Examination of Obstetric Patient

Common physical examination questions in O & G is 

Q1. Show me  how would you asses for anaemia

Q2. Examination the Abdomen 

Below is a sample of how to both the the examinations 

Q1. Assessing for anaemia  in pregnant

This picture taken from Google search . Thank you for this nice picture. It’s for teaching purposes only. 

• Wise greetings to pt. Check pts name 
• Introduce yourself & others including the lecture to pt 
• Get a cepharone
• Wash your hands 
• Explain to patient, madam/ Pn I would like to examine your hand/ conjunctiva & moth to look for any signs of anaemia 
• Please show me your hands check one hand is fine. Choose a free hand. If the hand has drip or branula, than avoid this hand & don’t cause pain or hurt the patient 
• Hands: Check the color of the palms and capillary refill time ( should be less than 2  sec)
• Findings: The palms are pink, and capillary refill time is less than 2 seconds.

• Note any koilonychia (signs of chronic anemia).
• Than say madam / Pn now I would like to check your eyes/ conjunctiva. One eye is fine.
• The Conjunctiva: Check one side for signs of anemia.
• Findings: Conjunctiva is pink / pale.
• Finally madam / Pn , l would like to check our lips/ and tongue . 
• The Lips: Observe for color.
• Findings: Lips are pink / pale.
• The Tongue: Ask the patient to open their mouth and stick out their tongue.
• Findings: The tongue is pink, and there is no glossitis. The us no angular stomatitis - both indicate chronic anaemia 

FINALLY TELL THE EXAMINER WHETHER THERE IS ANAEMIC OR NOT IN THIS PATIENT 

most of the time the examiner will ask few questions pertaining to anaemia

• What is the normal value of  haemoglobin in pregnancy. > 11g% 
• What are the causes of anaemia : Nutritional anaemia, chronic blood loss, haemoglobinopathies, myeloproliferative disorder, aplastic anemia & idiopathic causes . 

Q2. Examine the abdomen? 

INTRODUCTION TO ABDOMINAL EXAMINATION
1. Greet the patient and ask for permission to proceed.

2. Apply hand sanitizer.

3. Get a cepharone 

Tell patient, I would like to examine your abdomen, please let me know if there is any pain or discomfort. Thank you for your cooperation. 

On my in INSPECTION
• The Abdomen: It is distended due to the gravid uterus, which is evidenced by the presence of linea nigra and striae gravidarum.

• The Umbilicus: is Inverted / everted, centrally placed, and flat.
• look for any Scars: Note any scars. If present, assess the length and check for any rebound tenderness. Or ask patient to cough and see if there is hernia 
•  There is some Hyperpigmentation: Present / not present.
• if can see fFetal Movement: Visible / not visible. 

ON MY PALPATION. 
1. Begin with light palpation, observing the patient’s facial expressions.
• Findings: The abdomen is soft / firm and non-tender / tender.
2. Symphysis-Fundal Height: Measure the height by locating the fundus, marking it, and measuring down to the pubic symphysis.

Example finding: 33 cm. The SFH is 33 cms and if know the POA can say it’s Co response with the POA 

3. Proceeds with LEOPOLD’S MANEUVERS

Perform the maneuvers in the following order: fundal grip, lateral grip, pelvic grip, liquor estimation, and estimated fetal weight grip.
Key Points to Note:
• No pain during palpation.
• Singleton fetus (if non-twin pregnancy).
• Fetal lie: longitudinal / transverse.
• Fetal movement: palpable / not palpable.
• Fetal back is on the maternal right / left.
• Fetal head: engaged / non-engaged (specify if palpable).
• Liquor: adequate.
• Estimated fetal weight: approximately ____ g.
• Symphysis-fundal height is ____ cm and is consistent / smaller / greater with the gestational age of ____

4. AUSCULTATION
• Complete the examination by listening for the fetal heartbeat.

SUMMARY
In Summary: My patient, (Name), (Age) years old, Gravida ___ Para ____, at ………. POA/ POG presented with (chief complaint). & issues

MAIN ISSUE: PPROM

She also has risk factors 

1. Previous Lscs

2. GDM on diet control

3. Mild Anaemia latest Hb- 10.8g%

Findings: (Summarize key examination findings).
This script ensures clarity and maintains the professional flow of a comprehensive obstetric examination. 

TIPS : STUDENTS MUST PRACTICE EXAMINATIONS & PRACTICE PRESENTATION REPEATEDLY TO GET THE FLOW IN ORDER

Common suburethral masses and management

 Suburethral masses in women are relatively uncommon but can arise from various causes. They are typically located beneath the urethra in the anterior vaginal wall and can present with symptoms like urinary obstruction, incontinence, or dyspareunia, or may be asymptomatic and found incidentally. Below are the common causes and considerations:

Causes of Suburethral Masses

1. Urethral Diverticulum

• Ethiology: Congenital or acquired (e.g., due to chronic infection or trauma).

• Presentation:

 - Dysuria, post-void dribbling, dyspareunia, recurrent UTIs (“3 Ds” symptoms).

 - A soft, fluctuant mass may be palpable on vaginal examination.

• Diagnosis: MRI, ultrasound, or voiding cystourethrogram (VCUG).

• Management: Surgical excision.

2. Skene’s Gland Cysts/Abscesses

• Ethilogy: Blockage of Skene’s ducts, potentially 

                 secondary to infection.

• Presentation:

  - Tender, fluctuant suburethral mass.

   - May cause pain, dyspareunia, or dysuria.

• Management: Incision and drainage, with possible 

                antibiotics if infected.

3. Urethral Caruncle

• Ethilogy: Benign polypoid lesion at the urethral meatus, commonly in postmenopausal women due to estrogen deficiency.

• Presentation:

   - Small, red, friable mass at the urethral opening.

    - May bleed or cause irritation.

• Management: Observation, topical estrogen, or excision if symptomatic.

4. Urethral Prolapse

• Ethilogy: Circular eversion of the urethral mucosa, often in prepubertal girls or postmenopausal women.

• Presentation:

   - Circumferential suburethral swelling.

   - Can mimic a mass.

• Management: Topical estrogen, sitz baths, or surgical correction.

5. Benign Tumors

• Examples: Leiomyomas, fibromas, or lipomas.

• Presentation: Non-tender, well-circumscribed suburethral masses.

• Management: Surgical excision for symptomatic relief or diagnosis.

6. Malignancy

• Examples: Urethral carcinoma, rare suburethral metastases (e.g., bladder or vaginal cancer).

• Presentation: Firm, irregular mass with possible ulceration or bleeding.

• Management: Depends on histopathological diagnosis (e.g., surgery, chemotherapy, or radiotherapy).

7. Ectopic Ureters

• Etiology: Congenital anomaly where the ureter opens ectopically into the vaginal wall.

• Presentation: Continuous urinary dribbling from birth or early life.

• Diagnosis: Imaging (e.g., renal ultrasound or MRI).

• Management: Surgical correction.

Evaluation of Suburethral Masses

1. History:

• Symptoms: Dysuria, post-void dribbling, pain, bleeding, incontinence, or recurrent UTIs.

• Onset, duration, and aggravating/relieving factors.

2. Physical Examination:

• Inspect and palpate the anterior vaginal wall.

• Check for tenderness, size, consistency, and reducibility.

3. Imaging/Diagnostics:

• Pelvic Ultrasound: Initial investigation.

• MRI: Superior for soft tissue characterization.

• Cystourethroscopy: Direct visualization of the urethral lumen.

• VCUG: Useful for urethral diverticula.

4. Biopsy: Indicated for suspicious or recurrent masses to rule out malignancy.

Management Overview

• Symptomatic or enlarging masses often require surgical evaluation.

•.  For asymptomatic benign lesions, conservative management or observation may suffice.

•.  Always consider underlying infection or malignancy when evaluating these masses.

How to deal with Lower Segment Uterine Fibroid

Management of a lower segment uterine fibroid or cervical fibroid depends on factors such as the patient’s age, symptoms, desire for fertility, and the size and location of the fibroid. Here’s an overview:

1. Symptomatic Management

Medical Management:

• Non-hormonal: NSAIDs for pain relief.

• Hormonal:

   - Combined oral contraceptives or progestins to 

                regulate menstrual bleeding.

   - GnRH agonists (e.g., leuprolide) to shrink 

              fibroids temporarily before surgery.

 • Tranexamic acid for heavy menstrual bleeding.

2. Surgical Management

Fertility-preserving options:

• Myomectomy:

- Preferred for women desiring future pregnancies.

- Can be performed via laparotomy, laparoscopy, or hysteroscopy or robotics depending on fibroid size and location.

- For cervical fibroids or lower segment fibroids, open surgery may be required due to complex anatomy.

Non-fertility-preserving options:

• Hysterectomy:

       - Indicated for large, symptomatic fibroids in women 

         who have completed childbearing.

     -  Lower segment fibroids can increase complexity due to proximity to the bladder and ureters.

    Personal cases: both cases had abdominal hysterectomy 

3. Minimally Invasive Procedures

Uterine Artery Embolization (UAE):

- Shrinks fibroids by cutting off their blood supply.

- Effective for symptomatic relief but not  

           recommended for women planning pregnancies.

MRI-guided Focused Ultrasound Surgery (MRgFUS)

- Non-invasive option for small, symptomatic fibroids.

HIFU- High Intensity Focused Ultrasound 

- Is a minimally invasive procedure that uses sound waves to uterine fibroids. 

MWA : Microwave Ablation.

- Is a minimally invasive procedure that uses microwave energy to treat uterine fibroids 

4. Special Considerations for Lower Segment and Cervical Fibroids

Challenges:

• Close proximity to vital structures like the bladder, urethra, and rectum.

• Increased risk of surgical complications (e.g., hemorrhage, injury to pelvic organs).

• Pre-surgical Planning:

• Imaging (MRI or contrast-enhanced ultrasound) to map the fibroid’s size, location, and vascularity.

• Preoperative GnRH analogs may reduce fibroid size and vascularity.

5. Pregnancy Considerations

• Cervical or lower segment fibroids may complicate pregnancy or delivery (e.g., obstructed labor, malpresentation, increased cesarean risk).

• Regular monitoring during pregnancy.

• Myomectomy during pregnancy is avoided unless there are severe complications (e.g., torsion, necrosis).

Follow-Up and Long-Term Management

• Regular follow-up with imaging to monitor fibroid growth.

• Address recurrence risks, especially after myomectomy.

• Consider lifestyle modifications to manage symptoms.