OnExam
- Obstetric and Gynecological Physical Exam
Antenatal Examination
First Antenatal Visit
- Perform a complete head-to-toe physical examination
- Routine bloodwork includes CBC, Rh and blood type, antibody screen, TSH (as needed), HIV, VDRL, Hep B, Rubella
Routine Antenatal Visits
- Frequency varies but typical practice is every 4 weeks until 28weeks, then every 2 weeks until 36weeks then weekly until delivery.
- Assess the vital signs, special attention to BP
- Weight
- Recommended total weight gain for singleton pregnancy varies based on pre-pregnancy BMI:
- Low BMI (< 19.8): 12.5-18 kg (28-40 lb)
- Normal BMI (19.8-26): 11.5-16 kg (25-35 lb)
- High BMI (26-29): 7-11.5 kg (15-25 lb)
- Obese BMI (> 29): ~7kg (15 lb)
- Urine dipstick monitoring for proteinuria
- Measure symphysis fundal height
- Perform Leopold’s manoeuvres
- Fetal lie - orientation of the long axis of the fetus to that of the mother
- Longitudinal
- Transverse
- Oblique
- Fetal presentation - portion of the fetal body that is at the mother’s pelvic outlet
- Cephalic: fetal head is presenting
- Breech: sacrum or foot is presenting; can be frank, complete, or footling
- Transverse: shoulder or arm is presenting
- Fetal position - Relationship of the presenting part to the maternal pelvis
- This can only be determined intrapartum
- If cephalic presentation, most common position is left occiput anterior (LOA)
- Right occiput anterior (ROA), Left occiput transverse (LOT), Left sacrum posterior (LSP; breech), etc.
- Measure the fetal heart rate (FHR)
- Earliest detectability of fetal cardiac activity: 5 weeks via transvaginal ultrasound
- Hand-held Doppler instruments (“Doptone”) can usually identify FHR at ~10-12 weeks
- Earlier in pregnancy: Best done in the midline of the lower abdomen
- One technique is to place the transducer at the fundus of the uterus and aim downwards toward the vagina
- Having patient take a breath and then exhaling deeply can help relax her abdominal muscles
- Third trimester: FHR can be best detected over the fetal chest/back
- Use the information from Leopold’s manoeuvres
- e.g., if fetal presentation is cephalic and fetal back is on the maternal left, place transducer over the maternal left lower quadrant
- Normal FHR: 120-160bpm (upper end of this range during early pregnancy and lower end near term)
- Perform focused physical examination for any maternal symptoms (e.g., spotting, headaches, cough, etc.)
- Gestational Diabetes Screen at 24-28 weeks
- Group B strep rectovaginal swab at 35-37 weeks
- There are a number of signs of pregnancy that can be seen on physical examination. These include:
Pelvic Examination
Before the Examination
Patient
- Empty bladder
- Dorsal lithotomy position (heels in stirrups, slide buttocks to edge of bed, allow knees to fall out to side, head and shoulders elevated to 30°, arms at sides or folded across chest)
- Drape from midabdomen to knees and depress drape for eye contact
- Offer for a female chaperone
Examiner
- Communication is key!
- Inform patient of each step; be aware of wording (avoid trigger words such as "relax")
- Warm metal speculum with water
- Monitor comfort
- Be gentle
Equipment
- Gloves
- Speculum (small, medium, large)
- Pedersen: narrow, flat bills (elderly, not yet sexually active)
- Graves: wider, curved bills (sexually active)
- Light (overhead or attached to speculum)
- Water-soluble lubricant
- Swabs for cultures
- Cytology container and broom
External Examination
Patient
- In adolescent patients, assess sexual maturity using Tanner staging
- Inspect for masses, excoriations, erythema, maculopapules, vesicles, nits/lice:
- Mons pubis
- Labia
- Perineum
- Perianal area
- Separate labia and inspect the following for any inflammation, ulcerations, discharge, swelling, nodules:
- Labia minora
- Clitoris (enlarged in masculinizing conditions)
- Urethral meatus (urethral caruncle, prolapse)
- Introitus
- If swelling or history, palpate Bartholin's glands
Speculum Examination
Patient
- Warm metal speculum under water (test temperature on patient’s inner thigh)
- Small amount of water-soluble lubricant can be applied to the speculum (does NOT interfere with Pap cytology nor culture results)
- Avoid pressure on sensitive urethra:
- Gently insert speculum at slight angle from midline (e.g., 2 o'clock)
- Apply downward pressure and advance along a downward slope
- Rotate the speculum back to midline once inserted
- Carefully open the speculum to bring cervix into view
- Slightly withdraw speculum and reposition to visualize entire cervix
- Retroverted uterus: cervix may point more anteriorly
- Use swab to help clear secretions if obscuring your view
Cervix
- Note colour, position, surface characteristics, ulcerations, nodules, masses, bleeding, discharge (colour, consistency, amount, odour)
Swabs for culture
- Commonly testing for: Chlamydia, gonorrhea, bacterial vaginosis, trichomonas, yeast
- Location of swab is variable: Familiarize yourself with swabs available to you and how they are collected
Pap Smear
- Samples collected from both endocervix and ectocervix
- Cervical broom
- Insert into os and rotate 3-5 times in same direction
- Goal: collect cells from both endocervix and ectocervix
- Remove brush and place into preservative for liquid cytology
- Cervical spatula and endocervical brush
- Ayre’s spatula rotated 360° around os (ectocervix)
- Inserted brush into os (endocervix) and rotate 3 times
- Smear both samples onto glass slide and spray with fixative
- Only spatula used for Pap smear in pregnant women >10 weeks gestation
Vagina
- As you slowly withdraw speculum, observe the vaginal mucosa
- Note colour, inflammation, discharge, ulcers, masses
Bimanual Examination
Set up
- Lubricate index and middle finger of one of your gloved hands
- Stand at patient's side
- Applying posterior pressure towards perineum, insert two fingers into vagina
- With thumb extended and 4th/5th fingers flexed into palm, palpate:
Vaginal wall:
Cervix
Uterus
- Place other hand on patient's lower abdomen midway between umbilicus and symphysis pubis
- Elevate cervix and uterus with internal hand and press abdominal hand in and down to grasp uterus between hands
- Size, shape, consistency, mobility, tenderness, masses
- From anterior fornix, can palpate surface of the anteverted uterus; nodules may suggest myoma
- If retroverted uterus, may feel uterus against fingers at posterior fornix
Ovaries
- Abdominal hand on right lower quadrant and pelvic hand in right lateral fornix; try to identify right ovary or right adnexal masses
- If possible, note size, shape, consistency, mobility, tenderness
Rectovaginal Examination
- Some providers perform on all patients while others use specific indications (ie.Pelvic pain/mass, rectal symptoms, colon cancer screening, hx of pelvic cancer)
- Always perform after bimanual examination
- Index finger inserted into vagina and middle finger inserted into rectum
- Note sphincter tone
- Sweep horizontally against each other in scissoring fashion to assess septum (e.g., scarring)
- Remove index finger and use middle finger to palpate all sides of rectal vault (tenderness, nodules, masses)
Conclusion
- Provide patient with towel to wipe herself and panty liner/pad
- Explain that some spotting may occur
References
- Bernstein HB, Weinstein M. Normal pregnancy & prenatal care. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:187-202.
- Bickley LS. Female genitalia. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 429-457.
- Bickley LS, Thompson, JE. The pregnant woman. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 817-838.
- Harmanli O, Jones KA. Using lubricant for speculum insertion. Obstet Gynecol. 2010;116(2):415-417.
- Kawada C. Gynecologic history, examination, & diagnostic procedures. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:519-539.
- Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, eds. Well Woman Care. In: Williams Gynecology. New York: McGraw-Hill; 2008:2-24.
- Rowe T, Senikas V, Pothier M, Fairbanks J, Sams D. Canadian consensus guidelines on human papillomavirus. SOGC Clinical Practice Guidelines. No. 196. J Obstet Gynaecol Can. 2007;29(8 Suppl 3):S1-S56. http://www.sogc.org/guidelines/documents/gui196CPG0708revised.pdf. Accessed February 17, 2011.
- Berger H, Crane J, Farine D. Screening for gestational diabetes mellitus. SOGC clinical practice guidelines. 2002; 24 (11) : 894- 903
- Money D. and Dobson S. The prevention of early-onset neonatal group B Streptococcal Disease. SOGC clinical practice guidelines. 2004; 26(9): 826-32
- Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE. Chapter 14. Pediatric Gynecology. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE, eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.