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Obstetrics & Gynaecology: History Taking and Examination

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PART 1 - THE APPROACH TO THE PATIENT

• Empathy and attentive listening - the patient must feel her concerns are heard
• Confidentiality - privileged information belongs to the patient
• Non-judgmental attitude - especially regarding sexual practices, gender identity, and reproductive choices
• Whole-patient view - medical, psychological, social, cultural, and family dimensions all matter

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PART 2 - HISTORY TAKING

2.1 Chief Complaint and History of Present Illness

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2.2 Menstrual History (PALM-COEIN Framework)

• Age at menarche (normal: 10-16 years)
• Cycle regularity - is it regular (every 21-35 days)?
• Duration of bleeding - normally 2-7 days
• Amount of flow - number of pads/tampons per day, clots, flooding
• Dysmenorrhoea - primary (no cause) or secondary (endometriosis, fibroids)
• Intermenstrual bleeding (IMB) - bleeding between periods
• Post-coital bleeding (PCB) - suggests cervical pathology
• Post-menopausal bleeding (PMB) - always requires investigation (endometrial cancer until proven otherwise)
• LMP (Last Menstrual Period) - exact date, character (was it normal?)
• Premenstrual symptoms - breast tenderness, mood changes, bloating

"The menstrual history should include age at menarche, frequency and duration of periods, dysmenorrhoea or associated symptoms, last menstrual period, longest gap between menses, and any birth control." - Swanson's Family Medicine Review

• Amenorrhoea: absence of periods (primary >16 yrs, secondary >3 cycles)
• Oligomenorrhoea: cycles >35 days apart
• Menorrhagia: heavy periods (>80 mL or >7 days)
• Metrorrhagia: irregular, frequent bleeding
• Menometrorrhagia: both heavy and irregular

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2.3 Obstetric History - GTPAL System

"Gravidity = number of times the woman has become pregnant (includes preterm births, ectopic pregnancies, molar pregnancies, and abortions). Parity = number of pregnancies reaching viable gestational age (>20 weeks), INCLUDING stillbirths." - Williams Obstetrics, 24th Ed.

• Year of pregnancy and outcome
• Gestational age at delivery
• Mode of delivery (SVD, instrumental, LSCS - and reason)
• Birth weight of baby
• Any complications (PPH, pre-eclampsia, GDM, prolonged labour)
• Neonatal outcome

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2.4 Sexual History (5 P's)

1. Partners - How many partners in the last 3 months/12 months? Male, female, both?
2. Practices - Type of sexual activity (vaginal, oral, anal)?
3. Protection - Do you use condoms? Consistently?
4. Past STIs - Any previous infections? Treated?
5. Pregnancy plans - Are you currently trying to conceive or avoid pregnancy?

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2.5 Contraceptive History

• Current contraceptive method and duration of use
• Past methods used and why stopped
• Any complications (e.g., VTE on OCP, PID with IUD)
• Future contraceptive plans

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2.6 Smear/Screening History

• Last cervical smear - date and result
• Any previous abnormal smear (CIN grade, treatment - LLETZ, cryotherapy)
• HPV status if known
• Up-to-date with screening program?

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2.7 Past Medical and Surgical History

• Previous pelvic or abdominal surgery (affects adhesions, future fertility)
• Thyroid disease, diabetes, hypertension, epilepsy (all affect pregnancy)
• Autoimmune conditions (SLE, APS - recurrent miscarriage)
• Bleeding disorders (affects menorrhagia management)

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2.8 Drug History and Allergies

• Current medications (including OTC and herbal)
• Folic acid use (pre-conception/first trimester)
• Teratogenic drugs (warfarin, valproate, ACE inhibitors, retinoids)
• Drug allergies with reaction type

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2.9 Family History

• Breast cancer (BRCA1/2 risk)
• Ovarian cancer
• Endometrial cancer
• Cervical cancer
• Pre-eclampsia, gestational diabetes, thrombophilia
• Congenital anomalies

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2.10 Social History

• Smoking (pack years - affects fertility, pregnancy, cervical cancer)
• Alcohol use (units per week)
• Recreational drugs
• Occupation
• Relationship status, domestic violence screening ("Do you feel safe at home?")
• Ethnicity (certain conditions more prevalent, e.g., fibroids in Afro-Caribbean women)

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PART 3 - PHYSICAL EXAMINATION

3.1 General Examination

• General appearance: well/unwell, pallor (anaemia from menorrhagia), jaundice
• Vital signs: BP, pulse, temperature, respiratory rate, weight/BMI
• Thyroid: goitre, signs of thyroid dysfunction
• Breasts: detailed examination (see below)
• Cardiovascular and respiratory: baseline assessment
• Lymph nodes: inguinal nodes (vulval malignancy, STIs), supraclavicular nodes (metastatic disease)
• Abdomen: before pelvic exam

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3.2 Abdominal Examination

• Distension (ascites, mass, pregnancy)
• Visible scars (previous laparotomy, Pfannenstiel, laparoscopy ports)
• Striae gravidarum (pregnancy history)
• Linea nigra (pregnancy)
• Visible masses

• Start away from the area of tenderness
• Liver, spleen size
• All four quadrants systematically
• Any mass: site, size, shape, surface, consistency, tenderness, mobility, whether you can get below it
• Rebound tenderness (peritonism - PID, ruptured ectopic)

• Shifting dullness and fluid thrill (ascites - ovarian cancer)
• Organomegaly

• Bowel sounds
• Fetal heart sounds (in pregnancy, from ~12 weeks with Doppler, ~24 weeks with Pinard)

"Evidence of fullness or mass effect should be noted. This is particularly important in evaluating patients who may have a pelvic mass and in determining the extent of omental involvement, for example, with metastatic ovarian cancer." - Berek & Novak's Gynecology

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3.3 Obstetric-Specific Abdominal Examination

• Measured in cm from the symphysis pubis to the top of the uterine fundus
• From 20 weeks, fundal height in cm approximates gestational age in weeks
• SFH <10th centile = growth restriction; >90th centile = macrosomia, polyhydramnios, multiple pregnancy

• Normal FHR: 110-160 bpm
• Pinard stethoscope (from ~24 weeks) or Doppler (from ~12 weeks)
• Best heard over the fetal back

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3.4 Pelvic Examination

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A. External Genitalia - Inspection

• Mons pubis - hair distribution (decreased in hypoestrogenism, virilization causes male-pattern)
• Labia majora - skin characteristics, symmetry, swelling, ulcers, warts
• Labia minora - mucosal changes, lesions
• Clitoris - size (clitoromegaly in androgen excess), adhesions
• Urethral orifice - caruncle, prolapse, discharge
• Vaginal introitus - patency, hymenal remnants
• Perineum - old lacerations, episiotomy scars
• Anus - haemorrhoids, skin tags, fissures, warts

• Bartholin's glands (posterior labia majora): palpate for cyst/abscess - tender, fluctuant swelling at 5 or 7 o'clock position
• Skene's glands (paraurethral): milk the urethra for discharge if urethritis suspected
• Prolapse screen: Ask patient to bear down (Valsalva) - observe for anterior wall bulge (cystocele), posterior wall bulge (rectocele/enterocele), or cervical descent (uterine prolapse)

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B. Speculum Examination

1. Warm and lubricate the speculum (use warm water if Pap smear planned - lubricant can interfere)
2. Separate the labia with the non-dominant hand
3. Insert blades obliquely (45°), directed posteriorly along the vaginal axis
4. Once fully inserted, rotate to horizontal and open blades to visualize the cervix
5. Lock the blades open when the cervix is visualized

• Colour (bluish = Chadwick's sign of pregnancy)
• Rugae (atrophic if flat and pale = oestrogen deficiency)
• Discharge: colour, consistency, smell (white curdy = candidiasis; grey frothy malodorous = BV; green/yellow frothy = trichomoniasis; mucopurulent = gonorrhoea/chlamydia)
• Lesions: warts (HPV), ulcers (herpes, syphilis), cysts, prolapse

• Colour and appearance - smooth, ectropion (columnar epithelium on ectocervix - common, especially on OCP)
• OS: nulliparous (small round) vs multiparous (transverse slit)
• Discharge from os
• Nabothian follicles (benign retention cysts)
• Polyps
• Contact bleeding or friable tissue (malignancy until proven otherwise)
• Erosions/ulcers

• High vaginal swab (HVS) for candida, BV, trichomoniasis
• Endocervical swab for gonorrhoea and chlamydia (or NAAT)
• Cervical smear (Pap smear / liquid-based cytology) - as per screening schedule
• Colposcopy-directed biopsy if cervical lesion visible

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C. Bimanual Pelvic Examination

• Dominant hand: index and middle fingers lubricated and inserted into the vagina (posteriorly)
• Non-dominant (abdominal) hand: placed suprapubically to bring pelvic organs towards the vaginal fingers
• Right hand in vagina for right-handed examiners; left for left-handed

• Tenderness of the posterior fornix (pouch of Douglas tenderness = PID, ruptured ectopic, endometriosis)
• Masses in fornices

• Consistency: soft (pregnant = Hegar's sign), firm (normal), hard (malignancy)
• Mobility: fixed cervix = endometriosis, malignancy, PID
• Cervical excitation/motion tenderness (CMT): moving the cervix side-to-side causes pain = PID (Chandelier sign)
• Cervical Os: assess dilatation (in miscarriage/labour)

• Size: normal uterus is ~8x5x3 cm, pear-shaped; in pregnancy measured in weeks
• Shape: regular (normal) or irregular (fibroids)
• Position:
  • Anteverted/anteflexed (most common, ~80%)
  • Retroverted/retroflexed (~20% - normal variant; also endometriosis, adhesions)
• Consistency: firm (normal), soft (pregnancy), hard (calcified fibroids, malignancy)
• Mobility: mobile (normal) vs. fixed (malignancy, endometriosis, PID)
• Tenderness: extreme uterine tenderness = PID or ectopic

• Each adnexa palpated by moving vaginal fingers to each lateral fornix while abdominal hand pushes downward
• Note: size, shape, mobility, tenderness
• Normal ovaries are approximately 3x2x2 cm - often not palpable, especially in obese patients
• Adnexal mass: cyst (smooth, fluctuant), solid mass (malignancy), tender (ectopic, torsion, TOA)

"The size, shape, mobility, contour, consistency, and position of the uterus are determined. The patient is asked to provide feedback about any areas of tenderness, and her facial expressions are observed during the examination." - Berek & Novak's Gynecology

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D. Rectovaginal Examination

• Index finger in vagina, middle finger in rectum simultaneously
• Evaluates:
  • Rectovaginal septum - endometriosis deposits, rectovaginal fistula
  • Posterior uterine surface - fibroids, adhesions
  • Uterosacral ligaments - nodularity = endometriosis
  • Posterior cul-de-sac - deposits (ovarian cancer, endometriosis)
  • Rectal mucosa - polyps, cancer
  • Anal sphincter tone

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3.5 Obstetric-Specific Pelvic Examination (Clinical Pelvimetry)

• Diagonal conjugate = distance from the lower border of the symphysis pubis to the sacral promontory (normal ≥12.5 cm); subtract 1.5 cm to get the obstetric conjugate
• Ischial spines - assess their prominence (prominent spines = reduced transverse diameter)
• Sacrum - assess curvature (flat sacrum = reduced AP diameter)
• Subpubic angle - should be ≥90° (narrow angle = android pelvis, unfavourable for vaginal delivery)
• Cervical assessment in labour: dilation (0-10 cm), effacement, consistency, position, station of presenting part (Bishop's score)

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3.6 Breast Examination

• Symmetry and size
• Skin changes: peau d'orange (lymphoedema - malignancy), erythema (mastitis), dimpling
• Nipple: inversion (recent change = malignancy), discharge (colour - bloody = duct papilloma/carcinoma, milky = galactorrhoea, green = duct ectasia), Paget's disease

• All 4 quadrants + axillary tail
• Use flat of fingers in circular motion
• Any lump: size, shape, consistency (smooth = fibroadenoma/cyst; hard irregular = malignancy), fixity, tenderness
• Nipple discharge: express gently
• Axillary nodes: anterior, posterior, central, apical groups
• Supraclavicular nodes

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PART 4 - DOCUMENTATION AND FORMULATION

"Mrs. X, 28 years, G3P2+0 (2 normal vaginal deliveries, one early miscarriage), 32 weeks gestation by dates, consistent with scan. Baby cephalic, LOA, engaged 4/5. SFH = 31 cm. FHR 140 bpm. BP 130/85, urine protein 1+."

"Mrs. Y, 45 years, P2, LMP 2 weeks ago (normal). Presenting with 6-month history of menorrhagia. No IMB, PCB or PMB. No pelvic pain. Speculum: cervix normal, no lesions, smear up to date (normal 2023). Bimanual: uterus 10-12 week size, irregular, mobile, non-tender. No adnexal masses."

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PART 5 - COMMON SIGNS AND THEIR SIGNIFICANCE

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Quick Summary Table

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