Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter !+ , The -emale .e"rod/cti)e ystem Cha"ter !+ The -emale .e"rod/cti)e ystem P0++% 1""lied anatomy The "el)is The bony "el)is is com"osed of the % "el)ic bones 2ith the sacr/m and coccyx "osteriorly0 The "el)ic brim di)ides the 345false "el)is346 abo)e 7"art of the abdominal ca)ity8 and the 345tr/e "el)is346 belo20 Pel)ic inlet: also kno2n as the "el)ic brim0 -ormed by the sacral "romontory "osteriorly, the ilio"ectineal lines laterally and the sym"hysis "/bis anteriorly0 Pel)ic o/tlet: formed by the coccyx "osteriorly, the ischial t/berosities laterally and the "/bic arch anteriorly0 The "el)ic o/tlet has 9 2ide notches0 The sciatic notches are di)ided into the greater and lesser sciatic foramina by the sacrot/bero/s and sacros"ino/s ligaments 2hich can be considered "art of the "erimeter of the o/tlet clinically0

The "el)ic ca)ity: lies bet2een the inlet and the o/tlet0 :t has a dee" "osterior 2all and a shallo2 anterior 2all gi)ing a c/r)ed sha"e0

The contents of the "el)ic ca)ity The "el)ic ca)ity contains the rect/m, sigmoid colon, coils of the ile/m, /reters, bladder, female re"rod/cti)e organs, fascia, and "eritone/m0 -emale internal genital organs ;agina The )agina is a thin,2alled distensible, fibrom/sc/lar t/be that extends /"2ards and back2ards from the )estib/le of the )/l)a to the cer)ix0 :t is <=cm long and lies "osterior to the bladder and anterior to the rect/m0 The )agina ser)es as an eliminatory "assage for menstr/al flo2, forms "art of the birth canal, and recei)es the "enis d/ring sex/al interco/rse0 The fornix This is the )aginal recess aro/nd the cer)ix and is di)ided into anterior, "osterior, and lateral regions 2hich, clinically, "ro)ide access "oints for examining the "el)ic organs0 (ter/s The /ter/s is a thick,2alled, hollo2, "ear,sha"ed m/sc/lar organ consisting of the cer)ix, body and f/nd/s0 :n the n/lli"aro/s female, it is <=cm long, <>cm 2ide, and <%0>cm dee"0 The /ter/s is co)ered 2ith "eritone/m that forms an anterior /tero)esical fold, a fold bet2een the /ter/s and rect/m termed the "o/ch of ?o/glas, and the broad ligaments laterally0 The /ter/s recei)es, retains, and no/rishes the fertili@ed o)/m0 (terine orientation :n most females, the /ter/s lies in an ante)erted and anteflexed "osition0 1nte)ersion: the long axis of the /ter/s is angled for2ard0

.etro)ersion: The f/nd/s and body are angled back2ards and therefore lie in the "o/ch of ?o/glas0 Occ/rs in abo/t !>A of the female "o"/lation0 1 f/ll bladder may mimic retro)ersion clinically0 1nteflexion: the long axis of the body of the /ter/s is angled for2ard on the long axis of the cer)ix0 .etroflexion: The body of the /ter/s is angled back2ard on the cer)ix

P0++9 -allo"ian t/bes The fallo"ian or 345/terine346 t/bes are "aired t/b/lar str/ct/res, <!&cm long0 The fallo"ian t/bes extend laterally from the corn/a of the /terine body, in the /""er border of the broad ligament and o"ens into the "eritoneal ca)ity near the o)aries0 The fallo"ian t/be is di)ided into + "arts: :nf/ndib/l/m: distal, f/nnel,sha"ed "ortion 2ith finger,like 345fimbriae3460 1m"/lla: 2idest and longest "art of t/be o/tside the /ter/s0

:sthm/s: thick,2alled 2ith a narro2 l/men and therefore, least distensible "art0 Enters the horns of the /terine body0 :ntram/ral: that "art 2hich "ierces the /terine 2all0

The main f/nctions of the /terine t/be are to recei)e the o)/m from the o)ary, "ro)ide a site 2here fertili@ation can take "lace 7/s/ally in the am"/lla8 and trans"ort the o)/m from the am"/lla to the /ter/s0 The t/be also "ro)ides no/rishment for the fertili@ed o)/m0 O)aries The o)aries are 2hitish,grey, almond,sha"ed organs meas/ring <+cmBC%cm 2hich are res"onsible for the "rod/ction of the female germ cells, the o)a, and the female sex hormones, oestrogen and "rogesterone0 They are s/s"ended on the "osterior layer of the broad ligament by a "eritoneal extension 7meso)ari/m8 and s/""orted by the s/s"ensory ligament of the o)ary 7a lateral extension of the broad ligament and meso)ari/m8 and the ro/nd ligament 2hich stretches from the lateral 2all of the /ter/s to the medial as"ect of the o)ary0 Perine/m The "erine/m lies inferior to the "el)ic inlet and is se"arated from the "el)ic ca)ity by the "el)ic dia"hragm0 een from belo2 2ith the thighs abd/cted, it is a diamond,sha"ed area bo/nded anteriorly by the "/bic sym"hysis, "osteriorly by the ti" of the coccyx and laterally by the ischial t/berosities0

The "erine/m is artificially di)ided into the anterior /rogenital triangle containing the external genitalia in females and an anal triangle containing the an/s and ischiorectal fossae0

-emale external genital organs

These are sometimes collecti)ely kno2n as the 345)/l)a3460 :t consists of: Dabia maEora: a "air of fat,filled folds of skin extending on either side of the )aginal )estib/le from the mons to2ards the an/s0 Dabia minora: a "air of flat folds containing a core of s"ongy connecti)e tiss/e 2ith a rich )asc/lar s/""ly0 Die medial to the labia maEora0

;estib/le of the )agina: bet2een the labia minora, contains the /rethral meat/s and )aginal orifice0 .ecei)es m/co/s secretions from the greater and lesser )estib/lar glands0 Clitoris: short, erectile organ; the female homolog/e of the male "enis0 Dike the "enis, a cr/s arises from each ischio"/bic ram/s and Eoin in the midline forming the 345body346 ca""ed by the sensiti)e 345glans3460 F/lbs of )estib/le: % masses of elongated erectile tiss/e, <9cm long, lying along the sides of the )aginal orifice0 Greater and lesser )estib/lar glands0

P0+++ 1""lied "hysiology The menstr/al cycle Menstr/ation is the shedding of the f/nctional s/"erficial %H9 of the endometri/m after sex hormone 2ithdra2al0 This "rocess, 2hich consists of 9 "hases, is ty"ically re"eated <9&&,+&& times d/ring a 2omanIs life0 Coordination of the menstr/al cycle de"ends on a com"lex inter"lay bet2een the hy"othalam/s, the "it/itary gland, the o)aries, and the /terine endometri/m0 Cyclical changes in the endometri/m "re"are it for im"lantation in the e)ent of fertili@ation and menstr/ation in the absence of fertili@ation0 :t sho/ld be noted that se)eral other tiss/es are sensiti)e to these hormones and /ndergo cyclical change 7e0g0 the breasts and the lo2er "art of the /rinary tract80 The endometrial cycle can de di)ided into 9 "hases34J Phases of the menstr/al cycle The first day of the menses is considered to be day ! of the menstr/al cycle0 The "roliferati)e or follic/lar "hase This begins at the end of the menstr/al "hase 7/s/ally day +8 and ends at o)/lation 7days !9,!+80 ?/ring this "hase, the endometri/m thickens and o)arian follicles mat/re0 The hy"othalam/s is the initiator of the follic/lar "hase0 Gonadotro"hinreleasing hormone 7Gn.H8 is released from the hy"othalam/s in a "/lsatile fashion to the "it/itary "ortal system s/rro/nding the anterior "it/itary gland0 Gn.H ca/ses release of follicle stim/lating hormone 7- H80 - H is secreted into the general circ/lation and interacts 2ith the gran/losa cells s/rro/nding the di)iding oocytes0 - H enhances the de)elo"ment of !>,%& follicles each month and interacts 2ith gran/losa cells to enhance aromati@ation of androgens into oestrogen and oestradiol0 Only one follicle 2ith the largest reser)oir of oestrogen can 2ithstand the declining - H en)ironment 2hilst the remaining follicles /ndergo atresia at the end of this "hase0

-ollic/lar oestrogen synthesis is essential for /terine "riming, b/t is also "art of the "ositi)e feedback that ind/ces a dramatic "reo)/latory le/teinising hormone 7DH8 s/rge and s/bseK/ent o)/lation0 The l/teal or secretory "hase The l/teal "hase starts at o)/lation and lasts thro/gh to day %= of the menstr/al cycle0 The maEor effects of the DH s/rge are the con)ersion of gran/losa cells from "redominantly androgen,con)erting cells to "redominantly "rogesterone,synthesising cells0 High "rogesterone le)els exert negati)e feedback on Gn.H 2hich, in t/rn, 3LM - HHDH secretion0 1t the beginning of the l/teal "hase, "rogesterone ind/ces the endometrial glands to secrete glycogens, m/c/s, and other s/bstances0 These glands become tort/o/s and ha)e large l/mina d/e to 3LN secretory acti)ity0 "iral arterioles extend into the s/"erficial layer of the endometri/m0 P0++> :n the absence of fertili@ation by day %9 of the menstr/al cycle, the s/"erficial endometri/m begins to degenerate and conseK/ently o)arian hormone le)els 3LM0 1s oestrogen and "rogesterone le)els fall, the endometri/m /ndergoes in)ol/tion0 :f the cor"/s l/te/m is not resc/ed by h/man chorionic gonadotro"hin 7hCG8 hormone from the de)elo"ing "lacenta, menstr/ation occ/rs !+ days after o)/lation0 :f conce"tion occ/rs, "lacental hCG maintains l/teal f/nction /ntil "lacental "rod/ction of "rogesterone is 2ell established0 The menstr/al "hase This "hase sees the grad/al 2ithdra2al of o)arian sex steroids 2hich ca/ses slight shrinking of the endometri/m, and therefore the blood flo2 of s"iral )essels is red/ced0 This, together 2ith s"iral arteriolar s"asms, leads to distal endometrial ischaemia and stasis0 Extra)asation of blood and endometrial tiss/e breakdo2n lead to onset of menstr/ation0 The menstr/al "hase begins as the s"iral arteries r/"t/re, releasing blood into the /ter/s and the a"o"tosing endometri/m is slo/ghed off0 ?/ring this "eriod, the f/nctionalis layer of the endometri/m is com"letely shed0 1rteriolar and )eno/s blood, remnants of endometrial stroma and glands, le/cocytes and red blood cells are all "resent in the menstr/al flo20 hedding /s/ally lasts <+ days0 P0++O History,taking in gynaecology :t is im"ortant to remember that many females can be embarrassed by ha)ing to disc/ss their gynaecological "roblems, so it is )ital to a""ear confident, friendly, and relaxed0 1ltho/gh there are "arts "artic/lar to this history, most of it is the same as the basic o/tline described in Cha"ter % and 2e s/ggest that readers re)ie2 that cha"ter before going on0 ?emogra"hic details Pame, age, date of birth, occ/"ation0 Presenting com"laint 1sk the "atient to tell yo/ in her o2n 2ords 2hat she "ercei)es the main sym"tom or sym"toms to be0 ?oc/ment each in order of se)erity0 History of "resenting com"laint

More detailed K/estioning 2ill de"end on the nat/re of the "resenting com"laint34Qsee the follo2ing "ages0 1s described on "09O ascertain: The exact nat/re of the sym"tom0 The onset0
o o

Rhen and ho2 it began 7e0g0 s/ddenly, grad/ally34Qo)er ho2 longS8 :f longstanding, 2hy is the "atient seeking hel" no2S

Periodicity and freK/ency0

o o o o

:s the sym"tom constant or intermittentS :f intermittent, ho2 long does it last each timeS Rhat is the exact manner in 2hich it comes and goesS 3TU Ho2 does it relate to the menstr/al cycleS

Change o)er time0 Exacerbating and relie)ing factors0 1ssociated sym"toms0 The degree of f/nctional disability ca/sed0

Menstr/al history 1ge of menarche 7first menstr/al "eriod80 o Pormally abo/t !% years b/t can be as early as V or as late as !O0

?ate of last menstr/al "eriod 7DMP80 ?/ration and reg/larity of "eriods 7cycle80
o o

Pormal menstr/ation lasts +,' days0 1)erage length of menstr/al cycle is %= days 7i0e0 the time bet2een first day of one "eriod and the first day of the follo2ing "eriod8 b/t can )ary bet2een %! and +% days in normal 2omen0 "0++=80

Menstr/al flo2: 2hether light, normal, or hea)y 7see

Menstr/al "ain: 2hether occ/rs "rior to or at the start of bleeding0 :rreg/lar bleeding0
o

E0g0 intermenstr/al blood,loss, "ost,coital bleeding etc0

1ssociated sym"toms0
o

Fo2el or bladder dysf/nction, "ain0

Hormonal contrace"tion or H.T0 1ge at meno"a/se 7if this has occ/rred80

P0++' Past gynaecological history .ecord all details of: Pre)io/s cer)ical smears, incl/ding date of last smear, any abnormal smear res/lts, and treatments recei)ed0 Pre)io/s gynaecological "roblems and treatments incl/ding s/rgery and "el)ic inflammatory disease0 Contrace"tion :t is also essential to ask sex/ally acti)e 2omen of re"rod/cti)e age abo/t contrace"tion, incl/ding methods /sed, d/ration of /se and acce"tance, c/rrent method, as 2ell as f/t/re "lans0 Past obstetric history

Gra)idity and "arity: see

"0+O' for a f/ll ex"lanation0

?oc/ment the s"ecifics of each "regnancy: C/rrent age of the child and age of mother 2hen "regnant0 Firth 2eight0

Com"lications of "regnancy, labo/r, and "/er"eri/m0 Miscarriages and terminations0 Pote gestation time and com"lications0

Past medical history 1s described in Cha"ter %0 Pay "artic/lar attention to any history of chronic l/ng or heart disease and make note of all "re)io/s s/rgical "roced/res0 ?r/g history 1s in Cha"ter %0 1sk abo/t all medicationHdr/gs taken 7"rescribed, o)er the co/nter and illicit dr/gs80 .ecord dose, freK/ency, as 2ell as any kno2n dr/g allergies0 3TU Make "artic/lar note to ask abo/t the oral contrace"ti)e "ill 7OCP8 and hormone re"lacement thera"y 7H.T8 if not done so already0 -amily history Pote es"ecially any history of genital tract cancer, breast cancer and diabetes0 moking and alcohol 1s al2ays, doc/ment f/lly as described on "0++0

ocial history Take a standard Hx incl/ding li)ing conditions and marital stat/s0 This is also an extra chance to ex"lore the im"act of the "resenting "roblem on the "atientIs life34Qin terms of their social life, em"loyment, home life, and sex/al acti)ity0 P0++= 1bnormal bleeding in gynaecology Menorrhagia This is defined as *=&ml of menstr/al blood loss "er "eriod 7normal W %&,O&ml8 and may be ca/sed by a )ariety of local, systemic, or iatrogenic factors0 Menorrhagia is hard to meas/re, b/t "eriods are considered 345hea)y346 if they lead to freK/ent changes of sanitary to2els0 1s 2ell as the standard K/estions for any sym"tom, ask abo/t: The n/mber of sanitary "adsHto2els /sed "er day and the 345strength346 7absorbency8 of those "ads0 Fleeding thro/gh to clothes or onto the bedding at night 7345flooding34680

The need to /se % "ads at once0 The need to 2ear do/ble "rotection 7i0e0 "ad and tam"on together80 :nterference 2ith normal acti)ities0 3TU .emember to ask abo/t sym"toms of iron deficiency anaemia s/ch as lethargy, breathlessness, and di@@iness0

?ysmenorrhoea This is "ain associated 2ith menstr/ation34Qtho/ght to be ca/sed by 3LN le)els of endometrial "rostaglandins d/ring the l/teal and menstr/al "hases of the cycle res/lting in /terine contractions0 The "ain is ty"ically cram"ing, locali@ed to the lo2er abdomen and "el)ic regions, and radiating to the thighs and back0 ?ysmenorrhoea may be "rimary or secondary: Primary: occ/rring from menarche0 econdary: occ/rring in females 2ho "re)io/sly had normal "eriods 7often ca/sed by "el)ic "athology80 Rhen taking a history of dysmenorrhoea, take a f/ll "ain history as on "09V, a detailed

menstr/al history 7 "0++O8, and ask es"ecially abo/t the relationshi" of the "ain to the menstr/al cycle0 .emember to ask abo/t the f/nctional conseK/ences of the "ain34Qho2 does it interfere 2ith normal acti)itiesS :ntermenstr/al bleeding 7:MF8 :ntermenstr/al bleeding is /terine bleeding 2hich occ/rs bet2een the menstr/al "eriods0

1s for all these sym"toms, a f/ll standard battery of K/estions sho/ld be asked 7 f/ll menstr/al history 7 "0++O8, "ast medical and gynaecological histories 7

"09=8, as "0+%8 and

sex/al history 7 "0+&=80 1sk also abo/t the association of the bleeding 2ith hormonal thera"y, contrace"ti)e /se and "re)io/s cer)ical smears0 Postcoital bleeding This is )aginal bleeding "reci"itated by sex/al interco/rse0 :t can be ca/sed by similar conditions to intermenstr/al bleeding0 Take a f/ll and detailed history as abo)e0 P0++V Fox !+0! ome ca/ses of menorrhagia Hy"othyroidism0 :ntra,/terine contrace"ti)e de)ice 7:(C?80

-ibroids0 Endometriosis0 Poly"s34Qcer)ix, /ter/s0 (terine cancer0 :nfection 7 T:s80 Pre)io/s sterili@ation0 Rarfarin thera"y0 1s"irin0 Pon,steroidal anti,inflammatory dr/gs 7P 1:?s80 Clotting disorders 7e0g0 )on,RillebrandIs disease80

Fox !+0% ome ca/ses of secondary dysmenorrhoea Pel)ic inflammatory disease0 Endometriosis0

(terine adenomyosis0 -ibroids0 Endometrial "oly"s0 Premenstr/al syndrome0

Cessation of OCP0

Fox !+09 ome ca/ses of intermenstr/al bleeding Obstetric "regnancy, ecto"ic "regnancy, gestational tro"hoblastic disease0 Gynaecological: )aginal malignancy, )aginitis, cer)ical cancer, adenomyosis, fibroids, o)arian cancer0

:atrogenic anticoag/lants, corticosteroids, anti"sychotics, tamoxifen, and anti,e"ile"tic dr/gs 71E?s80

.:s, rifam"icin,

Fox !+0+ ome ca/ses of "ost,coital bleeding imilar to intermenstr/al bleeding, as 2ell as: ;aginal infection 2ith Chlamydia, gonorrhoea, trichomaniasis or yeast0 1lso cer)icitis0 P0+>& 1menorrhoea This is the absence of "eriods and may be 345"rimary346 or 345secondary3460 Primary: fail/re to menstr/ate by !O years of age in the "resence of normal secondary sex/al de)elo"ment or fail/re to menstr/ate by !+ years in the absence of secondary sex/al characteristics0 econdary: normal menarche, then cessation of menstr/ation 2ith no "eriods for at least O months0 3TU 1menorrhoea is a normal feat/re in "re"/bertal girls, "regnancy, d/ring lactation, "ostmeno"a/sal females, and in some 2omen /sing hormonal contrace"tion0 History,taking 1 f/ll and detailed history sho/ld be taken as described on es"ecially abo/t: Childhood gro2th and de)elo"ment0 :f secondary amenorrhoea:
o o o o o

"0++O, and

Cha"ter %0 1sk

1ge of menarche0 Cycle days0 ?ay and date of DM P0 Presence or absence of breast soreness0 Mood change immediately before menses0

Chronic illnesses0 Pre)io/s s/rgery 7incl/ding cer)ical s/rgery 2ith can ca/se stenosis and more ob)io/sly oo"horectomy and hysterectomy80

Prescribed medications kno2n to ca/se amenorrhoea s/ch as "henothia@ines, dom"eridone and metoclo"ramide 7"rod/ce either hy"er"rolactinaemia or o)arian fail/re80 :llicit or 345recreational346 dr/gs0 ex/al history0 Hx incl/ding any emotional stress at schoolH2orkHhome, exercise and diet34Qincl/de here any 2eight gain or 2eight loss0 ystems enK/iry: incl/de )asomotor sym"toms, hot fl/shes, )irili@ing changes 7e0g0 3LN body hair, greasy skin etc8, galactorrhoea, headaches, )is/al field dist/rbance, "al"itations, ner)o/sness, hearing loss0

Postmeno"a/sal bleeding This is )aginal bleeding occ/rring *O months after the meno"a/se0 :t reK/ires reass/rance and "rom"t in)estigation as it co/ld indicate the "resence of malignancy0 1s 2ell as all the "oints o/tlined abo)e, ask abo/t: Docal sym"toms of oestrogen deficiency s/ch as )aginal dryness, soreness, and

s/"erficial dys"are/nia 7 "0+>%80 :tching 7"r/rit/s )/l)ae34Qmore likely in non,neo"lastic disorders80 Presence of l/m"s or s2ellings at the )/l)a0

Cer)ical or endometrial malignancy Often "resent 2ith "rof/se or contin/o/s )aginal bleeding or 2ith a bloodstained offensi)e discharge0 P0+>! Fox !+0> ome ca/ses of amenorrhoea Hy"othalamic: idio"athic, 2eight loss, intense exercise0 Hy"ogonadism from hy"othalamic or "it/itary damage: t/mo/rs, cranio"haryngiomas, cranial irradiation, head inE/ries0

Pit/itary: hy"er"rolactinaemia, hy"o"it/itarism0 ?elayed "/berty: constit/tional delay0 ystemic: chronic illness, 2eight loss, endocrine disorders 7e0g0 C/shingIs syndrome, thyroid disorders80 (terine: m/llerian agenesis0 O)arian: PCO , "remat/re o)arian fail/re 7e0g0 T/rnerIs syndrome, a/toimm/ne disease, s/rgery, chemothera"y, "el)ic irradiation, infection80

Psychological: emotional stress at schoolHhomeH2ork0

Fox !+0O ome ca/ses of "ost,meno"a/sal bleeding Cer)ical carcinoma0 (terine sarcoma0

;aginal carcinoma0 Endometrial hy"er"lasiaHcarcinomaH"oly"s0 Cer)ical "oly"s0 Tra/ma0 Hormone re"lacement thera"y0 Fleeding disorder0 ;aginal atro"hy0

P0+>% Other sym"toms in gynaecology Pel)ic "ain and dys"are/nia 1s 2ith any ty"e of "ain, "el)ic "ain may be ac/te or chronic0 Chronic "el)ic "ain is often associated 2ith dys"are/nia0 ?ys"are/nia is "ainf/l sex/al interco/rse and may be ex"erienced s/"erficially at the area of the )/l)a and introit/s on "enetration or dee" 2ithin the "el)is0 ?ys"are/nia can lead to fail/re to reach orgasm, the a)oidance of sex/al acti)ity and relationshi" "roblems0 Fox !+0' Gynaecological )ers/s gastrointestinal "ain ?isting/ishing bet2een "ain of gynaecological and gastrointestinal origin is often diffic/lt0 This is beca/se the /ter/s, cer)ix, and adnexa share the same )isceral inner)ation as the lo2er ile/m, sigmoid colon, and rect/m0 Xo/ sho/ld be caref/l in yo/r history to r/le o/t a gastrointestinal "roblem and kee" an o"en mind0 Rhen taking a history of "el)ic "ain or dys"are/nia, yo/ sho/ld obtain a detailed history as for any ty"e of "ain 7 "09V8 incl/ding site, radiation, character, se)erity, mode and rate of onset, d/ration, freK/ency, exacerbating factors, relie)ing factors, and associated sym"toms0 Xo/ also need to establish the relationshi" of the "ain to the menstr/al cycle0 1sk also abo/t: ?ate of DMP0 Cer)ical smears0

:ntermenstr/al or "ost,coital bleeding0 Pre)io/s gynaecological "roced/res 7e0g0 :(C?, hysterosco"y80 Pre)io/s "el)ic inflammatory disease or genito/rinary infections0

Pre)io/s gynaecological s/rgery 7adhesion formationS80 ;/l)al discharge0 Fo2el habit, na/sea, and )omiting 7 "0%%O80

1 detailed sex/al history 7 "0+&=8 sho/ld also incl/de contrace"ti)e /se and the degree of im"act the sym"toms ha)e on the "atientIs normal life, and "sychological health0

;aginal discharge ;aginal discharge is a common com"laint d/ring the child,bearing years0 1s 2ell as the standard K/estions 7 "0++O8 ask abo/t: Colo/r, )ol/me, odo/r, and "resence of blood0 :rritation0

3TU ?onIt forget to ask abo/t diabetes and obtain a f/ll ?Hx incl/ding recent antibiotic /se34Qboth of 2hich may "reci"itate candidal infection0 Obtain a f/ll sex/al history 7 "0+&=80 1 f/ll gynaecological history sho/ld incl/de history of cer)ical smear testing, /se of ring "essaries, and recent history of s/rgery 73LN risk of )esico)aginal fist/lae80 3TU Do2er abdominal "ain, backache, and dys"are/nia s/ggest P:?0 3TU Reight loss and anorexia may indicate /nderlying malignancy0

P0+>9 Physiological )aginal discharge Physiological discharge is /s/ally scanty, m/coid, and odo/rless0 :t occ/rs 2ith the changing oestrogen le)els d/ring the menstr/al cycle 7discharge 3LN in K/antity mid,cycle and is a "hysiological sign of o)/lation8 and "regnancy0 :t may arise from )estib/lar gland secretions, )aginal trans/date, cer)ical m/c/s, and resid/al menstr/al fl/id0 Pathological )aginal discharge This /s/ally re"resents infection 7trichomonal or candidal )aginitis8 and may be associated 2ith "r/rit/s or b/rning of the )/l)al area0 Candida albicans: the discharge is ty"ically thick and ca/ses itching0 Facterial )aginitis: the discharge is grey and 2atery 2ith a fishy smell0 een es"ecially after interco/rse0

Trichomonas )aginalis: the discharge is ty"ically "rof/se, o"aK/e, cream,colo/red and frothy0 :t also has a characteristic 345fishy346 smell0 This may also be accom"anied by /rinary sym"toms, s/ch as dys/ria and freK/ency0

Fox !+0= ome ca/ses of dys"are/nia cars from e"isiotomy0 ;aginal atro"hy0

;/l)itis0 ;/l)ar )estib/litis0 P:?0 O)arian cysts0 Endometriosis0 ;aricose )eins in "el)is0 Ecto"ic "regnancy0 :nfections 7 T:s80 Fladder or /rinary tract disorder0 Cancer in the re"rod/cti)e organs or "el)ic region0

P0+>+ ;/l)al sym"toms The main sym"tom to be a2are of is itching or irritation of the )/l)a 7"r/ritis )/l)ae80 :t can be debilitating and socially embarrassing0 Embarrassment often delays the 2oman seeking ad)ice0 Ca/ses incl/de infection, )/l)al dystro"hy, neo"lasia, and other dermatological conditions0 1sk es"ecially abo/t: The nat/re of onset, exacerbating and relie)ing factors0 1bnormal )aginal discharge0

History of cer)ical intrae"ithelial neo"lasia34QC:P 7tho/ght to share a common aetiology 2ith )/l)al intrae"ithelial neo"lasia34Q;:P80 ex/al history0 ?ermatological conditions s/ch as "soriasis and ec@ema0 ym"toms s/ggesti)e of renal or li)er "roblems 7 ?iabetes0 "0%9+80

(rinary incontinence This is an obEecti)ely demonstrable in)ol/ntary loss of /rine that can be both a social and hygienic "roblem0 The t2o most common ca/ses of /rinary incontinence in females are gen/ine stress incontinence 7G :8 and detr/ser o)er,acti)ity 7?O80 Other less commonly enco/ntered ca/ses incl/de mixed G : and ?O, sensory /rgency, chronic )oiding "roblems and fist/lae0 Rhen taking a history of /rinary incontinence, ascertain /nder 2hat circ/mstances they ex"erience the sym"tom0 ee also "0%9O0 .emember to ask abo/t the f/nctional conseK/ences on the "atientIs daily life0 Gen/ine stress incontinence Patients notice small amo/nts of /rinary leakage 2ith a co/gh, snee@e, or exercise0 One third may also admit to sym"toms of ?O0 1sk abo/t: P/mber of children 73LN risk 2ith 3LN "arity80 Genital "rola"se0

Pre)io/s "el)ic floor s/rgery0

?etr/ser o)er,acti)ity (rge incontinence, /rgency, freK/ency and noct/ria 7see History of noct/rnal en/resis0 Pre)io/s ne/rological "roblems0

"0%9O80 1sk abo/t:

Pre)io/s incontinence s/rgery0 :ncontinence d/ring sex/al interco/rse0 ?Hx 7see note /nder 345the elderly "atient346 "0+=+80

O)erflo2 incontinence ;oiding disorders can res/lt in chronic retention leading to o)erflo2 incontinence and 3LN "redis"osition to infection0 The "atient may com"lain of hesitancy, straining, "oor flo2, and incom"lete em"tying in addition to /rgency and freK/ency0 -ist/lae /s"ect if incontinence is contin/o/s d/ring the day and night0 P0+>> Genital "rola"se Genital "rola"se is descent of the "el)ic organs thro/gh the "el)ic floor into the )aginal canal0 :n the female genital tract, the ty"e of "rola"se is named according to the "el)ic organ in)ol)ed0 ome exam"les incl/de: (terine: /ter/s0 Cystocoele: bladder0

;aginal )a/lt "rola"se: a"ex of )agina after hysterectomy0 Enterocoele: small bo2el0 .ectocoele: rect/m0

Mild degrees of genital "rola"se are often asym"tomatic0 More extensi)e "rola"se may ca/se )aginal "ress/re or "ain, introital b/lging, a feeling of 345something coming do2n346, as 2ell as im"aired sex/al f/nction0 (terine descent often gi)es sym"toms of backache es"ecially in older "atients0 There might be associated sym"toms of incom"lete bo2el em"tying 7rectocoele8 or /rinary sym"toms s/ch as freK/ency or incom"lete em"tying 7cystocoele or cysto,/rethrocoele80 Fox !+0V ome ca/ses of genital "rola"se Oestrogen deficiency states: s/ch as ad)ancing age and the meno"a/se 7atro"hy and 2eakness of the "el)ic s/""ort str/ct/res80 Childbirth: "rolonged labo/r, instr/mental deli)ery, fetal macrosomia, 3LN "arity0

Genetic factors: e0g0 s"ina bifida0 Chronic raised intra,abdominal "ress/re: e0g0 chronic co/gh, consti"ation0

Fox !+0!& ome other common )/l)al conditions ?ermatitis: ato"ic, seborrhoeic, irritant, allergic, steroid,ind/ced 7itch, b/rning, erythema, scale, fiss/res, lichenification80 ;/l)o)aginal candidiasis: itch, b/rning, erythema, )aginal discharge0

Dichen scleros/s: itch, b/rning, dys"are/nia, 2hite "laK/es, atro"hic 2rinkled s/rface0 Psoriasis: remember to look for other areas of "soriasis; scal", natal cleft, nails0 ;/l)al intrae"ithelial neo"lasia: itch, b/rning, m/ltifocal "laK/es0 Erosi)e )/l)o)aginitis: erosi)e lichen "lan/s, "em"higoid, "em"hig/s )/lgaris, fixed dr/g er/"tion 7chronic "ainf/l erosion and /lcers 2ith s/"erficial bleeding80 1tro"hic )aginitis: secondary to oestrogen deficiency 7thin, "ale, dry )aginal e"itheli/m0 /"erficial dys"are/nia, minor )aginal bleeding and "ain80

P0+>O O/tline gynaecological examination The gynaecological examination sho/ld incl/de a f/ll abdominal examination before "roceeding to the "el)ic, s"ec/l/m, and biman/al examinations0 Ex"lain to the "atient that yo/ 2o/ld like to examine their genitalia and re"rod/cti)e organs and reass/re them that the "roced/re 2ill be K/ick and gentle0 Xo/ sho/ld ha)e a cha"erone "resent, "artic/larly if yo/ are maleY0 1s al2ays, ens/re that the room is 2arm and 2ell lit, "referably 2ith a mo)eable light so/rce and that yo/ 2ill not be dist/rbed0

The examination sho/ld follo2 an orderly ro/tine0 The a/thorsI s/ggestion is sho2n belo20 :t is standard "ractice to start 2ith the cardio)asc/lar and res"iratory systems34Qthis not only gi)es a meas/re of the general health of the "atient b/t establishes a 345"hysical ra""ort346 before yo/ examine more delicate or embarrassing areas0 Fox !+0!! -rame2ork for the gynaecological examination General ins"ection0 Cardiores"iratory examination0

1bdominal examination0 Pel)ic examination

o o o o

External genitalia34Qins"ection0 External genitalia34Q"al"ation0 "ec/l/m examination0 Fiman/al examination 7345P;346 examination80

3TU Perform bedside /rinalysis, if able0 Y This is contro)ersial at the time of 2riting34Qattit/des )ary bet2een co/ntries0 :n the (Z, official ad)ice is that all doctors sho/ld ha)e a cha"erone 2hen "erforming an intimate examination and the cha"erone sho/ld be the same sex as the "atient0 :n "ractice, male doctors "erforming an examination on a female and females "erforming an examination on a male sho/ld al2ays ha)e a cha"erone "resent 2hilst the need for a cha"erone in other sit/ations is E/dged at the time0 General ins"ection and other systems 1l2ays begin 2ith a general examination of the "atient 7as described in Cha"ter 98 incl/ding tem"erat/re, hydration, coloration, n/tritional stat/s, lym"h nodes, and blood "ress/re0 Pote es"ecially: ?istrib/tion of facial and body hair, as hirs/tism may be a "resenting sym"tom of )ario/s endocrine disorders0 Height and 2eight0

Examine the cardio)asc/lar and res"iratory systems in t/rn 7see

Cha"ters ' and =80

Freast examination is a ro/tine "art of the "roced/re in gynaecology in many co/ntries0 :n the (Z, it sho/ld be "erformed 7 2omen o)er +> years0 P0+>' 1bdominal examination Cha"ter !98 if there are sym"toms or at first cons/ltation in

1 f/ll abdominal examination sho/ld be "erformed 7see Cha"ter V80 Dook es"ecially in the "eri/mbilical region for scars from "re)io/s la"arosco"ies and in the s/"ra"/bic region 2here trans)erse incisions from caesarean sections and most gynaecological o"erations are fo/nd0 P0+>= Pel)ic examination The "atient sho/ld be allo2ed to /ndress in "ri)acy and, if necessary, to em"ty her bladder first0 et,/" and "ositioning Fefore starting the examination, al2ays ex"lain to the "atient 2hat 2ill be in)ol)ed0 Ens/re the abdomen is co)ered0 Ens/re good lighting and remember to 2ear dis"osable glo)es0 1sk the "atient to lie on her back on an examination co/ch 2ith both knees bent /" and let her knees fall a"art34Qeither 2ith her heels together in the middle or se"arated0 The lithotomy "osition, in 2hich both thighs are abd/cted and feet s/s"ended from lithotomy stirr/"s is /s/ally ado"ted 2hen "erforming )aginal s/rgery0 Examination of the external genitalia (nco)er the mons to ex"ose the external genitalia making note of the "attern of hair distrib/tion0 1""ly a l/bricating gel to the examining finger0

e"arate the labia from abo)e 2ith the forefinger and th/mb of yo/r left hand0 :ns"ect the clitoris, /rethral meat/s, and )aginal o"ening0 Dook es"ecially for any:
o o o o o

?ischarge0 .edness0 (lceration0 1tro"hy0 Old scars0

1sk the "atient to co/gh or strain do2n and look at the )aginal 2alls for any "rola"se0

Pal"ation Pal"ate the length of the labia maEora bet2een the index finger and th/mb0 o The tiss/e sho/ld feel "liant and fleshy0

Pal"ate for FartholinIs gland 2ith the index finger of the right hand E/st inside the introit/s and the th/mb on the o/ter as"ect of the labi/m maEora0
o

FatholinIs glands are only "al"able if the d/ct becomes obstr/cted res/lting in a "ainless cystic mass or an ac/te FartholinIs abscess0 The latter is seen as a hot, red, tender s2elling in the "osterolateral labia maEora0

P0+>V P0+O& "ec/l/m examination "ec/l/m examination is carried o/t to see f/rther inside the )agina and to )is/ali@e the cer)ix0 :t also allo2s the examiner to take a cer)ical smear or s2abs0 There are different ty"es of )aginal s"ec/la 7see -ig0 !+0!8 b/t the commonest is the C/scoIs or bi)al)e s"ec/l/m0 :t is im"ortant that yo/ familiari@e yo/rself 2ith the o"eration of the s"ec/l/m before examining a "atient so that yo/ can concentrate on the findings0 :nserting the s"ec/l/m Ex"lain to the "atient that yo/ are abo/t to insert the s"ec/l/m into the )agina and "ro)ide reass/rance that this sho/ld not be "ainf/l0 Rarm the s"ec/l/m /nder r/nning 2ater and l/bricate it 2ith a 2ater,based l/bricant0

(sing the left hand, o"en the li"s of the labia minora to obtain a good )ie2 of the introit/s0 Hold the s"ec/l/m in the right hand 2ith the main body of the s"ec/l/m in the "alm 7see -ig0 !+0%8 and the closed blades "roEecting bet2een index and middle fingers0 Gently insert the s"ec/l/m into the )agina held 2ith yo/r 2rist t/rned s/ch that the blades are in line 2ith the o"ening bet2een the labia0 The s"ec/l/m sho/ld be angled do2n2ards and back2ards d/e to the angle of the )agina0 Maintain a "osterior ang/lation and rotate the s"ec/l/m thro/gh V&#[ to "osition handles anteriorly0 Rhen it cannot be ad)anced f/rther, maintain a do2n2ard "ress/re and "ress on the th/mb "iece to hinge the blades o"en ex"osing the cer)ix and )aginal 2alls0 Once the o"tim/m "osition is achie)ed, tighten the th/mbscre20

-indings :ns"ect the cer)ix 2hich is /s/ally "ink, smooth and reg/lar0 Dook for the external os 7central o"ening8 2hich is ro/nd in the n/lli"aro/s female and slit,sha"ed after childbirth0 Dook for cer)ical erosions 2hich a""ear as stra2berry,red areas s"reading circ/mferentially aro/nd the os and re"resent extension of the endocer)ical e"itheli/m onto the s/rface of the cer)ix0

:dentify any /lceration or gro2ths 2hich may s/ggest cancer0 Cer)icitis may gi)e a m/co"/r/lent discharge associated 2ith a red, inflamed cer)ix 2hich bleeds on contact0 Take s2abs for c/lt/re0

.emo)ing the s"ec/l/m 3TU This sho/ld be cond/cted 2ith as m/ch care as insertion0 Xo/ sho/ld still be examining the )aginal 2alls as the s"ec/l/m is 2ithdra2n0 (ndo the th/mbscre2 and 2ithdra2 the s"ec/l/m0
o

The blades sho/ld be held o"en /ntil their ends are )isible distal to the cer)ix to a)oid ca/sing "ain0

.otate the o"en blades in an anticlock2ise direction to ens/re that the anterior and "osterior 2alls of the )agina can be ins"ected0 Pear the introit/s, allo2 the blades to close taking care not to "inch the labia or hairs0

P0+O!

-ig0 !+0! 7a8 imIs s"ec/l/m34Q/sed mainly in the examination of 2omen 2ith )aginal "rola"se0 7b8 C/scoIs s"ec/l/m0

-ig0 !+0% Hold the s"ec/l/m in the right hand s/ch that the handles lie in the "alm and the blades "roEect bet2een the index and middle fingers0 Fox !+0!% 1 2ord abo/t s"ec/la Many de"artments and clinical areas no2 /sed "lasticHdis"osable s"ec/la0 These do not ha)e a th/mb,scre2 b/t a ratchet to o"enHclose the blades0 Take care to familiari@e yo/rself 2ith the o"eration of the s"ec/l/m before starting the examination0 P0+O% Fiman/al examination ?igital examination hel"s identify the "el)ic organs0 :deally the bladder sho/ld be em"tied, if not already done so by this stage0 This examination is often kno2n as "er )aginam or sim"ly 345P;3460 Getting started Ex"lain again to the "atient that yo/ are abo/t to "erform an internal examination of the )agina, /ter/s, t/bes, and o)aries and obtain )erbal consent0

The "atient sho/ld be "ositioned as described on

"0+>'0

Ex"ose the introit/s by se"arating the labia 2ith the th/mb and forefinger of the glo)ed left hand0 Gently introd/ce the l/bricated index and middle fingers of the right hand into the )agina0

:nsert yo/r fingers 2ith the "alm facing laterally and then rotate V&#[ so that the "alm faces /"2ards0 The th/mb sho/ld be abd/cted and the ring and little finger flexed into the "alm 7see -ig0 !+0980

;agina, cer)ix and fornices -eel the 2alls of the )agina 2hich are slightly r/gose, s/""le and moist0 Docate the cer)ix34Q/s/ally "ointing do2n2ards in the /""er )agina0
o o

The normal cer)ix has a similar consistency to the cartilage in the ti" of the nose0 1ssess the mobility of the cer)ix by mo)ing it from side to side and note any tenderness 7345excitation3468 2hich s/ggests infection0

Gently "al"ate the fornices either side of the cer)ix0 Place yo/r left hand on the lo2er anterior abdominal 2all abo/t +cm abo)e the sym"hysis "/bis0 Mo)e the fingers of yo/r right 345internal346 hand to "/sh the cer)ix /"2ards and sim/ltaneo/sly "ress the fingerti"s of yo/r left 345external346 hand to2ards the internal fingers0
o

(ter/s

Xo/ sho/ld be able to ca"t/re the /ter/s bet2een yo/r % hands0

Pote the follo2ing feat/res of the /terine body:

o

i@e: a /niformly enlarged /ter/s may re"resent a "regnancy, fibroid or endometrial t/mo/r0 ha"e: m/lti"le fibroids tend to gi)e the /ter/s a lob/lated feel0 Position0 /rface characteristics0 1ny tenderness0 3TU .emember that an ante)erted /ter/s is easily "al"able biman/ally b/t a retro)erted /ter/s may not be0

o o o o o

1ssess a retro)erted /ter/s 2ith the internal fingers "ositioned in the "osterior fornix0

O)aries and fallo"ian t/bes Position the internal fingers in each lateral fornix 7finger "/l"s facing the anterior abdominal 2all8 and "lace yo/r external fingers o)er each iliac fossa in t/rn0 P0+O9

Press the external hand in2ards and do2n2ards and the internal fingers /"2ards and laterally0 -eel the adnexal str/ct/res 7o)aries and fallo"ian t/bes8, assessing si@e, sha"e, mobility and tenderness0
o

O)aries are firm, o)oid and often "al"able0 :f there is /nilateral or bilateral o)arian enlargement, consider benign cysts 7smooth and com"ressible8 and malignant o)arian t/mo/rs0 Pormal fallo"ian t/bes are im"al"able0 There may be marked tenderness of the lateral fornices and cer)ix in ac/te infection of the fallo"ian t/bes 7sal"ingitis80

o o

Masses :t is often not "ossible to differentiate bet2een adnexal and /terine masses0 Ho2e)er, there are some general r/les: (terine masses may be felt to mo)e 2ith the cer)ix 2hen the /ter/s is shifted /"2ards 2hile adnexal masses 2ill not0 :f s/s"ecting an adnexal mass, there sho/ld be a line of se"aration bet2een the /ter/s and the mass and the mass sho/ld be felt distinctly from the /ter/s0

Rhilst the consistency of the mass may hel" to disting/ish its origin in certain cases, an /ltraso/nd may be necessary0

-inishing the examination Rithdra2 yo/r fingers from the )agina0 o :ns"ect the glo)e for blood or discharge0

.e,dra"e the genital area and allo2 the "atient to re,dress in "ri)acy,offer them assistance if needed0

-ig0 !+09 Correct "osition of the fingers of the right hand for "er )aginam examination0

-ig0 !+0+ Fiman/al examination of the /ter/s0 P0+O+ Taking a cer)ical smear Theory The (Z has a Pational creening Program to detect "re,malignant conditions of the cer)ix0 Romen bet2een the ages of %& and O> years recei)e an in)itation to attend for screening e)ery 9 years0 1 sam"le of cells from the sK/amo,col/mnar E/nction are obtained and a cytological examination "erformed to look for e)idence of ceri)al intrae"ithelial neo"lasia 7C:P80 This stage of the condition is easily and s/ccessf/lly treated0 The maEority of (nits are no2 /sing liK/id based cytology 7DFC8 in order to minimi@e the n/mber of inadeK/ate sam"les0 EK/i"ment "ec/la of different si@es0 ?is"osable glo)es0

.eK/est form0 am"ling de)ice,"lastic broom 7Cer)ex,Fr/sh#\80 DiK/id,based cytology )ial,"reser)ati)e for sam"le0 Patient information leaflet0

Fefore yo/ start Ens/re the 2oman /nderstands "/r"ose of examination0 ?isc/ss ho2 and 2hen she 2ill recei)e the res/lts0

Pro)ide a "atient information leaflet0 ?oc/ment the date of last menstr/al "eriod0 ?oc/ment the /se of hormonal treatment 7e0g0 contrace"tion, H.T80 .ecord the details of last smear and "re)io/s abnormal res/lts0 1sk abo/t irreg/lar bleeding 7e0g0 "ost,coital or "ost,meno"a/sal80 Rhere a""ro"riate, offer screening for Chlamydia infection 7/nder %> years, sym"tomatic80

Proced/re Pre"are 2oman as for )aginal examination remembering to make her comfortable and

allo2 "ri)acy34Qsee "0+O&0 Rrite the "atientIs identification details on DFC )ial0 :nsert C/sco s"ec/l/m to identify and )is/ali@e cer)ix as on abnormal feat/res of the cer)ix "0+O&0 .ecord any

:nsert the "lastic broom so that the central bristles of the br/sh are in the endocer)ical canal and the o/ter bristles in contact 2ith the ectocer)ix 7see fig0 !+0>80 (sing "encil "ress/re, rotate the br/sh > times in a clock2ise direction0
o

The bristles are be)elled to scra"e cells only on clock2ise rotation0

.inse the br/sh thoro/ghly in the "reser)ati)e 7ThinPre"#\8 or break off br/sh into the "reser)ati)e 7 /rePath#\80 Place in trans"ort "ackaging 2ith com"leted reK/est form0 .emo)e the s"ec/l/m as "0+O&0

1llo2 the "atient to re,dress in "ri)acy0

P0+O>

-ig0 !+0> The end of a ty"ical cer)ex,br/sh#\0

-ig0 !+0O .e"resentation of ho2 to /se a cer)ex,br/sh#\0 Pote that the longer, central bristles are 2ithin the cer)ical canal 2hist the o/ter bristles are in contact 2ith the ectocer)ix0 Fox !+0!9 Cer)ical smears in "regnancy

Cer)ical smears sho/ld not be "erformed d/ring "regnancy0 The increase in cer)ical m/c/s 7and res/ltant 3LM in the n/mber of cells obtained8 /s/ally renders the sam"le inadeK/ate and the res/lts /nreliable0 P0+OO History,taking in obstetrics 1ltho/gh there are "arts "artic/lar to this history, most is the same as the basic o/tline described in Cha"ter % and 2e s/ggest that readers re)ie2 that cha"ter before going on0

The "arts of the history detail belo2 are only those that differ from those described in Cha"ter % and earlier in this cha"ter 7 "0++O80 ?emogra"hic details Pame, age, and date of birth0 Gra)idity and "arity34Qsee Fox !+0!>0 Estimated date of deli)ery 7E??8 The E?? can be calc/lated from the last menstr/al "eriod 7DMP8 by PaegeleIs r/leY, 2hich ass/mes a %=,day menstr/al cycle0 Fox !+0!+ Calc/lating the E?? /btract 9 months from the first day of the DMP0 1dd on ' days and ! year0 :f the normal menstr/al cycle is ]%= days, or *%= days, then an a""ro"riate n/mber of days sho/ld be s/btracted from or added to the E??0 -or exam"le, if the normal cycle is 9> days, ' days sho/ld be added to the E??0 :t is im"ortant to also consider at this "oint any detail that may infl/ence the )alidity of the E?? as calc/lated from the DMP; s/ch as: Ras the last "eriod normalS Rhat is the /s/al cycle lengthS

1re the "atientIs "eriods /s/ally reg/lar or irreg/larS Ras the "atient /sing the oral contrace"ti)e "ill in the 9 months "rior to conce"tionS :f so, calc/lations based on her DMP are /nreliable0

Pamed after the German Obstetritian, -ran@ Paegele follo2ing its "/blication in his Dehrb/ch der Geb/rtsh/elfe "/blished for mid2i)es in !=9&0 The form/la 2as act/ally de)elo"ed by Harmanni Foerhaa)e0 Foerhaa)e H0 7!'++8 Praelectiones 1cademicae in Pro"ias :nstit/tiones .ei Medicae0 ;on Haller 1, ed0 GBUttingen: ;andehoeck0 > 7"art %8: +9'0 C/rrent "regnancy 1bo/t the "atientIs general health and that of her fet/s0 :f there is a "resenting com"laint, the details sho/ld be doc/mented in f/ll as on -etal mo)ements0 "09=0 and "0++O0 1lso ask abo/t:

Pot /s/ally noticed /ntil %& 2eeksI gestation in the first "regnancy and != 2eeksI in the second or s/bseK/ent "regnancies0

1ny im"ortant laboratory tests or /ltraso/nd scans0

o

:ncl/de dates and details of all the scans, es"ecially the first scan 7dating or n/chal transl/cency scan80

P0+O' Fox !+0!> Gra)idity and "arity These terms can be conf/sing and, altho/gh it is 2orth kno2ing the definitions and ho2 to /se them, they sho/ld be s/""lemented 2ith a detailed history and not relied on alone as yo/ may miss s/btleties 2hich alter yo/r o/tlook on the case0 Gra)idity The n/mber of "regnancies 7incl/ding the "resent one8 to any stage0 Parity The n/mber of li)e births 7at any stage of gestation8 and stillbirths after %+ 2eeksI gestation0 Pregnancies terminating before %+ 2eeksI gestation can be 2ritten after this n/mber 2ith a "l/s sign0 Exam"les 1 2oman 2ho is c/rrently %& 2eeks "regnant and has had % normal deli)eries: o Gra)ida 9, Para %0

1 2oman 2ho is not "regnant and has had a single li)e birth and one miscarriage at !' 2eeks:
o

Gra)ida %, Para !^!0

1 2oman 2ho is c/rrently %> 2eeks "regnant, has had 9 normal deli)eries, one miscarriage at V 2eeks and a termination at ' 2eeks:
o

Gra)ida O, Para 9^%0

T2ins There is some contro)ersy as to ho2 to ex"ress t2in "regnancies0 Most "eo"le s/ggest that they sho/ld co/nt as ! for gra)idity and % for "arity34Qb/t yo/ sho/ld check yo/r local "ractice on this0 P0+O= Past obstetric history 1sk abo/t all of her "re)io/s "regnancies incl/ding miscarriages, terminations and ecto"ic "regnancies0 -or each "regnancy, note: 1ge of the mother 2hen "regnant0 1ntenatal com"lications0

?/ration of "regnancy0 ?etails of ind/ction of labo/r0 ?/ration of labo/r0 Presentation and method of deli)ery0 Firth 2eight and sex of infant0

3TU 1lso enK/ire abo/t any com"lications of the "/er"eral "eriod0 The "/er"eri/m is the "eriod from the end of the 9rd stage of labo/r /ntil in)ol/tion of the /ter/s is com"lete 7abo/t O 2eeks80 Possible com"lications incl/de: Post"art/m haemorrhage0 :nfections of the genital and /rinary tracts0

?ee" )ein thrombosis0 Perineal com"lications s/ch as breakdo2n of the "erineal 2o/nds0 Psychological com"lications 7e0g0 "ostnatal de"ression80

Past gynaecological history .ecord all "re)io/s gynaecological "roblems 2ith f/ll details of ho2 the diagnosis 2as made, treatments recei)ed, and the s/ccess or other2ise of that treatment0 .ecord the date of the last cer)ical smear and any "re)io/s abnormal res/lts0

Take a f/ll contrace"ti)e history0

Past medical history Take a f/ll PMH as on "0+%0 Pote es"ecially those conditions 2hich may ha)e an im"act on the "regnancy incl/ding: ?iabetes0 Thyroid disorders0

1ddisonIs disease0 1sthma0 E"ile"sy0 Hy"ertension0 Heart disease0 .enal disease0 :nfectio/s diseases s/ch as TF, H:;, sy"hilis, and he"atitis0

:dentification of s/ch conditions 2ill allo2 the obstetrician to consider early referral to a s"ecialist for shared care0

1ll "re)io/s o"erati)e "roced/res0 Flood transf/sions and recei"t of other blood "rod/cts0 Psychiatric history34Qmay extend beyond 345sim"le346 "ost,natal de"ression0

P0+OV ?r/g history

Take a f/ll ?Hx 7 "0++8 2hich sho/ld incl/de all "rescribed medication, o)er,the, co/nter medicines, and illicit dr/gs0 .ecord any dr/g allergies and their nat/re0 :f c/rrently "regnant, ens/re the "atient is taking +&&mcg of folic acid daily /ntil !% 2eeksI gestation to red/ce the incidence of s"ina bifida0

moking and alcohol 1 f/ll history sho/ld be taken, as al2ays 7 "0+O80 -amily history -Hx is an im"ortant as"ect of the obstetric history and sho/ld not be o)erlooked0 1sk abo/t any "regnancy,related conditions s/ch as congenital abnormalities, "roblems follo2ing deli)ery etc0 1sk also abo/t a -Hx of diabetes0

3TU 1sk es"ecially if there are any kno2n hereditary illnesses0 1""ro"riate co/nselling and in)estigations s/ch as chorionic )ill/s sam"ling or amniocentesis may need to be offered0

ocial history 1 f/ll standard Hx 7 "0+=8 sho/ld be taken0 1sk abo/t: Her "artner34Qage, occ/"ation, health0 Ho2 stable the relationshi" is0

:f she is not in a relationshi", 2ho 2ill gi)e her s/""ort d/ring and after the "regnancyS 1sk if the "regnancy 2as "lanned or not0 :f she 2orks, enK/ire abo/t her Eob and if she has any "lans to ret/rn to 2ork0 Xo/ may also /se this o""ort/nity to gi)e ad)ice on reg/lar exercises and the a)oidance of certain foods0 e0g0 t/na 7high Mg content8 soft cheeses 7risk of listeria8 calfIs

li)er 7high )itamin 1 content80 ee the Oxford Handbook of Obstetrics and Gynaecology! for more details0
!

1r/lk/maran 7%&&>80 Oxford Handbook of Obstetrics and Gynaecology0 Oxford (ni)ersity Press, Oxford0 Fox !+0!O 1 2ord abo/t deli)eries The )erb 345to deli)er346 is often mis/sed by st/dents of obstetrics as it is often mis/sed by the "o"/lation at large0 Fabies are not deli)ered0 :n fact, the mothers are 345deli)ered of346 the child,as in being relie)ed of a b/rden0 Check yo/r nearest dictionary_ P0+'& Presenting sym"toms in obstetrics Fleeding34Qd/ring "regnancy Treat as any sym"tom0 :n addition, yo/ sho/ld b/ild a clear "ict/re of ho2 m/ch blood is being lost, 2hen and ho2 it is affecting the c/rrent "regnancy0 1fter establishing an exact time,line and other details abo/t the sym"tom, ask abo/t: Exact nat/re of the bleeding 7freshHold80 1mo/nt of blood lost0
o

P/mber of sanitary "ads /sed daily0

Presence of clots 7and, if "resent, si@e of those clots80 Presence of "ieces of tiss/e in the blood0 Presence of m/coid discharge0 -etal mo)ement0 1ssociated sym"toms s/ch as abdominal "ain 7associated 2ith "lacental abr/"tion; "lacenta "rae)ia is "ainless80 Possible trigger factors34Qrecent interco/rse, inE/ries0 1ny history of cer)ical abnormalities34Qand the res/lt of the last smear0

1bdominal "ain 1 f/ll "ain history sho/ld be taken as on "09V incl/ding site, radiation, character, se)erity, mode and rate of onset, d/ration, freK/ency, exacerbating factors, relie)ing factors, and associated sym"toms0 Take a f/ll obstetric history and systems enK/iry0 1sk es"ecially abo/t a "ast history of "re, eclam"sia, "re,term labo/r, "e"tic /lcer disease, gallstones, a""endicectomy, cholecystectomy0 .emember that the "ain may be /nrelated to the "regnancy so kee" an o"en mind_ Ca/ses of abdominal "ain in "regnancy incl/de:

Obstetric: "retermHterm labo/r, "lacental abr/"tion, ligament "ain, sym"hysis "/bis dysf/nction, "re,eclam"siaHHEDDP syndrome, ac/te fatty li)er of "regnancy0 Gynaecological: o)arian cyst r/"t/re, torsion, haemorrhage, /terine fibroid degeneration0 Gastrointestinal: consti"ation, a""endicitis, gallstones, cholecystitis, "ancreatitis, "e"tic /lceration0 Genito/rinary: cystitis, "yelone"hritis, renal stones, renal colic0

Dabo/r "ain This is /s/ally intermittent, reg/lar in freK/ency and associated 2ith tightening of the abdominal 2all0 P0+'! Fox !+0!' ome ca/ses of )aginal bleeding in early "regnancy Re s/ggest the reader t/rns to the Oxford Handbook of Obstetrics and Gynaecology! for more detail0 Ecto"ic "regnancy ym"toms: light bleeding, abdominal "ain, fainting if "ain and blood loss is se)ere0 igns: closed cer)ix, /ter/s slightly larger and softer than normal, tender adnexal mass, cer)ical motion tenderness0 Threatened miscarriage ym"toms: light bleeding0 ometimes: cram"ing, lo2er abdominal "ain0 igns: closed cer)ix, /ter/s corres"onds to dates0 ometimes, /ter/s is softer than normal0 Com"lete miscarriage ym"toms: light bleeding0 ometimes: light cram"ing, lo2er abdominal "ain and a history of ex"/lsion of "rod/cts of conce"tion0 igns: /ter/s smaller than dates and softer than normal0 Closed cer)ix0 :ncom"lete miscarriage ym"toms: hea)y bleeding0 ometimes: cram"ing lo2er abdominal "ain, "artial ex"/lsion of "rod/cts of conce"tion0 igns: /ter/s smaller than dates and cer)ix dilated0 Molar "regnancy ym"toms: hea)y bleeding, "artial ex"/lsion of "rod/cts of conce"tion 2hich resemble gra"es0 ometimes: na/sea and )omiting, cram"ing lo2er abdominal "ain, history of o)arian cysts0 igns: dilated cer)ix, /ter/s larger than dates and softer than normal0 :nformation ada"ted from the RHO de"artment of re"rod/cti)e health research "/blication, 345;aginal bleeding in early "regnancy3460

1r/lk/maran 7%&&>80 Oxford Handbook of Obstetrics and Gynaecology0 Oxford (ni)ersity Press, Oxford0 P0+'% Fleeding,after "regnancy This is called 345"ost,"art/m haemorrhage346 or PPH0 Primary PPH: *>&&ml of blood loss 2ithin %+ ho/rs follo2ing deli)ery0 econdary PPH: any excess bleeding bet2een %+ ho/rs and O 2eeks "ost deli)ery0 7Po amo/nt of blood is s"ecified in the definition80 3TU Take a f/ll history as for bleeding d/ring "regnancy on "0+'&0 1sk also abo/t sym"toms of infection34Qan im"ortant ca/se of secondary PPH0 Hy"ertension Hy"ertension is a common and im"ortant "roblem in "regnancy and yo/ sho/ld be alert to the "ossible sym"toms 2hich can res/lt from it s/ch as headache, bl/rred )ision, )omiting and e"igastric "ain after %+ 2eeks, con)/lsions or loss of conscio/sness0 Pregnancy,ind/ced hy"ertension T2o readings of diastolic blood "ress/re V&,!!&, + ho/rs a"art after %& 2eeks gestation0 Po "rotein/ria0 Mild "rotein/ric "regnancy,ind/ced hy"ertension T2o readings of diastolic blood "ress/re V&,!!&, + ho/rs a"art after %& 2eeks gestation and "rotein/ria %^0 e)ere "rotein/ric "regnancy,ind/ced hy"ertension ?iastolic blood "ress/re !!& or greater after %& 2eeksI gestation and "rotein/ria 9^0 Other sym"toms may incl/de: hy"er,reflexia, headache, clo/ding of )ision, olig/ra, abdominal "ain, "/lmonary oedema0 Eclam"sia Con)/lsions associated 2ith raised blood "ress/re andHor "rotein/ria beyond %& 2eeks gestation0 May be /nconscio/s0 P0+'9 Fox !+0!= ome ca/ses of bleeding in %ndH9rd trimesters 7*%+ 2eeks8 This is kno2n as 345ante"art/m haemorrhage346 71PH80 ee the Oxford Handbook of Obstetrics and Gynaecology! for more detail0 Placenta "rae)ia The "lacenta is "ositioned o)er the lo2er "ole of the /ter/s, obsc/ring the cer)ix0 Fleeding is /s/ally after %= 2eeks and often "reci"itated by interco/rse0 -indings may incl/de a relaxed /ter/s, fetal "resentation not in "el)is and normal fetal condition0 Placental abr/"tion This is detachment of a normally located "lacenta from the /ter/s before the fet/s is deli)ered0 Fleeding can occ/r at any stage of the "regnancy0 Possible findings incl/de a tense, tender /ter/s, 3LM or absent fetal mo)ements, fetal distress, or absent fetal heart so/nds0 Fox !+0!V ome ca/ses of "ost,"art/m haemorrhage

Primary (terine atony 7most freK/ent ca/se80 Genital tract tra/ma0

Coag/lation disorders0 .etained "lacenta0 (terine in)ersion0 (terine r/"t/re0

econdary .etained "rod/cts of conce"tion0 Endometritis0

:nfection0

Fox !+0%& .isk factors for "ost,"art/m haemorrhage P/lli"arity, m/lti"arity, "olyhydramnios, "rolonged labo/r, m/lti"le gestation, "re)io/s PPH or 1PH, "re,eclam"sia, coag/lation abnormalities, genital tract lacerations, 1sian or His"anic ethnicity0 P0+'+ Fox !+0%! Minor sym"toms of "regnancy These so,called 345minor346 sym"toms of "regnancy are often ex"erienced by a n/mber of 2oman as normal, "hysiological changes occ/r0 This is not to say that they sho/ld be ignored as they may "oint to "athology0 Pa/sea and )omiting The se)erity )aries greatly and is more common in m/lti"le "regnancies and molar "regnancies0 Persistence of )omiting may s/ggest "athology s/ch as infections, gastritis, biliary tract disease or he"atitis0 Heartb/rnHgastro,oeso"hageal refl/x Heartb/rn is a freK/ent com"laint d/ring "regnancy d/e "artially to com"ression of the stomach by the gra)id /ter/s0 ee Consti"ation "0%%=0

Often secondary to 3LN "rogesterone0 :m"ro)es 2ith gestation 7 "0%9&80 hortness of breath ?/e to dilatation of the bronchial tree secondary to 3LN "rogesterone0 Peaks at %&,%+ 2eeks0 The gro2ing /ter/s also has an im"act0 Other "ossible ca/ses 7s/ch as PE8 need to be considered0 ee "0!V=0 -atig/e ;ery common in early "regnancy, "eaking at the end of the first trimester0 -atig/e in late "regnancy may be d/e to anaemia0

:nsomnia ?/e to anxiety, hormonal changes and "hysical discomfort0 Pr/rit/s Generali@ed itching in the third trimester may resol)e after deli)ery0 Filiary "roblems sho/ld be excl/ded 7 "0%9+80 Haemorrhoids May resol)e after deli)ery0 ;aricose )eins Es"ecially at the feet and ankles0 ;aginal discharge Excl/de infection and s"ontaneo/s r/"t/re of the membranes0 Pel)ic "ain tretching of "el)ic str/ct/res can ca/se ligament "ain 2hich resol)es in the second half of the "regnancy0 ym"hysis,"/bis dysf/nction ca/ses "ain on abd/ction and rotation at the hi"s and on mobili@ation0 Fackache Often first de)elo"s d/ring the >,'th months of "regnancy0 Peri"heral "araesthesiae -l/id retention can lead to com"ression of "eri"heral ner)es s/ch as car"al t/nnel syndrome0 Other ner)es can be affected, e0g0 lateral c/taneo/s ner)e of the thigh0 P0+'> P0+'O O/tline obstetric examination Ex"lain to the "atient that yo/ 2o/ld like to examine their 2omb and baby and reass/re them that the "roced/re 2ill be K/ick and gentle0 Xo/ sho/ld ha)e a cha"erone "resent, "artic/larly if yo/ are male0 1s al2ays, ens/re that the room is 2arm and 2ell lit, "referably 2ith a mo)eable light so/rce and that yo/ 2ill not be dist/rbed0 1s for the gynaecological examination, yo/ sho/ld follo2 an orderly ro/tine0 The a/thorsI s/ggestion is sho2n belo20 :t is standard "ractice to start 2ith the cardio)asc/lar and res"iratory systems,this not only gi)es a meas/re of the general health of the "atient b/t establishes a 345"hysical ra""ort346 before yo/ examine more delicate or embarrassing areas0 Fox !+0%% -rame2ork for the obstetric examination General ins"ection0 Cardiores"iratory examination0

1bdominal ins"ection0 1bdominal "al"ation0

o

(terine si@e0

o o o o

-etal lie0 -etal "resentation0 Engagement0 1mniotic fl/id estimation0

1/sc/ltation of the fetal heart0 ;aginal examination0

3TU Perform bedside /rinalysis 7"artic/larly "rotein8 if able0 General ins"ection 1l2ays begin 2ith a general examination of the "atient 7as in Cha"ter 98 incl/ding tem"erat/re, hydration, coloration, n/tritional stat/s, lym"h nodes, and blood "ress/re0 Pote es"ecially: 1ny bro2nish "igmentation o)er the forehead and cheeks kno2n as chloasma0 ?istrib/tion of facial and body hair, as hirs/tism may be a "resenting sym"tom of )ario/s endocrine disorders0

Height, 2eight, and calc/late FM: 7

"0OO80

3TU Flood "ress/re sho/ld be meas/red in the left lateral "osition at +>#[ to a)oid com"ression of the :;C by the gra)id /ter/s0 1naemia is a common com"lication of "regnancy so examine the m/cosal s/rfaces and conE/ncti)ae caref/lly 7 "0>=80 Cha"ters ' and =80

Examine the cardio)asc/lar and res"iratory systems in t/rn 7see

o

-lo2 m/rm/rs are common in "regnancy and, altho/gh /s/ally of no clinical significance, m/st be recorded in detail0

1 ro/tine breast examination is not normally indicated /nless a female "atient com"lains of breast sym"toms, in 2hich case yo/ m/st caref/lly look for any "athology s/ch as cysts or solid nod/les0

P0+'' P0+'=

1bdominal examination :ns"ection Dook for the abdominal distension ca/sed by the gra)id /ter/s rising from the "el)is0 Dook also for: 1symmetry0 -etal mo)ements0

/rgical scars0
o o

P/bic hairline 7trans)erse s/"ra"/bic Pfannenstiel incision80 Para/mbilical region 7la"arosco"ic scars80

C/taneo/s signs of "regnancy incl/ding:

o

Dinea nigra 7black line8 2hich stretches from the "/bic sym"hysis /"2ards in the midline0 .ed stretch marks of c/rrent "regnancy 7striae gra)idar/m80 Rhite stretch marks 7striae albicans8 from a "re)io/s "regnancy0 Other areas that can /ndergo "igmentation in "regnancy incl/de the ni""les, )/l)a, /mbilic/s and recent abdominal scars0

o o o

(mbilical changes:
o o

-lattening as "regnancy ad)ances0 E)ersion secondary to 3LN intra,abdominal "ress/re 7e0g0 ca/sed by m/lti"le "regnancies or "olyhydraminios80

Pal"ation Fefore "al"ating the abdomen, al2ays enK/ire abo/t any areas of tenderness and )isit those areas last0 Pal"ation sho/ld start as for any standard abdominal examination 7Cha"ter V8 before "roceeding to more s"ecific manoe/)res in an obstetric examination0 (terine si@e This "ro)ides an estimation of gestational age in 2eeks and is obEecti)ely meas/red and ex"ressed in centimetres as the sym"hysial,f/ndal height 7the distance from the sym"hysis "/bis to the /""er edge of the /ter/s80 Fox !+0%9 The sym"hysial,f/ndal height 7cm8 3`a 2eeks of gestation Fet2een !O,9O 2eeks, there is a margin of error of #b%cm, #b9cm at 9O,+& 2eeks, and #b+cm at +& 2eeks on2ards0

Xo/ need a ta"e,meas/re for this,donIt start 2itho/t it_ (se the /lnar border of the left hand to "ress firmly into the abdomen E/st belo2 the stern/m0

Mo)e the hand do2n the abdomen in small ste"s /ntil yo/ can feel the f/nd/s of the /ter/s0 Docate the /""er border of the bony "/bic sym"hysis by "al"ating do2n2ard in the midline starting from a fe2 centimetres abo)e the "/bic hair margin0 Meas/re the distance bet2een the t2o "oints that yo/ ha)e fo/nd in centimetres /sing a flexible ta"e,meas/re0

P0+'V

-ig0 !+0' The distance bet2een the f/nd/s 7/""er border of the /ter/s8 and the "/bic sym"hysis can be /sed as a g/ide to the n/mber of 2eeksI gestation0 Xo/ can also, therefore, E/dge 2hetherthe /ter/s is smaller or largerthan ex"ected 2hich may "oint to "roblems 2ith the "regnancy0 Fox !+0%+ (terine si@e34Qmilestones The /ter/s first becomes "al"able at !% 2eeksI gestation0 %& 2eeksI gestation W at the le)el of the /mbilic/s0

9O 2eeksI gestation W at the le)el of the xi"histern/m0

P0+=& -etal lie This describes the relationshi" bet2een the long axis of the fet/s and the long axis of the /ter/s and, in general, can be: Dongit/dinal: the long axis of the fet/s matches the long axis of the /ter/s0 Either the head or the breech 2ill be "al"able o)er the "el)ic inlet0 Trans)erse: the fet/s lies at right angles to the /ter/s and the fetal "oles are "al"able in the flanks0

ObliK/e: the long axis of the fet/s lies at an angle of +>#[ to the long axis of the /ter/s, the "resenting "art 2ill be "al"able in one of the iliac fossae0

Examination techniK/e The best "osition is to stand at the motherIs right side, facing her feet0 P/t yo/r left hand along the left side of the /ter/s0 P/t yo/r right hand on the right side of the /ter/s0

Pal"ate systematically to2ards the midline 2ith one and then the other hand34Q/se 345di""ing346 mo)ements 2ith flexion of the MCP Eoints to feel the fet/s 2ithin the amniotic fl/id0 Xo/ sho/ld feel the fetal back as firm resistance or the irreg/lar sha"e of the limbs0 Xo/ sho/ld no2 "al"ate more 2idely /sing the %,handed techniK/e abo)e to stabili@e the /ter/s and attem"t to locate the head and the breech0
o

The head can be felt as a smooth, ro/nd obEect that is ballotable34Qthat is, it can be 345bo/nced346 7gently8 bet2een yo/r hands0 The breech is softer, less discrete and is not ballotable0

-etal "resentation This is the "art of the fet/s that "resents to the motherIs "el)is0 Possible "resenting "arts incl/de: Head: 345ce"ahalic346 "resentation0 One o"tion in a longit/dinal lie0 Freech: 345"odalic346 "resentation0 The other o"tion in a longit/dinal lie0

ho/lder: seen in a trans)erse lie0

Examination techniK/e tand at the motherIs right side, facing her feet0 Place both hands on either side of the lo2er "art of the /ter/s

Fring the hands together firmly b/t gently0

Xo/ sho/ld be able to feel either the head, breech, or other "art as described abo)e /nder 345fetal lie3460

:t is also "ossible to /se a one,handed techniK/e 7Pa/likIs gri"8 to feel for the "resenting "art34Qthis is best left to obstetricians0 :n this, yo/ /se a c/""ed right hand to hold the lo2er "ole of the /ter/s0 This is "ossible in <V>A of "regnancies at abo/t +& 2eeks0 P0+=!

-ig0 !+0= ome exam"les of fetal lie0 P0+=% Engagement Rhen the 2idest "art of the fetal sk/ll is 2ithin the "el)ic inlet, the fetal head is said to be 345engaged3460 :n a ce"halic "resentation, "al"ation of the head is assessed and ex"ressed as the n/mber of fifths of the sk/ll "al"able abo)e the "el)ic brim0 1 fifth of a fetal sk/ll is ro/ghly eK/al to a finger breath on an ad/lt hand0 The head is engaged 2hen 9 or more fifths are 2ithin the "el)ic inlet34Qthat is 2hen % or less fifths are "al"able0 Rhen 9 or more fifths are "al"able, the head is not engaged0 P/mber of fet/ses The n/mber of fet/ses "resent can be calc/lated by assessing the n/mber of fetal "oles 7head or breech8 "resent0 :f there is one fet/s "resent, % "oles sho/ld be "al"able 7/nless the "resenting "art is dee"ly engaged80

:n a m/lti"le "regnancy, yo/ sho/ld be able to feel all the "oles exce"t one34Qas one is /s/ally t/cked a2ay o/t of reach0

1mniotic fl/idHliK/or )ol/me estimation The ease 2ith 2hich fetal "arts are "al"able can gi)e an indication as to the "ossibility of 3LM or 3LN amniotic fl/id )ol/me0 3LN )ol/me 2ill gi)e a large,for,dates /ter/s that is smooth and ro/nded0 The fetal "arts may be almost im"ossible to "al"ate0 3LM )ol/me may gi)e a small,for,dates /ter/s0 The fet/s 2ill be easily "al"able gi)ing an irreg/lar, firm o/tline to the /ter/s0 Perc/ssion This is /s/ally /nhel"f/l in an obstetric examination /nless yo/ s/s"ect "olyhydramnios 7increased amniotic fl/id )ol/me8, in 2hich case, yo/ may 2ish to attem"t to elicit a fl/id thrill 7 "0%O&80 1/sc/ltation 1/sc/ltation is /sed to listen to the fetal heart rate 7-H.80 This is /s/ally "erformed /sing an electronic hand,held ?o""ler fetal heart rate monitor and can be /sed as early as !+ 2eeks0 (sing PinardIs fetal stethosco"e 1 PinardIs fetal stethosco"e is not /sef/l /ntil %= 2eeksI gestation0 :t is a sim"le,looking de)ice rather like an old,fashioned ear,tr/m"et 7-ig0 !+0V80 Place the bell of the instr/ment o)er the anterior fetal sho/lder34Q2here the fetal heart so/nds are best heard0 Press yo/r left ear against the stethosco"e so as to hold it bet2een yo/r head and the motherIs abdomen in a 345hands,free346 "osition or hold the instr/ment lightly 2ith one hand0

Press against the o""osite side of the motherIs abdomen 2ith yo/r other hand so as to stabili@e the /ter/s0 :t sho/ld so/nd like a distant ticking noise0 The rate )aries bet2een !!& and !>&Hmin/te at term and sho/ld be reg/lar0 3TU .ecord the rate and rhythm of the fetal heart0

P0+=9 ;aginal examination ;aginal examination allo2s yo/ to assess cer)ical stat/s before ind/ction of labo/r0 Xo/ sho/ld attem"t this only /nder adeK/ate s/"er)ision if yo/ are /ns/re of the "roced/re0 This examination allo2s yo/ to assess the degree of cer)ical dilatation 7in centimetres8 /sing the examining fingers0 Examination of the )agina and cer)ix sho/ld be "erformed /nder ase"tic conditions in the "resence of r/"t/red membranes or in cases 2ith abnormal )aginal discharge0

TechniK/e The examination sho/ld be "erformed as described on "0+O%0 The findings take ex"erience to recogni@e0 The st/dent sho/ld not shy a2ay from this examination d/e to its intimate nat/re0 -indings 1ssess: ?egree of dilation0 o -/ll dilation of the cer)ix is eK/i)alent to !&cm0
o

Most obstetric de"artments 2ill ha)e "lastic models of cer)ices in )ario/s stages of dilatation 2hich yo/ can "ractice feeling0

The length of the cer)ix0

o

Pormal <9cm b/t shortens as the cer)ix effaces secondary to /terine contraction0

The consistency of the cer)ix 2hich can be described as:

o o o

-irm0 Mid,consistency0 oft 7this consistency facilitates effacement and dilatation80

Position0
o

1s the cer)ix /ndergoes effacement and dilatation it tends to be "/lled from a "osterior to an anterior "osition0

tation of the "resenting "art0

o

The le)el of the head abo)e or belo2 the ischial s"ines 2hich may be estimated in centimetres0

-ig0 !+0V 1 PinardIs stethosco"e0 P0+=+ The elderly "atient :t is easy to be sed/ced into thinking that the "rinci"al foc/s sho/ld be on )ery 345medical346 diagnoses s/ch as /rinary tract infections, 2hich contrib/te to significant morbidity 7and mortality8 in older "eo"le0 Continence iss/es are sadly o)erlooked in most clinical assessments34Qdes"ite costing the (Z Pational Health er)ice #c+%+m "er ann/m 7on fig/res from %&&&80 Darge,scale s/r)eys of "re)alence ha)e sho2n /" to %&A of 2omen o)er +& re"orting diffic/lties 2ith continence; so 2hilst more common in older "eo"le, yo/ sho/ld al2ays be mindf/l of "roblems in yo/nger ad/lts too0 1ltho/gh continence iss/es are one of the 345Geriatric Giants346 of disease "resentation, it is im"ortant to recall the "hysiology of the "ost meno"a/sal changes34Qs/ch as )aginal atro"hy and loss of secretions34Q2hich can com"licate /rinary tract infections, continence and /tero, )aginal "rola"se in older "atients0 1ssessment Tact and /nderstanding: altho/gh "roblems are common, "atients may be rel/ctant to disc/ss them, or ha)e them disc/ssed in front of others0 Engaging in a disc/ssion abo/t bladder andHor sex/al f/nction can seem da/nting34Qb/t if done em"athetically, remembering ne)er to a""ear to E/dge, or be embarrassed34Qyo/ may re)eal "roblems that ha)e serio/sly affected yo/r "atientIs K/ality of life0 Treating "roblems s/ch as these, e)en 2ith )ery sim"le inter)entions, can be of immeas/rable )al/e to the "atient0 Holistic assessment of /rinary "roblems: learn to think 2hen asking abo/t bladder f/nction, and 2ork o/t a "attern of dysf/nction34Qe0g0 bladder instability or stress incontinence0 .emember that bladder f/nction may be disr/"ted by dr/gs, "ain, lack of "ri)acy0 Continence iss/es may reflect "oor mobility, )is/al and cogniti)e decline0

Genital sym"toms: ne)er forget to consider )aginal or /terine "athology34Q)ie2 "ostmeno"a/sal bleeding 2ith s/s"icion0 ?ischarges may re"resent acti)e infection 7if candida34Qconsider diabetes8 or atro"hic )aginitis 7see o""osite80 Past medical history: "regnancies and "re)io/s s/rgery in "artic/lar may hel" "oint to a diagnosis of stress incontinence0 1re /rinary tract infections rec/rrent34Qhas bladder "athology been excl/dedS ?r/gs: many are ob)io/s34Qdi/retics and anticholinergics; some are more s/btle34Qsedati)es may "ro)oke noct/rnal loss of continence; ?oes yo/r "atient drink tea or coffeeS Tailored f/nctional history: the cornerstone of these "ages34Qand of any assessment yo/ "erform0 This largely relates to bladder f/nction34Qis the la)atory /" or do2nS Ho2 are the stairsS ?oes yo/r "atient already ha)e continence aids34QbottlesHcommodesH"ads, and do they manage 2ith themS

P0+=> Fox !+0%> 1 2ord on atro"hic )aginitis (" to +&A of "ostmeno"a/sal 2omen 2ill ha)e sym"toms and signs of atro"hic )aginitis and the )ast maEority 2ill be elderly and may be rel/ctant to disc/ss this 2ith their doctors0 1 res/lt of oestrogen deficiency, the s/bseK/ent 3LN )aginal "H and thinned endometri/m lead to both genital and /rinary sym"toms and signs0 3LM in )aginal l/brication "resents 2ith dryness, "r/rit/s, and discharges, accom"anied by an 3LN rate of "rola"se0 (rinary com"lications can res/lt in freK/ency, stress incontinence, and infections0 Caref/l "hysical examination often makes the diagnosis clear 2ith labial dryness, loss of skin t/rgidity, and smooth, shiny )aginal e"itheli/m0 1 range of treatment o"tions incl/ding to"ical oestrogens, sim"le l/bricants, and contin/ed sex/al acti)ity 2hen a""ro"riate are all key inter)entions to manage this common condition0 Re thank ?r .ichard -/ller for "ro)iding this "age0