History & Physical
Examination(H&P) in
OB/GYN
DR . R AYAN G . A L BA R A K ATI , M BBS , S B - O B
AS S ISTANT P ROF ESSOR OB/ GYN
HEA D OF OBST E TRI CS & GYN ECOLOGY
Introduction
Why the H&P?
What's special about OBGYN patients?
What's the difference in the OB/GYN H&P from the medical and
surgical one ?
The doctor should always:
1. Knock before entering the patient’s
room.
2. Identify himself or herself.
6. Ensure cleanliness, good grooming,
and good manners in all patient
encounters.
3. Meet the patient initially when she
is fully dressed, if possible.
7. Beware that a casual & familiar
approach is not acceptable to all
patients.
4. Address the patient courteously
and respectfully.
8. Maintain the privacy of the
patient’s medical info. & records.
5. Respect the patient’s privacy and
modesty.
9. Be mindful and respectful of any
cultural preferences.
Obstetric History
A complete history must be recorded at the time of:
•
The prepregnancy evaluation
•
At the initial antenatal visit
•
First encounter.
we start by documenting the patient identification including:
1.
Age
2.
Gravidity
3.
Parity
4.
Abortions
5.
last menstrual cycle (LMP)
6.
gestational age (GA) in weeks, Term , preterm, post date
7.
Expected date of confinement (EDC) or Expected date of delivery (EDD)
8.
Any significant medical illness
( G __ P__ + __ )
CHIEF COMPLAIN
In addition to any complain, you have to comment on:
1. Abdominal pain
2. Per vaginal loss
3. Fetal movement (after the age of viability)
HISTORY OF PRESENT ILLNESS
•
Details about the chief complain
•
Details about current pregnancy
PREVIOUS PREGNANCIES
Each prior pregnancy should be reviewed in chronologic order and the following
information recorded:
1. Date of delivery
2. Location of delivery
3. Duration of gestation in weeks
6. Type of anesthesia. Any
complications of anesthesia should be
noted.
7. Maternal complications
4. Type of delivery
(spont./induction/vaginal/instrumental 8. Newborn weight.
/operative)
9. Newborn gender.
5. Duration of labor in hours.
10. Fetal and neonatal complications
MENSTRUAL HISTORY
A good menstrual history is essential because it is the determinant for
establishing the EDC.
Nägele’s rule for establishing the EDC is to add 9 months and 7 days to the first
day of the last normal menstrual period
You will ask about:
Menarche, Regularity, duration, interval between cycles, amount of bleeding,
associated symptoms( pain, mood disturbance), inter-menstrual bleeding
Note the terms: oligo menorrhea, hypo menorrhea, menorrhagia, poly
menorrhea, Amenorrhea, menometrorrhagia
Obstetric wheel
CONTRACEPTIVE HISTORY
Oral contraceptives use and time of discontinuation
Intrauterine devices(IUDs), can cause early pregnancy loss, infection,
and premature delivery.
GYNECOLOGICAL HISTORY
• Hx of Gynecological diseases, e.g fibroids, polycyctic ovarian
syndrome (PCOS), ovarian cyst, pelvic inflammatory disease, etc.
•
Hx of infertility
•
Sexual Hx
MEDICAL HISTORY
In addition to common disorders, such as diabetes mellitus,
hypertension, and renal disease, which are known to affect
pregnancy outcome, all serious medical conditions should be
recorded.
SURGICAL HISTORY
• Each surgical procedure should be recorded chronologically, including:
• date
• hospital
• complications.
• Trauma must also be listed (e.g., a fractured pelvis may result in diminished
pelvic capacity).
SOCIAL HISTORY
•
Habits such as smoking, alcohol use, and other substance abuse.
•
The patient’s contact or exposure to domesticated animals
•
The patient’s type of work and lifestyle may affect the pregnancy.

DRUG HISTORY

FAMILY HISTORY

MEDICATION HISTORY

BLOOD TRANSFUSION AND ALLERGIES

VACCINATION HISTORY

SYSTEMIC REVIEW
Obstetric Physical
Examination
GENERAL PHYSICAL EXAMINATION
• This procedure must be systematic, thorough and performed as early as
possible in the prenatal period.
• A complete physical examination provides an opportunity to detect
previously unrecognized abnormalities.
•
Normal baseline levels must also be established, (Wt., BP, and cardiac status).
ABDOMINAL EXAMINATION
Inspection
Fundal height
Leopold's Maneuvers:
I.
First maneuver: Fundal Grip
II. Second maneuver: lateral Grip
III. Third maneuver: Pawlick's Grip
IV. Fourth maneuver: Pelvic Grip
PELVIC EXAMINATION
(1) inspection of the external genitalia,
vagina, and cervix.
Note: In cervix digital examination, you
comment on:
(2) collection of cytological specimens
I.
(3) Palpation of the cervix, uterus, and
adnexa.
II. Effacement
(4) Rectal and rectovaginal.
(5) Cervix assessment.
(6) Clinical pelvimetry
Dilatation
III. Position
IV. Consistency
V. Membrane status
VI. Liquor
Cervix appearance at speculum exam
Bimanual
examination for
adnexal
assessment
Bimanual Eamination for uterus
assessment
Clinical Pelvimetry
Assessing the diagonal
conjugate
SYMPTOMS & SYMPTOMS OF
PREGNANCY
SYMPTOMS
SIGNS
1.
Discoloration and cyanosis of the vulva,
vagina, and cervix (Chadwick’s sign)
2.
pigmentation of the midline of the lower
abdomen (linea nigra)
4. Nausea & Vomitting
3.
Pigmentation under the eyes (chloasma or
the mask of pregnancy)
5. Tiredness
4.
Early uterine changes (Piskacek’s sign ,
Hegar’s sign), round globular fundus
5.
Quickening
1. Amenorrhea
2. Urinary frequency
3. Breast engorgement
6. Easy fatigability
Gynecologic History
MENSTRUAL HISTORY
1. Age at menarche
2. interval between periods
3. duration of menses
4. character of the flow (scant, normal, heavy, usually without clots).
5. Any intermenstrual bleeding (metrorrhagia).
6. The date of onset of the LMP and the date of the previous one
7. Menstrual cramps (dysmenorrhea);
8. Midcycle pain ( mittelschmerz ) and a midcycle increase in vaginal secretions
CONTRACEPTIVE HISTORY
• The type and duration of each contraceptive method, along with any
complications.
•
These may include:
I.
amenorrhea or thromboembolic disease with oral contraceptives
II.
dysmenorrhea, heavy bleeding (menorrhagia), or pelvic infection with the intrauterine
device
III.
contraceptive failure with the diaphragm, contraceptive sponge, or contraceptive cream.
OBSTETRIC HISTORY
Each pregnancy and delivery and any associated complications
should be listed sequentially with relevant details and dates.
SEXUAL HISTORY
I.
The health of, and current relationship with, the husband or partner(s) may
provide insight into the present complaints.
II. Inquiry should be made regarding any pain (dyspareunia), bleeding, or
dysuria associated with sexual intercourse.
III. Sexual satisfaction (should be discussed tactfully).
PAST HISTORY
•
Any significant past medical or surgical history should be recorded, as
should the patient’s family history.
•
Family History
•
Drug & Allergy Hx
•
Immunization Hx
•
Blood transfusion Hx
Gynecologic Physical
Examination
1)
2)
3)
4)
5)
6)
General Examination
Vital signs
Head & Neck
Breast
Abdominal
Pelvic examination including Pap smear
& bimanual rectal examination
Tanner scale
HAIR DISTRIBUTION
Tanner I no pubic hair at all
Tanner II small amount of long, downy hair with slight pigmentation
Tanner III hair becomes more coarse and curly, and begins to extend laterally
Tanner IV adult-like hair quality, extending across pubis but sparing medial thighs
Tanner V hair extends to medial surface of the thighs [15+]
Tanner scale
TANNER
BREAST
I  No glandular tissue: areola follows the skin contours of the chest
II  Breast bud forms,small area of surrounding glandular tissue; areola begins to widen
III  Breast more elevated,extends beyond the borders of the areola, which continues to
widen but remains in contour with surrounding breast
IV  Increased breast size and elevation; areola projecting from the
V  Breast reaches final adult size; areola returns to contour with a projecting central
papilla.
Tanner scale
stage of
females
Diagram of
Vulva and
anatomical
structures
Different sizes of
the Bi-valved
vaginal Speculum
Bimanual rectal
exam to assess the
recto vaginal
septum
THANK YOU