Sunday, 23 October 2022

GYNAECOLOGICAL EXAMINATION

INTRODUCTION:

- Gynaecological examination includes examination of the female pelvic organs and

the abdomen (during pregnancy).

PELVIC EXAMINATION:

PATIENT POSITIONING
- The pelvic examination is usually performed with the patient lying supine on an of ce
examination table with the knees exed, and with the feet in supporting stirrups.
- Some examination tables have supports that t behind the knees instead.
- Electric examination tables are available, with which the patient’s head can be lowered
from a seated position; these can be advantageous for the elderly or for patients with
mobility problems.
- The patient’s head is often elevated with a pillow, or by slightly elevating the head of the
examining table.
- This allows better eye contact between the practitioner and the patient and may help the
patient to relax

EQUIPMENTS
- In order to perform a pelvic examination the practitioner should have a good light source,
non-sterile gloves, a speculum of proper size, and water-soluble lubricant.
- A variety of the most commonly used specula, materials with which to obtain cervical
cytologic samples, xative, and large cotton-tipped swabs should be immediately available
in the examination room.
- Swabs and transport media for the collection of samples for Neisseria gonorrhea,
Chlamydia trachomatis, and saline wet mounts, as well as pH paper should be on hand

EXTERNAL GENITALIA
- There can be a tendency to focus on insertion of the speculum for obtaining cytology
specimens.
- The examiner should always remember to inspect the external genitalia rst for normalcy
of appearance and hair distribution.
- Any lesions or developmental abnormalities are noted. Hormonal abnormalities may
cause changes in the external genitalia, such as clitoromegaly.
- States accompanied by low levels of estrogen are associated with atrophy of the
mucosae.
- The skin should be inspected and palpated for super cial and subcutaneous lesions
- The Bartholin’s (greater vestibular) gland openings are located at approximately the 5 and
7 o’clock positions, just lateral and posterior to the vaginal ori ce.
- They may be visible, but the normal Bartholin’s gland is not palpable. The Skene’s
(paraurethral) glands are likewise not palpable in the healthy state.
- The urethra is inspected for the presence of caruncle and other ndings

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 VAGINA AND CERVIX

- Speculum insertion is more comfortable if the instrument is warmed.
- The speculum can be moistened with warm water, which does not interfere with the
results of cultures, cytology, or wet mount.
- Lubricants can alter the results of these studies, and should only be used if none of these
studies will be undertaken.
- The examiner may exert gentle downward (posterior) pressure at the introitus with one or
two ngers before inserting the speculum
- The vagina and cervix are inspected for lesions. The vagina is also inspected for the
presence or absence of rugae to assess the level of estrogen present.
- The examiner assesses any vaginal discharge that is present for normalcy in appearance,
color, consistency, and odor.
- Physiologic vaginal discharge is scant in amount, occulent, and white. The pH of the
normal vagina is less than 4.2. Normal cervical mucus is clear
- If indicated, the examiner now proceeds to evaluate vaginal wall relaxation and uterine
prolapse

ABDOMINAL EXAMINATION
- Examination of the abdomen is likewise included in the general gynecologic examination
- The abdomen should be examined utilizing the standard techniques of inspection,
auscultation, percussion, and palpation.
- The contour of the abdomen and appearance of the skin should be noted.
- Auscultation aids in the assessment of intestinal peristalsis (bowel sounds) and in the
detection of abdominal bruits.
- Percussion is utilized to determine the size of abdominal and pelvic structures such as the
liver and masses, as well as any abdominal uid collection such as ascites. Percussion is
also useful for assessing abdominal and pelvic tenderness.
- Finally, palpation is performed to assess for tenderness, organ enlargement, and masses

INSPECTION
SKIN CHANGES
1. MASK OF PREGNANCY
- “Mask of pregnancy” is also referred to as melasma and chloasma.
- Melasma causes dark splotchy spots on your face.
- These spots most commonly appear on your forehead and cheeks and are a result of
increased pigmentation

2. STRIAE GRAVIDARUM
- Striae gravidarum are linear purple-red lesions which over time lose their pigmentation
and atrophy, leaving scar-like tissue
- It is associated with stretching of the skin causing disruption to the collagen bers and
elastin in the dermis as the uterus grows

3. LINEA NIGRA
- The Pregnancy Line, of cially called Linea Nigra, is the dark line that develops across
your belly during pregnancy.

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 SHAPE OF THE UTERUS

- Ovoid longitudinall
- Ovoid transversel
- Round in multiparous wome

CONTOUR OF THE ABDOMINAL WALL

- Pendulous abdomen due to loose abdominal muscle in multiparous women

PALPATION
ASSESSING THE FUNDAL HEIGHT
- Place the ulnar border of the left hand over the upper border of the fundus to assess the
fundal height
- From the fundal height, the period of gestation can be estimated
- Start from the xiphisternum and gradually proceed downwards towards the symphysis
pubis, lifting your hand between each step down, till you nally feel a bulge/ resistance,
which is the uterine fundus
- Mark the level of the fundus
- Measure the length from the upper border of the symphysis pubis to the top of the fundus
- At pubic symphysis - 12th wee
- Equidistant from pubic symphysis and umbilicus - 16th wee
- At the umbilicus - 24th wee
- Equidistant from xiphisternum and umbilicus - 30th wee
- At the xiphisternum - 36th wee
INCREASED FUNDAL HEIGHT
- Polyhydramnio
- Twin
- Big baby syndrome - in diabetic mothe
- Pelvic tumor
- Hydatidiform mol
DECREASED FUNDAL HEIGHT
- Oligohydramnio
- Growth retardatio
- Fetal deat

OBSTETRICS GRIP
- Leopold’s Maneuvers or the Obstetric Grips are the movements or the actions carried out
by an examiner during the abdominal palpation of a gravid mother after 28 weeks of
gestation
- There are 4 Leopold’s Maneuvers or the Obstetric Grip
- They are fundal grip, umbilical grip, rst pelvic grip and second pelvic grip

FUNDAL GRIP
- It is performed by using both hands
- While doing the maneuver examiner must face toward the patient’s face

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 - Examiner places the palmer aspect of both hands on the fundus

- Locate which pole of the fetus is occupying the fundus area. Like- Cephalic pole, Podalic
pole
- Soft irregular mass - breech (podalic pole
- Hard, smooth globular mass - head (cephalic pole

LATERAL / UMBILICAL GRIP

- It is also performed by using both hands
- Here also the examiner must face toward the patient’s face
- Palpate the lateral aspect of the umbilicus, keeping one hand steady and using another
hand to palpate, and repeat the process on both sides
- By this action examiner will locate the back, limbs, and anterior shoulder
- Smooth curved, resistant surface - bac
- Small, knobby irregular surface - limb

FIRST PELVIC GRIP

- Here examiner again uses both hands
- Faces the face toward the patient’s feet
- Palpate the presentation, presenting part, check the engagement and attitude by using
both hands

SECOND PELVIC GRIP OR PAWLIK’S GRIP

- In this only one hand is used
- Here examiner facing the face toward the patient’s face
- Palpate by keeping the ulnar border of the right hand at the symphysis pubis and grasp
the presentation
- By this maneuver, the examiner Identi es the presentation, descent, and engagement

FETAL MOVEMENTS
- BALLOTMENT - A sharp upward pushing against the uterine wall with a nger inserted
into the vagina for diagnosing pregnancy by feeling the return impact of the displaced
fetus also : a similar procedure for detecting a oating kidney
- Internal ballottement: can be elicited at 16 weeks by a push to the foetal parts with the two
ngers through the anterior fornix.
- External ballottement: can be elicited at 20 weeks by a push to the foetal parts with one
hand abdominally and the other hand receiving the impulse
- Ballottement is when the lower uterine segment or the cervix is tapped by the examiner’s
nger and left there, the fetus oats upward, then sinks back and a gentle tap is felt on the
nger

AUSCULTATION
1. FETAL HEART
- Fetal heart can be heard from 17th - 20th week of pregnancy using pinard’s fetoscope
- The Fetal heart sounds are best heard over left scapulae of fetus which comes in contact
with the utrine wall

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 - Initially the rate is about 140-160 beats/min but gradually it settles to 120-140 beats/min
- Importance of hearing fetal heart sounds - positive sign of pregnancy, indicates fetus is
alive, helps in determining the presentation and position of fetus

UTERINE SOUFFLE
- A blowing sound, synchronous with the cardiac systole of the mother, heard on
auscultation of the pregnant uterus
- Sounds are due to ow of blood through dilated uterine blood vessels

FUNIC SOUFFLE
- A hissing souf e synchronous with fetal heart sounds, probably from the umbilical cord.

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