HEALTH SCIENCE

DEPARTMENT OF OBSTETRICS & GYNECOLOGY

HISTORY AND PHYSICAL EXAMINATION

FORMAT IN OBSTETRICS AND GYNECOLOGY
I. OBSTETRICS
HISTORY
 Identification:
Name: Occupation:
Age: Date of admission:
Marital status: Ward:
Religion: Bed No.:
 Chief complaint-
- ANC follw up
- Vaginal bleeding
- Leakage of liquor
- Pushing down pain
- Decreased/ absent
fetal movement
- Body swelling,
headach, blurring of
vission, etc

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  History of present pregnancy
Should include the following information:
 Gravidity – all previous pregnancies – term live
births, abortions, ectopic pregnancy or hydatidiform
mole.
 Parity – all pregnancies that have extended beyond
fetal viability whether the fetus is delivered alive or
dead-
≥28 weeks – UK and Ethiopia
≥20 weeks WHO
 Abortion(s)
 LNMP
1st day of the last menstrual period
To be considered reliable:
Menstrual cycle should have been regular
No use of OCP for at least 3 months prior to LMP
or 3 regular cycles
If lactating should have seen 3 regular cycles
 Calculate the EDD
40 weeks or 280 days after LMP – only 5% of
pregnant women delivered on this day
Term pregnancy  37-42 completed weeks
Preterm pregnancy  <37 completed weeks
Post term pregnancy  >42 completed weeks
To calculate the EDD
If using Gregorian calendar:
Naegele’s rule: LMP – 3 months + 7 days
If using Ethiopian calendar:
LMP + 9 months + 10 days or (5 if pagume is
5 or 4 days if pagume is 6) if pagume is
passed

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  Calculate the gestational age in completed weeks
and days
 Quickening: 1st time the mother felt fetal
movement(date/month, not the month of pregnancy)
Used to date the pregnancy if the LMP is unknown
Primigravida – 18-20 weeks
Multigravida – 16-18 weeks
 ANC status should be documented(when where
what was done or counseled at each visit) or if not
followed the reason should be sought
 Elaborate the chief complaint
 Any complaints during the present pregnancy;
eventful or uneventful
 Ask for danger signs
Vaginal bleeding
Leakage of liquor
Abdominal pain
 Assess fetal wellbeing – ask about fetal movements
 Other negative or positive statements according
to the patient’s complaints e.g. headache, blurring of
vision, epigastric pain or convulsion in hypertensive
disorders of pregnancy etc

 Past Obstetric History

Document all previous pregnancies in chronological order
Date of gestation, length of gestation, birth weight, fetal
outcome, length of labor, fetal presentation, mode of
delivery, complications: ante partum, intrapartum, and
post partum;

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

Date of ante Length Lengt Mode Birth Postpar

gestatio partu of h of of outcom t cxnns
n m gestatio labor deliver e
n y
1988 Non term 24hr Svd 3kg None
alive
2002 GDM term 72hr c/s 4.5 s/b PPH

 Gynecologic History
Contraception: use or need for any form of
contraception, type and duration
Sexual history: including history of STIs. Assess
risk of HIV/AIDS
History of gynecologic operations: history of
FGC, history of gynecologic surgery e.g. prior uterine
surgery- hysterectomy, metroplasty, D&C, E&C, MVA
Menstrual history: age at menarche, interval
between periods, duration of flow, amount and
character of flow, degree of discomfort.
Normal menstrual cycle: 1-8 days of flow, 21-35
days cycle length, 5/28 days average, 10-80 ml - 50 ml on
average of blood flow, dark non clotting blood.
Clotting of menstrual blood, increased number of
pads used and anemia indicate pathology.

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  Past Medical and Surgical History
Medical disorders may affect the outcome of
pregnancy and the physiologic changes of pregnancy
may aggravate the medical disorder e.g. diabetes
mellitus, hypertension, thyrotoxicosis, or
hypothyroidism.
Previous blood transfusion: may be related to
hemolytic disease of the new born
Hypersensitivity to drugs:
History of maternal infections during
pregnancy: STD, rubella

 Personal, family and social history:

Early child hood history: number of siblings,
whether parents and siblings are alive or dead.
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
complications e.g. preeclampsia, preterm labor,
PROM etc
Family history: diabetes mellitus, hypertension,
tuberculosis, twinning, hereditary disease and
chromosomal anomalies and pregnancy induced
hypertension, allergies, mental disorders- run in
families

 Review of Systems

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PHYSICAL EXAMINATION
Should be conducted:
 In an environment that is aesthetically pleasing
to the patient
 In the presence of a female assistant (chaperone)
 With adequate gowning and draping to avoid
embarrassment
 With warm instruments, reassurance, and
adequate lighting

General App
earance
Vital Signs
Blood pressure: should be measured in a sitting
position or 30 degree left lateral tilt to avoid supine
hypotension syndrome due to venacaval compression
Pulse: 10-15 beats per minute increase in pregnancy
Respiratory rate: 1-4 breaths per minute increase
in pregnancy
Weight: ideal body weight found by using Broca’s
formula
Height in cm – 100 (20% above or below is the
normal range)
BMI
Height: <150 cm is considered high risk for
contracted pelvis (CPD)
HEENT: emphasize on conjunctiva, sclera, teeth
LGS: Thyroid
Breasts: detailed exam

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 Nipple retraction should be treated during
pregnancy so that it would not interfere with
breast feeding
Chest: same as non pregnant
CVS: same as non pregnant
PMI may shift to the left
S3 gallop may be heard normally
Functional systolic murmurs ≤grade III may be heard
Abdomen:
Inspection:
-Distension, symmetry – tilted to the right tilted
to the left, site of distension, uniformity, shape
and movement
-Linea nigra – midline hyper pigmentation due to
increased MSH during pregnancy
-Striae gravidarum – purplish marks in the
abdomen due to distensionnew striae or old
striae (striae albicans)
-Umbilicus: flat, inverted or everted
-Scars: subumbilica midline or pfannestien
-Distended veins
-Flanks- full or not
-Visible fetal movements
-Pulsatile mass
Palpation:
Superficial palpation:
Look for rigidity, tenderness, superficial mass,
characterize the mass, abdominal wall defect,
Deep palpation:
Look for mass, organomegally

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 Obstetric palpation: Leopold’s Maneuver
1st – fundal palpation:
Have two purposes:
A. Fundal height measurement:
Correct for dextrorotation.
Methods:
a.finger method – below the umbilicus one
finger corresponds with 1 week of gestation
b.tape method – at 18-34 weeks of gestation its
accuracy is ± 2 weeks of the actual GA
c. land mark method –
At the symphysis pubis12 weeks
At the umbilicus20 weeks
At the xiphisternum38 weeks
Midway between the symphysis and
umbilicus16 weeks
Midway between umbilicus and
xiphisternum28 weeks
o FW estimation by Johnson formula(Fh-11 or 12)155 +
375 gram
B. What occupies the fundus:
Soft irregular bulky mass the breech
Hard, round ballotable masshead
2 – lateral palpation:
nd

Have two purposes:

A.to know the lie-
B.to identify the side of the back-
3rd – pelvic palpation:
It has three purposes:
A.presentation -
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 B.descent – using the 5th rule
5/5 - floating
4/5 - fixed
2/5 - engaged
C.attitude-
Cephalic prominence on the side of the back –
extended
Cephalic prominence opposite to the side of the
back - flexed
4th – Pawlik’s grip:
It has two purposes:
A.to know the presentation
B.to know the descent/ to check floating or not/
Percussion:
Shifting dullness and fluid thrill – ascites,
polyhydramnios
Auscultation:
FHR 1st heard at 20 weeks of gestation with Dee
Lee/Pinnard stethoscope, more on the side of the
back
Below the umbilicus in cephalic presentation
Above the umbilicus in breech presentation

Pelvic assessment:
Done at two times during pregnancy unless otherwise
indicated due to complications and in labor
1. early – during the 1st trimester
 To diagnose pregnancy
 To date pregnancy

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  To diagnose pelvic problems like ovarian cysts,
uterine anomalies like septate early
2.late – above 37 weeks
A. pelvic assessment to diagnose contracted pelvis
 Soft tissue assessment
 Bony pelvis assessment
Inlet:
 Calculate the diagonal conjugate
DC – 1.5 cm=TC (AP diameter)
 Is the sacral promontory reachable or not?
 Head fitting (Muller Hinton) test
Mid cavity
 Assess prominence of ischial spines
 Sacrospinous ligament should accommodate
2 fingers
 Concavity of the sacrum – concave normally
 Pelvic sidewalls – straight, convergent,
divergent
Outlet:
 Sub pubic arch should accommodate 2
fingers
 The intertuberous diameter should
accommodate four knuckles of the clenched
fist
 The coccyx should be mobile
B. to assess the Bishop’s score

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 Assess the status of the cervical ripening for
induction
Components of the Bishop’s score:
 Cervical effacement
 Cervical dilatation
 Cervical consistency
 Cervical position
 Station of the presenting part
3. In labor: assess dilatation, effacement, station,
position, molding, and caput
GUS: CVA tenderness or suprapubic tenderness
Extremities: look for edema – pretibial, pedal and ankle
(dependant)
80% of pregnant women have edema
Other areas to look for pathological (non dependant
edema)
Facial edema
Tightening of rings
Sacral edema
Abdominal wall edema

CNS: Reflexes, Consciousness, Gross neurologic deficit

summary
Assesment
DDX
Investigation
Treatment plan
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II. GYNECOLOGY
History
Identification: same as obstetrics
Chief complaint:
Gynecologic patients may present with any of the
following complaints;
 Cessation of menses
 Vaginal bleeding
 Vaginal discharge
 Lower abdominal pain
 Pain during intercourse
 Pain during menstruation
 Mass protruding through introitus
 Ulcer over the external genitalia
 Urinary incontinence
 Abdominal distension
 Hirsuitism
 Sexual assault
History of present illness:
 Reproductive history: , parity, abortions

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 Each complaint should be discussed in detail; where
exactly it occurs, date and time of onset, abating or
getting worse, duration when it occur.
Examples:
 Abnormal uterine bleeding:
 Describe clearly onset, duration of flow, amount
– indicated by the number of pads used, clotting
of menstrual blood.
 Describe relations of AUB with menstrual cycle
and LMP.
 Vaginal discharge:
 Color, odor, amount, viscosity
 Timing in relation to the menstrual cycle
 Association with bleeding – may indicate
malignancy
 Itching may indicate infection
 Abdominal pain: PQRST
 Location (position)
 Quality
 Radiation
 Severity
 Timing – intermittent, constant
 Relation to the menstrual cycle – could be
primary or secondary dysmenorrheal
 contraceptive history, sexual history and menstrual
history should be included if pertinent

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  positive and negative statements pertinent to the
presenting complaint
Menstrual history: age at menarche, interval between
periods, duration of flow, amount and character of flow,
degree of discomfort and age at menopause.
Gynecologic history: as in obstetrics
Past obstetric history: as in obstetrics
Past medical and surgical history: as in obstetrics
Systemic review:

Physical examination
General appearance:

Vital signs: as in obstetrics

 Weight - obesity is a risk factor for certain gynecologic
problems – endometrial Ca, ovarian Ca
 Height- especially important in post menopausal
women to document loss of height from osteoporosis
and vertebral fracture
Breast examination:
 Inspection:
With patient’s hand by the side, hands pressing on the
hips and hands above the head.
Symmetry, dimpling, peau’d’ orange, nipple
retraction, ulceration, eczematous nipple lesions
should be documented
 Palpation:

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 All four quadrants & axillary tail; nipples for
discharge; axillary, supraclavicular and cervical lymph
nodes should be examined. Detailed description of a
mass

Abdominal examination:
 Inspection: as usual as is done for other patients
 Auscultation: bruit over a mass
 Palpation: superficial – deep
Abdominal mass description should include;
 Size:
 Origin:
 Consistency:
 Mobility:
 Tenderness:
 Surface contour:
Check for organomegally – liver, spleen, kidneys
 Percussion: shifting dullness, fluid thrill
Differentiation of a large ovarian mass and
ascites
Large ovarian tumor has central dullness with
tympani at the flanks as opposed to ascites with
central tympani
Pelvic examination:
Have four components:
1. examination of the external genitalia
 Pubic hair – pattern –

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 Masculine – diamond shaped
Feminine- inverted triangle
Infected hair follicles etc
 Skin of vulva, Mons pubis and perineal area,
inspected for dermatitis or discoloration e.g. whitish
discoloration in vulvar dystrophies; ulcers or
swellings e.g. sebaceous cysts or tumors
 Labia majora and minora – ulcers, swellings or
tumors as condyloma accuminata, evidence of FGC
 Urethral orifice – milk for discharge, urethral
caruncle or tumor
 Area of Bartholin’s gland – 5 and 7 O’clock positions
Inspection and palpation for swelling
 Discharge or bleeding from the introitus
 Hymen –
Unruptured many forms - annular septate,
imperforate, pathological
Ruptured – after the birth of many children –
carunculate myrtiformis
Examination is very important in case of sexual
assault
 Check for perineal support – open the labia with two
fingers and ask the patient to bear down to document
genital prolapse
2.speculum examination
Speculum deepened in warm water but not lubricants
 Types–Cuscose (Grave’s) bivalve speculum

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  Simp’s speculum
The following should be documented:
 vagina:
Color – pink, whitened, inflamed
Congenital anomalies like vaginal septa
Rugae folds – formed, flattened
 frornices – firmed, flattened, bulging
Discharge – color, amount
Scars, lacerations
 cervix:
Color - pink bluish
Os: Nulliparous - pinpointed
Multiparous - slit like
Erosions, scars, lacerations, ulcer, mass, Nabuthian
cyst
Effacement, dilatation, bleeding from os, or from
the surface
Any mass detected on the cervix
Papanicolau’s smear
3.digital vaginal examination
The patient should have voided just prior to the
examination
 Vaginal mass, tenderness or stenosis
 Fornices –formed or obliterated; bulging,
tenderness
 Cervix – consistency –
Tip of the nosenormal

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 Firm to hard malignancy
 Excitation (motion tenderness)
 Effacement, position, dilatation
4.bimanual pelvic examination
Note the following:
 Cervix: 3-4 cm in diameter round tip of the nose
consistency
External os usually closed
Smooth surface normally
Can be moved 2-4 cm in any direction without
discomfort
 Uterus: dimensions of normal uterus
 9 cm length
 7 cm width
 2 cm depth
 70-90 gms
 Assess the following regarding the uterus
 Position: anteverted – normally
Ante flexed – body of the uterus flexed at the
cervix
Retroverted and retroflexed in 20% of cases
– may indicate pathology
 Tenderness
 Mobility
 Fixation
 Size
 Shape

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  Surface contour
 Consistency
 Adnexa (tubes, ovaries, broad ligament and
parametra)
 Ovaries: 3 cm x2 cm x1 cm in size
May be palpable in thin women with soft
abdominal walls
Tender normally
 Tubes: 7 mm at its greatest diameter
 Adnexae should not be palpable in post
menopausal women
 Description of an adnexal mass is similar to a
uterine mass

Rectal examination: in virgins

 To assess the involvement of the rectal mucosa in
malignancies
 To assess the parametrial soft tissue in the broad
ligament connecting the cervix and body of the
uterus to the pelvic sidewalls in staging of
malignancies
 Normally parametria is not palpable or is free
 Indurated or nodular parametria indicate
malignant infiltration or infection

Rectovaginal examination:

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  Performed with the index finger in the vagina and
middle finger in the rectum and assess the
structures in between the two fingers
 To examine the rectovaginal septum or
uterosacral ligaments for nodularity or
infiltration
 Also to differentiate rectocele from enterocele

GUS: as in obstetrics
Extremities: as in obstetrics
CNS: as in obstetrics
SUMMARY
ASSESSMENT
DDX
IX
TREATMENT PLAN

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Duties of a physician
As a physician you must:
 Make the care of your patient your first concern
 Treat every patient politely and considerately
 Respect patients’ dignity and privacy
 Listen to patients and respect their views
 Give patients information in a way they can understand
 Respect the rights of patients to be fully informed in
decisions about heir care
 Keep your professional knowledge up to date
 Recognize the limits of your professional competence
 Be honest and trustworthy
 Respect and protect confidential information
 Make sure thatyour personal beliefs do not prejudice your
patients’ care
 Act quickly to protect patients from risk if you have
goodreason to believe thatyou or a colleague may not be fit to
practise
 Avoid abusing your position as a doctor
 Work with colleagues in the ways that best serve
patients’interests
 In all these matters you must never discriminate unfairly
against your patients or colleagues and you must always be
prepared to justify your actions to them.

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