---

Gynecology & Obstetrics: History Taking and Complete Physical Examination

Source: Berek & Novak's Gynecology (16th ed.), Creasy & Resnik's Maternal-Fetal Medicine (8th ed.), Comprehensive Gynecology (7th ed.)

---

PART 1: HISTORY TAKING

Opening the Interview

• Introduce yourself and your role on the team
• Ensure privacy; ask any accompanying person to step outside
• Use open-ended questions first ("What brings you in today?")
• Do not interrupt; allow the patient to tell her story spontaneously
• Listen for both verbal and non-verbal cues

---

1. Sociodemographic Details

• Name, age, address
• Marital status
• Occupation / source of income
• Referred by whom

---

2. Chief Complaint (CC)

• Temporal onset - "When did this first start?"
• "Did you feel completely well before this symptom appeared?"

---

3. Menstrual History (CRITICAL in Gynae/Obs)

Key terms: Menorrhagia (heavy periods), Metrorrhagia (irregular bleeding), Menometrorrhagia (heavy + irregular), Oligomenorrhea (infrequent), Amenorrhea (absent for >3 months)

---

4. Obstetric History

• T = Term deliveries (≥37 weeks)
• P = Preterm deliveries (20-36 weeks)
• A = Abortions (spontaneous + induced)
• L = Living children

• Date, gestational age at delivery
• Mode of delivery (SVD, instrumental, LSCS - and indication for LSCS)
• Birth weight
• Any complications (pre-eclampsia, PPH, shoulder dystocia, NICU admission)
• Outcome of baby (alive and well, stillbirth, neonatal death)
• Duration of labour

---

5. Current Pregnancy History (if pregnant)

• Is this pregnancy planned or unplanned?
• LMP and EDD (by Naegele's rule: LMP + 9 months + 7 days)
• Age of gestation (AOG)
• Antenatal care received so far
• Any first-trimester bleeding, nausea/vomiting, fever
• Fetal movements - when first felt (quickening), current frequency
• Results of ultrasound scans
• Any complications: hypertension, gestational diabetes, placenta praevia
• Medications and supplements taken

---

6. Contraceptive History

• Current contraceptive method
• Duration of use
• Satisfaction with method
• Any side effects
• Desire for future fertility

---

7. Sexual History

• Age at first intercourse (coitarche)
• Number of partners (current and lifetime)
• Any dyspareunia (pain during intercourse - superficial vs. deep)
• Any postcoital bleeding
• Sexually transmitted infections (STIs) - past or present
• Partner's health

---

8. Past Gynecological History

• Previous gynecological operations (myomectomy, hysterectomy, ovarian cystectomy, LLETZ)
• History of STIs (chlamydia, gonorrhoea, PID, herpes, HPV)
• Previous cervical smears - last date and result
• History of ovarian cysts, fibroids, endometriosis, PCOS

---

9. Past Medical & Surgical History

• Hypertension, diabetes, cardiac disease, thyroid disorders, epilepsy, autoimmune conditions
• Previous surgeries and anaesthetic complications
• Blood transfusions
• Allergies (medications, latex, iodine)

---

10. Drug History

• Prescription medications (especially teratogens if pregnant)
• Over-the-counter medications
• Herbal/complementary medicines
• Folic acid supplementation (400 mcg/day ideally started pre-conception)
• Contraceptive pills

---

11. Family History

• Breast cancer, ovarian cancer, cervical cancer
• Endometrial cancer
• Thromboembolism (DVT/PE) - relevant for OCP use
• Diabetes, hypertension (relevant in pregnancy)
• Genetic conditions

---

12. Social History

• Smoking (pack-years; very important in pregnancy - IUGR, placental abruption)
• Alcohol (units per week)
• Illicit drugs (cocaine/heroin linked to IUGR, placental abruption)
• Occupation and stress levels
• Housing situation and social support
• Domestic violence screen - ask sensitively and privately

---

13. Review of Systems (Relevant in OB/Gyn)

---

PART 2: PHYSICAL EXAMINATION

Before You Begin

• Explain every step to the patient in advance
• Ensure a chaperone is always present
• Ensure privacy and dignity at all times
• Instruct patient to empty her bladder before examination
• Wash hands in front of the patient

---

General / Head-to-Toe Examination

General Appearance

• Build: height, weight, BMI (obesity relevant to PCOS, fertility, pregnancy outcomes)
• Pallor (anaemia from menorrhagia, ectopic pregnancy)
• Jaundice
• Cyanosis
• Oedema (pre-eclampsia, heart failure)
• Lymphadenopathy (inguinal nodes enlarged in vulval cancer, STIs)
• Hirsutism / acne / acanthosis nigricans (PCOS features)
• Thyroid enlargement on neck inspection

Vital Signs

• Blood pressure (pre-eclampsia: BP ≥140/90 mmHg)
• Pulse (tachycardia in haemorrhage, thyrotoxicosis)
• Temperature (infection/PID)
• Respiratory rate
• Oxygen saturation
• Weight and BMI

---

CNS Examination (in Obstetrics/Gynecology)

In Pre-eclampsia / Eclampsia:

• Level of consciousness - GCS score; confusion, agitation, drowsiness
• Headache - severe, frontal or occipital (raised intracranial pressure)
• Visual disturbances - scotomata, blurring, photophobia
• Reflexes - Brisk deep tendon reflexes (DTRs) especially the patellar/knee jerk; clonus (≥3 beats of ankle clonus = significant)
• Signs of cerebral irritation - hyperreflexia, seizure activity

• Flex the knee slightly
• Rapidly dorsiflex the foot and sustain the pressure
• Count the number of beats: ≥3 = significant, indicates imminent eclampsia risk

Cranial Nerves (when indicated):

• Visual fields - homonymous hemianopia in posterior cortex involvement
• Fundoscopy - papilloedema (raised ICP), hypertensive retinopathy
• CN VII (facial nerve) - relevant in Bell's palsy of pregnancy

In Hyperemesis Gravidarum:

• Wernicke's encephalopathy signs: ophthalmoplegia, ataxia, confusion (thiamine deficiency)
• Test eye movements (CN III, IV, VI), gait, cognition

Routine Neuro Screen (all obstetric patients):

• Test deep tendon reflexes - especially knee jerk and ankle jerk
• Note symmetry
• Assess for sensory deficits in the legs (relevant for epidural anaesthesia, disc prolapse in pregnancy)

---

Cardiovascular Examination

• Pulse: rate, rhythm, character
• Blood pressure: both arms if hypertension suspected
• JVP: elevated in cardiac failure
• Praecordium: apex beat (in advanced pregnancy it shifts superiorly and laterally due to dextrorotation)
• Auscultation: soft systolic murmurs are common in normal pregnancy (increased blood flow); diastolic murmurs are always abnormal
• Peripheral oedema: ankles, sacrum (non-pitting vs. pitting)

---

Respiratory Examination

• Inspection: respiratory rate, symmetry, use of accessory muscles
• Palpation: trachea (midline), expansion
• Percussion
• Auscultation: breath sounds, added sounds (wheeze in asthma - important in pregnancy)

---

Thyroid Examination

• Inspection: enlarged thyroid (goitre)
• Palpation: size, consistency, nodules, tenderness, tracheal deviation
• Assess for signs of hyper- or hypothyroidism: tremor, warm/cold hands, reflexes, eye signs
• Thyroid dysfunction affects menstrual regularity, fertility, and pregnancy

---

Breast Examination

Preparation:

• Patient sits facing you with arms at sides, then arms raised, then hands on hips (pectoral contraction)

Inspection (systematic, both breasts):

• Size and symmetry
• Skin changes: dimpling, peau d'orange (lymphoedema - malignancy), erythema
• Nipples: inversion, retraction, eczematous changes (Paget's disease), discharge

• Nipples and areola enlarge and darken
• Montgomery glands (tubercles around areola) become prominent from 6-8 weeks
• Colostrum may be expressed from 16 weeks onwards

Palpation (patient supine, ipsilateral arm raised above head):

• Use flat of fingers in a systematic pattern (spiral or quadrant method)
• All four quadrants + axillary tail (tail of Spence)
• Note any lumps: site, size, shape, consistency (soft/firm/hard), surface, edges, mobility, tenderness, transillumination
• Axillary lymph nodes: anterior, posterior, lateral, medial, central, infraclavicular, supraclavicular nodes
• Nipple discharge: express gently; note colour (clear/milky/blood-stained), unilateral vs. bilateral, uniductal vs. multiductal

---

Abdominal Examination

Preparation:

• Patient supine; in late pregnancy, tilt slightly left lateral to relieve aortocaval compression
• Ask patient to empty bladder before examination
• Expose abdomen adequately (from xiphisternum to symphysis pubis)

Inspection:

• Distension / contour
• Linea nigra - darkening of the midline from xiphoid to pubis (increased MSH in pregnancy)
• Striae gravidarum (stretch marks) - old = silver, recent = pink-purple
• Scars (previous LSCS - Pfannenstiel, midline laparotomy, laparoscopic port scars)
• Visible peristalsis
• Umbilicus (everted in large uterus/ascites)
• Hernias
• Fetal movements visible in late pregnancy

Auscultation (before palpation to avoid disturbing bowel sounds):

• Bowel sounds: normal, increased (obstruction), absent (ileus)
• Aortic and iliac bruits
• Fetal heart sounds: using a Pinard stethoscope or Doppler (audible from 12 weeks with Doppler, 20-24 weeks with Pinard)
  • Normal fetal heart rate: 110-160 bpm
  • Best heard over fetal back

Palpation - Gynecological:

• Superficial then deep palpation of all four quadrants
• Identify any mass: site, size, shape, surface (smooth/irregular), consistency, edges, mobility, tenderness
• Organomegaly: liver, spleen, kidneys
• Shifting dullness / fluid thrill: assess for ascites (ovarian cancer, liver disease)
• Pelvic mass: arises from the pelvis (cannot get below it), dull to percussion, moves with uterus on bimanual examination

Palpation - Obstetric (Fundal Height):

• Measure symphysis-fundal height (SFH) with tape measure
• Expected: fundal height in cm ≈ gestational age in weeks (from 20-36 weeks)
• Landmarks:
  • 12 weeks: uterus just palpable above symphysis pubis
  • 20 weeks: at umbilicus
  • 36 weeks: at xiphisternum
  • Term (38-40 weeks): slightly lower as head engages

---

Leopold's Maneuvers (4 Steps)

Fetal Lie: longitudinal (99%), transverse, oblique Fetal Presentation: vertex (cephalic), breech, shoulder, face, brow Station: -5 to +5 cm in relation to ischial spines

---

Pelvic Examination

A. External Genitalia

• Mons pubis - hair distribution (escutcheon pattern)
• Labia majora - skin colour, swelling, warts, ulcers, cysts
• Labia minora - asymmetry, fusion, lesions
• Clitoris - size (clitoromegaly in hyperandrogenism)
• Urethral orifice - caruncle, prolapse, discharge; milk undersurface of urethra for Skene's gland discharge (suspected urethritis)
• Vaginal introitus - hymen, scars, atrophy
• Perineal body - scars from previous perineal tears, episiotomy
• Bartholin's glands (at 4 and 8 o'clock at the posterior introitus) - palpate for cysts or abscesses
• Anus - fissures, fistulae, haemorrhoids, perianal skin tags

• Anterior wall bulge = Cystocele (bladder prolapse)
• Posterior wall bulge = Rectocele (rectal prolapse) or Enterocele
• Cervix/uterus descending = Uterine prolapse

---

B. Speculum Examination

• Graves speculum: most common (large, medium, small sizes)
• Pederson speculum: same length but narrower - for nulliparous, non-sexually active, or atrophic patients

1. Warm the speculum with water (do NOT lubricate if taking smears or cultures)
2. Insert blades obliquely (at 45°) into introitus, pressing gently on perineum
3. Advance posteriorly along vaginal wall, then rotate to horizontal position
4. Open blades to expose cervix
5. Systematically inspect all surfaces of the vagina and cervix

• Blood, abnormal discharge (note character: white/cottage cheese = Candida; grey/fishy = BV; frothy/green = Trichomonas)
• Mucosal colour (Chadwick's sign in pregnancy: blue-purple congestion from 6-8 weeks)
• Lesions, ulcers
• Atrophic changes (pale, dry, thin in postmenopausal women)

• Size, shape (nulliparous: round os; multiparous: slit-like/fish-mouth os)
• Ectropion (columnar epithelium visible on ectocervix - common in OCP users and pregnancy)
• Lesions, polyps, ulcers, warts
• Discharge from the os
• Nabothian follicles (retention cysts - benign)
• Cervical motion tenderness (assess later with bimanual exam)

• Use Aylesbury spatula (360° rotation at external os) + cytobrush (180° into endocervical canal)
• Smear onto slide and fix immediately, OR use liquid-based cytology (LBC) vial
• Do not take during menstruation

---

C. Bimanual (Vagino-Abdominal) Examination

1. Apply water-soluble lubricant to gloved index and middle fingers
2. Insert 2 fingers into vagina (index + middle) - press on perineum first
3. Place other hand flat on lower abdomen (infraumbilical area)
4. Press abdominal hand gently downward while sweeping pelvic organs toward vaginal fingers

• Position (anterior/posterior/central)
• Consistency (normal = firm like tip of nose; soft in pregnancy = Hegar's sign from 6-8 weeks)
• Tenderness on cervical excitation (cervical motion tenderness = CMT; positive in PID, ectopic pregnancy)
• Os (open or closed; closed in threatened miscarriage, open in inevitable miscarriage)

• Size (compare to gestational weeks)
• Shape (regular/irregular - fibroids cause irregular enlargement)
• Position: anteverted (normal), retroverted (10-15% of women), anteflexed, retroflexed
• Consistency
• Mobility (fixed = adhesions, endometriosis, malignancy)
• Tenderness

• Place vaginal fingers in lateral fornix, abdominal hand above iliac crest
• Bring hands together gently
• Normal: tube is NOT palpable; ovary (~4×2×3 cm) may or may not be palpable, slightly tender
• Abnormal: adnexal mass - note size, consistency (cystic/solid), tenderness, mobility

---

D. Rectovaginal Examination

• Index finger in vagina, middle finger in rectum
• Allows higher palpation of the pelvis
• Assess the rectovaginal septum (thickened/nodular = endometriosis)
• Palpate uterosacral ligaments (nodular/tender = endometriosis)
• Assess posterior uterine wall
• Check for mass in the pouch of Douglas (Douglas' pouch)

E. Rectal Examination (when indicated)

• Inspect perianal region: skin colour, fissures, fistulae, haemorrhoids, excoriations
• Ask patient to strain - any prolapse, internal haemorrhoids
• Palpate ischiorectal fossae, perianal region
• Digital rectal exam: sphincter tone, rectal wall, any masses (rectocele), stool character

---

Special Examinations in Obstetrics

Fundal Height Measurement

• Measure from upper border of symphysis pubis to top of fundal contour using tape measure
• Document in the obstetric notes
• SFH <10th centile = consider IUGR; >90th centile = macrosomia, polyhydramnios, multiple pregnancy

Fetal Heart Auscultation

• Using Pinard's stethoscope (from 24 weeks) or Doppler (from 12 weeks)
• Normal: 110-160 bpm
• Heard best over the fetal back
• In vertex presentation: heard in lower abdomen (left or right depending on position)
• In breech: heard at or above umbilicus

Auscultation of Fetal Heart in Context of Fetal Position:

Assessment of Engagement

• Fifths palpable above the brim (by abdominal palpation):
  • 5/5 above brim = completely unengaged
  • 3/5 above brim = not engaged
  • 2/5 above brim = engaged (head is at the level of the ischial spines)
  • 0/5 above brim = fully engaged

---

Vaginal Examination in Labour (VE)

• Score ≥8 = favourable cervix, good chance of successful induction
• Score ≤5 = unfavourable, may need cervical ripening agents

---

Urinalysis / Dipstick Testing (in every obstetric visit)

• Protein: trace normal; 1+ or more requires 24-hour collection or PCR ratio - pre-eclampsia
• Glucose: gestational diabetes, normal renal threshold reduced in pregnancy
• Leucocytes/nitrites: UTI (very common in pregnancy - Escherichia coli most common)
• Blood: haematuria - UTI, renal stones, malignancy

---

Summary: Complete OB/Gyn Examination at a Glance

HISTORY
  ├── Sociodemographic details
  ├── Chief complaint + SOCRATES analysis
  ├── Menstrual history (menarche, LMP, cycle, dysmenorrhea)
  ├── Obstetric history (GPAL + details of each pregnancy)
  ├── Contraceptive history
  ├── Sexual history
  ├── Past gynaecological history + cervical smears
  ├── Past medical/surgical history
  ├── Drug history
  ├── Family history
  └── Social history (smoking, alcohol, drugs, domestic violence)

EXAMINATION
  ├── General: appearance, BMI, pallor, oedema, lymph nodes
  ├── Vital signs: BP, HR, temp, RR, SpO2
  ├── CNS: reflexes (clonus in pre-eclampsia), GCS, vision, Wernicke's screen
  ├── CVS: pulse, BP, murmurs (physiological in pregnancy), oedema
  ├── Respiratory: breathing, added sounds
  ├── Thyroid: size, consistency, signs
  ├── Breasts: inspection (skin, nipples), palpation (quadrants), axillary nodes
  ├── Abdomen:
  │     ├── Inspection: linea nigra, striae, scars, distension
  │     ├── Auscultation: bowel sounds, fetal heart
  │     ├── Palpation: organomegaly, uterine size, SFH
  │     └── Leopold's maneuvers (lie, presentation, position, engagement)
  └── Pelvic:
        ├── External genitalia + Valsalva (prolapse)
        ├── Speculum: vagina, cervix, smear/swabs
        ├── Bimanual: cervix (CMT), uterus, adnexae
        ├── Rectovaginal: uterosacral ligaments, POD
        └── VE in labour: Bishop score, station, membranes

---

• Berek & Novak's Gynecology, 16th ed., Chapter 1: Initial Assessment, pp. 54-69
• Creasy & Resnik's Maternal-Fetal Medicine, 8th ed.
• Comprehensive Gynecology, 7th ed. (Mendiratta V, Lentz GM, Chapter 7)
• Unkels R et al., "Gynecological History Taking and Examination" - GLOWM