OBSTETRICS & GYNECOLOGIC

HISTORY TAKING
&
PHYSICAL EXAMINATION
Mizan Tepi University
Dep`t of Biomedical Sciences

By: Dr. Demissew; Nov. 2013

For 3rd year Public health Officer Students

Obstetrics and
Gynecology
Obstetrics: deals with the pregnant state and
its sequels
Gynecology: deals with the physiology and
pathology of the female reproductive organs
in the non-pregnant state

Obstetrics
Obstetrics is the branch of medicine that

deals with parturition, its antecedents, and its

sequels (Oxford English dictionary, 1933)
The word obstetrics is derived from the Latin
term obstetrix, meaning midwife

Aims of Obstetrics
The transcendent objective of obstetrics is

that every pregnancy be wanted and that it

culminate in a healthy mother and a healthy
baby
Obstetrics strive to minimize the number of

women or infants who die as a result of the

reproductive process or who are left
physically, intellectually, or emotionally
injured there from.
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We are all products of our environment, our

background, and our culture.

The importance of ascertaining the patient's
general, social, and familial situation cannot be
overemphasized. The physician should avoid
being judgmental, particularly with respect to
questions about sexual practices and sexual
orientation.
Good communication is essential to patient
assessment and treatment.
The foundation of communication is based on
key skills: empathy, attentive listening, expert
knowledge, and rapport. These skills can be
learned and refined.
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The Hippocratic Oath demands that physicians

be circumspect with all patient-related

information.
For
physicianpatient
communication to be effective, the patient
must feel that she is able to discuss her
problems fully.
Different styles of communication may affect
the physician's ability to perceive the patient's
status and to achieve the goal of optimal
assessment and successful treatment. The
intimate and highly personal nature of many
gynecologic conditions requires particular
sensitivity to evoke an honest response.

Some patients lack accurate information about

their illness. Lack of full understanding of an

illness can produce dissatisfaction with medical
care, increased anxiety, distress, coping
difficulties, unsuccessful treatment, and poor
treatment response.
After a dialogue has been established, the
patient assessment proceeds with obtaining a
complete history and performing a physical
examination. Both of these aspects of the
assessment rely on good patientphysician
interchange and attention to details.

At the completion of the physical examination,

the patient should be informed of the findings.

When the results of the examination are
normal, the patient can be reassured
accordingly. When there is a possible
abnormality, the patient should be informed
immediately; this discussion should take place
after the examination with the patient clothed.

Obstetric History (pregnant

women)
Identification:
Name
Age< 18 yrs

> 35 yrs high risk group

--- Women life cycle

Prepubertal
Adolescence
Reproductive age group
Perimenopausal
Postmenopausal

Address
Occupation
Religion
Marital Status :unmarried & unsupported
high risk
Date
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Chief Complaint(s):
E.g. Of Obst.C/C are:
ANC follow up
Vaginal bleeding
Time of onset
Flow---amount, duration,

Leakage of liquor
Pushing down pain
Decreased/ absent fetal movement
Body swelling, headache, blurring of

vision, etc

10

HPP(History of present pregnancy)

Gravidity
The total number of pregnancies of any gestation
Includes current pregnancy, abortions, ectopic
pregnancies, and hydatidiform moles
twins count as one pregnancy

Eg. G 3 means she had previous 2 pregnancies, now

she is pregnant for the 3rd time.
Nulligravida: describes a woman who is not now
and never has been pregnant
Primigravida=a woman who is currently pregnant
but never has been pregnant before.
Multigravida= a woman who experiencing
pregnancy for the second time or more
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Parity= pregnancies that have extended beyond

fetal viability whether the fetus is delivered alive

or dead
=Number of delivery in the past
Age of viability:
28 weeks Eastern and developing countries
20 weeks - most developed countries (USA...)
- Twin/triplet/quadriplet, etc. delivery is
considered as one parity.
Abortion-number pregnancies terminated below
the age of viability, i.e. <28 wks
- it could be induced or spontaneous.
Ectopic pregnancies: number of past
extrauterine pregnancies, if there was any.

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E.g. This is a G 5, P 2, A1, E1

means,
she had 4 past pregnancies(2 delivered, 1 aborted, 1 was
ectopic pregnancy and she is currently pregnant for the 5th
time).
Then calculate the age of the current pregnancy (GA) in weeks
from the last normal menstrual period-LNMP
LNMP: is the first day of last normal menstrual period.

Normal period means the usual

monthly period, but not any bleeding.
Menstrual cycle should be regular, predictable, cyclic
& spontaneous
No use of any form CP for at least 3 months prior to
LNMP or 3 regular cycles
If lactating , she should see at least 3 regular cycles

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 EDD(EDC): is expected date of delivery (confinement) 40 wks

or 280 days after LNMP 5% of pregnant women deliver on

this day

Term pregnancy -37 42 completed weeks

Preterm pregnancy - < 37 completed wks
Post term pregnancy > 42 completed wks

To calculate EDD1. If we are using European Calendar :

Negales rule: LNMP 3 from the month&+7 to the date.
E.g., if the last menstrual period began September 10, the
expected date of delivery is June 17
2. If we are using Ethiopian Calendar :
LMP+9 (to the month + 10 (to the day) or ( +5 days if
pagume is 5 or 4 days if pagume is 6 and if pagume is passed )
E.g. LNMP 10/1/00
EDD will be on 20/10/00
LNMP 24/3/01
EDD will be on 4/13/01
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 GA- Calculated in completed wks and days of gestation up

to the day on which it is calculated.

On the day of EDD GA is 40 weeks(280 d).
E.g. LNMP 10/1/01, EDD 20/10/01
GA on 16/6/01 will be 22wks and 2days
NB: The assumption is that the cycle is 28 days if longer cycle
longer EDD, short cycle shorter EDD b/c ovulation always
occurs 14 days prior to next cycle.
NB: mention about regularity of the cycle, recent use of
hormonal contraception to ascertain the LMP is really
normal & reliable and the GA calculated is actual.
E.g. Of the 1st part of HPP:
This is a G5, P2, Ab1, Ect1 mother whose LNMP was
on10/1/01 making EDD on 20/10/01 and GA of 22 weeks
and 2 days by date. She had 4 regular menstrual cycles
before LNMP after she
discontinued OCP/Depo provera 4 months back. OR
Menses was regular and she has never used hormonal
contraceptives.
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Quickening- 1st time the mother felt fetal movement by

date/month if possible (not the month of pregnancy), the
type, the progress in fetal movement, etc.
NB: knowing Quickening(1st fetal mov`t) helps to estimate
GA in case of unreliable or unknown LNMP.
Primigravida 18- 20 wks
Multigravida- 16 -18 wks
Then add wks passed since---- =GA
Describe:
How was pregnancy diagnosed?
E.g. Early pregnancy U/S or urine p-test b/c of missed
period .
when pregnancy 1st diagnosed?
Note: Parameters used to estimate/calculate GA are:
LNMP
Ultrasound parameters
Date of quickening
Fetal heart tone
Uterine size/fundal height/

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ANC status should be documented and if not

followed the reason should be sought

If she had already started (when, where started? what
was done during each visits?)
E.g. What type of counseling, examination,
investigation, medications given?
E.g. She knew that she was pregnant after she had missed
period and had positive urine p-test at a H.C on 20/2/0.
She started ANC at a H.C at 2 months of pregnancy on
10/3/01. Until now she had 3 visits. On the 1st visit she
was told about----, BP, Wt, Ht, measured, general P/E
done, Lab was requested and the results were
Hgb--,Bgp& Rh--,VDRL--,FBS--,HBSAg--,HIV--, U/A--.
She was given Vaccination for TT(refer the schedule
and the purposes, other vaccinations), Supplemented
with Iron, vitamins 1x2/d etc.
Treated for-------diseases with----drugs

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 Elaborate the chief complaint... she was referred to this

hospital b/c of-- Any complaints during the present pregnancyeventful or uneventful ask for danger signs:
Obstetrical
vaginal bleeding
Leakage of liquor
Decreased fetal mov`ts
Headache etc.
Medical: HTN, DM, etc. Other
Fetal movements decreased or increased ? Useful to assess
fetal well being
Other negative and positive statement according to the
patient`s compaints

Is the pregnancy planned, wanted, supported?

Whether birth planning discussed- place of birth, route of

birth, transport, money prepared, etc.
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Past obstetrics history : document all previous

pregnancies in chronological order
S.
N.

Date of
deliver
y

Wks of
gestati
on

Length Mode
of
of
labor
delive
ry

Birth Wt AP
out
cx
com
n
e

IP
cx
n

PP
cx
n

Alive
or
not

1
2
3
etc
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Gynecologic History ( including abortion)

Contraception
present and past contraception hx, type and duration
compliance
reasons for discontinuing
complications/failure/side-effects
Sexual history - Hx of STD. Assess risk of HIV/AIDS
Hx of Gyne operations (Major and minor) circumcision,
previous gyne surgeries- e.g. Prior uterine surgery-hysterotomy,
metroplasty, D&C, MVA, E&C....
Menstrual history
Age at menarche, interval b/w periods, duration of flow,
amount and character of flow-( number of pads, clotting),
degree of discomfort
Normal menstrual cycles 1-8 days of flow/ 21 36 days cycle
length
5/28 days on average
30-80 ml in amount;about 50ml on average
LMP
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Abnormal menstrual cycles:

Menorrhagia regular cycle, heavy flow >80ml
Metrorrhagia--- irregular cycle
Menometrorrhagia --- irregular cycle, excessive
in amount
Metrotaxis---- continuous uterine bleeding
Hypomenorrhea---normal cycle, shorter duration
of flow
Polymenorrhea---frequent cycles (<21 days of
cycle length)
Oligomenorrhia----cycle length >35 days

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Past History
Lists childhood illnesses
Lists adult illnesses with dates for at least four

categories: medical; surgical; obstetric/gynecologic;

and psychiatric
Includes health maintenance practices such as:
immunizations, screening tests, lifestyle issues, and
home safety

Family History
Outlines or diagrams of age and health, or
age and cause of death of siblings, parents, and

grandparents
Documents presence or absence of specific illnesses
in family, such as hypertension, coronary artery
disease, etc.

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Personal and Social History

Describes educational level, family of origin, current
household, personal interests, and lifestyle
Review of Systems
Documents presence or absence of common
symptoms related to each major body system

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Physical Examination
To interpret physical findings & reach at a Dx:
1st try to know normal physiologic & anatomic changes in
pregnancy.
2nd understand the abnormal findings.

General appearance (G/A):

Observe the patients general state of health, height, build,

and sexual development.

Obtain the patients weight.
Note posture, motor activity, and gait; dress, grooming,
and personal hygiene; and any odors of the body or breath.
Watch the patients facial expressions and note manner,
affect, and reactions to persons and things in the
environment.
Listen to the patients manner of speaking and note the
state of awareness or level of consciousness.
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Vital Signs
Bp .mmHg, Rt arm, sitting position, Kort1/4
Wt.---PR-----RR------T-------

Ht.---BMI----

HEENT--LGS -LN, Breast, Thyroid

Chest--CVS---

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Abdomen
- General: insp, ausc. palp, perc,
- Obstetric:
Leopold maneuver(I, II, III, & IV)
I..
II..
III.
IV.

Auscultation for FHB, best heard at

It is possible to detect FHT by hand held Doppler
as early as 10 wks' gestation. It may be detected by
fetoscope by 1820 wks' gestation.

Leopold`s Maneuvers
I. Fundal palpation---fundal height, what occupies

fundus
II.Lateral palpation---Lie, side of the back
III.Pelvic palpationPresentation, Descent of presenting
part, Attitude of the fetal head
IV.Pawliks gripPresentation, Descent of fetal head
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Leopold I
involves the examiner placing both of his or her hands

on each upper quadrant of the patient's abdomen and

gently palpating the fundus with the tips of the fingers
to define which fetal pole is present in the fundus. If it is
the fetus' head, it should feel hard/firm, round and
smooth. In a breech presentation, a large, soft,
irregular, nodular mass is felt. Fundal height will be
determined in two ways: Tape method and finger
method .
Fundal height determination
Finger method: measure the upper limit of the fundus
starting from at the level of superior border of
symphysis pubis by number of fingers in successive
manner. Below umbilicus, one finger represents one wk
size; while one finger represents for two wks size of
gestation.
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Tape method: The fundal height is measured

with a tape from the top of the symphysis

pubis, over the uterine curve, to the top of the
fundus This technique places an emphasis on
change in growth patterns rather than the
absolute measurement in centimeters, which
can vary between patients.
Fundal height (determined by measuring the

distance in centimeters from the pubic symphysis

to the curvature of the fundus) correlates roughly
with the estimated gestational age at 2634 wks
(Fig below). After 36 wks, the fundal height may
decrease as the fetal head descends into the
pelvis.
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Leopold I

29

30

31

Leopold II
involves palpation in the paraumbilical regions

with both hands by applying gentle but deep

pressure. The purpose is to differentiate the
fetal back (a hard, resistant structure) from its
limbs (irregular, mobile small parts) to
determine the fetus' position. Place one hand
on each side of the woman's abdomen, aiming
to capture the body of the fetus between them.
Use one hand to steady the uterus and the
other to palpate the fetus.
The hand on the fetal back feels a smooth,
firm surface the length of the hand (or longer)
by 32 weeks of gestation. The hand on the fetal
arms and legs feels irregular bumps, and also
perhaps kicking if the fetus is awake and active.
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Leopold II

33

Leopold III
is suprapubic palpation by using the thumb and

fingers of the dominant hand. This maneuver has 3

purposes: to know fetal presentation, descent
(floating=5/5, fixed=4/5, and engaged=2/5) and
fetal attitude (extended, flexed or military).
As with the first maneuver, the examiner ascertains
the fetus' presentation.
Turn and face the woman's feet. Using the flat
palmar surfaces of the fingers of both hands and, at
the start, touching the fingertips together, palpate
the area just above the symphysis pubis. Note
whether the hands diverge with downward pressure
or stay together. This tells you whether or not the
presenting part of the fetushead or buttocksis
descending into the pelvic inlet.

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If the fetal head is presenting, the fingers feel a smooth,

firm, rounded surface on both sides.

If the hands diverge, the presenting part is descending
into the pelvic inlet.
If the hands stay together and you can gently depress the
tissue over the bladder without touching the fetus, the
presenting part is above your hands.
If the presenting fetal part is descending, palpate its
texture and firmness. If not, gently move your hands up
the lower abdomen and capture the presenting part
between your hands.
The fetal head feels smooth, firm, and rounded; the
buttocks, firm but irregular.
The presenting part is grasped, identified, and evaluated
for engagement.
The fetal descent is determined by the rule of 5 th using an
examiner fingers.
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Leopold III

36

Leopold IV
The fourth maneuver answers the question, On

which side is the cephalic prominence? This

maneuver can be performed only when the head is
engaged; if the head is floating, the maneuver is
inapplicable. The examiner faces the patient's feet
and places a hand on either side of the uterus, just
above the pelvic inlet. When pressure is exerted in
the direction of the inlet, one hand can descend
farther than the other. The part of the fetus that
prevents the deep descent of one hand is called
the cephalic prominence.

37

The fourth Leopold maneuver reveals the position of

the cephalic prominence. In a flexion attitude, the
cephalic prominence is on the same side as the small
parts.

38

In the fourth Leopold maneuver, in an extension

attitude, the cephalic prominence is on the same
side as the back.

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 GUS

CVA or suprapubic tenderness

Examination of external genitalia
Pelvic examination---done 2x during pregnancy unless
indicated

1. Early---first

2. Late

trimester

To diagnose pregnancy
To date pregnancy
To diagnose pelvic problems/ pathology

in pregnancy (38 wks or at term) --to diagnose

contracted pelvis

Soft tissue assessment

Bony pelvis assessment

Pelvic inlet -----Diagonal conjugate

---- Head fitting test ( Mueller-Hiltons maneuver)
Mid cavity-------Ischial spine, sacrospinous ligament, concavity of
sacrum
Outlet
..Subpubic arch angle

To asses the Bishops score---cervical status

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PERFORMING CLINICAL PELVIMETRY

The pelvis is usually assessed in terms of

the inlet, midcavity, and outlet.

Inlet
The inlet can only be adequately evaluated

prior to engagement of the fetal head, since

once the head occupies the midcavity the
posterior inlet cannot be accessed. The
examiner first assesses the anteroposterior
(AP) diameter of the inlet by measuring the
diagonal conjugate (distance from the
undersurface of the symphysis pubis to the
sacral promontory).
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The obstetric conjugate (the narrowest AP

diameter of the inlet) is estimated by

subtracting 2 cm from the diagonal
conjugate.
The transverse diameter of the inlet cannot
be measured clinically. An idea of the shape
and the extent of the circumference of the
inlet can be gained by sweeping the
examining fingers laterally along the pelvic
brim. If more than two thirds of the brim
can be easily palpated, and especially if
the posterior portions of the brim can be felt,
there may be a contracted inlet.
42

Midcavity (Midpelvis)
The midcavity of the pelvis is evaluated
by assessing the shape of the sacrum
(curved or straight), the width of the
sacrosciatic notch, and the prominence of,
and distance between, the ischial spines. A
contracted midpelvis characteristically
shows a flattened forward projecting
sacrum, prominent ischial spines with a
narrowed interspinous distance, and a
shortened sacrospinous ligament which is
less than two fingerbreadths long.

43

Outlet
Evaluation of the outlet consists of:
determining the distance between the
ischial
tuberosities
(normally
approximately 10 cm)
palpating the coccyx to determine its
orientation and mobility (normally mobile
and not protruding into the pelvic cavity)
evaluating
the subpubic angle (>90
degrees) and retropubic angle (flattened
in a platypelloid pelvis and sharply
angulated in an android pelvis)
determining
the
convergence
or
divergence of the pelvic sidewalls
44

Vaginal examination to determine the diagonal

conjugate.

45

Ext--- General inspection may be done with the

woman seated or lying on her left side.

Inspect the legs for varicose veins.

Varicose veins may begin or worsen during

pregnancy.

Inspect the hands and legs for edema.

Palpate for pretibial, ankle, and pedal

edema. Edema is rated on a 0 to 4+ scale.
Physiologic edema is more common in
advanced pregnancy, during hot weather,
and in women who stand for long periods.

CNS
Check knee and ankle reflexes.

46

If the mother is in labor, additional Hx. & P/E

Hx.
C/C:

Pushing down pain /--hrs

Leakage of liqour/---hrs
Vaginal bleeding/----hrs
HPP: elaborate on the C/C
P/E.
G/A: in labor pain
Uterine contraction (frequency/10min
intensity(mild, moderate, severe),
duration in seconds. E.g. 2/40-50/10`
FHB/min. The normal fetal heart rate is 110170
bpm.
Pelvic exam. Speculum-for PROM, APH(no PV)
PV: Cx. dilat.(cm), effacement(%), presentation,
position, station, caput, moulding, color of liquor if
membrane is ruptured.
47

Assessment:
Problems identified:
e.g. Teen age, age >35yrs, Primigravida,
nullipara, Post term, bad obstetric hx,
Twin Pregnancy
PIH, GDM etc
Risk Assessment:( look for RF starting from
identification)
Low risk/ High risk pregnancy
( give reason for the risk assessed)
Recommendation:
Investigations:-----------Place, route and time(GA) of delivery( based
on RF)
Cxn. anticipated( maternal/fetal/neonatal)
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Gynecologic Hx & P/E

1. Identification-----2. C/C: e.g.:
Cessation of menses
Vaginal bleeding
Vaginal discharge
Lower abdominal pain
Pain during menses
Mass protruding out of the introitus
Ulcers on external genitalia
Urinary incontinense
Abdominal distension
Abnormal hair growth patern : hirsutism
Sexual assault
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3. HPI: start with

This is a Para--, Abo--- mother, who
was relatively healthy until---when she
started to experience-------Then elaborate on the C/C----Like medical/surgical hx.include all
relevant
information------,
aggravating/relieving factors etc.
Events during menarcheal age, during
pregnancy, delivery and purperium, while
using contraception, if in menopause
menopausal symptoms etc.

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4. Past Obst. Hx.--5. Gynecological HxContraception hx

Sexual hx
Hx. of gynec. operations
Menstrual hx

6.
7.
8.
9.

Past Hx..
Family Hx
Personal and Social Hx
Review of systems.
51

Physical Examination
1.General: like medical/ surgical
2.Pelvic Examination
a) Speculum Examination:
-to inspect the vagina, cervix
b) Digital vaginal examination(PV) &
Bimanual Examination
-to palpate vaginal wall, cervix, uterus
(size in wks), adnexal
structures (ovary,
tubes, parametrium)
-for mass,
-for tenderness
-to palpate pouch of Douglas:
-for fullness, tenderness etc.
-discharge-color, odor,
consistency etc
-blood on examining finger.
52

Method of the Female Pelvic

Examination
The patient is instructed to empty her bladder. She

is placed in the lithotomy position and draped

properly.
The examiner's right or left hand is gloved,
depending on his or her preference. The pelvic area
is illuminated well, and the examiner faces the
patient.
The following order of procedure is suggested for
the pelvic examination:
A. External genitalia
1. Inspect the mons pubis, labia majora, labia minora,
perineal body, and anal region for characteristics of
the skin, distribution of the hair, contour, and
swelling. Palpate any abnormality.
53

2. Separate the labia majora with the

index and middle fingers of the gloved
hand and inspect the epidermal and
mucosal characteristics and anatomic
configuration of the following structures
in the order indicated below:
a. Labia minora
b. Clitoris
c. Urethral orifice
d. Vaginal outlet (introitus)
e. Hymen
f. Perineal body
g. Anus
54

3. If disease of the Skene glands is

suspected, palpate the gland for abnormal
excretions by milking the undersurface of
the urethra through the anterior vaginal
wall. Examine the expressed excretions by
microscopy and cultures.
If there is a history of labial swelling,
palpate for a diseased Bartholin gland
with the thumb on the posterior part of the
labia majora and the index finger in the
vaginal orifice. In addition, sebaceous
cysts, if present, can be felt in the labia
minora.
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56

Palpation of vestibular glands.

57

58

59

B. Introitus
With the labia still separated by the
middle and index fingers, instruct the
patient to bear down.
Note the presence of the anterior wall of
the vagina when a cystocele is present or
bulging of the posterior wall when a
rectocele or enterocele is present. Bulging
of both may accompany a complete
prolapse of the uterus.
The supporting structure of the pelvic
outlet is evaluated further when the
bimanual pelvic examination is done.
60

C. Vagina and cervix

Inspection of the vagina and cervix using a
speculum should always precede palpation.
Select a speculum of appropriate size and
shape, and moisten it with warm, but not hot,
water. (Lubricants or gels may interfere with
cytologic studies and bacterial or viral
cultures.) You can enlarge the vaginal introitus
by lubricating one finger with water and
applying downward pressure at its lower
margin. Check the location of the cervix to help
angle the speculum more accurately. Enlarging
the introitus greatly eases insertion of the
speculum and the patient's comfort.
61

With

your other hand (usually the left),

introduce the instrument into the vaginal
orifice with the blades oblique, closed, and
pressed against the perineum. Carry the
speculum along the posterior vaginal wall, and
after it is fully inserted, rotate the blades into
a horizontal position and open them.
Maneuver the speculum until the cervix is
exposed between the blades. Gently rotate the
speculum around its long axis until all surfaces
of the vagina and cervix are visualized. Be
careful not to pull on the pubic hair or pinch
the labia with the speculum. Separating the
labia majora with your other hand can help to
avoid this.
62

Two

methods help you to avoid placing

pressure on the sensitive urethra. (1) When
inserting the speculum, hold it at an angle
(shown below on the left), and then (2) slide
the speculum inward along the posterior wall
of the vagina, applying downward pressure to
keep the vaginal introitus relaxed.

63

1. Inspect the vagina for the following:

a. The presence of blood
b. Discharge. This should be studied to detect trichomoniasis,
monilia, and clue cells and to obtain cultures, primarily for
gonococci and chlamydia.
c. Mucosal characteristics (i.e., color, lesions, superficial
vascularity, and edema)
The lesion may be:

1. Inflammatoryredness, swelling, exudates, ulcers,

vesicles
2. Neoplastic
3. Vascular
4. Pigmentedbluish discoloration of pregnancy
(Chadwick's sign)
5. Miscellaneous (e.g., endometriosis, traumatic
lesions, and cysts)
d. Structural abnormalities (congenital and acquired)
64

2.

Inspect the cervix for the same factors listed

above for the vagina. Note the following
comments relative to the inspection of the
cervix:
a.Unusual bleeding from the cervical canal, except
during menstruation, merits an evaluation for
cervical or uterine neoplasia.
b.Inflammatory lesions are characterized by a
mucopurulent discharge from the os and redness,
swelling, and superficial ulcerations of the surface.
c. Polyps may arise either from the surface of the
cervix projecting into the vagina or from the cervical
canal. Polyps may be inflammatory or neoplastic.
d.Carcinoma of the cervix may not dramatically
change the appearance of the cervix or may appear
as lesions similar in appearance to an inflammation.
Therefore, a biopsy should be performed if there is
suspicion of neoplasia.
65

Uterine cervix: normal and pathologic

appearance.

66

Differences in cervical os appearance due to labor and

delivery.
A. Nulliparous cervix.
B. Parous
cervix

67

D. Bimanual palpation
The pelvic organs can be outlined by bimanual
palpation; the examiner places one hand on the
lower abdominal wall and the finger(s) (one or
two) (see Fig.) of the other hand in the vagina (or
vagina and
rectum
in the
rectovaginal
examination) (see Fig.). Either the right or left
hand may be used for vaginal palpation. The
number of fingers inserted into the vagina should
be based on what can comfortably be
accommodated, the size and pliability of the
vagina, and the weight of the patient. For
example, adolescent, slender, and older patients
might be best examined with a single finger
technique.
68

1.Introduce the well-lubricated index finger and,

in some patients, both the index and the
middle finger into the vagina at its posterior
aspect near the perineum.
Test the strength of the perineum by pressing
downward on the perineum and asking the
patient to bear down. This procedure may
disclose a previously concealed cystocele or
rectocele and descensus of the uterus.
Advance the fingers along the posterior wall
until the cervix is encountered. Note any
abnormalities of structure or tenderness in the
vagina or cervix.

69

2. Press the abdominal hand, which is resting

on the infraumbilical area, very gently

downward, sweeping the pelvic structures
toward the palpating vaginal fingers.
Coordinate the activity of the two hands to
evaluate the body of the uterus for:
a. Position
b. Architecture, size, shape, symmetry, tumor
c. Consistency
d. Tenderness
e. Mobility

Tumors,

if

found, are evaluated for

location,
architecture,
consistency,
tenderness, mobility, and number.
70

3. Continue the bimanual palpation, and evaluate the

cervix for position, architecture, consistency, and
tenderness, especially on mobility of the cervix.
Rebound tenderness should be noted at this time.
The intravaginal fingers should then explore the
anterior, posterior, and lateral fornices.
4. Place the vaginal finger(s) in the right lateral
fornix and the abdominal hand on the right lower
quadrant. Manipulate the abdominal hand gently
downward toward the vaginal fingers to outline the
adnexa.
A normal tube is not palpable. A normal ovary (about
4 3 2 cm in size, sensitive, firm, and freely
movable) is often not palpable.
If an adnexal mass is found, evaluate its location
relative to the uterus and cervix, architecture,
consistency, tenderness, and mobility.
71

5. Palpate the left adnexal region, repeating the technique

described previously, but place the vaginal fingers in the
left fornix and the abdominal hand on the left lower
quadrant.
6. Follow the bimanual examination with a rectovaginal
abdominal examination.
The rectovaginal examination has three primary purposes:
To palpate a retroverted uterus, the uterosacral
ligaments, cul-de-sac, and adnexa;
To screen for colorectal cancer in women 50 years or
older; and
To assess pelvic pathology
Insert the index finger into the vagina and the middle
finger into the rectum very gently. Place the other hand on
the infraumbilical region. The use of this technique makes
possible higher exploration of the pelvis because the culde-sac does not limit the depth of the examining finger.
7. In patients who have an intact hymen, examine the
pelvic organs by the rectal-abdominal technique.
72

E. Rectal examination
1.Inspect the perianal and anal area, the pilonidal
(sacrococcygeal) region, and the perineum for the
following aspects:
a. Color of the region (note that the perianal skin is
more pigmented than the surrounding skin of the
buttocks and is frequently thrown into radiating folds)
b. Lesions

The perianal and perineal regions are common

sites for itching. Pruritus ani is usually indicated by

thickening, excoriations, and eczema of the
perianal region and adjacent areas.
The anal opening often is the site of fissures,
fistulae, and external hemorrhoids.
The pilonidal area may present a dimple, a sinus,
or an inflamed pilonidal cyst.
73

2.

Instruct the patient to strain down and note whether

this technique brings into view previously concealed
internal hemorrhoids, polyps, or a prolapsed rectal
mucosa.
3. Palpate the pilonidal area, the ischiorectal fossa, the
perineum, and the perianal region before inserting the
gloved finger into the anal canal.

Note the presence of any concealed induration or tenderness in any

of these areas.

4. Palpate the anal canal and rectum with a welllubricated, gloved index finger. Lay the pulp of the
index finger against the anal orifice and instruct the
subject to strain downward. Concomitant with the
patient's downward straining (which tends to relax the
external sphincter muscle), exert upward pressure until
the sphincter is felt to yield. Then, with a slight rotary
movement, insinuate the finger past the anal canal into
the rectum. Examine the anal canal systematically
before exploring the rectum.
74

5. Evaluate the anal canal

a.Tonus of the external sphincter muscle and the
anorectal ring at the anorectal junction
b. Tenderness (usually caused by a tight sphincter,
anal fissure, or painful hemorrhoids)
c. Tumor or irregularities, especially at the pectinate
line
d. Superior aspect: Reach as far as you can. Mild
straining by the patient may cause some lesions,
which are out of reach of the finger, to descend
sufficiently low to be detected by palpation.
e. Test for occult blood: Examine the finger after it is
withdrawn for evidence of gross blood, pus, or
other alterations in color or consistency. Smear the
stool to test for occult blood (guaiac).
75

6. Evaluate the rectum

a. Anterior wall
1.Cervix: size, shape, symmetry, consistency, and
tenderness, especially on manipulation
2. Uterine or adnexal masses
3. Rectouterine fossa for tenderness or
implants
In patients with an intact hymen, the
examination of the anterior wall of the rectum is
the usual method of examining the pelvic organs.

b. Right lateral wall, left lateral wall,

posterior wall, superior aspect; test for
occult blood

76

77

1, Graves extra long;

2,
3,
4,
5,
6,
7,

Graves regular;
Pederson extralong;
Pederson regular
Huffman virginal;
pediatric regular; and
pediatric narrow.
78

79

The bimanual examination.

80

The rectovaginal examination.

81

Assessment:
Plan:

Investigation.
Medical treatment
Surgical treatment.

82

A Big Blessing!!!!!

83