OnExam

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
  1. Warm metal speculum under water (test temperature on patient’s inner thigh)
  2. Small amount of water-soluble lubricant can be applied to the speculum (does NOT interfere with Pap cytology nor culture results)
  3. 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
  4. 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
  5. 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:
  • nodules or tenderness
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

  1. 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.
  2. 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.
  3. 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.
  4. Harmanli O, Jones KA. Using lubricant for speculum insertion. Obstet Gynecol. 2010;116(2):415-417.
  5. 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.
  6. 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.
  7. 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.
  8. Berger H, Crane J, Farine D. Screening for gestational diabetes mellitus. SOGC clinical practice guidelines. 2002; 24 (11) : 894- 903
  9. Money D. and Dobson S. The prevention of early-onset neonatal group B Streptococcal Disease. SOGC clinical practice guidelines. 2004; 26(9): 826-32
  10. 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.