CLINICAL SKILLS PRACTICAL

BY

DR. MUSINGUZI

OBGY

1
INSTRUMENTS
MVA
SYRINGE
A. Identify
B. Sterilisation
process
C. Uses
D.Instruments
you will need
together with it
E. Advantages
F. Demonstrate
how to use it.
Sterilisation USES
Evacuation
• Deassemble after use
Therapeutic abortion
and put in chlorine
Suction curettage-molar
soln 0.5% for 10 min
Endometrial sampling
• Wash thoroughly with
water and soap, • Cusco's spec.
cleanse • Sponge holding forceps
• Put in cidex soln • Vallusselum
(glutarylahihyde) for
30-40min ADVANTAGES
• Then cleanse with • Requires less skills to operate
distilled water • Minimal chances of uterine
• Store in a sterile perforation
container
• Causes less pain
• Its sterilization process is quicker
Karman cannula or
plastic suction
cannula

• Evacuation
• Therapeutic
abortion
• Suction
curettage-
molar
• Endometrial
sampling
 Cusco’s/ bivalve
self retaining
USES
• To visualize the cx and
vag, fornices for any
local cause (polyp,
ectopy) of APH
• To inspect the cx and
to prepare cx smear
for cytologyscreening.
Decontamination
• To detect leakage of
High level disinfection
liquor from the cx os
with 0.5% jik
in a case of suspected
Sterilization: steam
PROM
dry heat
 SIM’S SPECULUM
USES double bladed post. Vaginal
• Demonstration of
the ant. Wall of vag.
(VVF)
• To inspect CX and
vag.
• Clean vag.
Following delivery
• Local bleeding
exclusion incase of
PPH
• Used during D/E
 Uterine sound

• To know the position of the

uterus and the length of the
uterine cavity prior to dilatation
of the cx in D + E
• To sound the uterine cavity to
detect any foreign body (IUCD).
• It acts as a 1st dilator of the cx
canal.
 Uterine curette

Can be sharp at both ends or at 1 end and blunt

at the other. Used in D + C for incomplete abort
and In D + E operation (blunt end)
It can also be used in D + C operation 1 wk week
following evacuation of hydatidiform mole.
 FLUSHING CURETTE

It is a blunt curette used in the operation of D + E.

Previously, it was used to flush the uterine cavity
with lukewarm antiseptic solution—passing
through the communicating channel.
UTERINE DRESSING
FORCEPS
The instrument is most often
confused with laminaria tent
introducing forceps. The blades are
transversely serrated while in the
latter, there is a groove on either
blade.
USES: To swab the uterine cavity
following D + E with small gauze
pieces and
To dilate the cervix in lochiometra or
pyometra
LAMINARIA TENT AND THE TENT INTRO.
FORCEPS

Similar to uterine dressing forceps. Has a groove on either blade to catch the
laminaria tent.
Laminaria tent: It is dehydrated, compressed, Chinese sea-weeds. It is
sterilized by keeping it in absolute alcohol at least for 24 hours. Usually
more than one tents are to be introduced to prevent dumbling of the ends.
USE: It produces slow dilatation of the cervical canal, as it swells up due
to hygroscopic action
Isabgul tents (Isogel): It is dried granules prepared from the husks of
“certain mucilaginous tropical seeds”.
CERVICAL DILATORS

A: Hawkin ambler
B: Das
Uses
• Incomplete abortion
• In suction evacuation
• In MTP by D + E
 MULTIPLE TOOTHED VULSELLUM

It is used to hold the anterior lip of the cervix in D + E

operation, suction evacuation
Disadvantage
It produces trauma to the soft and vascular cervix, Allis tissue
forceps is used instead.
 GIANT VULSELLUM

It is used in destructive operation specially in

evisceration to have a good grip of the fetal
parts for giving traction
 OVUM FORCEPS

It has got no catch and the blades are slightly bent and
fenestrated, hence minimizes uterine injury. It prevents
crushing of the conceptus.
Indication: incomplete abortion
Qn: How to differentiate it from a sponge holding forceps.?
 OVUM FORCEPS

• The tip of this instrument is rounded cup like to avoid

perforation and to hold large tissue.
• This instrument has no catch . This is to avoid
perforation of wall.
SPONGE HOLDING
FORCEPS
• Toileting the vulva, vag. and perineum
prior to and following delivery.
• Antiseptic painting of the abdo. wall
prior to C/S.
• To hold the membranes if it threatens
to tear during delivery of the placenta.
• To catch hold the cervix (2 pairs are
needed) for inspection in suspected
cervical tear.
• To catch hold the cervix during
encirclage operation.
DOYEN’S RETRACTOR
USES: To retract the abdo.
wall and bladder for proper
exposure of LUS during LSCS.
It ‘s introduced after opening the
abdomen; and temporarily taken
off while the baby is delivered, and
reintroduced after delivery of the
baby and finally to be removed
after toileting the peritoneal
cavity.
DOYEN’S RETRACTOR
Deaver's Retractor

For retraction of deep structures

 Allis' Forceps

• used for grasping tough structures like Rectus

sheath or fascia in operations like
tubectomy,LSCS, abdominal hysterectomy.
ALLIS TS FORCEPS
other Uses
• To hold the ant. lip of the CX in D + E
operation.
• To hold the apex of the episiotomy
wound during repair.
• To catch hold the margins of the
peritoneum, rectus sheath, vaginal
mucosa during repair.
• To catch hold the torn ends of the
sphincter ani externus prior to suture in
repair of complete perineal tear.
• To catch hold the margins
and angles of the uterine flaps in LSCS
after the delivery of the baby as an
alternative to Green-Armytage
hemostatic clamp.
GREEN–ARMYTAGE
HEMOSTATIC FORCEP

• Used in lower segment

cesarean section. Total of 4
forceps are required 1 for each
angle and one for each flap.
• Functions: uterine haemostat
and to catch hold of the
margins so that they are not
missed during suture.
• It cannot be used in classical
cesarean section. Alternative to
this Allis tissue forceps may be
used
TOOTHED VS NON
TOOTHED
DISSECTING FORCEP
 LONG STRAIGHT/STITCH SCISSORS

USES: To cut the (i) umbilical cord (ii) to make episiotomy

(iii) to cut suture materials as in cesarean section.
 DISSECTING SCISSORS

Metzenbaum straight and curved SCISSORS

 NEEDLE HOLDER

• For grasping needle at the time of suturing.

• The inner surface of tip has serrations and a small grove for firm
grasp of the curved needle.
• The box joint is placed very close to tip to give adequate
pressure because of the lever effect.
 HEMOSTAT
USES:
• clamping bleeding vessels.
• grasping tissue at the time of
operation.
(Opening and closing peritoneum).
• It is also used to hold stay sutures.
• To clamp the pedicle while removing the
uterus as in rupture uterus
• The umbilical cord may be clamped as
an alternative to Kocher’s.
NB: It comes in two shapes straight and
curved.
Usually straight is used for rough work like
stay and curved is used as hemostat.
HEMOSTATIC FORCEPS
 Ayre's Spatula
• Taking Pap Smear for screening of
carcinoma cervix.
• Made of wood so that cells can adhere
to its porous surface.
• The long end is inserted into cervical
canal and rotated in 360 degrees.
• The exfoliated cells obtained are
smeared on glass slide
• The other broad end is used for
obtaining cells from lateral vagina for
knowing the hormonal status.
KOCHER’S
HEMOSTATIC
FORCEPS
USES:
• To clamp the umbilical
cord—for better grip and
effective crushing effect
to occlude the vessels.
• In low rupture of the
membranes as surgical
induction of labor or
augmentation of labor
 Babcock's Forceps

• Used for grasping tubular structures like fallopian tube

in tubectomy in modified Pomeroy's operation, ureter
,appendix etc.
• The tip is atraumatic as there are no sharp tooth.
EPISIOTOMY
SCISSORS
It is bent on edge. The
blade with blunt tip goes
inside the vagina.
Read on
• Indications of episiotomy
• Should episiotomy be
made in all cases? (P.568)
• Types (p. 569)
• Structures cut (p. 570)
• Complications of
episiotomy (p.571)
(ref. Duttas)
Cord scissor and clamp

The cord clamp is to be

kept in place until it
falls off together with
the
detached stump of
umbilical cord.
FOLEY’S CATHETER
• It is used for CBD in cases of
(Eclampsia , retroverted gravid
uterus, To give rest to the
bladder following any
destructive operation and/or in
a case with suspected bladder
injury and prevention of VVF
• In the mgt. of atonic PPH.
• To control atonic PPH.
• Mechanical induction
 VENTOUSE VACCUM EXTRACTOR

• Indications of its use (p. 580) Advantages over forceps (p.

581)
• Conditions to be fulfilled for its application (p. 575) Methods
of its use (p. 581) Hazards of ventouse delivery p. 582)
• Advantages of a silastic cup over the metallic one (p. 580).
• What is flexion point ? p. 582.
METAL CUP VS. SIALASTIC CUP
KIELLAND’S FORCEPS:
It is usually used as rotation
forceps in deep transverse arrest
of OPP of the head or in unrotated
vertex or face presentation.

Self assessment:
• Identification of blades (p. 578
• Special advantages over the long
curved forceps (p. 578
• Methods of application (p. 579)
• Hazards of its use (p. 579).
 BULD SYRINGE
• Suction of mucus from babies mouth and
nostrils
 AMBUBAG

For ventilation during neonatal resuscitation

 EMMERGENCY OBS DRUGS
• Oxytocin
• Magnesium sulphate
• Misoprostol
• Ergomtrine
• Tranexemic acid
• Hydralazine
• Labetalol
• OTHERS: Dexa, nifedipine,
methyldopa, Vit K, Vit A, Niverapine
 LABETALOL
• MOA: Combined alpha and beta adrenergic
blocking agent
• DOSE:
– orally 100mg BD to 2400mg daily
– IV (acute) 10-20mg IV every 30 mins. until
desired effect, Max. 80mg
• S/E: tremors, headache, asthma, CCF
• Contra: hepatic, asthma, CCF
 HYDRALAZINE
• MOA: acts by peripheral vasodilation as it relaxes the arterial
smooth muscle
• DOSE:
– orally 100mg daily in 4 divided doses
– For SB >160 or DBP >110mmHg give
– IV 5mg every 20-30mins max. 30mg or hydralazine 40-60mg in
500ml RL slow drip 8 hrly, stop when SBP >90 and DBP
<110mmHg
• S/E: maternal hypotension, tachycardia, arrhythmia, palpitations,
fluid retention, neonatal thrombocytopenia.
• Contra: bse of variable sodium retention, diuretics maybe used and
bse of arrhythmias, propranolol maybe be admin, iv
NIFEDIPINE
• MOA: calcium channel blocker
• DOSE: orally 10-20mg BD

METHLYDOPA :
• MOA: is a central acting alpha agonist
• DOSE: 250mg – 500mg BD/TDS
 Magnesium sulphate
MOA:
– depresses CNS, blocks peripheral neuromuscular
transmission, produces anticonvulsant effects;
decreases amount of ACH release at end-plate by
motor nerve impulse
– Promotes movt. of calcium, potassium and sodium in
and out of cells and stabilizes excitable membranes
DOSE:
– Loading dose of 4g of 20% slowly IV and 10g of 50%
half into each buttock with 1ml of 2% lignocaine
– Maintenance dose of 5g 4 hourly for 6 doses for 24
hours with 1ml of 2% lignocaine
 MgSo4 cont...
• Indications: in S. PET, Eclampsia
– Prevention of fits
– Treatment of fits
– Tocolysis: dose?
– nueroprotection?
• How do you monitor its toxicity? Reflexes, RR,
Urine output
• Antidote: calcium gluconate: 1gm IV (10ml of
10% soln. slowly.
• Complications: ??
• Read more on S/E and contraindications
 OXYTOCIN
• Its a uterotonic • MOA
• USES: – activiates G-protein-
– prevent. of PPH: active mgt of coupled receptors that
3rd stage trigger increases in
– Mgt of PPH intracellular leves of ca.
– Induction of labor levels in uterine myofibrils,
wc results in unterine
– Augmentation of labor
contractions, increase local
• DOSE: in mgt of PPH ? PGs prodn, wc further
10IM/20IV stimulates uterine
• READ ON: contraindications contractions.
• S/E: water toxicity . Bse it has
ADH like effects
 MISOPROSTROL
• Uterotonic
• uses
– CX ripening: 25mcg PO/ post. Vag. Fornix in term
– Induction of labor (not for augmentation)
– Control of PPH: 800mcg
• Routes of admin: oral, vag. sublingual or
rectal
• Contra?
• NB:
Contraceptives
 IUD
Use: contraceptive
Duration: 10-12 years
Precautions observed when using it:
avoid STIs, check strings every menses
Requirements that shd be contained in a
set for its insertion: speculum, sponge,
uterine sound, scissors, swabs, receiver
Instruments for removal: spec, long A.
Forceps, sponge holding forceps
Which instrument is required for its
removal if it disappears into
endometrium: alligator forceps
MOA:
• biochemical and histological changes in
the endometrium
• impaired tubal motility
• impaired sperm ascent
• toxic to sperm

Contraindications
• Preg.
• CX cancer
• Active PID
• Puerperal sepsis

• Read on the preliminaries before its

insertion and the actual steps of insertion:
(p. 540 Dutta)
 Jadelle
Type: hormonal implant
Contains: levonorgestrel
(progestin) 150mg
Route of admin: subdermal
implant
Duration: 5 years

MOA:????
 IMPLANON
Steps of insertion
– Site: medial aspect of the non dominant hand
– Swab the area with antiseptic
– Provide/infiltrate L.A under the skin
– Open pack and remove inserter needle that contains the
implanon
– Gently insert under the skin (subdermal), rotate anticlock wise,
and push the implanon into subdermal space. Them remove the
inserter and palpate for implanon
• MOA
– Inhibit ovulation
– Reduce tubal motility
– Makes endometrium thin
– Thickens the CX mucus
• Contains: etonorgestrel 68mg
• Duration: 3 years
 Combined oral contraceptives
COCS
• Contains: progesterone
(levonorgestrel, dexogestrel
75mcg)
and estrogen (ethyl estrdiol
30mcg)
• Has 21 hormal tablets and
7 non hormal tabs, iron
• Reason for addition of non
hormoal tabs?: to allow
menstrual flow in the last 7
days of the cycle
• Triphasic COCPS..? read
• MOA..? read
Oral contraceptive Pills - 0CPS
Progesterone only pills- POPs/Mini pills
DOSE: one tablet daily continuously at the
same time irrespective of menstruation
MOA: acts by the contraceptive effect of
progesterone..read
Has a higher incidence of menstrual
irregularities and ectopic pregnancy
Does not affect lactation, there4 suitable
for lactating women
Mention other progesterone only
contraceptives...depo, sub dermal
implants, mirena, emergency pills etc
Read more on advantages and
complications of OCPS...
Cycle beads
 Read on
• DMPA (injectable contraceptive)
• Emergency contraceptives – postinor-2
SUTURES
 CHROMIC CATGUT
• Is an absorbable suture
manufactured from gut of large
animals.
• is brown in color and is treated
with chemicals to delay the
absorption up to 7 days.
• USES: most commonly for
suturing of episiotomy, perineal
tears, tubal ligation with
modified Pomeroy's Method, for
closing peritoneum in LSCS and
hysterectomy.
 VICRYL
• synthetic delayed absorbable
suture colored violet.
• absorbed after 90 days.
• It causes less tissue reaction than
catgut and maintains strength for
longer time than catgut.
• It is used for suturing uterus in
LSCS and tying pedicals in
Hysterectomy.
 Other Important Topics
• Malaria in pregnacy
• PROM/UTI
• HTN/PET
• APH (placent abruption vs placenta previa),PPH
• Breech/ shoulder dystocia
• PID
• HIV/PMCT
• Abortion
• IUFD
• Induction of labor
• C/S> prep, indications, post/op care.
• Partograph
• Labor.
• safemotherhood pillars/cause of maternal mortality in uganda.
TRANEXAMIC ACID
WARFARIN
HEPARIN
 DETOVERINE(NO-SPA)

• Class: Antispasmodic
• It is a muscle relaxant.
• It is a selective inhibitor of phosphodiesterase4(PDE4);
which is an enzyme responsible for degradation of cyclic
adenosine monophosphate(cAMP), inhibition of PDE4
leads to elevated levels of cAMP leading to smooth muscle
relaxation.
History Taking and Examination
of Obstetric/Gyn Pts

Dr. MUSINGZI RONARD

OBGY
 History
• Most common reason why women seek medical consultation
• Pain
• PV bleeding
• Female pt is knowledgeable and will ask Qns, assess them properly
• Obst/Gyn complaints are very sensitive and personal to women, handle
them with care
• Create relationship
• May need presence of another person
• May object presence of students/some specific people
 General cnsideration
• Always have another person in the examination room with you as a
chaperone (especially if you are the opposite gender).

• Introduce your self to the patient.

• Address the patient using her last name unless she states otherwise.

• Wash or sanitize your hands.

• Ask before you touch, encourage her to ask questions and help her feel
as comfortable as possible during examination.

• Cover what is not being examined.

 Patient identification
• Date of admission
• Name • Distance from home to the facility
• Age • Referral status
• Sex • Date of taking history
• Tribe • LNMP
• Religion • EDD for obstetric cases
• Address • WOA
• Next of Kin Determine the significance of
• Education level. each
• Nearest heath Unit.KM & cost
• Marital status.
• Occupation
 Patient Identiication
• Time
• Time and date of admission on the ward
• Timing of Rx
• Referred pts need special attention
• Complications arising from the ward are a sign of bad obstetric care

• Name
• Both names
• Age
• Extremes of age are associated with complications
• Different problems
• Teenage pregnancy: care of the newborn, unemployment
• Elderly: associated with congenital abnormalities, fibroids
• Tribe
• Some conditions are common more common in some tribes
• Cultural practices: carry placenta home, early sex after delivery,
Kiiza

• Religion: polygamy Vs STIs, FP, Blood transfusion

• Address

• Level of health facility in locality, transport, access, problem areas

• Next of Kin
• Not the attendant
• Care giver
• The one to go to in case of a problem
• Gravidity: currently pregnant

• Parity: pregnancy carried beyond viability 22 – 28wks

• 1st +: abortion, Bwt < 500g

• 2nd + Ectopic pregnancy

• Nulliparity: 1st pregnancy, Prime gravida, Grand multiparity: >5

pregnancy
• LNMP:1st day of the last Menses
• EDD: Use Niegeler’s formula
• Add 7 to date, add 9(-3) to month
• Assumptions
• No conception in 1st 7days after menses
• All women have 28 day cycle
• Pregnancy lasts 9 calendar months
• 280 days = 40 WOA
• 266 days = 38 WOA
• Term: 37 – 40 WOA
• Pre mature <37 WOA
• Post datism > 40 WOA
• Postterm >=42 WOA
Main reason of consultation

• Not necessarily pain/bleeding

• May be
• Worry
• Concern
• Omission
• Duration – how long
• Periodicity
Presenting complaint
• This is a statement as to what the patient perceives to be the problem.

• As the consultation progresses and the relationship between doctor and

patient develops, it may become apparent that the real presenting
problem is something separate.

• Even so, it is important to start with the patient’s chief concern as a

way of building trust and rapport with someone who is likely to be
anxious.
 History of presenting complaint:
• Chronological progression of the illness and all treatment sought up to date.

• Associated factors

• Relieving/aggravating factors

• Any Rx given for this problem

• Investigations carried out for this problem

• Any interventions done before related to the PC

• Review other systems and relate them to the PC

 HPC(SOCRATE)
1. Site: ask where the symptom is, local/diffuse ??
2. Onset: clarify when the symptom first started and if it the onset was sudden(rapid) or gradual, pattern,
worse/better since onse.
3. Character: ask the patient to describe how the symptom feels, Nature – colicky, piercing sharp/dull/stabbing,
burning/cramp/crushing
4. Radiation: ask if the symptom moves anywhere else [to thigh/loin/elsewhere]
5. Associated symptoms: ask if there are any other associated symptoms
6. Time course: ask how the symptom has changed over time. When did the pain start?”; if pain is chronic
“What made you seek attention now?” “Is the pain worse at any particular time of the cycle?”
7. Exacerbating or relieving factors: ask if anything makes the symptom worse or better? What do you do to
make yourself comfortable?” “Is the pain better after menstruation?”
8. Severity: ask how severe the symptom is on a scale of 0-10 the pain?” "Does it interrupt your life?"
Screen for other key obstetric symptoms (e.g. nausea, vomiting, reduced fetal movements, vaginal bleeding,
abdominal pain, vaginal discharge or fluid loss, headaches, visual disturbance, epigastric pain, oedema,
pruritis, unilateral leg swelling, chest pain, shortness of breath, fatigue, fever, weight loss). Explore the
patient's ideas, concerns and expectations
 vaginal
• Discharge [colour, consistency, amount, smell]; weight changes; fever,
bowel problems [constipation, diarrhoea, etc]; urinary problems [dysuria,
frequency, hesitancy, nocturia, colour change, incontinence, feeling of
incomplete emptying

• In case of pv bleeding: Onset, the frequency, amount, and duration of the

flow, associated with pain or painless.

Complications e.g CVS symptoms and signs

 Review of Systems (ROS):
Skin: Rashes, skin discolorations.

Head: Headaches, dizziness, masses, seizures.

Eyes: Visual changes, eye pain.

Ears: Tinnitus, vertigo, hearing loss.

Nose: Nose bleeds, discharge, sinus diseases.

Mouth and Throat: Dental disease, hoarseness, throat pain.

Respiratory: Cough, shortness of breath, sputum (color).

Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dyspnea; dyspnea on

exertion, claudication, edema, valvular disease.
 ROS contin
• Gastrointestinal: Dysphagia, abdominal pain, nausea, vomiting,
hematemesis, diarrhea, constipation, melena (black tarry stools), hematochezia
(bright red blood per rectum).

• Genitourinary: Dysuria, frequency, hesitancy, hematuria, discharge.

• Endocrine: Polyuria, polydipsia, skin or hair changes, heat intolerance.

• Musculoskeletal: Joint pain or swelling, arthritis, myalgias.

• Skin and Lymphatics: Easy bruising,

History of present pregnancy:-
• -LNMP,

• -EDD,

• -WOA,

• -1st trimester events,

• -later pregnancy events,

• -Booking- when and where,

• -Number of antenatal visits.

 Hx of Present pregnancy

• Must review for pregnant mothers

• Note salient features/events
– Xssive wt gain cf. other pregnancies
– Signs of early pregnancy
– Cervical circlage
– Febrile episodes
– Quickening: feeling of 1st fetal movements
– Lightening: reduction of FH at term
– ANC: How many times, PMTCT risk identification, recommendations
– Booking BP
 Past Obstetric Hx

Details of all previous pregnancies carried beyond 28weeks e.g.

Para 1+2; Mention the abortion but detail only the one pregnancy
carried beyond 28/40. The details of abortion /Ectopic will be in
gynaecological history.
• Mode of delivery, place of delivery, any special events eg
PPH, Vacuum/Forceps delivery, C/S, cervical tear
• Outcome of the pregnancy: abortion, LB, SB, Bwt,
immunisation, current baby’s condition
• Poor obstetrics Hx: >3 abortions, perinatal deaths (death of
baby within 28 days of birth)
• Baby with obstetric palsy
 Past obstetric history
Year Place GA at ANC Onset MOD BWT Sex Intrap Postp
of of deiver prob of artum artum
deliver deliver y labour compll compi
y y ication cation
s
Current status of the children

Year of delivery

Events in early pregnancy

Events in later pregnancy

Labour- place, duration, who assisted

Outcome-sex, birth weight (if known), whether it cried immediately after birth.

Pueperium

Development of the baby

Immunization

NB: For grand multipara- summarise the normal uneventful pregnancies and only elaborate on those which had complications or adverse outcomes.
• Year of delivery
• 2. Gestational age at delivery
• 3. Antenatal problems
• 4. Onset of labour (spontaneous or induced)
• 5. Mode of delivery
• 6. Complications occurred at delivery
• 7. Complications during postpartum period
• 8. Details about the baby:
• Baby’s gender
• Weight at delivery
• Viability of baby (livebirth or stillbirth)
• Baby abnormality
• Breastfeeding
 Gynae History
• Need privacy, pt should be interviewed alone.
• Any gyn procedures/operations
• Hx suggestive of STD/STI
• Abortions whether spontaneous or induced and events
surrounding them
–Ectopic gestation –events
–Treatment for infertility
–other gynaecological conditions.
• AVD, describe
• genital sores
• Genital itching
• Elicit predisposing factors for particular tumours, or rule them
out to narrow down your iist of differencials
 Menstrual Hx

• Age of menarche, duration, amt, recent changes

• Cycle
• Menstrual Disorder
– Dysmenorrhea
– Menorrhagia
– Oligomenorrhea
– Hypermenorrhea
– Cryptomenorrhea
– Polymenorrhea
• Menopause, perimenopausal symptoms
 Contraception Hx

• Knowledge
– Methods and how they are used
• Use of
• Discontinuation: reason, when
 Past Medical Hx
Previous admissions for medical illnesses

• Chronic illnesses
– DM
– HTN
– HIV
– TB
– Asthma
– Renal D’se
• D’ses likely to affect the pregnancy
– HTN
• D’ses likely to be worsened by the pregnancy
– Heart d’se
– Renal d’se
– asthma
 Surgical Hx

• Any operations, indications, when

• Pelvic fractures
• Disability, polio, trauma
• Blood transfusion
 Family history-Genetics

• Order with siblings

• Parents
• familial illnesses/conditions.
• twins
 Social Hx

• Alcohol
• Smoking
• Drug abuse
• Married/single/student
• Destitute
 Summary

• Clear, precise, brief statement containing salient features of the

patients’ Hx/ complaints
– Name, age, (sex), Gravidity (if pregnant) and Parity, WOA, PC, duration,
important associations. Include important negatives/positives to narrow
down your differrentials
• Common important Positives/Negatives
– Rupture of membranes, PV bleeding for a mother in labour
– Urinary symptoms for a mother presenting with LAO and PV discharge
 General Examination
1. Self introduction and consent.
2. Position of the patient (sitting up).
3. General condition of the patient and temperature
4. Hand: Nails – Colour , Capillary filling, Clubbing, Splinter
haemorrhages
5. Examine: conjuctival pallor, Sclera for jaundice
6. Inspect the mouth: colour of the tongue and gum, comment on
hard palate, condition of the teeth, lesions in the mouth, cyanosis
7. Palpate for lymph nodes: Cervical, auricular, submental, Axillary
8. Examine the thyroid
9. Pedal oedema
Examine the Hands:
Look for:
• Palllor, palmar erythema, koilonychias, clubbing,
periphreral cyanosis. capillary refill
• Pulse rate: rhythm, volume
• Blood pressure: right arm
• Temperature
EYE: Conjunctiva pallor, scleral jaundice,
exophthalmos.
Mouth: pale mucous membrane(sign of Anaemia),
presence of angular stomatitis which indicates IDA,while
Glossitis indicates folate deficiency. Central cyanosis may be
present in patient with heart diseases.
• Neck: lymph nodes
• Thyroid: the thyroid may sometimes be enlarged, reflecting increase metabolism in
pregnancy.
• Legs: peripheral Oedema: pitting, non pitting
• Chest: Equal expansion, tactile fremitus, percussion,
auscultation, rhonchi, crackles, rubs, breath sounds,
egophony, whispered pectoriloquy.

• Heart: Point of maximal impulse (PMI), thrills

(palpable turbulence); regular rate and rhythm (RRR),
first and second heart sounds (S1, S2); gallops (S3, S4),
murmurs (grade 1-6), pulses (graded 0-2+).

• Breast: Dimpling, tenderness, masses, nipple discharge;

axillary masses.
• Abdomen: Contour (flat, scaphoid, obese, distended); scars, bowel
sounds, bruits, tenderness, masses, liver span by percussion;
hepatomegaly, splenomegaly; guarding, rebound, percussion note
(tympanic), costovertebral angle tenderness (CVAT), suprapubic
tenderness.

• Genitourinary: Inguinal masses, hernias, scrotum, testicles,

varicoceles.

• Extremities: Joint swelling, range of motion, edema (grade 1-4+);

cyanosis, clubbing, edema (CCE); pulses (radial, ulnar, femoral,
popliteal,posterior tibial, dorsalis pedis; simultaneous palpation of
radial and femoral pulses).
 Systemic examination

• CVS
– As physicians have told you
– PR, BP, HS, JVP
• RS
– RR, chest movts/expansion
– Auscultate for breath sounds
 Abdominal exam
1.Self introduction
2.Proper exposure
3.Stand at foot of bed (Inspect for distension, symmetry and
movement)
4.Stand on Right side of Patient’s bed and proper position
5.Continue inspection from Right side of bed
6.Superficial palpation for tenderness
7.Deep palpation starting from the left kidney, spleen, liver to right
kidney
8.Percussion
9.Auscultation
• Conclusion (likely diagnosis)
 Abdominal exam

• Empty bladder before exam

• Expose abd well: coastal margin to pubis
• Pt lies comfortably on a couch, arms by the side of the
trunk
• Ensure privacy
 Inspection
• Foot of the bed
– Obvious things
– Wasting/scaphoid
– Distention
– Movt with respiration
– Visible swelling/mass
• Then come closer and demonstrate knowledge
of each parameter you mention by touching it
 Abdominal examination:
General instruction:
• You should be on the right side of the patient to facilitate the movement of the
right arm.
• Examination done by the palm of the hand rather than the tips of the fingers with
warm hands(except in some maneuvers).
• Engage the patient in conversation to decrease the rigidity of the abdominal wall.
• Examine the inguinal canal and inguinal lymph nodes.
• Positioon and exposure:
• The patient lies flat with slightly raised head on a pillow.
• Her knees drown up to decrease rigidity of the abdominal wall.
• The abdomen is divided into 9 quadrants by two vertical lines(mid clavicular
plain which extends from mid clavicular to the mid inguinal ) and two horizontal
lines the upper horizontal line (transpyloric plain at the level of the first lumber
vertebra bisects the distance between the umbilicus and xiphisternum) the lower
horizontal line (inter-crestal plane extend between the highest points on the iliac
crest ).
 Abdominal examination (Cont.):
• Ask about areas of tenderness before start the examination.
INSPECTION:
1. Abdominal contour: asymmetry?
2. Respiratory movements.
3. Look for fetal movement
4. Abdominal skin:
 scars of previous operation (CS,hysterotomy)
 pigmentation
 cutaneous signs of pregnancy linea nigra,
striae:] rubra (redish ), albicans(white)[, gravidarum.
5. Umbilicus:
 Site, shape (inverted ,flat ,everted),discharge , discoloration,
• swelling , nodule.
 striae

Linea Nigra
Abdominal examination (Cont.):
6. Hair distribu6on:
 Feminine (trisngular with horizonal upper border)
 Masculine distribution (extension of the pubic hair towrds the
umbilicus).
7. hernial orifices:
 cough impulse : ask patient to cough and look at the hernia
orifices(umblical,paraumbilical,inguinal,incisonal).
8. divarication of the recti.
Causes of abdominal enlargement (7F&ovarian tumor):
(fetus, false pregnancy, flatus, fat, full bladder, fluid, fibroid,
ovarian tumor)
• Touch and show the examiner the following
– Operation scars
– Stria gravidarum/albicantes
– Linea nigra, therapeutic marks, birth marks, tattoos
 Palpation

• Talk to the Pt all the time

• 1st superficially to localise any tenderness, guarding
• Deep palpation
– Masses
– Organs: enlarged; liver, spleen, uterus, adnexa
• If uterus is enlarged: pregnancy or tumour

If a mass is palpable, assess size [measure diameter in centimetre or gestational

age equivalence], form [regular/irregular], consistency [hard, soft, cystic],
mobility, tenderness, relationship to abdominal wall [superficial, intraabdominal],
etc.
• If mass is present determine Next the ovaries need to be examine. To
its: do this, locate the hipbone and move
• size approximately 3cm medially. The
• whether it is centrally or external hand is then swept towards the
laterally located hair-line in a diagonal line. Evaluate the
• nature ovary for its:
size
• shape
consistency
• consistency shape
• tenderness mobility
• mobility
 Obstetric Exam
1. Self introduction and consent
2. Proper exposure
3. Stand on the Right side of the bed
4. Measure the fundal length using a tape measure.
5. Pelvic palpation for presentation
6. Fundal palpation for lie
7. Lateral palpation for the side of the fetal back.
8. Auscultate for the fetal heart for 1 minute
9. Feel Radial pulse with left hand
10.Watch with second hand in the right hand
11.Get the rhythm
• The breech gives the sensation of a large, nodular mass,
whereas the head feels hard and round and is more
mobile.
 LEOPOLD MANEUVERS:
1. The first maneuver (fundal grip): involves palpating the fundus to determine
which part of the fetus occupies the fundus.
Maneuver:
• by grasping the fundus of the uterus by the palms of the 2 hands with your
fingers quite close together.
2. The second maneuver(Lateral grip): involves palpaAng the either side of the
abdomen to
• determine on which side the fetal back lies.
• First method :
• One hand used to support the uterus and the level of the umbilicus, other
hand is used to palpate the other side of the uterus from above downwards
in three lines (paramedian, midclavicular, midaxillary).
• Second method:
• Two hands are laid site by side at the level of the umbilicus and palpate the
structure underneath them ,one hand supports and the other palpate the
uterus and compare.
 LEOPOLD MANEUVERS:
3. The third maneuver (Pawlick’s grip): involves grasping the presenting part
between the thumb and third finger just above the pubic symphysis to determine
what fetal part is lying above the pelvic inlet or lower abdomen.
1. By siting beside the patient while she is supine with flexed hip and knee
2. Try to catch the lower uterine segment by the right hand which the palm resting
on the symphysis pubis
3. the thumb is parallel to the right inguinal ligament and the other four fingers is
parallel to the left inguinal ligament
• 4. Try to feel the presented part between the thumb and other 4 fingers
4. The fourth maneuver(Pelvic grip): involves palpaAng for the brow and the
occiput of the fetus
 determine the fetal position when the fetus is in a vertex presentation.
 now you turn your face towards the patient 's feet.
 The two hands are placed flat on both sides of the lower part of the abdomen
and push there downward towards the pelvis and feel the sides of the presenAng
part by your fingers
DESCENT OF THE FETAL HEAD:
• Assessed abdominally, Assess how much of the head is still felt per
abdomen
• When only 2/5 or less of the fetal head palpated above the level of
symphysis pubis, this implies the head is engaged.
→The vertex has passed or is at the level of ischial
DESCENT OF THE FETAL HEAD: