9 Objectives (details on page 21) 1.

Correlate history
and physical
Group CPC 1. Evaluate, diagnose, and treat a prescribed obstetric or examination
gynecologic condition. findings to a
(PAPER
2. Demonstrate an appropriate level of knowledge, be able particular OB or
CASE) to organize information and develop a differential Gyne condition.
diagnoses and treatment plan for the given disease 2. Construct
condition. appropriate
differential
diagnoses.
Preceptor’s Role 3. Request pertinent
1. Facilitate discussion of the given paper case, laboratory exams
synthesize inputs from students and summarize key and accurately
learning points in the case. interpret results.
2. Check student’s report. 4. Formulate
3. Complete evaluation form. diagnosis.
5. Design a
management plan
and discuss
rationale for such
plan.
6. Submit a written
case discussion.

MEETINGS 1, 2, 3
HISTORY-TAKING
Objectives
1. Obtain a thorough obstetric and gynecologic history of a patient using effective communication skills
and following basic tenets of confidentiality.
2. Record a complete obstetric and gynecologic history based on information elicited during patient
interview.

Preceptor’s Role
1. Definition of Terms (Williams Obstetrics 25th Edition; Philippine Journal of Obstetrics and
Gynecology. Terms and Terminologies in Obstetrics. Volume 32.2008; POGS CPG on AUB
November 2011)
A. General Terminologies (student’s reading assignment)
a. Menstrual Age: calculated from the first day of the last menstrual period (LMP) and is
generally used during the fetal period, in ultrasound, and in clinical practice.
b. Gestational Age: also known as menstrual age or age of gestation
c. Ovulation Age: used when describing the embryonic period and often, the previable
fetal period. It is usually 2 weeks later than the gestational age in a 28-day cycle.
d. Embryonic Period: commences at the beginning of the 3rd week after
ovulation/fertilization and ends just before the 8th week
e. Fetal Period: occurs 8 weeks after fertilization or 10 weeks after the onset of the LMP in
a 28-day cycle
f. Nulligravida: a woman who currently is not pregnant, nor has she ever been pregnant
g. Gravida: a woman who currently is or she has been pregnant in the past, irrespective of
the pregnancy outcome. With the establishment of the first pregnancy, she becomes a
primigravida, and with successive pregnancies, a multigravida
h. Nullipara: a woman who has never completed a pregnancy beyond 20 weeks gestation.
She may or may not have been pregnant or may have had a spontaneous or elective
abortion(s) or an ectopic pregnancy
i. Primipara: a woman who has been delivered only once of a fetus or fetuses born alive
or dead with an estimated length of gestation of 20 or more weeks. In the past, a 500-g
birthweight threshold was used to define parity. This threshold is no longer as pertinent
because of the survival of infants with birthweights less than 500g.
j. Multipara: a woman who has completed two or more pregnancies to 20 weeks or more.
Parity is determined by the number of pregnancies reaching 20 weeks and not by the

5
 number of fetuses delivered. Parity is the same (para 1) for a singleton or multifetal
delivery or delivery of a live or stillborn infant.
k. Parturient: a woman in labor
l. Puerperium: the period of time encompassing the first few weeks following birth. The
duration of this period in considered by most to be between 4 and 6 weeks.
m. Term Neonate: A neonate born anytime after 37 completed weeks of gestation and up
until 42 computed weeks of gestation
n. Preterm Neonate: A neonate born before 37 completed weeks (the 259th day)
o. Post term Neonate: A neonate born anytime after completion of the 42nd week,
beginning with day 295.
p. Abortus: A fetus or embryo removed or expelled from the uterus during the first half of
gestation—20 weeks or less, or in the absence of accurate dating criteria, born weighing
< 500g.
q. Last Menstrual Period (LMP): 1st day of the last menstrual period

B. Abnormal uterine bleeding (AUB)- student’s reading assignment

Encompasses any significant deviation from normal frequency, regularity, heaviness
(volume or amount) and duration of menstrual bleeding. It is used to describe all
abnormal signs and symptoms arising from the uterus.
a. Acute AUB-episode of heavy bleeding that is of sufficient quantity to require immediate
intervention to prevent further blood loss.
b. Chronic AUB- bleeding from uterine corpus that is abnormal in volume, regularity,
and/or timing, and has been present for the majority of the past 6 months.
c. Intermenstrual bleeding (IMB)- occurs between clearly defined cyclic and predictable
menses, which may occur randomly or predictably on the same day in each cycle. This
is intended to replace the term “metrorrhagia.”
d. Heavy menstrual bleeding (HMB)- profuse and/or prolonged menstruation. This is
intended to replace “menorrhagia.”
e. Dysfunctional Uterine Bleeding (DUB)- excessive bleeding of uterine origin that is not
due to complications of pregnancy or to any systemic or local pathology.
• Ovulatory DUB- regular cycles with heavy bleeding
• Anovulatory DUB- irregular, prolonged and/or heavy bleeding

2. Teach students how to elicit and record the OB score, compute for the age of gestation and
expected date of delivery by giving examples/ exercises.
A. Recording of OB Score: Format is G__P__ ( F__-P__-A__-L__) Example: G3P1(1-0-1-1)
G: Gravida
P: Parity
F: Number of full term pregnancy
P: Number of preterm pregnancy
A: Number of Abortion including ectopic pregnancy and molar pregnancy
L: Number of living children
B. Computation of the Age of Gestation: In calculating the expected weeks of gestation by
dates: Age of gestation can be counted from the 1st day of the last menstrual period (LMP).
This is known as the menstrual age
Example: LMP: October 30, 2018
Date on Consult: May 19, 2019
AOG: 28-5/7 weeks AOG

For Unreliable LMP

Example: Irregular menses, unrecalled LMP:
Presumptive signs (~6weeks AOG) and date of quickening (16 weeks for
multigravida, 20 weeks for primigravid)
Use early ultrasound: 8-12 weeks most reliable for aging
Example:
Ultrasound done: March 18, 2019 at 10 6/7 weeks
Compute for AOG on June 18, 2019
So, 13 Mar + 30 April + 31 May + 18 June
=92 ÷ 7= 13 1/7 weeks AOG by Early Ultrasound
Age of Gestation:
40 weeks (280 days)- Mean duration of pregnancy
FIRST TRIMESTER 0-14 weeks
SECOND TRIMESTER 15-28 weeks
THIRD TRIMESTER 29-42 weeks
6
 C. Computation of Expected Date of Delivery: The expected date of delivery can be
determined by adding 7 days to the first day of the last menstrual period, subtracting 3
months and adding1 year (Naegele’s rule)

Example: LMP: October 30, 2013

EDD: August 6, 2014

3. Teach the components and format of a complete menstrual history, obstetric history, sexual history,
contraceptive history and immunization history as part of a complete problem-oriented medical
record.

OB & GYN HISTORY INFORMATION

Menstrual History - Menarche
- Cycle interval
- Duration of flow
- Amount of flow (number of pad changes per day; soaked or not?)
- Pain or dysmenorrhea (intensity, at what day?, need for
analgesics?, progressive with time?
- Last normal menstrual period (LMP or LNMP)
>same characteristics as previous menses
>differentiated from "implantation bleeding" (minimal flow;
absence of symptoms related to usual menses)
- Previous menstrual period (or PMP) to verify interval of cycle
Clinical dimensions Descriptive terms Normal limits
of menstruation and (5th-95th percentile)
menstrual cycle
Frequency of Frequent <21
menses (days) Normal 21-35
Infrequent >35
Regularity of Absent
menses (cycle to Regular Variation 2-20days
cycle variation over Irregular Variation>20 days
12 months, in days)
Duration of flow Prolonged >8
(days) Normal 4.5-8
Shortened <4.5
Volume of monthly Heavy >80
blood loss (ml) Normal 5-80
Light <5
OB History - Obstetrical code or score : G_P_ (FT- PT- A- L)
- Age of gestation (weeks)
- EDD/EDC (computed using LNMP)
- Previous deliveries:
Date of delivery
Manner of delivery, indication if not spontaneous
Complications (mother /baby)
Neonatal outcome- weight, sex, Apgar score
Prenatal History - How many times? Where? When? By whom? Medications? Work-
ups and results? Immunizations given? Abnormal findings?
Sexual History - Age at sexual debut
- # of partners
- Frequency of coitus
- Sexual problems- dyspareunia, frigidity
- Postcoital bleeding
- Sexual preference, type of sexual activity (oral, anal, etc.)
Contraceptive - Method used
History - Compliance
- Duration of use
- Side effects
- Reason for discontinuation

7
 Immunization History - MMR
- Varicella
- Tetanus
- Hep B
- Flu
- HPV
Social History - Smoking (number of sticks per day, smoking years)
- Alcohol consumption
- Illicit drug use
- Occupational hazards (chemicals, pesticides, radiation)
- Other risk-taking behaviors (tattoo, etc)

4. Demonstrate proper and complete history-taking in a pregnant patient.

5. Facilitate RETURN DEMO of students, add missed-out aspects and correct inaccuracies.

6. Check written report on interview for history-taking on an assigned patient.

MEETINGS 4, 5, 6
PHYSICAL EXAM
Objectives:
1. Perform a thorough obstetric and gynecologic examination
2. Record a complete obstetric and gynecologic findings based on information elicited during patient
examination.
3. Observe the proper set-up for the examinations.

Preceptor’s Role:
1. Demonstrate the performance of a thorough obstetric and gynecologic examination. (Abdominal,
Pelvic Examination: Speculum, Bimanual, Rectovaginal, Pelvimetry), including the set-up.
2. Emphasize the differences of an examination done between a pregnant and non-pregnant patient.
3. Facilitate return demo of students, add missed-out aspects and correct inaccuracies in the specific
physical exam procedure performed.
4. Check written report on physical examination findings of a given patient as to content and format.

THE OBSTETRIC EXAMINATION

A. Uterine Size
B. Consistency and shape of the uterus (early in pregnancy)
C. Presentation and position of the fetus
i. Fetal Lie - the relation of the fetal long axis to that of the mother and is either
longitudinal or transverse. Occasionally, the fetal and the maternal axes may
cross at a 45-degree angle, forming an oblique lie.

ii. Presenting part - is that portion of the fetal body that is either foremost within
the birth canal or in closest proximity to it

iii. Attitude or habitus - characteristic posture that the fetus assumes in the later
months of pregnancy
D. Size and movements of the fetus
E. Mobility of the fetal head
F. Consistency, size and engagement of the head
i. Engagement – descent of the leading edge of the presenting part to the
level of the ischial spines (station 0)
G. Vaginal examination to detect position, length, consistency and dilatation of the cervix
i. Cervical dilatation – determined by estimating the average diameter of the
cervical opening by sweeping the examining finger from the margin of the

8
 cervical opening on one side to that on the opposite side. The diameter
tranversed is estimated in centimeters.
ii. Cervical effacement - “obliteration” or “taking up” of the cervix. It is manifest
clinically by shortening of the cervical canal from a length of approximately 2 cm
to a mere circular orifice with almost paper-thin edges. This is expressed in
percentage based on the original length.
iii. Position of the Cervix – is determined by the relationship of the cervical os to the
fetal head and is categorized as posterior, mid-position or anterior.
iv. Consistency of the Cervix – is determined to be soft, firm or intermediate if
between these two.
v. Station – of the presenting fetal part in the birth canal is described in relationship
to the ischial spines, which are halfway between the pelvic inlet and the pelvic
outlet. When the lowermost portion of the presenting part is at the level of the
ischial spines, it is designated as station zero (0). As the presenting part
descends from the inlet toward the ischial spines, the designation is -5, -4, -3, -
2, -1 then 0 station. Below the ischial spines, as the presenting part descends, it
passes +1, +2, +3, +4 and +5 stations to delivery. Station +5 cm corresponds to
the fetal head being visible at the introitus.

FUNDIC HEIGHT MEASUREMENT

MEASURE-
MENT OF
FUNDIC -Palpate the fundus uteri & describe its size in relation to the
HEIGHT maternal symphysis & navel (20 weeks AOG or <)

(Textbook of -Identify superior border of symphysis pubis, apply tape measure at

Obstetrics: this point up to the fundal area (without depressing the hand in the
Physiologic fundus)
and Pathologic
Obstetrics.2nd -The fundus can usually be felt above the pubic symphysis 12 weeks
edition) after the last menstrual period. At 16 weeks it rises to approximately
halfway between the symphysis and the umbilicus, and it is at the
level of the umbilicus by 20 weeks. Between the 21st – 30th week
there is a linear correlation between the AOG and the fundic height.
By the 36th week, the fundus is just below the xiphoid process,
where it may remain until the onset of labor in multipara. In most
primigravidas, the fundal height drops slightly at the time of
lightening.

Height of Fundus at Different Ages of Gestation

9
 LEOPOLD’S MANEUVER

LEOPOLD’S
MANEUVERS
- The purpose is to determine how the fetus is positioned inside the
uterus – the fetal lie, presentation, attitude, position and station of
the presenting part.

- The mother lies supine and comfortably positioned with her

abdomen exposed.

L1 - Stand by the woman’s side facing her head with fingers of both
examining hands together, palpate gently with fingertips. This first
maneuver answers the question, “WHAT FETAL PARTS OCCUPY
THE UPPER POLE OF THE FUNDUS”

- The first maneuver is also called the fundal grip. The examiner
palpates the fundal area and distinguishes between the irregular,
nodular breech and the round, mobile and ballotable head.

L2 - DETERMINES FETAL LIE.

This, together with the firt maneuver, helps determine fetal lie.
Palms are placed on either side of the maternal abdomen, and
gentle but deep pressure is exerted. On one side, a hard, resistant
structure is felt— the back. On the other, numerous small, irregular,
mobile parts are felt—the fetal extremities.

** Auscultate Fetal Heart Tone (FHT) over the curved portion of the
fetus

- The second maneuver answers the question, “ON WHICH SIDE IS

THE FETAL BACK?”. This maneuver is also called the umbilical
grip, enables the fetal position to be determined by disclosing
whether the back is in an anterior, transverse or posterior position.
This will in turn give a clue to the position of the fetal head – occiput
anterior, posterior, or transverse.

L3 - DETERMINES PRESENTATION/ ENGAGEMENT

-grasp with the thumb and fingers of one hand the lower portion of
the maternal abdomen just above the symphysis pubis.
(confirms presenting part; if the presenting part is engaged, proceed
to L4)

-The third maneuver answers the question “WHAT FETAL PART

LIES ABOVE THE PELVIC INLET?”. A single examining hand is
placed just above the symphysis so as to grasp the presenting part
(Pawlick’s grip). If the head is not engaged, it will be readily
recognized as round, ballotable object that can be easily displaced
upward. If the head is engaged, the shoulder is felt as a relatively
fixed, knoblike part.

L4 -DETERMINES ENGAGEMENT (or descent to the Inlet) and

ATTITUDE
- face the mother’s feet and, with the tips of the first three fingers of
each hand, exerts deep pressure in the direction of the axis of the
pelvic inlet

**Note whether the hands diverge (engaged) with downward

pressure, or stays together (floating or unengaged).

-The fourth maneuver answers the question, “ON WHICH SIDE IS

THE CEPHALIC PROMINENCE?”. It confirms the findings of the
third maneuver and in addition determines the attitude of the fetus in
10
 utero. The examiner faces the patient’s feet and places one hand
each on either side of the lower pole of the uterus just above the
inlet. When pressure is exerted in the direction of the inlet, one hand
will descend further than the other. The part of the fetus that
prevents the deep descent of one hand is called the cephalic
prominence. In flexion attitude, it is on the same side as the small
parts while in extension attitude, it is on the same side as the fetal
back. This maneuver is also called the pelvic grip.

LEOPOLD’S MANEUVER
(Williams
Obstetrics 25th
Edition)

PELVIC EXAMINATION

Patient - Explain importance of evaluating woman’s anatomy

Preparation - Ask patient to empty bladder before examination; remove under-
garment
- Instruct & assist patient to lie in dorsal lithotomy, applying drapes
appropriately (mid-abdomen to knees)
- Instruct woman to move buttocks towards the end of the examining
table with thighs flexed, abducted & externally rotated at the hips
- Turns on and positions droplight.

External -Assess pubic hair (Tanner stage)

Genital -Separate labia & inspect the following structures for mass,
Examination discharge, congestion:
Minora
Clitoris
Urethral meatus
Introitus
Speculum
Exam: - ensure availability of sterile gloves, speculum, instrument for Pap
Preparation smear (Ayres spatula/Cytobrush; Extended tip spatula/Cytobrush;
Cotton Tipped Applicator Dipped in Saline Solution; Cervex-
Brush®); marked slide with woman’s ID, fixing solution

11
 Speculum - Wear gloves on both hands
Exam: - Separate the labia using thumb and 4th/5th digits of the examining
Technique hand
- Ask patient to relax
(Comprehen- - Insert speculum by placing the transverse diameter of the blades in
sive the oblique position and guiding the blades through the introitus in
Gynecology a downward motion with the tips pointing toward the rectum
5th Ed.) - Turn the speculum so that the transverse axis of the blades is in
the transverse axis of the vagina
- Blades should be inserted to their full length and then opened so
that the physician may inspect for the position of the cervix
- Once the blades are inserted and the cervix is visualized, the
speculum should be opened and the introitus widened so that the
cervix can be adequately inspected and a Pap smear taken. This
can be done by using the screw adjustment on the base of the
speculum.
- Light adjusted to fully view the cervix.
- see page 28 for various findings on speculum examination

Vaginal Exam
(see page 15)

H. Clinical Pelvimetry
i. Planes and Diameters of the Pelvis
a. The plane of the pelvic inlet- the superior strait
b. The plane of the pelvic outlet- the inferior strait
c. The plane of the midpelvis- the least pelvic dimensions
d. The plane of greatest pelvic dimension- of no obstetrical significance

ii. Pelvic Inlet – bounded posteriorly by the promomtory and the alae of the sacrum,
laterally by the linea terminalis, and anteriorly by the horizontal pubic rami and the
symphysis pubis.
a. Obstetrical conjugate – the obstetrically important anteroposterior diameter. It is the
shortest distance between the promontory of the sacrum and the symphysis
pubis. The obstetrical conjugate is estimated indirectly by substracting 1.5 to
2 cm from the diagonal conjugate. Normally, this measures 10 cm or more.
b. Diagonal conjugate – Determined by measuring the distance from the lower margin
of the symphysis to the sacral promontory.
c. Transverse Diameter – constructed at right angles to the obstetrical conjugate and
represents the greatest distance between the linea terminalis on either side. It
usually intersects the obstetrical conjugate at a point approximately 4 cm in front
of the promontory. Not measurable on examination.

12
 Measurement of the diagonal conjugate. (P=sacral promontory, S=symphysis pubis)

Diameters of the Pelvic Inlet

iii. Midpelvis - the midpelvis is measured at the level of the ischial spines. The
anteroposterior diameter through the level of the ischial spines normally measures at
least 12.0 cm.
Interspinous diameter- It is usually the smallest pelvic diameter which
measures 10 cm or slightly greater.

Adult female pelvis demonstrating the interspinous diameter of the Midpelvis

iv. Pelvic Outlet - This consists of two approximately triangular areas that are not in the
same plane. They have a common base, which is a line drawn between the two ischial
tuberosities. The apex of the posterior triangle is at the tip of the sacrum, and the lateral
boundaries are the sacrosciatic ligaments and the ischial tuberosities. The anterior
triangle is formed by the area under the pubic arch. Three diameters of the pelvic outlet
usually are described: the antero-posterior, transverse and posterior sagittal.

13
 THE GYNECOLOGIC EXAMINATION

IMPT: Breast Examination is a part of the Gynecologic examination but will not be included here
because it will be taught under SURGERY.

A. ABDOMINAL EXAMINATION

• The abdomen is examined by inspection, palpation, percussion and auscultation, with the
patient in the recumbent position.
• Scars, striations, diastasis of the recti, and hernias of the abdominal wall should be noted.
Asymmetry of the abdominal contour suggests an abnormal mass. Large myomas are likely to
be irregular, whereas a pregnant uterus is normally symmetric. An ovarian cyst may resemble
closely a symmetric myoma. On inspection alone, cystic tumors may be indistinguishable from
ascites.
• Percussion may aid in delimiting the edge of tumors, the height of the urinary bladder, and
loops of distended bowel. It may also differentiate the free fluid of ascites, from the
encapsulated fluid within an ovarian cyst. Paracentesis should not be performed diagnostically
because of the risk of rupturing an ovarian cyst that may be malignant or have irritating
contents that could initiate a chemical peritonitis.
• In the case of ascites, the abdomen is symmetric and there is shifting dullness, dullness in the
flanks, and tympany in the anterior abdomen. With an ovarian cyst the upper abdomen is flat,
and there is seldom shifting dullness, but there is tympany in the flanks and dullness in the
anterior abdomen over the cyst.
• Palpation of the upper abdomen should precede that of the lower abdomen and pelvis. In thin
women, the lower pole of the kidney normally may be palpated. An attempt should be made to
feel the lower edges of the liver and spleen. Tenderness in the costovertebral angles should
be noted. The inguinal region should be palpated to detect hernia and lymphadenopathy.
Palpation should begin as far away as possible from areas of tenderness. Persistence of
spasm after a few moments of gentle depression of the anterior abdominal wall suggests
peritoneal irritation. The other major sign of peritonitis is rebound tenderness.
• Pain arising from abdominal viscera should be distinguished from that arising from the
abdominal wall. When the cause of pain is visceral, tenderness is elicited when the tensed
abdominal wall is palpated.

B. PELVIC EXAMINATION

• The patient’s feet are placed in stirrups and her buttocks are brought well over the edge of the
table. Eye contact between the physician and the patient should be preserved.
• Her knees should be separated as widely as possible and the examiner positioned comfortably
with a well-focused bright light.

1. INSPECTION AND PALPATION OF THE EXTERNAL GENITALIA

• The external genitalia are examined in the following sequence: clitoris, urethral meatus,
Skene’s ducts, the perineal body, and the perianal region. Skene’s ducts, the urethra,
and Bartholin’s ducts may be inflamed. In the case of acute gonorrhea, they may
produce a purulent discharge. Bartholin’s gland is not normally palpable unless
involved in a cyst or abscess, and its opening onto the labia is not visible except in the
presence of inflammation. The size of the clitoris (especially its width) should be noted
and inflammation, atrophy, ulcer, or discharge involving the labia, mons, and perineum
recorded.

• After the labia are separated, the fourchette and hymen should be examined for
evidence of tears and scarring. In the virgin, the labia majora are apposed. In the
nonvirginal nulliparous woman, various degrees of gaping and scarring are normal. In
parous women, these changes are exaggerated. In older women, some degree of
labial atrophy is normal. At this point in the examination, the patient is asked to bear
down and cough, to see whether she loses urine (stress incontinence). Descent of the
anterior vaginal wall, posterior vaginal wall, or cervix represents cystocele, rectocele
and uterine prolapse, respectively.

2. SPECULUM EXAMINATION
• Choose the appropriate speculum size depending on age and parity:
14
 No sexual experience: virginal or nasal
Nulligravid and menopausal: small to medium
Multigravida: medium to large
• Because lubricants interfere with preparation of the cytologic smear, the speculum
should be inserted without lubrication but moistened with warm water.
• To minimize discomfort during introduction of the speculum, the perineum should be
depressed, avoiding contact with the anterior portion of the vagina and the clitoris.

3. INTERNAL EXAMINATION
• The patient may help to relax her abdominal wall by taking fast shallow breaths.
• The uterus and adnexa are palpated between the internal (vaginal) hand and the
external (abdominal) hand during the bimanual examination. By depressing the
patient’s perineum and by resting his elbow on his thigh, the examiner may be able to
reach farther into the vagina. The examiner may find it helpful to rest one foot on a low
stool. At the beginning of the internal examination, the cervix is located and its size,
mobility, and consistency noted.
• Pain on motion of the cervix should be recorded.
• The corpus should then be palpated between the abdominal hand, which makes
downward pressure on the uterus, and the vaginal hand, which pushes it upward. The
size, mobility, consistency, position and shape of the uterus should be recorded.
• Physical diagnosis is rendered difficult when the patient fails to relax, when the
examination causes pain, when the patient is obese, and when the bladder or rectum is
filled.
• The normal oviduct (fallopian tube) is rarely palpable even under ideal conditions of
examination.
• Before an attempt is made to ascertain the size and consistency of the ovary, the
position and size of the uterus must be known. If an ovarian enlargement is felt, it is
most important to describe whether it is cystic or solid, and unilateral or bilateral.
• Because any solid ovarian mass may represent a malignant tumor, the description of
any adnexal lesion must be recorded accurately. The size of a pelvic mass should be
noted in centimeters rather than in terms of fruits, vegetables, or eggs of various birds.
• It is valuable to accompany the description of abnormal findings by a drawing because
subsequent management may depend on whether a lesion has regressed, remained
the same size, or grown since that last examination.
• A normal ovary, may be felt in a thin, cooperative patient by even a relatively
inexperienced examiner, but even a distinctly enlarged ovary may not be palpable by an
expert in an obese or uncooperative patient. If there is any doubt about the presence of
an adnexal mass, consultation should be obtained, because any ovarian enlargement is
a potentially serious lesion. The average dimensions of the normal adult ovary are 3 x
2 x 1.5 cm, although ovarian size varies considerably during the reproductive period.
• Any adnexal mass greater in size than the normal ovary should be investigated
carefully. The average dimensions of the postmenopausal ovary are 2 x 0.5 x 0.5 cm.
Any palpable ovary in the postmenopausal woman must be considered abnormal.
• For accurate diagnosis of an adnexal mass, the pelvic examination occasionally must
be performed under anesthesia, especially in children.

4. RECTOVAGINAL EXAMINATION
• The rectovaginal examination must be performed last because it is usually the most
uncomfortable, but it should never be omitted from the gynecologic examination.
• The middle finger is inserted into the rectum and the index finger into the vagina. The
tissues of the rectovaginal septum are felt between the two fingers.
• Moving the fingers laterally from the cervix to the right and left permits systematic
palpation of the parametria. The parametria consisting of the cardinal and uterosacral
ligaments, which may be involved in inflammatory or neoplastic diseases, are palpable
only on rectovaginal examination.
• Lesions detected on rectovaginal palpation include a high rectocele, an enterocele,
endometriosis and masses on the posterior uterine wall and in the cul-de-sac and
rectovaginal septum.
• Palpation of the parametria is requisite to clinical staging of carcinoma of the cervix.
• Occasionally in children and older virgins, the rectal examination is substituted for the
vaginal. If the findings are suspicious or inconclusive, examination under anesthesia
may be required.

15
 • During rectal examination, attention is directed to hemorrhoids, fistulas, fissures,
anorectal polyps and tumors, and the commonly encountered condyloma acuminata.
• Women who have been raped or claim to have been raped may come, often with police
escort, for examination and possible treatment. The physician’s duty at such time is to
record the history as accurately as possible, preferably in the patient’s own words, and
to record objectively the physical findings.

THE PELVIC EXAMINATION: Step-by-Step Procedure

A. Patient Preparation
1. Greet patient and introduce self.
2. Explain what procedure is to be done, its importance, and how it will be done, and what the
patient will feel.
3. Ask patient to void.
4. Instruct patient to remove undergarments.

B. Patient positioning
1. Apply drapes on patient
2. Assist patient in lithotomy position
3. Make sure buttocks are at the edge of the bed/table

C. Preparation of materials to be used

1. Prepare clean examining gloves
2. Choose appropriate speculum size
3. Prepare materials for procedure (Example: Pap smear kit: slide with label, sampling device
(Ayre’s spatula, cotton swab/cytobrush/ broom), fixative (hair spray)
4. Position and turn on the drop light.

D. Examination of the external genitialia

1. Wear clean gloves on both hands.
2. Inspect pubic hair for distribution/pattern (Tanner)
3. Inspect/palpate labia majora, minora, urethral meatus, clitoris, hymen and vestibule, and
perineal body for masses, discharge, ulcers, congestion

E. Insertion of the Speculum

1. Lubricate the outer surface of the blades of the speculum with a water-based gel. If pap smear
is to be done, lubrication using water only is done.
2. Hold the speculum handle on the left hand.
3. Separate the labia majora using the thumb and 4th/5th digit of the right hand.
4. Inform patient to relax while the speculum is being inserted.
5. Gently insert the tip of the speculum blade through the introitus in an oblique orientation.
6. Avoid touching the urethral meatus with the speculum,
7. Gently push the speculum until midway into the vagina.
8. Once midway, turn the blades in a horizontal orientation.
9. Advance the tips of the blades in a downward direction toward the rectum, while
applying posterior pressure.
10. Open the blades and adjust to expose the cervix once the full length of the blades are in.
11. Lock the speculum screw to keep the blades open if a procedure (see item F) is to be done.
12. Inspect the vaginal walls and cervix for color, masses, discharge, bleeding, inflammation, and
ulcerations.

F. Performance of procedures: cervical assessment, Gram stain, wet mount KOH, ferning test
(*see next table below).

G. Removal of the speculum.

1. Unlock the screw of the speculum
2. Close the blades, making sure that the cervix is not trapped.
3. Gradually withdraw the speculum from the vagina.
4. Place the speculum in a collection bin for cleaning.

H. Bimanual examination
1. Apply water-based lubricant on the examining fingers.
2. Separate the labia majora using the thumb and 4th digit of the right hand.
3. Insert the 2nd and 3rd fingers of the right hand into the vagina.
4. Palpate the area of the Bartholin’s gland for masses and pain.
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 5. Palpate the vaginal walls for masses
6. Assess the fornices (anterior, posterior and lateral) if formed or bulging (ascites or masses)
For OBSTETRICS:
7. Palpate the cervix for size, consistency, pain, position (anterior, midposition, posterior)
and if in labor: dilatation, effacement, presenting part (position, station, syclitism, caput,
or molding), presence of bag of waters.
8. Assess the shape and size of the uterus using the abdominal hand to determine the level of
the fundus.
9. Perform a clinical pelvimetry
For GYNECOLOGY (also for obstetrics if done in the first trimester)
7. Palpate the cervix for size, consistency, position, masses/nodularities, motion tenderness
8. Advise the patient to relax the abdominal wall.
9. Palpate the uterus between the abdominal hand which makes downward pressure on the
hypogastric area, and the vaginal hand, which pushes the cervix up. Note the size,
position, consistency, mobility, and shape of the uterus.
10. Palpate the right adnexa by placing downward pressure to the right of the corpus with
the abdominal hand, with the vaginal hand on the right lateral fornix.
11. Repeat the same procedure for the left adnexa.

I. Rectovaginal examination (for GYNECOLOGY)

1. Advise the patient to relax her anal sphincter.
2. The middle finger is inserted into the rectum and the index finger into the vagina.
3. Note the tone of the sphincter and the rectovaginal septum for masses, check for
hemorrhoids.
4. Follow the same procedure for a bimanual examination (gynecology).

J. End of Procedure
1. Inform the patient that the procedure is finished and thank her for cooperating.
2. Wipe the external genitalia clean of lubricant, discharge or blood.
3. Dispose gloves and other materials used in appropriate bins.

* Performance of Procedures during a Speculum Examination:

• PAP  Smear  (using  cytobrush  and  Ayre’s  spatula)  

1. Place the spatula onto the ectocervix and rotate 3600.
2. Transfer the sample on one half of the slide by smearing the spatula.
3. Insert the brush in the endocervial canal and rotate 3600 .
4. Transfer the sample by rolling the brush on the other half of the same glass slide.
5. Spray with a fixative, holding it one foot away from the slide, using the left hand.
6. Let slide dry.
7. Ensure proper labeling of slide before sending to laboratory.

• VIA  (visual  inspection  with  Acetic  Acid)  if  Pap  smear  not  available  
1. Soak a clean cotton swab in 3-5% acetic acid
2. Apply (not rub) on cervix.
3. After 60 seconds from application, start examining transformation zone for acetowhite
lesions.

• Gram  stain  
1. Using a sterile cotton applicator, insert into the endocervical canal and rotate 2 times.
2. Smear specimen on a slide and let dry.
3. Let specimen dry.
4. Label properly.
5. Send to the laboratory.

• Wet  Mount  
1. Using a sterile cotton applicator, collect specimens from the posterior fornix
2. Smear specimen on a slide, taking care not to dry it.
3. Immediately place 3 drops of NSS onto specimen.
4. Examine right away under a microscope for motile flagellated protozoa and WBCs, or clue
cells

• KOH  Mount  
1. Using a sterile cotton applicator, collect specimens from the posterior fornix
2. Smear specimen on a slide, taking care not to dry it.
3. Immediately place 3 drops of KOH solution onto specimen.
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 4. Examine right away under a microscope for pseudohyphae and spores

• FERNING  test  (  for  amniotic  fluid)  

1. Using a sterile cotton applicator, collect specimens from the posterior fornix
2. Smear specimen on a slide.
3. Allow specimen to dry.
4. Examine under the microscope for ferning pattern.

MEETING 7
OFFICE PROCEDURES
Objectives
1. Demonstrate knowledge in performing cervical cancer screening using Pap smear and VIA and
cervical cultures, KOH and normal saline wet smears of vaginal secretions.
2. Demonstrate knowledge as to the purpose of the different office procedures and be able to request
the appropriate test for a particular clinical condition.
3. Demonstrate knowledge in the indication and interpretation of cytology, smears and culture reports.
4. Demonstrate basic knowledge in the use of obstetric ultrasound and its role in prenatal care.

Preceptor’s Role
1. Discuss the common office procedures performed in the ambulatory clinical setting.
2. Demonstrate the following procedures in a real patient:
3. Facilitate RETURN DEMO of students, add missed-out aspects and correct inaccuracies
4. Guide the students on how to interpret results of procedures.

A. PAP SMEAR

The recommended collecting device is the combination of endocervical brush and extended tip spatula
or the cervical broom (see page 29). When two devices are used, the ectocervical device should be
used first. The cotton tip applicator is no loner recommended for use because of its poor yield. Its use
is reserved only for pregnant patients to avoid bleeding incurred with the other devices. Samples
should be taken from the ectocervix, transformation zone and the endocervix.

For best results, there should be no bleeding and the patient should be instructed to avoid douching
and intercourse for the 24 hours preceding examination. The best time to perform the procedure is
between Day 8-12, after the menses and before ovulation.

When using the cervical broom:

Insert the central bristles of the brush into the endocervical canal. Use gentle pressure in the direction
of the cervix until the lateral bristles bend against the ectocervix.

Maintaining the gentle pressure, rotate the broom four to five times in a clockwise direction, by rolling
the shaft between thumb and forefinger. Transfer the sample to the microscope slide with a painting
action, applying first one side of the bristles and then the other. Immediately apply fixative to the slide.

B. VISUAL INSPECTION WITH ACETIC ACID (VIA)

This is a simple, inexpensive, and painless technique based on presence or absence of a white color
change on the cervix following application of 5% acetic acid. It involves the visual examination of the
transformation zone through the naked eye after acetic acid application. This is the most commonly
used cervical cancer-screening test in low-resource setting where see-and-treat approach is possible.
The result is immediately available avoiding the need for a return visit (see page 31) . The acetowhite
color is brought about by the denaturation of nuclear proteins that are present in large amounts in
dysplastic cells. At the same time, the acetic acid dehydrates the cell bringing about the compact
densely white appearance of the denatured proteins. The effect is temporary so that a repeat
application of the acetic acid may be necessary for thorough evaluation.

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