History taking and physical examination in

Obstetric & Gynecology

Dr.Gemechu M(MD)
 I.OBSTETRICS Hx and P/E

• Obstetrics – Disease or physiologic change during pregnancy period

• Components of Hx
– ID
– Source of referral
– Source of HX
– Previous Admissions
– Chief complaints
– History of present pregnancy
– Past obstetric Hx
– Gynecological Hx
– Past medical and surgical illness
– Systemic review
– Personal and social history
– Family history
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 History of present pregnancy

• Should include the following information

• Gravidity – all previous pregnancies including term live
birth, still births, abortions, ectopic Pregnancy or
Hydatidiform mole
• Parity – Pregnancies that have extended beyond fetal
viability whether the fetus is delivered alive or dead.
– Fetal viability > 28 weeks - UK and Ethiopia
– Fetal viability > 20 week WHO
• Abortion -Termination of pregnancy < 28 weeks- UK
and Ethiopia

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 Cont….
• LMP or LNMP
– LNMP - 1st day of last menstrual cycle
– To be considered as reliable
• Menstrual cycle should have been regular
• No use of OCP for at least 3 months prior to LNMP or
seen 3 regular cycles after stopped OCP
• No use of Dipo for at least 6 months prior to LNMP or
seen 3 regular cycles after stopped it
• If lactating, she should have seen at least 3 regular
cycles

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 Cont….
• LNMP is used to Calculate
• Gestation age
• EDD(Expected date of delivery),EDD is 40 weeks or
280 days after LNMP
– 85% of pregnant women deliver on this day.
• Term pregnancy: 37 – 42 complete weeks.
• Preterm pregnancy: < 37 complete weeks.
• Post term pregnancy: > 42 ›› ››

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• LNMP to calculate EDD
Negel’ s rule-
In Gregorian calendar
EDD = LMP – 3 month + 7 days + 1 year
E.g. if LMP is on 20/06/20012
LMP 20/ 06/2012
+ 7/ -3/ +1
EDD= 27/03/2013
In Ethiopian calendar –
EDD=LMP + 9 month + 10 days or
EDD=LMP + 9 month +5/6 if pagume is passed (5
if pagume is 5 days, 6 if pagume is 6)
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• To get EDD in Ethiopian calendar, the formula is
EDD=LMP + 9 month + 10 days or
EDD=LMP + 9 month + 5/6 (if pagume is
passed) (5 if pagume is 5 days, 6 if pagume is 6)
Eg. LMP day= 10/07/2005
i.e. LMP = 10/ 07/2005
+ 09
=16 months (12 months & 4
months) since it is 16 months this means, it is in the
fourth month of the next year and passes pagume so
add 5 days (in the day of the LMNP i.e. 10 + 5= 15
therefore, EDD is in 15/04/2006
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• LNMP to Calculate gestational age
• To get gestational age , subtract LNMP day from
visiting day, the d/ce is the gestational age
Eg. LMP day= 10/07/2005
Visiting day= 24/03/2006
i.e. 24/ 03/2006
- 10/ 07/2005
14/ 08 (8 months&14 days)but it
passes pagume so add 5 days, it is 8 months & 19
days(14+5=19).
In weeks : (8 x 30) + 19=259 days =37 weeks

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 Cont….
• Fetal quickening - 1st time the mother felt movement
• Used to date the pregnancy if LMP is unknown.
• Primigravida = 18- 20 weeks
• Multigravida = 16- 18 Weeks.
• ANC -Status should be documented & if not followed, the
reason should be sought

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 Cont….
• Elaborate the chief complaint
• Any ANC during the present pregnancy- eventful or uneventful
• Ask for danger signs
– Vaginal bleeding
– Leakage of liquor
– Abdominal pain etc
• Fetal movements decreased or increased? Useful to assess fetal
Well-being.
• Other negative and positive statement according to the patient’s
complaints e.g. Headache, blurring of vision, epigastric pain or
convulsion in hypertensive disorders of pregnancy etc.

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 Past obstetric history
• Document all previous pregnancies in chronological order.
- Year of gestation
- Length of Gestation
- Length of labor
- Mode of Delivery- Vaginal or C/S
- Birth Outcome – alive or dead baby?
- Ante Partum complication
- Postpartum complication
- Child alive or not
• Important because most obstetric problems are recurrent and
have a chance of recurring in the current pregnancy e.g APH,
PPH, PROM, DM, C/S, Ectopic pregnancy & abortion.
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 Gynecologic history
• Contraception – Used for any form of contraception, type
and duration
• Sexual history – Including history of STD(HIV /
AIDS)
• History of gynecologic operations including-History
of female genital cutting, History of previous
gynecologic surgery – e.g. prior uterine
surgery, Hysterectomy, D&C (Dilatation &
curratage ), MVA(Manual Vacuum Aspiration)

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 Cont….
• Menstrual history
• Age at menarche
• Interval between periods
• Duration of flow
• Amount and character of flow
• Degree of discomfort

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 Cont….
• Criteria for normal menstrual cycles
– 1-8 days of flow ( 5 days on average)
– 21 – 35 days cycle length ( 28 days on aver.)
– 10 – 80 ml (50ml on average amount of blood flow)
– color of blood- dark red
– non clotting blood
• Clotting of menstrual blood, increased number of pads used
and anemia indicate pathology.

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 P/E in obstetrics

Physical examination-
• Should be conducted in an environment that is
aesthetically pleasing to the patient.
• A female assistant (chaperone) should be present
whenever possible
• Adequate gowning and draping to avoid
embarrassment.
• Warm instruments, reassurance and adequate lighting
• Each system should be examined if necessary but
abdominal examination is mandatory
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 Cont…
• The most specific technique used to examine abdomen with
pregnancy are:
– Inspection
– Palpation:-Obstetric palpation/Leopold maneuver
– Percussion
NB: If the patient has compliant other than
pregnancy, the detail of examination on respective
system should be done by using the four
techniques

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 Cont…
Inspection
• Distension- Symmetrical, Tilted
to the right or the left, site of
distention, uniformity, shape and
movement
• Linea nigra- midline
hyperpigmentaion due to
increased Melanocyte
stimulating hormone during
pregnancy
• Strea gravidarum –purplish
mark on the abdomen due
cracking of dermal layer and
dilation of vessels (due Dr.Gemechu
to 17
 Obstetric palpation-Leopold maneuver

1st Leopold maneuver– Fundal palpation

• Has two purposes
1. Determination of fundal height and
2. What occupies the fundus-- the head or the
buttock?

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 Cont….
1. Fundal height measurement – after correcting for
dextrorotation. There are two methods of measuring the
fundal height.
• Finger method
– Below the umbilicus - 1 finger = 1 weeks
– Above the umbilicus – 1 finger = two Weeks
– If Uterus is at symphysis- 12 Weeks of GA
– At the umbilicus – 20 weeks of GA
– At Xiphisternum – 38 weeks of GA
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 Cont….
• Tape measurement – from symphysis to fundus height
measurement in centimeters with tape meter(1cm=1wk)
2. What occupies the fundus –
• If you find soft irregular bulky mass- the breech occupies the
fundus
• If you find Hard round ballootable mass – Head occupies
the fundus

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Dr.Gemechu 21
 Cont….
2nd Leopold maneuver– Lateral palpation
• Has two purposes
– To know the lie
– To know side of the back
1. Lie: The longitudinal axis of the fetus in relation to the longitudinal
axis of the mother.
2. Side of the back – to auscultate the fetal heart rate (FHR) on that side.
– FHR can be auscultated at 20 weeks by using the pinnard
stethoscope/ ordinary fetoscope or at 10-12 weeks using Doppler.

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Dr.Gemechu 23
 Cont….
3rd Leopold maneuver– pelvic
palpation
• It has three purposes.
• These are to know the
1) Presentation
2) Descent of presenting part
3) Attitude of the fetal head
A. Presentation – Part of the fetus that occupies the lower
uterine pole. E.g. Cephalic presentation, Breech
presentation, Shoulder presentation
B. Descent is level of fetal presenting part to maternal bony
pelvis
• Measured by palpating fetal head in terms of fingers: 5/5 –
floating, 4/5 – fixed, 2/5 – engaged
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 Cont…
C. Attitude – relationship of the fetal head to the fetal trunk
• Cephalic prominence on the side of the back…….extended
attitude
• Cephalic prominence on opposite side of the back…flexed
attitude
• Flexed is normal, extended or military are abnormal attitudes.

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 Cont….
4th Leopold maneuver – Pawlik,s grip
• It has two purposes.
– To know
1. Presentation
2. Descent of fetal head – floating or fixed
• By using the thumb and fingers of one hand
to grasp the lower fetal pole and assess the
presenting part and descent into pelvis;
however, this tends to be contraindicated for
inexperienced hand.

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 Cont…
• NB: Each system examined accordingly if necessary
» GA
» VS
» HEENT
» LGS
» RS
» CVS
» GUS
» MSS/IS
» CNS

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 II.GYNECOLOGICAL Hx and P/E

• Hx and P/E on diseases related reproductive organ for non-

pregnant
a. Identification: same as obstetric history
b. Chief complaints: same as obstetric history
• Gynecologic patients may present with any one of the
following complaints
E.g:- Cessation of menses
Vaginal bleeding and discharge
Lower abdominal pain
Pain during menstruation
Mass protruding out of the introitus
Ulcers on external genitalia

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 C. History of present illness
• Reproductive history-Parity, Abortions included
• Each complaints should be discussed in detail
Example 1. Vaginal discharge
- Color, odor, amount, Viscosity
- Timing in relation to menstrual cycle
- Itching – indicates infection
2. Vaginal bleeding
 Onset
 Duration of flow
 Amount – indicated by number of pads used, clotting of
menstrual blood. Describe relation of AUB to menstrual
cycle & LNMP.
• Negative – positive statements pertinent to the presenting complaints
should be discussed in detail
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 Cont…
d. Gynecologic history- As in obstetrics(Contraceptive history,
sexual history and menstrual history)
• Should be included in the HPI if pertinent to the present
complaints other wise can be included in the past gynecologic
history
• Menstrual history- Age at menarche, interval between periods,
duration of flow, amount and character of flow, degree of
discomfort and age at menopause
e. Past obstetric history- As in obstetrics
f. Past medical and surgical history-as in obstetrics
g. Personal and family history-As in obstetrics
h. Systemic review
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 Physical examination in Gynecology

a. General appearance
b. Vital sign
c. All system examined accordingly
d. Pelvic examination(GUS) – has 5 components
1. Examination of external genitalia
2. Speculum examination
3. Digital vaginal examination
4. Bimanual pelvic examination
5. Rectovaginal–abdominal examination

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 Cont…
1. Examination of external genitalia- Inspection and palpation

• Pubic hair pattern- Masculine-diamond shaped and Feminine-

inverted triangle.
• Infected hair follicles etc.
• Skin of vulva, mons pubis and perineal area
• Swelling E.g. sebaceous cysts or tumors
• Evidence of FGM-scarring etc.
• Discharge or bleeding from the introitus – should be noted.
• Hymen- Intact or perforated
-Examination is important in cases of sexual assault.
• Tenderness
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 Cont…
2. Speculum examination
• To examine vagina and cervix by using speculum
• Types- Graves speculum, Cisco’s bivalve speculum,
Pederson speculum, Sims speculum
• Choice of several sizes depending on age etc

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 Cont…
The following should be documented.
Vagina
- Color- pink, whitened, inflamed
- Congenital anomalies like vaginal septa
- Fornices-formed, flattened, bulging especially posterior fornix
- Discharge- color, amount
- Scars, lacerations
Cervix
- Os - Nulliparous –pinpointed.
- Multiparious – slit-like
- Scars, ulcer, mass
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 Cont…
3. Digital vaginal examination
• Note the following
– The patient should have voided just prior to examination to
avoid difficulty in examining the uterus and adnexa by the
distended bladder.
– Vaginal masses, tenderness or stenosis
– Tenderness

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 Cont…
4. Bimanual pelvic examination
• To delineate the uterus and adnexa between the 2 fingers in the
vagina and the flat of the other hand on the lower abdominal wall.
• Note the following.
– Cervical status-Consistency, surface, tenderness
– Uterus-Position, tenderness, mobility, fixation, consistency,
surface
– Adnexae-Refers to the tubes, ovaries and broad ligament
• May be palpable in thin women with soft abdominal walls
• Tender normally
• Check for mass

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 Cont…
5. Rectovaginal–abdominal examination
– Following bimanual examination
– Index finger into the vagina and the middle finger into the
rectum
– This technique makes possible higher exploration of the
pelvis

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