Gynaecological and obstetric history and examination

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Chapter 1 Gynaecological and obstetric history and examination

THE WOMAN PRESENTING WITH GYNAECOLOGICAL PROBLEMS

It is generally accepted that most gynaecological problems are medical or psychological, rather than surgical. For this reason it is crucial that a careful history of the woman’s complaints is obtained.

History

Doctors must be sensitive to the woman’s beliefs and feelings, tactful, communicative, courteous, gentle and unhurried. The history of the patient’s complaints should be recorded sequentially.

The manner in which the woman answers questions may give a clue to the origin of the complaint. This is important, as studies in the UK and Australia show that 14–17% of women have psychiatric morbidity. Other studies have noted a significant relationship between gynaecological symptoms, adverse life events and psychiatric morbidity. The doctor should exclude depression by inquiring about sadness, irritability, fatigue and so on. The questions should seek information about the woman’s:

• Menstrual history. Age at menarche; duration of the menstrual cycle; menstrual pain; and the duration and severity of menstruation. This may cause some confusion. For example, if the woman says that she bleeds for 5 days every 20 days, the doctor may believe that her periods are occurring too frequently. The doctor may need to explain that the menstrual cycle starts on day 1 of bleeding and includes the menstrual phase as well as the interval between menstrual bleeds. The woman in the example given in this designation would bleed for 5 days every 25 days, which is normal. This designation is conveniently recorded as 5/25.

• Obstetric history (if any). The number of pregnancies and the outcome, that is, spontaneous miscarriages or induced abortions; ectopic gestation; children born, their birthweights and the year of the birth of each; complications occurring during pregnancy, labour or the puerperium (the end of the third stage of labour until involution of the uterus is complete, i.e. approximately 6 weeks).

• Previous medical history (past illnesses and operations) and family history

• Psychological and psychiatric history and family history

• Current medications

• Sexual history. This needs to be obtained with sensitivity, and matters such as physical and sexual abuse should be left until later in the interview. An explanation of why such questions are being asked will help communication.

• Details of contraceptive use, including any side-effects

• History of the main complaint.

In an older woman more emphasis should be placed on the menopausal history rather than menarche and menstruation.

Examination

Unless the patient has been seen recently, a general examination should be carried out as the gynaecological complaint may only be a local manifestation of a general disorder. This examination, which can be performed quite quickly, should include inspection of the head and neck, palpation of the supraclavicular areas for enlarged lymph nodes, auscultation of the heart and lungs, and determination of the pulse rate and blood pressure.

The gynaecological portion of the examination should include:

• A breast examination

• An abdominal examination

• An inspection of the external genitalia

• A pelvic examination, by speculum, and then digitally as a bimanual vaginoabdominal examination

• A rectal examination in certain instances.

Breast examination

With the patient sitting facing the examiner, the breasts are inspected, first with the patient’s arms at her sides and then with her arms raised above her head (Fig. 1.1). The shape, contour and size of the breasts, their height on the chest wall, and the position of the nipples are compared, any nipple retraction being noted. The supraclavicular regions and axillae are next palpated. The latter can only be palpated satisfactorily if the pectoral muscles are relaxed. This relaxation can be obtained if the physician supports the patient’s arms while palpating the axillae. Palpation is then performed with the patient lying supine, her shoulders elevated on a small pillow. Palpation should be gentle and orderly, using the flat of the fingers of one hand. Each portion of the breast should be palpated systematically, beginning at the upper, inner quadrant, followed by palpation of each portion sequentially until the upper, outer quadrant is finally examined.

Fig. 1.1 Breast self-examination. (A) Inspection of the breasts – the patient’s arms at her side. (B) Inspection of the breasts – the patient’s arms raised above her head. During the inspection, the contour of the breasts, the size and shape of the areolae and the condition of the nipples are examined. An indentation or a bulge in the contour may indicate a lesion. (C) Placing hand on hip tenses the pectoralis major, accentuating any tethering from an infiltrating neoplasm. (D) Axillary palpation. (E) Systematic examination of four quadrants of the breast. (F) Palpation of the upper outer quadrant of the breast.

The breast self-examination that many doctors recommend to women is similar to the breast examination made by the doctor, except that the woman usually does not palpate the axillary area. Figure 1.1 demonstrates how a woman should examine her breasts. The technique can easily be taught to her by her doctor.

Abdominal examination

The examination is conducted with the patient lying comfortably on her back, having emptied her bladder immediately beforehand. Inspection of the abdomen will show its contour, and the presence of striae and scars or of dilated veins. If the patient raises her head and coughs, hernias and divarication of the recti abdominis muscles will be evident. Palpation of the viscera is performed systematically, the liver, the gallbladder, the spleen and the kidneys being palpated in turn. The caecum and colon are next palpated, the hand pressing down gently as the patient breathes out. Percussion may be required if the presence of free fluid is suspected.

Pelvic examination

The pelvic examination should follow the abdominal examination and should never be omitted unless the patient is a virgin. The external genitalia are first inspected under a good light with the patient in the dorsal position, the hips flexed and abducted, and knees flexed. If she or the doctor prefers, she may lie in the left lateral position. Some women are more comfortable and feel less exposed in the latter position. The patient must have voided just before the examination (unless she is complaining of stress incontinence), and should preferably have defacated that morning. If urinary infection is suspected, a midstream specimen of urine may be obtained at this time.

The patient is asked to strain down, to enable detection of any evidence of prolapse, after which a bivalve speculum is inserted and the cervix visualized. For the woman’s comfort the speculum should be warmed and the doctor’s approach sensitive and communicative. If the physician intends to take a cervical smear to examine the exfoliated cells, no lubricant apart from water should be used on the speculum. The vagina and cervix are inspected by opening the bivalve speculum (Fig. 1.2). If the patient has a prolapse, the degree of the vaginal wall or uterine descent can best be assessed if a Sims speculum is used, with the patient in the left lateral position (Fig. 1.3).

Fig. 1.2 Introducing the bivalve speculum. Care should be taken to avoid applying painful pressure on the urethra by inserting the speculum initially obliquely.

Fig. 1.3 The patient in the left lateral position; a Sims speculum has been inserted into the vagina.

Digital examination follows, one or two fingers of the gloved hand being introduced. For the right-handed person it is usual to use the right hand as the fingers of this hand are more ‘educated’, and vice versa for the left-handed person. After the labia minora have been separated with the left hand to expose the vestibule, the fingers are introduced, passing upwards and backwards to palpate the cervix. The left hand simultaneously palpates the pelvis through the abdominal wall, so that the uterus and ovaries may be palpated. Normal Fallopian tubes (oviducts) are never palpable. As the intravaginal fingers push the cervix backwards, the abdominally located hand is placed just below the umbilicus and the fingers reach down into the pelvis, slowly and smoothly, until the fundus is caught between them and the fingers of the right hand in the anterior vaginal fornix (Fig. 1.4).

Fig. 1.4 Bimanual examination of the uterus. Note that the bladder is empty, the patient having voided just before the examination. (A) The vaginal fingers push the cervix back and upwards so that the fundus can be reached by the abdominally located fingers. (B) The vaginally located fingers now palpate the anterior surface of the uterus, which is held in position by the abdominally located fingers.

The information obtained by bimanual examination includes:

• By palpation of the uterus. Position, size, shape, consistency, mobility, tenderness, attachments. The normal uterus is positioned either anteriorly or posteriorly and is about 9 cm long. It is pear-shaped and firm in consistency, and can be moved in all directions. It is normally tender when squeezed between the two hands.

• By palpation of the ovaries and Fallopian tubes. The tips of the vaginally located fingers are placed in each lateral fornix in turn and then pushed backwards and upwards as far as possible without causing pain. The abdominally located fingers simultaneously press backwards about 5 cm medial and parallel to the superior iliac spine (Fig. 1.5). The normal oviduct cannot be palpated, and the normal ovary may or may not be felt. If the latter is palpable, it is extremely tender on bimanual pressure.

Fig. 1.5 Bimanual palpation of the adnexal area. Note the position of the fingers; normally the ovary cannot be felt. In this case a cystic mass lying in the position of the ovary can be identified.

Rectal examination

A rectal examination, or a rectoabdominal bimanual examination, may replace a vaginal examination in children and in virgin adults, but the examination is less efficient and more painful than the vaginal examination. A rectal examination is a useful adjunct to a vaginal examination when either the outer parts of the broad ligaments or the uterosacral ligaments require to be palpated. On occasion, a rectovaginal examination, with the index finger in the vagina and the middle finger in the rectum, may help to determine if a lesion is in the bowel or between the rectum and the vagina. Box 1.1 describes the skills required in performing a gynaecological examination.

Box 1.1 Patient–doctor skills needed during conduct of a gynaecological examination

• Ensure your patient understands what is involved and why the examination is being conducted

• Explain what you are about to do as you are conducting the examination

• When appropriate, make eye contact with your patient: do not always talk to the vulva

• Be efficient but not rushed

• Observe your patient’s physical appearance and behaviour; be sensitive to anxiety, tension, withdrawal, signs of abuse, and inappropriate or unusual behaviour

• Be sensitive to her needs and preferences: having a third person present, using a sheet to cover herself

• Ask your patient to let you know if she is uncomfortable at any time during the examination

• Be reassuring and give feedback about what you are observing and feeling during the examination

• After the examination, allow the woman to dress and sit down with her to discuss your findings

• Use simple English and be prepared to draw diagrams: women are not always able to conceptualize their reproductive organs

• Give your patient the opportunity to ask you questions

Tests

Appropriate tests may be required. For example, if the woman complains of a vaginal discharge, swabs should be taken to determine the cause (see p. 293). Urinary symptoms may require a midstream specimen of urine to assist in reaching a diagnosis.

Medical practitioners have a crucial role in encouraging sexually active women to have a cervical smear (Pap smear) taken at regular intervals, to detect abnormal cells. At present only half of women over the age of 40, who are at greatest risk of developing cervical carcinoma, have regular Pap smears.

Investigations

Pelvic ultrasound

The development of pelvic ultrasound scanning enables doctors to identify many disorders in the genital tract with greater accuracy than with clinical examination. Ultrasound is particularly helpful in establishing patency of the Fallopian tubes and in defining cystic, benign and malignant tumours of the internal genital organs. The examination may be made transabdominally through a full bladder, or transvaginally when the bladder is empty.

Colposcopy

The colposcope is a low-powered microscope for inspecting the cervix and vagina in cases where abnormal cells have been detected by a Pap smear. The cervix and vagina are exposed by introducing a bivalve vaginal speculum. The colposcope is placed in front of the vagina and its focal length is adjusted to examine the suspect part of the lower genital tract (see p. 293).

Computed tomography and magnetic resonance imaging

These technologies have a role in assessing the nature and spread of malignant disease of the genital organs, but due to their costs should only be used when they are likely to provide information that would confer a real benefit.

Laparoscopy

Inspection of the pelvic organs with a laparoscope inserted into the peritoneal cavity through a small subumbilical incision may give valuable information about the state of the pelvic organs, particularly in cases of infertility, chronic pelvic pain and probable ectopic gestation. Techniques have been developed which enable operations to be conducted through a laparoscope, potentially reducing the postoperative analgesia requirements and the length of hospital inpatient stay.

Hysterosalpingography

The injection through the cervix of a radio-opaque substance and following its progress on a screen as it fills the uterus and Fallopian tubes provides information in cases of infertility.

Hysteroscopy

A small fibreoptic telescope is inserted through the cervix into the uterine cavity, which is inspected. The procedure may help the doctor to reach a diagnosis in cases of menstrual disorders. Endometrial polyps, submucous fibroids and intrauterine adhesions and septae can be removed and the endometrium ablated (see p. 225) using this technique.

Endometrial biopsy

This technique is used to obtain a sample of endometrium for histological examination, by introducing a small curette through the cervix without anaesthesia. Endometrial biopsy has a role in the investigation of infertility and in helping to reach a diagnosis in cases of postmenopausal bleeding.

THE MATERNITY PATIENT

Most women consulting a medical practitioner have a good idea that they are pregnant. The woman may have:

• Missed a menstrual period (has amenorrhoea)

• Noticed that her breasts are fuller and may be tender

• Nausea and perhaps may have vomited

• Frequency of micturition

• Purchased a ‘home pregnancy test’ or have had the test taken by her pharmacist.

The woman visits the doctor to confirm that she is pregnant and either to seek antenatal care from the doctor or to be referred to an obstetrician or to a hospital clinic.

History

At this first visit the doctor should take a history in the manner described earlier. The information includes more than that described for gynaecological examination. The history of previous pregnancies should be detailed and include information about:

• Spontaneous and induced abortions

• Complications during pregnancy

• The gestation period at delivery

• The method of delivery (spontaneous vaginal birth, forceps, ventouse delivery, caesarean section)

• Complications in the puerperium

• Birthweight of the baby, neonatal complications and long-term outcome

• Maternal physical and mental health during and after each pregnancy

• Breastfeeding history.

Once the pregnancy has been confirmed the medical practitioner should enquire about matters that may be associated with complications or a poor outcome:

• Whether the pregnancy was wanted

• Any problems, e.g. nausea or vomiting, bleeding, abdominal–pelvic pain

• Cigarette smoking, caffeine intake, alcohol and other prescribed and social drug use

• Prepregnancy body weight, recent and past history of weight loss or weight gain, and eating behaviour

• Family and community support

• Current and past history of depression and anxiety, and eating and weight disorders

• Current and past history of physical and sexual abuse

• Family history of hypertension, diabetes mellitus, and congenital and familial disorders

• Whether the woman has any concerns or worries about this pregnancy.

The medical practitioner should enquire about these matters again during the pregnancy.

Examination

Having taken a history the doctor should examine the woman as described earlier, although a vaginal examination does not need to be performed. Indications for conducting a vaginal examination include a vaginal discharge, active bleeding and to take a Pap smear if it has not been done in the previous 12 months. If the doctor performs a vaginal examination between 6 and 10 weeks after the woman’s last menstrual period (LMP) the uterus may feel as if it is separate from the cervix. This is because the cervix has softened, and the examiner’s fingers seem to meet below the ball-shaped uterus (Hegar’s sign), as shown in Figure 1.6.

Fig. 1.6 Hegar’s sign.

In most cases the doctor will confirm the pregnancy either clinically or by an immunological pregnancy test. The test depends on the fact that human chorionic gonadotrophin (hCG) is secreted into the circulation within 10 days of conception. Using a sensitive monoclonal antibody test, small amounts of the β fraction of hCG can be detected if the woman is pregnant.

A question invariably asked by the woman when the pregnancy has been confirmed is ‘When can I expect my baby to be born?’ This can be determined by asking the woman if the length of her menstrual cycle falls into the normal range (22–35 days). The calculation is to add 1 year and 10 days to the first day of her LMP and then to subtract 3 months. This gives the estimated date of confinement (EDC). Thus if her LMP began on 14 November 2010 she may expect to give birth on 24 August 2011 (±14 days). Most doctors do not need to do the calculations, as obstetric calculation discs are readily available.

The calculation has to be altered if the woman’s menstrual cycle is prolonged, or if she was taking oral contraceptives during the cycle before she became pregnant, as ovulation may have been delayed and conception may have occurred up to 14 days later than expected. In these two circumstances the EDC will be later than calculated, and to obtain greater accuracy of prediction an ultrasound examination at the 18th to 20th week of pregnancy may be needed. Many obstetricians have an ultrasound of the fetus performed routinely at the time of the first visit, to accurately establish the gestation and fetal viability. Women appreciate an early ultrasound of their fetus and hearing its heart beat.

Most women seek to have the pregnancy confirmed during the first 10 weeks, but some delay until later. The uterus becomes palpable early in the second trimester (i.e. from 13 weeks’ gestation) on abdominal examination (Fig. 1.7) and fetal heart sounds can be heard using an ultrasonic heart detector at this time. The woman feels her fetus moving from about 18 weeks’ gestation.

Fig. 1.7 The abdominal markings of uterine growth related to the number of weeks after the last menstrual period.

Once pregnancy has been diagnosed further investigations should be made. These are discussed in Chapter 6.

Evidence of a previous pregnancy

In a few cases the woman may deny that she has been pregnant before, but the doctor is suspicious. This suspicion can grow stronger if:

• The breasts show pigmentation of the areolae.

• The abdominal wall has silver-grey longitudinal lines (striae gravidarum).

• On inspection of the vulva, the perineum shows evidence of damage and repair.

However, a firm diagnosis cannot be given as these signs can be produced by other disorders.

Pseudocyesis

Emotional disturbance, such as an intense desire to have a baby or fear of losing a lover, may lead some women to believe that they are pregnant when they are not. The emotions stop the release of gonadotrophic hormones, with resultant amenorrhoea. The woman’s emotions cause her to complain of the symptoms of pregnancy, often in a bizarre order. The breasts become full and may secrete a cloudy fluid; the abdomen becomes enlarged because of fat or flatus. On superficial examination the woman appears to be pregnant; however, vaginal examination shows the uterus to be normal in size. It may be necessary to have an ultrasound examination to convince the woman that she is not pregnant. Once the absence of pregnancy has been confirmed, the woman should be given sympathetic psychiatric attention.

Medicolegal aspects and patient–doctor communication

Obstetrics and gynaecology has for some time been perceived as a high-risk speciality for medicolegal claims. The reasons for this appear to be:

1. The pregnant woman’s (and her family’s) expectation that she will give birth to a perfect baby.

2. The gynaecological patient’s expectation that her diagnosis, treatment and operation, if needed, will have a perfect result.

3. The trend of some lawyers using contingency litigation in medicolegal claims.

4. The large amounts of compensation determined by some judges and juries.

What can be done?

The doctor

The doctor should take the following measures to reduce litigation:

First consultation

The doctor should listen carefully to what the patient says and should seek clarification of the issues. The patient (and her partner if she wishes) should be given ample opportunity to ask questions, which the doctor should answer in clear English, if necessary through an appropriate interpreter. They should outline the treatment they intend to follow, stating the benefits and disadvantages (if any) of the proposal. Written information should be made available to the woman and her family whenever possible. Except in emergency situations, treatment or surgery should not be instituted precipitously, giving the patient time to reflect and ask further questions. The conversation should be recorded by the doctor in the notes, dated and signed.

Follow-up visits

At each visit the doctor should follow the procedure outlined above, giving more time for the woman to ask questions to clarify issues she may find obscure. Again the doctor’s notes should be completed meticulously, dated and signed, and pathology and ultrasound reports should be seen, evaluated and signed off before they are filed.

Operative procedures in obstetrics and gynaecological surgery

When a consultant or a trainee undertakes an operative procedure, the record of that procedure should be recorded in some detail in the operation notes, preferably by the operating surgeon, signed and dated. When the woman is visited after childbirth or after an operative procedure she should be given time and the opportunity to ask questions, and the answers should be given simply and clearly. All observations should be recorded and signed.

Ultimately, a reduction in litigation will occur if the doctor can communicate well with the patient, being sensitive to her concerns and answering her questions without showing any haste or impatience (Box 1.2).

Box 1.2 Doctor–patient communication

Good communication is essential to patient assessment, treatment, and the avoidance of subsequent medicolegal problems.

To achieve this the doctor should:

• Listen attentively and with empathy to what the patient is saying

• Listen more and talk less, only interrupting the patient to clarify a point

• Avoid being confrontational, condescending, overbearing or judgemental, particularly in sensitive matters such as sexual preferences, practices and abuse

• Avoid using medical jargon, use simple clear and understandable English, and make sure the patient understands the explanation of the obstetric, gynaecological, medical or surgical procedures proposed

• Provide consumer information in a pamphlet or DVD format

• Avoid creating the appearance that he or she wants to conclude the consultation prematurely

• Make a follow-up appointment if there is any doubt that the patient understood clearly, so the issues can be discussed further with the woman and, if she wishes, her partner

Related

Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology