Abdominal examination

The system of examination described in Chapter 12 is recommended, but should focus on inspection and palpation; percussion and auscultation are less important in gynaecological practice. The presence or absence of scars should be noted. Laparoscopic scars can be subtle, particularly if tucked within the umbilicus. Occasionally (usually to avoid the risk of perforation through adhesions in the lower abdomen) the entry point for laparoscopic surgery may be via Palmer’s point in the mid-clavicular line, under the rib cage. Transverse suprapubic (Pfannenstiel’s) incisions may also be difficult to see in the suprapubic crease unless specifically looked for.

Suprapubic examination is particularly important as gynaecological masses arise out of the pelvis and the examining hand cannot get below it. Do this part of the abdominal palpation with the ulnar border of the left hand, starting at or around the umbilicus, and work your way down. When an abdominopelvic mass is present, its characteristics and size, either in centimetres measured from the symphysis pubis upwards, or estimated as weeks’ gestation of an equivalent-size pregnancy, are recorded (see Fig. 4.1). Note its consistency (hard if a fibroid, usually soft if a pregnancy), regularity (subserosal fibroids and ovarian masses are usually irregular) and the presence of any tenderness. It can sometimes be difficult to elicit such signs if there is a scar in the lower abdomen or if the patient is obese. If nothing is palpable arising out of the pelvis, it is reasonable to conclude that any pelvic swelling is less than the size of a 12-week pregnancy. If ascites is suspected, check the supraclavicular and inguinal lymph nodes and look for an associated hydrothorax.

Figure 4.1 Approximate fundal height with changing gestation.

Pelvic examination

In gynaecology, pelvic examination (PE) is usually undertaken vaginally but it may also be performed rectally. The instruments used are shown in Figure 4.2. PE should always be preceded by abdominal examination. Patients will often be anxious and tense, so it is crucial to explain every step sensitively but clearly. Medical students should only undertake a PE in the presence of a supervisor; the same applies to trainees in gynaecology, except where specific permission has been granted by the trainer. In many centres, students begin to learn the technique of PE using simulated models.

Figure 4.2 Equipment for the gynaecological examination.

PE commences with inspection of the perineum in the dorsal or left lateral position and is followed by internal digital examination, using the index and middle fingers (one finger only may be possible if the vagina does not accommodate two). Generally, but not always, a speculum examination precedes the digital examination (if it is important to visualize any discharge, take swabs or take a cervical smear, the speculum should always be passed first; Fig. 4.3). In the event of the patient experiencing undue discomfort (be it speculum or digital), the examination should cease immediately. Make note of any inflammation, swelling, soreness, ulceration or neoplasia of the vulva, perineum or anus (Fig. 4.4). Small warts (condylomata acuminata) appearing as papillary growths may occur scattered over the vulva; these are due to infection with the human papilloma virus (HPV). Inspect the clitoris and urethra and ask the patient to strain and then cough to demonstrate any uterovaginal prolapse or stress incontinence (Fig. 4.5). If the patient has given a history of involuntary incontinence, it is important that the bladder is reasonably full and that more than one substantial cough is taken, as the first cough frequently fails to demonstrate leakage of urine. It is kind to press on the anus with a tissue or swab to reduce the risk of involuntary flatus, indicating to the patient the reason for doing so.

Figure 4.3 Discharge due to Chlamydia trachomatis.

Figure 4.4 The vulva.

Figure 4.5 In cystocele, there is downward prolapse of the anterior part of the pelvic floor, straightening the angulation of the bladder neck and leading to urinary incontinence. In rectocele, the posterior part of the pelvic floor is mostly affected, sometimes with associated faecal incontinence. In some patients, the whole pelvic floor is weak, with double incontinence or prolapse of the uterus. In enterocele, there is a prolapse of viscera from the pouch of Douglas as part of a severe pelvic floor weakness.

For the digital examination, disposable gloves are used and the examining fingers should be lightly lubricated with a water-based jelly. With the patient in the supine position and with her knees drawn up and separated, the labia are gently parted with the index finger and thumb of the left hand while the index finger of the right hand is inserted into the vagina, avoiding the urethral meatus and exerting a sustained pressure on the perineal body until the perineal musculature relaxes. Watch for any sign of discomfort. The full length of the finger is then introduced, assessing the vaginal walls in transit until the cervix is located. At this stage, a second finger can be inserted to improve the quality of the digital examination or, alternatively, a speculum can be used if a cervical smear is required. The examination is continued with the left hand placed on the abdomen above the symphysis pubis and below the umbilicus – the bimanual examination (Fig. 4.6). The hand provides gentle directional pressure to bring the pelvic viscera towards the examiner’s fingers in the vagina and serves to assess the size, mobility and regularity of masses. The cervix is then identified; it is approximately 3 cm in diameter, with a variably sized and shaped dimple in the middle, the cervical os. When the uterus is anteflexed and anteverted, the os is normally directed posteriorly. A retroverted uterus means the uterus is tipped backwards so that it aims towards the rectum instead of forward towards the belly. The consistency of the cervix is firm and its shape is irregular when scarred. Increased hardness of the cervix may be caused by fibrosis or carcinoma. As a ‘soft’ cervix indicates the possibility of pregnancy, even greater caution and gentleness is necessary. The mobility of the cervix is usually 1-2 cm in all directions, and testing this movement should produce only mild discomfort. If the cervix is moved when there is pelvic inflammation, particularly in association with ectopic pregnancy, extreme pain (cervical excitation) results.

Figure 4.6 Bimanual examination of the pelvis.

It is possible to estimate the size, shape, position, consistency and regularity of the uterus and the relationship of the fundus of the uterus to the cervix (flexion). Uterine size is generally described as normal, bulky or in terms of weeks of gestation (e.g. 6 weeks, 8 weeks, 10 weeks size, etc.) even in the absence of pregnancy. Its mobility and shape (symmetrical or non-symmetrical) may be assessed and the ovaries and fallopian tubes palpated, although these can be difficult to feel in healthy women. Aside from the ovaries in some women, no other swellings should be palpable about the uterus in women of reproductive years. The pouch of Douglas is then explored through the posterior fornix via the arch formed by the uterosacral ligaments and the cervix.

Speculum examination

This is an essential part of a gynaecological examination. Several types of specula are available for use, including the bivalve type (e.g. Cusco’s) used for displaying the cervix (Fig. 4.7) and the single- or double-ended Sims’ (duckbill) speculum (Fig. 4.8) used to retract the vaginal walls. Occasionally, use is made of the Ferguson’s speculum, which may be required to inspect the cervix when vaginal prolapse is so severe that a bivalve speculum fails to provide a sufficient view. If a cervical smear is to be taken, care should be taken not to get lubricant on the cervix, as this can adulterate the quality of the sample, so the taking of the smear before digital examination is good practice without using excessive lubrication. The speculum should be warmed to body temperature and lubricated with water or a water-based jelly. All the necessary equipment, such as spatulas, slides, forceps, culture swabs, etc., should be prepared before the examination begins (see Fig. 4.2).

Figure 4.7 Cusco’s speculum used to display the cervix.

Figure 4.8 Sims’ speculum used to display the anterior vaginal wall.

Carefully explain to the patient what will happen in the examination. Ask her to lie on her back with her feet together and knees drawn apart, as for the PE. Separate the labia and then the introitus with the thumb and index finger of the left hand and then insert the lightly lubricated bivalve speculum with the handle directly upwards, allowing it to be accommodated by the vagina. When it has been inserted to its full length, the blades of the speculum are opened and manoeuvred so that the cervix is fully visualized (the left hand should now be free to do this; see Fig 4.7). The screw adjuster or ratchet on the handle is then locked so that the speculum is maintained in place. Any discharge (see Fig 4.3) and the condition of the cervical epithelium, its colour, any ulceration or scars and retention cysts (nabothian follicles) should be noted.

General examination

Again, this should follow the approach outlined in Chapter 2. In obstetric practice, height and weight (and calculated BMI) are important. As a general rule, labour is more efficient if the woman is above 152 cm in height, and hypertension, hyperglycaemia and anaesthetic difficulties are more common if the BMI is above 30 kg/m². Record the blood pressure (it should be 140/90 or lower in a normal pregnancy) and examine carefully for oedema, not only in the ankles but also in the fingers (can she remove her rings easily?) and face. Breast examination is not indicated unless there is a complaint related to the breasts themselves, although it is common for women to ask questions related to breastfeeding.

Abdominal examination in pregnancy

Ask the patient to empty her bladder before the abdominal examination. Make sure the light is good, the room comfortably warm and that there is maximum exposure of the area to be examined (Box 4.1). Look for striae gravidarum, linea nigra, previous caesarean section or other scars and any visible fetal or other movements (unlikely before 30 weeks’ gestation but usually indicative of good health). Ideally the patient is examined flat, but she may be more comfortable semirecumbent. It is not usually an uncomfortable examination except in certain pathological situations. If part of the examination is likely to be painful, this should be left to the very end.

Ask about any tender areas before palpating the abdomen. Using the flat of the hand as well as the examining fingers can enhance comfort and gentleness; this allows the outline of a mass or pregnant uterus to be delineated more readily. In late pregnancy, palpation may produce uterine contractions, which can obscure details of the uterine contents. Remember that, for women in their first pregnancy, the abdominal musculature (particularly rectus abdominis) has not been previously stretched, such that it is sometimes difficult to be sure about findings on palpation.

The size of the uterus (Fig. 4.9) is traditionally estimated by the fundal height (see Fig. 4.1): the distance from the symphysis pubis to the fundus (top portion) of the uterus. This is a useful measure, even though it is only one dimension of a globular mass. In a normal pregnancy, the fundal height is just above the symphysis pubis at 12 weeks’ gestation, at the umbilicus at 22 weeks and at the xyphisternum at 36 weeks. When the fundus is equidistant from the symphysis pubis and the umbilicus, the gestation is 16 weeks, and when equidistant from the xiphisternum and umbilicus, it is about 30 weeks. From 36 weeks, the fundal height is also dependent on the level of the presenting part, and therefore decreases as the presenting part descends into the pelvis. This is the phenomenon of a ‘lightening’ sensation experienced by the mother. The height of the fundus above the symphysis is usually recorded in centimetres and, from 20 weeks onwards, the number of centimetres above the symphysis is approximately in accord with the number of weeks of pregnancy, up to 38 weeks. This measurement is generally accepted to be objective and, importantly, is reproducible when different healthcare professionals participate in the same woman’s care. Common causes of deviation from these measurements include multiple pregnancy, multiple fibroids, intrauterine growth retardation and excess or reduced amniotic fluid volume (poly- and oligohydramnios respectively).

Figure 4.9 Magnetic resonance image of the female pelvis. The uterus is arrowed.

Next, determine the lie of the fetus (this is the relationship of the long axis of the fetus to the maternal spine – longitudinal usually, but sometimes oblique or transverse). To confirm the lie, the location of the fetal limbs and back should be identified (Fig. 4.10).

Figure 4.10 Method of abdominal palpation to determine fetal lie and location of back.

The presentation (the part of the fetus that occupies the lower pole of the uterus) can usually be determined by abdominal palpation if it is cephalic (head), breech (buttocks or feet) or shoulder. Other types of presentation, such as cord and compound, cannot be determined by palpation. At term, over 95% of babies present by the head, but at 30 weeks, because of the greater mobility of the fetus and the relatively larger volume of amniotic fluid, only 70% do so. The breech can usually be distinguished by its size, texture and ability to change shape. However, an ultrasound examination may be needed to confirm this.

The presenting part refers to the part of the fetus that is felt on vaginal examination through the cervix (see vaginal examination in labour, below). The head may be presenting but the flexion of the head, or the extension of it, will govern what the presenting part is. In cephalic presentations, the smallest diameters presented to the pelvis occur when the head is well flexed. Thus, in a flexed head, it will be a vertex presentation, and in a deflexed head, it will be the brow or even the face. Flexion of the head is termed the attitude. These observations are not usually possible to ascertain on abdominal examination. For a breech presentation, an equivalent assessment is made to determine whether the breech is extended (frank), flexed (complete) or footling (incomplete). Once the presenting part has a relationship to the pelvis, that relationship can be vertical (the level) or rotational (the position) (Fig. 4.11). When the flexed head presents, the fetal occiput is termed the denominator. When the face presents, the denominator is the mentum (chin) and when the breech presents, it is the sacrum.

Figure 4.11 Method of abdominal palpation to determine presenting part.

The presenting part is said to be engaged when the largest diameter has passed through the pelvic brim. It is conventional to estimate the number of fifths of the head that can be palpated through the abdominal wall and this indicates its level (Fig. 4.12). Thus, if there are three or more fifths palpable, the baby’s head will be unengaged. If less than three-fifths are palpable, then the baby’s head is probably engaged in the pelvis, but this does depend on the overall size of the fetal head and of the pelvis. Remember that the pelvic brim has an angle of approximately 45° to the horizontal when the mother is lying flat. If the abdominal wall is reasonably thin, the unengaged head can be palpated by the examiner’s fingers passing round its maximum diameter. This means it is above the pelvic brim. When this does not occur, the widest diameter must be below the examining fingers, and fixity of the baby’s head in the pelvis is also a guide. This means it is engaged. Engagement will usually occur as the leading edge of the baby’s head, on vaginal examination, reaches the level of the ischial spines (zero station).

Figure 4.12 The vertical relationship of the presenting part to the pelvic inlet (the level).

Fetal movements, both as reported by the mother and observed by the examiner during the examination, are noted. An estimate is made of the fetal size and volume of liquor by a combination of palpation and ballottement. This requires considerable practice. Last, the fetal heart rate (FHR) (normally between 115 and 160 beats/min) is recorded either using a Pinard stethoscope (Fig 4.13) or, more often, with a sonicaid device.

Figure 4.13 Listening over the fetal back to the fetal heart with a Pinard stethoscope (historical).

Vaginal examination in pregnancy

Vaginal examination (VE) is not usually recommended in early pregnancy. If there there is bleeding or retention of urine, it may provide useful information, but the widespread availability of ultrasound scanning has made diagnosis in this situation far less intrusive. In the situation of a threatened abortion (‘miscarriage’), it is more appropriate to perform a detailed ultrasound examination, even on the next working day if necessary, than to undertake a VE that may not be particularly helpful and may lead to anxiety (and, possibly later, accusations that the examination contributed to fetal loss). Exceptions to this approach include a suspected ectopic pregnancy with haemodynamic instability, or the situation of considerable vaginal blood loss in early pregnancy, in which it is important quickly to diagnose the presence of (and remove) the products of conception at the cervical os. Cervical smears are rarely indicated in pregnancy, unless there is suspicion of a cervical malignancy or one is required for follow up of known cervical neoplasia.

A case for VE can be made in the situation of possible cervical incompetence. This is a situation in which previous surgery or loop diathermy has led to thinning and dilatation of the cervix such that the weight of the pregnancy sac is too great for the cervix to withstand. The patient, usually somewhere between 16 and 24 weeks into pregnancy, may complain of a small vaginal loss and irregular contractions. If the natural history is allowed to progress, there will be rupture of the membranes followed by a short and painful labour, with subsequent delivery of a fetus (almost always non-viable). Scanning of the cervix in cases at risk has replaced these examinations to some extent but it remains a difficult problem to diagnose.

Vaginal examination in labour

Assessment of whether a woman is in labour is not always straightforward. A VE may help, but is contraindicated if there is painless loss of blood and/or it is known that the patient has a low-lying placenta; potentially dangerous blood loss can occur if a VE disturbs a low-lying placenta.

Vaginal examination in labour should always be preceded by an abdominal examination as described above, together with observation of any contractions, their intensity, frequency, length of time and whether and how much pain they provoke. The VE aims to answer the following questions:

The Bishop score is an amalgam of the above findings (excepting the presenting part) at VE and is used to determine whether a woman is likely to have a successful vaginal delivery and whether labour ought to be induced. A low score is indicative of an ‘unfavourable cervix’ (firm, posterior, long, closed cervix with a high presenting part). In contrast, a ‘favourable cervix’ is one which is associated with an efficient labour – anterior (easy to reach), soft, open, thinned, with a low presenting part.

By repeating abdominal and vaginal examinations at intervals, the diagnosis and progression of labour can be ascertained. Vaginal examination is a potential introduction of infection and can be unpleasant and uncomfortable, so it is usual to not perform this more frequently than 4 hourly. Once labour is established, the cervix should progressively dilate at a rate of approximately 1 cm per hour.

Pregnancy testing

Most pregnancy tests depend on the detection of human chorionic gonadotrophin (hCG) or its β subunit in urine or blood respectively. As the developing placental tissue produces increasing amounts of hCG from about 10 days postfertilization, pregnancy diagnosis is now possible even before the first missed period.

Bacteriological and virus tests

Bacteriological and virus tests used in gynaecology and obstetrics include the following:

Imaging

Hysterosalpingography

The preferred contemporary technique to image the uterine cavity and fallopian tubes is hysterosonography (hysterosalpingo contrast sonography, HyCoSy), rather than X-ray hysterosalpingography, in which the flow of saline or galactose microparticles through the tubes and uterus is visualized with a vaginal ultrasound probe, thereby avoiding exposure to radiation (Fig. 4.14).

Figure 4.14 An abnormal X-ray hysterosalpingogram: uteri didelphys (double uterus).

Ultrasound

Transabdominal ultrasound enables a wide field of view, greater depth of penetration and transducer movement. Transvaginal ultrasound, with higher frequency transducers, gives increased resolution and diagnostic power but over a more limited area. More recently, 3-D scanners have been introduced, and these give improved image quality (Fig. 4.15).

Figure 4.15 An ultrasound image with shading which gives an impression of three dimensions. Its use scientifically is not yet determined, but patients love it for the view it gives of their babies.

In obstetrics, the integrity, location and the number of gestation sacs can be viewed in early pregnancy. By 11-13 weeks, mono- or dichorionicity, nuchal translucency, nasal bone development and gross fetal abnormality can be detected (Fig. 4.16). Changes in the cervix can be measured, giving an indication of possible late miscarriage or early premature labour. Anatomical anomaly scanning at 18-20 weeks is performed, particularly of the fetal heart and head and to detect functional activity. By 24 weeks, uterine and placental blood flow can be assessed, as can blood flow through fetal arteries.

Figure 4.16 Ultrasound scan for early dating.

In gynaecology, ultrasound is useful in the diagnosis of pelvic tumours and in the assessment of bladder function, by measuring residual urine volume and bladder neck activity. It is also helpful in the preoperative preparation for repair of anal sphincter damage.

Endometrial sampling (biopsy)

Sampling of the endometrium is often diagnostically useful (Fig. 4.17). Formerly, this was performed by a dilatation of the cervix and curettage (D&C) to obtain histological material from the cavity of the uterus. Dilatation of the cervix is very painful and requires general anaesthesia. The definitive assessment is now usually by hysteroscopy and directed biopsy. With current miniature fibreoptic systems, this can be done under local analgesia in an outpatient setting.

Figure 4.17 An endometrial biopsy curette, a pipette cell sampler and fixing medium.

Hysteroscopy

In this technique, the cavity of the uterus is viewed using small-diameter fibreoptic telescopes and cameras (Fig. 4.18). Diagnostic hysteroscopy using a 4-mm hysteroscope can be performed as both an inpatient and an outpatient procedure for disorders such as abnormal bleeding, subfertility and recurrent miscarriage. This technique can also be adapted with larger hysteroscopes to be used operatively for the resection of uterine adhesions, polyps, septae, submucous fibroids (Fig. 4.19) and endometrium.

Figure 4.18 Hysteroscopic view of an intrauterine device in situ.

Figure 4.19 Hysteroscopic view of submucosal fibroids.

Laparoscopy

Visualization of the pelvic and abdominal viscera is particularly valuable if it can be done without a major injury to the abdominal wall (Fig. 4.20). The abdomen is inflated with carbon dioxide under general or local anaesthesia, so that the anterior abdominal wall is lifted away from the viscera, allowing inspection of the abdominal and pelvic contents using a fibreoptic telescope illuminated by a light source remote from the patient. Laparoscopy may be useful diagnostically (e.g. in the investigation of pelvic pain or infertility) and therapeutically (e.g. sterilization procedures, ectopic pregnancy).

Figure 4.20 Diagram of a diagnostic laparoscopy.

Biochemical tests

Biological tests

Although biochemical tests provide useful information as the likelihood of a problem with a fetus, biological tests are generally more specific and accurate. It is important before commencing these tests that the woman’s attitude to the possible outcomes is explored. Detailed counselling by a trained professional may be required.

Amniocentesis

Samples of amniotic fluid may be used for the following:

Chromosome analysis: amniotic fluid is sampled at 13-18 weeks’ gestation, and is currently safer than chorion biopsy. The amount of desquamated fetal cells obtained is much smaller than from chorion biopsy, and cell culture is necessary, so chromosomal analysis is not immediately possible. However, rapid preliminary results can be obtained using the fluorescent in situ hybridization (FISH) technique (Fig. 4.21). This test is mostly used for prenatal diagnosis of Down’s syndrome and other chromosomal abnormalities.

DNA analysis: fetal cells obtained by amniocentesis, CVS or cordocentesis (see below) can be used for DNA analysis of nuclear chromatin in order to test directly for a number of genetically determined diseases in families known to be at risk. DNA testing and chromosomal studies should only be carried out with fully informed parental consent, and with the help of a genetic counselling service.

Cordocentesis: in this procedure, a needle is inserted through the abdominal wall and into the amniotic sac to obtain fetal blood from the placental insertion of the cord. It is used in special centres when chromosomal abnormality, haemophilia, haemoglobinopathies, inborn errors of metabolism, fetal viral infections or fetal anaemia are suspected. Although the procedure carries more risk than amniocentesis, it is less traumatic than fetoscopy (which views the amniotic sac contents directly) while still permitting rapid diagnosis.

Figure 4.21 Multicoloured FISH. The FISH technique is ‘fluorescent in situ hybridization’. The picture is not meant for detail but to show the overall multicoloured appearance of the specific nucleic acid sequences on metaphase chromosomes, which allows the antenatal diagnosis of Down’s syndrome, X-linked disorders, Turner’s syndrome, Klinefelter’s syndrome and trisomies 13 and 18.

Biophysical tests

Cardiotocography (CTG)

Assessment of the fetal heart rate and its variation with fetal and uterine activity can be recorded antenatally or in labour with ultrasound using the Doppler principle (Figs 4.22 and 4.23). A pressure transducer is attached to the abdominal wall so that variations in uterine activity can be matched with the ultrasound recordings. In labour, once the membranes rupture, a more accurate recording of the fetal heart rate can be achieved by an electrode attached to the fetal scalp (Fig. 4.24). The recording is triggered by the fetal electrocardiogram.

Figure 4.22 Cardiotocography equipment.

Figure 4.23 An abnormal cardiotocograph showing late variable decelerations during uterine contractions with fetal tachycardia.

Figure 4.24 Fetal scalp electrode.