SKILL LABORATORY PRACTICE MODULE

BLOCK : REPRODUCTIVE SYSTEM

MODULE :#2
TOPIC : Gynecologic and Obstetric Examination
General objectives :
After completion of obstetrics and gynecology module, the students shall be competent in
history taking, performing physical examination, providing patient education, documenting-
reporting, and developing a good patient-physician relationship, specifically in obstetrics
and gynecology, in a professional manners as they will become health care providers in
primary health centers.
Sub Module 2.1. Gynecologic examination
I. Sub module objectives:
After completion of gynecologic l sub module practice, the students shall be competent in
history taking, performing physical examination, providing patient education, documenting-
reporting, and developing a good patient-physician relationship, specifically in gynecology ,
in a professional manners as they shall be health care providers in primary health centers.
II. Expected Competency :
a. Students should be able to perform anamnesis in gynecology
b. Students should be able to perform general and obstetric physical diagnosis
c. Students should be able to document and report examination result
d. Students should be able to provide patient education
e. Students should be able to develop patient-physician relationship
III. Topic
a. Gynecologic assessment (inspection, palpation, vaginal examination)
b. Gynecologic counseling plan
IV. Method
a. Lecture/ reading assignment
b. Case presentation
c. Discussion, case study, demonstration, tutorial
d. Mannequin (anatomy model) practice
V. Laboratory facility
a. Class room
b. Reading materials
c. Audiovisual Aids
d. Anatomy model (pelvic model : normal, cervical polyps and uterine myoma)
e. Student learning guide
f. Tutor
g. Tutor guide
VI. Venue
a. Gynecology clinic mock-up
b. Training room
VII. Organizer
Department of Obstetrics and Gynecology, Medical School Universitas Islam Bandung.
IX. Evaluation
a. Written examination
b. Case examination
c. Competency assessment in model, based on check list

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 X. LEARNING GUIDE
GYNECOLOGIC ASSESSMENT
No. S T E P PERFORMANCE
SCALE
1 2 3 4 5
I History taking in gynecologic assessment

A Chief complaint
Greet the patient and introduce yourself , develop a warm and helpful
environment
Politely ask : Patient identity
Find out : is there anyone accompanying the patient, if so, ask one to
accompany her in the examining room
B Anamnesis
1. Ask the reason why the patient needs to come to the clinic
2. Ask the followings
 marital history
 Menstrual cycles, first day of last menstrual period (LMP), duration
 Parity and number of living children, last delivery/abortion
 History of ectopic pregnancy
 History of menstruation-related pain
 Anemia, general fatigue
 History of urinary tract infection, sexually transmitted disease or pelvic
inflammatory disease
 Promiscuity (multiple sexual partner)
 Other complaints such as bleeding or vaginal discharge, enlargement
of abdomen, feeling abdominal mass that brings the patient to the
clinic.
Note :
For further explanation regarding history taking, please refer to History
taking learning guide in the other section of this book
II INFORMED CONSENT
5. Explain the procedure to the patient
6. Explain the goals or the expected result of the examination
7. Explain that some women may experience certain discomfort during
procedure and sometime worry, but that it shall not harm or put her in danger
8. Make sure that the patient understand about the procedure and the aim of
the examination
9. Ask for verbal consent, if the patient agrees, soon as she understands the
procedure
III PREPARATION
10. A. Patient
 Examining table
 Cotton and high disinfectant level solution
 Nelaton catheter (voiding is best)
 Grave’s speculum and tray
 Instrument table
 Lamp
B. Examining physician
 High-level disinfected hand gloves

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  Soap and tap water
 Apron
 Clean and dry towel
IV PHYSICAL EXAMINATION
11. General
 General state
 Habitus ( asthenia, athletic, picnic)
 Height
 Weight
 Color of conjunctiva, icterus, edema,
 Vital sign (blood pressure, pulse, respiratory, temperature)
 Cardiopulmonary state
 Inspection for abdominal enlargement or mass
 Palpation of liver and spleen
V GETTING READY
12. Ask the patient to void and to take off her under wear
13. Ask the patient to lay down on the examining table, and put her in a
lithotomy position
14. Using apron and turn on the lamp and direct it to the examining area
15. Wash the hands with soap, and dry with clean dry towel
SPECIFIC
16. Inspect suprapubic bulging and try to palpate uterine fundus. Locate mass or
abdominal tenderness
VI PUTTING ON HANDGLOVES
17. Take the gloves, unfold it and put it on the table.
18. Use your left thumb and index finger to hold the the right gloves on the tip of
the folded part
19. Insert your right hand by gentle traction of the tip of the folded part up way to
your fore arm
20. Take the left glove by slipping your four right fingers under the folded part of
the left glove, and use your thumb to hold the gloves upright.
21. Insert your left hand to the gloves and tighten it up by unfolding and pulling it
upward to your fore arm
SPECIFIC
22. Sitting on a chair the physician faces genital aspect of the patient
23. Take some cotton and high disinfectant level solution and wipe it on the
examining area
24. Inspect the whole vulva and perineum
25. Separate the labium mayora to open the vulva with the left thumb and index
fingers, then inspect the urethral meatus and vaginal introitus
26. With your right thumb and index finger palpate and explore both sides of the
labium mayora, especially in the bartholin gland area. Inspect and record any
abnormalities found.
27. Take a Grave’s speculum with your right hand, apply speculum using gel
lubricant, insert the left index finger into the introitus to make a slit, and then
insert the tip of the specula into the introitus parallel to the labia. Make sure
that there is no tissue trapped between the blades, and slowly push them in.
28. When the blades are far enough inside the vagina, turn it 90 ° clockwise so that
the handle is directed downward.

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29. Arrange the blades by opening the blade lock, so each blade touches the
anterior and posterior vaginal wall.
30. Push the knob on the speculum to make it open wider and the vaginal lumen
and portio is visible.
 Notice the shape and size of portio, fornices, the vaginal wall, also any
bleeding or discharge from the ostium.
 Pay attention to any abnormalities on portio like erosion, fragile mass on
the portio lips or any mass coming out from external uterine ostium
NOTE :
If pap smear collection is planned for current examination, it is done after the
step above
See learning guide for pap smear collection in other parts of the learning guide
31. Release the knob and let the blades be in the original position, turn it 90 °
counter clockwise until the blades are pararel to the labia and take it out.
32. Put the speculum in a basin filled with decontamination solution
33. The examining physician shall now stand, apply your right index and middle
finger using gel lubricant, and then separate the labium mayora to open the
vulva with the left thumb and index fingers.
34. Insert your right index and middle finger into the vagina to perform vaginal
examination (bimanual examination)
35. Put the tip of your left four fingers upon the suprasymphisis, try to feel the
uterine fundus
(if the size may be palpable).
36. Define the uterine size, consistency and mobility
Note :
If the uterus is retroflexed, try to do the step above by performing rectovaginal
toucher (see bottom of this learning guide)
37. Try to palpate the adnexal area, find any mass or tenderness, also the mobility
of the mass.
38. In the fornices try to find any cervical motion tenderness
Note :
Cervical motion tenderness is aiming at eliciting visceral pain which usually
result from peritoneal irritation. The visceral peritoneum covering the female
genital tract is ligamentum latum or broad ligament. Refer further to your
anatomy book, to precisely see the connections with uterus, tubes, ovaries and
Douglas pouch.
Performing cervical motion tenderness :
 With your 2 inner fingers surround the portio, move the portio gently to
the left and right
 Pay attention to patient’s reaction and expression.
Caution: It may be very painful if peritoneal irritation exists !!
39. While your left hand is still on the suprasymphisis, take out your right fingers
from the vagina.
40. Take your outer fingers off the abdominal wall.
41. Wipe clean the vulva and perineum from secret or liquids.
42. Put the cotton/gauze into the disposal bin
43. Tell the patient that the examination is completed
44. Let her get dressed and be seated for consultation
45. Put the instrument soaked in the decontamination solutions.
46. Put your hands (still wearing the glove) in the decontamination solution and

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 then slowly take it off.
Pay attention that you do not spill any liquids or secret to your surroundings.
Note : The gloves and the instruments should be processed further.
See equipment treatment in the other chapter of infection prevention of this
learning guide.
VII DATA RECORDING
47. Record your result in the medical record
FINAL CONCLUSION
48. Draw a conclusion of the examination result and record it in the medical
record
49. State the patient condition in the conclusion/working diagnosis/differential
diagnosis
50. State the prognosis of the disease in regards to the result of examination
VIII MANAGEMENT PLAN
51. Suggest additional examination if necessary, such as routine laboratory,
ultrasonography scanning and others
Note:
Final diagnosis sometimes includes the findings from routine laboratory and
other additional examination.
52. Describe the condition to the patient
53. Arrange for follow up visit
54. Explain that if special examination or interdisciplinary consultation is needed .
informed consent would be requested.
Note :
The patient has the right to ask for expert assistant and referral to higher
rank medical facility
55. Tell important signs of symptoms the patient should be aware of and to
immediately come back for consultation
56. Tell the patient where the higher rank health facility is located and the referral
system
57. Make sure that the patient understands about all the information, the result of
examination and diagnosis and the management plan
58. Give the medical record visiting card , show the patient the way out and greet
her.

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