The Female Reproductive System

Chapter 14 - The Female Reproductive System
Chapter 14
The Female Reproductive System
P.442

Applied anatomy
The pelvis
The bony pelvis is composed of the 2 pelvic bones with the sacrum and coccyx posteriorly. The pelvic brim divides the ‘false pelvis’ above (part of the abdominal cavity) and the ‘true pelvis’ below.
Pelvic inlet: also known as the pelvic brim. Formed by the sacral promontory posteriorly, the iliopectineal lines laterally and the symphysis pubis anteriorly.
Pelvic outlet: formed by the coccyx posteriorly, the ischial tuberosities laterally and the pubic arch anteriorly. The pelvic outlet has 3 wide notches. The sciatic notches are divided into the greater and lesser sciatic foramina by the sacrotuberous and sacrospinous ligaments which can be considered part of the perimeter of the outlet clinically.
The pelvic cavity: lies between the inlet and the outlet. It has a deep posterior wall and a shallow anterior wall giving a curved shape.
The contents of the pelvic cavity
The pelvic cavity contains the rectum, sigmoid colon, coils of the ileum, ureters, bladder, female reproductive organs, fascia, and peritoneum.
Female internal genital organs
Vagina
The vagina is a thin-walled distensible, fibromuscular tube that extends upwards and backwards from the vestibule of the vulva to the cervix. It is ~8cm long and lies posterior to the bladder and anterior to the rectum.
The vagina serves as an eliminatory passage for menstrual flow, forms part of the birth canal, and receives the penis during sexual intercourse.
The fornix
This is the vaginal recess around the cervix and is divided into anterior, posterior, and lateral regions which, clinically, provide access points for examining the pelvic organs.
Uterus
The uterus is a thick-walled, hollow, pear-shaped muscular organ consisting of the cervix, body and fundus. In the nulliparous female, it is ~8cm long, ~5cm wide, and ~2.5cm deep. The uterus is covered with peritoneum that forms an anterior uterovesical fold, a fold between the uterus and rectum termed the pouch of Douglas, and the broad ligaments laterally.
The uterus receives, retains, and nourishes the fertilized ovum.
Uterine orientation
In most females, the uterus lies in an anteverted and anteflexed position.
Anteversion: the long axis of the uterus is angled forward.
Retroversion: The fundus and body are angled backwards and therefore lie in the pouch of Douglas. Occurs in about 15% of the female population. A full bladder may mimic retroversion clinically.
Anteflexion: the long axis of the body of the uterus is angled forward on the long axis of the cervix.
Retroflexion: The body of the uterus is angled backward on the cervix
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Fallopian tubes
The fallopian or ‘uterine’ tubes are paired tubular structures, ~10cm long. The fallopian tubes extend laterally from the cornua of the uterine body, in the upper border of the broad ligament and opens into the peritoneal cavity near the ovaries. The fallopian tube is divided into 4 parts:
Infundibulum: distal, funnel-shaped portion with finger-like ‘fimbriae’.
Ampulla: widest and longest part of tube outside the uterus.
Isthmus: thick-walled with a narrow lumen and therefore, least distensible part. Enters the horns of the uterine body.
Intramural: that part which pierces the uterine wall.
The main functions of the uterine tube are to receive the ovum from the ovary, provide a site where fertilization can take place (usually in the ampulla) and transport the ovum from the ampulla to the uterus. The tube also provides nourishment for the fertilized ovum.
Ovaries
The ovaries are whitish-grey, almond-shaped organs measuring ~4cm×2cm which are responsible for the production of the female germ cells, the ova, and the female sex hormones, oestrogen and progesterone.
They are suspended on the posterior layer of the broad ligament by a peritoneal extension (mesovarium) and supported by the suspensory ligament of the ovary (a lateral extension of the broad ligament and mesovarium) and the round ligament which stretches from the lateral wall of the uterus to the medial aspect of the ovary.
Perineum
The perineum lies inferior to the pelvic inlet and is separated from the pelvic cavity by the pelvic diaphragm.
Seen from below with the thighs abducted, it is a diamond-shaped area bounded anteriorly by the pubic symphysis, posteriorly by the tip of the coccyx and laterally by the ischial tuberosities.
The perineum is artificially divided into the anterior urogenital triangle containing the external genitalia in females and an anal triangle containing the anus and ischiorectal fossae.
Female external genital organs
These are sometimes collectively known as the ‘vulva’. It consists of:
Labia majora: a pair of fat-filled folds of skin extending on either side of the vaginal vestibule from the mons towards the anus.
Labia minora: a pair of flat folds containing a core of spongy connective tissue with a rich vascular supply. Lie medial to the labia majora.
Vestibule of the vagina: between the labia minora, contains the urethral meatus and vaginal orifice. Receives mucous secretions from the greater and lesser vestibular glands.
Clitoris: short, erectile organ; the female homologue of the male penis. Like the penis, a crus arises from each ischiopubic ramus and join in the midline forming the ‘body’ capped by the sensitive ‘glans’.
Bulbs of vestibule: 2 masses of elongated erectile tissue, ~3cm long, lying along the sides of the vaginal orifice.
Greater and lesser vestibular glands.
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Applied physiology
The menstrual cycle
Menstruation is the shedding of the functional superficial 2/3 of the endometrium after sex hormone withdrawal. This process, which consists of 3 phases, is typically repeated ~300-400 times during a woman's life. Coordination of the menstrual cycle depends on a complex interplay between the hypothalamus, the pituitary gland, the ovaries, and the uterine endometrium.
Cyclical changes in the endometrium prepare it for implantation in the event of fertilization and menstruation in the absence of fertilization. It should be noted that several other tissues are sensitive to these hormones and undergo cyclical change (e.g. the breasts and the lower part of the urinary tract).
The endometrial cycle can de divided into 3 phases…
Phases of the menstrual cycle
The first day of the menses is considered to be day 1 of the menstrual cycle.
The proliferative or follicular phase
This begins at the end of the menstrual phase (usually day 4) and ends at ovulation (days 13-14). During this phase, the endometrium thickens and ovarian follicles mature.
The hypothalamus is the initiator of the follicular phase. Gonadotrophinreleasing hormone (GnRH) is released from the hypothalamus in a pulsatile fashion to the pituitary portal system surrounding the anterior pituitary gland. GnRH causes release of follicle stimulating hormone (FSH). FSH is secreted into the general circulation and interacts with the granulosa cells surrounding the dividing oocytes.
FSH enhances the development of 15-20 follicles each month and interacts with granulosa cells to enhance aromatization of androgens into oestrogen and oestradiol.
Only one follicle with the largest reservoir of oestrogen can withstand the declining FSH environment whilst the remaining follicles undergo atresia at the end of this phase.
Follicular oestrogen synthesis is essential for uterine priming, but is also part of the positive feedback that induces a dramatic preovulatory leuteinising hormone (LH) surge and subsequent ovulation.
The luteal or secretory phase
The luteal phase starts at ovulation and lasts through to day 28 of the menstrual cycle.
The major effects of the LH surge are the conversion of granulosa cells from predominantly androgen-converting cells to predominantly progesterone-synthesising cells. High progesterone levels exert negative feedback on GnRH which, in turn, ↓ FSH/LH secretion.
At the beginning of the luteal phase, progesterone induces the endometrial glands to secrete glycogens, mucus, and other substances. These glands become tortuous and have large lumina due to ↑ secretory activity. Spiral arterioles extend into the superficial layer of the endometrium.
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In the absence of fertilization by day 23 of the menstrual cycle, the superficial endometrium begins to degenerate and consequently ovarian hormone levels ↓. As oestrogen and progesterone levels fall, the endometrium undergoes involution.
If the corpus luteum is not rescued by human chorionic gonadotrophin (hCG) hormone from the developing placenta, menstruation occurs 14 days after ovulation. If conception occurs, placental hCG maintains luteal function until placental production of progesterone is well established.
The menstrual phase
This phase sees the gradual withdrawal of ovarian sex steroids which causes slight shrinking of the endometrium, and therefore the blood flow of spiral vessels is reduced. This, together with spiral arteriolar spasms, leads to distal endometrial ischaemia and stasis. Extravasation of blood and endometrial tissue breakdown lead to onset of menstruation.
The menstrual phase begins as the spiral arteries rupture, releasing blood into the uterus and the apoptosing endometrium is sloughed off.
During this period, the functionalis layer of the endometrium is completely shed. Arteriolar and venous blood, remnants of endometrial stroma and glands, leucocytes and red blood cells are all present in the menstrual flow.
Shedding usually lasts ~4 days.
P.446

History-taking in gynaecology
It is important to remember that many females can be embarrassed by having to discuss their gynaecological problems, so it is vital to appear confident, friendly, and relaxed.
Although there are parts particular to this history, most of it is the same as the basic outline described in Chapter 2 and we suggest that readers review that chapter before going on.
Demographic details
Name, age, date of birth, occupation.
Presenting complaint
Ask the patient to tell you in her own words what she perceives the main symptom or symptoms to be. Document each in order of severity.
History of presenting complaint
More detailed questioning will depend on the nature of the presenting complaint—see the following pages. As described on p.36 ascertain:
The exact nature of the symptom.
The onset.
When and how it began (e.g. suddenly, gradually—over how long?)
If longstanding, why is the patient seeking help now?
Periodicity and frequency.
Is the symptom constant or intermittent?
If intermittent, how long does it last each time?
What is the exact manner in which it comes and goes?
â–¶ How does it relate to the menstrual cycle?
Change over time.
Exacerbating and relieving factors.
Associated symptoms.
The degree of functional disability caused.
Menstrual history
Age of menarche (first menstrual period).
Normally about 12 years but can be as early as 9 or as late as 16.
Date of last menstrual period (LMP).
Duration and regularity of periods (cycle).
Normal menstruation lasts 4-7 days.
Average length of menstrual cycle is 28 days (i.e. the time between first day of one period and the first day of the following period) but can vary between 21 and 42 days in normal women.
Menstrual flow: whether light, normal, or heavy (see p.448).
Menstrual pain: whether occurs prior to or at the start of bleeding.
Irregular bleeding.
E.g. intermenstrual blood-loss, post-coital bleeding etc.
Associated symptoms.
Bowel or bladder dysfunction, pain.
Hormonal contraception or HRT.
Age at menopause (if this has occurred).
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Past gynaecological history
Record all details of:
Previous cervical smears, including date of last smear, any abnormal smear results, and treatments received.
Previous gynaecological problems and treatments including surgery and pelvic inflammatory disease.
Contraception
It is also essential to ask sexually active women of reproductive age about contraception, including methods used, duration of use and acceptance, current method, as well as future plans.
Past obstetric history
Gravidity and parity: see p.467 for a full explanation.
Document the specifics of each pregnancy:
Current age of the child and age of mother when pregnant.
Birth weight.
Complications of pregnancy, labour, and puerperium.
Miscarriages and terminations. Note gestation time and complications.
Past medical history
As described in Chapter 2. Pay particular attention to any history of chronic lung or heart disease and make note of all previous surgical procedures.
Drug history
As in Chapter 2. Ask about all medication/drugs taken (prescribed, over the counter and illicit drugs). Record dose, frequency, as well as any known drug allergies.
â–¶ Make particular note to ask about the oral contraceptive pill (OCP) and hormone replacement therapy (HRT) if not done so already.
Family history
Note especially any history of genital tract cancer, breast cancer and diabetes.
Smoking and alcohol
As always, document fully as described on p.44.
Social history
Take a standard SHx including living conditions and marital status.
This is also an extra chance to explore the impact of the presenting problem on the patient's life—in terms of their social life, employment, home life, and sexual activity.
P.448

Abnormal bleeding in gynaecology
Menorrhagia
This is defined as >80ml of menstrual blood loss per period (normal = 20-60ml) and may be caused by a variety of local, systemic, or iatrogenic factors. Menorrhagia is hard to measure, but periods are considered ‘heavy’ if they lead to frequent changes of sanitary towels.
As well as the standard questions for any symptom, ask about:
The number of sanitary pads/towels used per day and the ‘strength’ (absorbency) of those pads.
Bleeding through to clothes or onto the bedding at night (‘flooding’).
The need to use 2 pads at once.
The need to wear double protection (i.e. pad and tampon together).
Interference with normal activities.
â–¶ Remember to ask about symptoms of iron deficiency anaemia such as lethargy, breathlessness, and dizziness.
Dysmenorrhoea
This is pain associated with menstruation—thought to be caused by ↑ levels of endometrial prostaglandins during the luteal and menstrual phases of the cycle resulting in uterine contractions. The pain is typically cramping, localized to the lower abdomen and pelvic regions, and radiating to the thighs and back.
Dysmenorrhoea may be primary or secondary:
Primary: occurring from menarche.
Secondary: occurring in females who previously had normal periods (often caused by pelvic pathology).
When taking a history of dysmenorrhoea, take a full pain history as on p.39, a detailed menstrual history ( p.446), and ask especially about the relationship of the pain to the menstrual cycle. Remember to ask about the functional consequences of the pain—how does it interfere with normal activities?
Intermenstrual bleeding (IMB)
Intermenstrual bleeding is uterine bleeding which occurs between the menstrual periods.
As for all these symptoms, a full standard battery of questions should be asked ( p.38), as full menstrual history ( p.446), past medical and gynaecological histories ( p.42) and sexual history ( p.408).
Ask also about the association of the bleeding with hormonal therapy, contraceptive use and previous cervical smears.
Postcoital bleeding
This is vaginal bleeding precipitated by sexual intercourse. It can be caused by similar conditions to intermenstrual bleeding. Take a full and detailed history as above.
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Box 14.1 Some causes of menorrhagia
Hypothyroidism.
Intra-uterine contraceptive device (IUCD).
Fibroids.
Endometriosis.
Polyps—cervix, uterus.
Uterine cancer.
Infection (STIs).
Previous sterilization.
Warfarin therapy.
Aspirin.
Non-steroidal anti-inflammatory drugs (NSAIDs).
Clotting disorders (e.g. von-Willebrand's disease).
Box 14.2 Some causes of secondary dysmenorrhoea
Pelvic inflammatory disease.
Endometriosis.
Uterine adenomyosis.
Fibroids.
Endometrial polyps.
Premenstrual syndrome.
Cessation of OCP.
Box 14.3 Some causes of intermenstrual bleeding
Obstetric pregnancy, ectopic pregnancy, gestational trophoblastic disease.
Gynaecological: vaginal malignancy, vaginitis, cervical cancer, adenomyosis, fibroids, ovarian cancer.
Iatrogenic anticoagulants, corticosteroids, antipsychotics, tamoxifen, SSRIs, rifampicin, and anti-epileptic drugs (AEDs).
Box 14.4 Some causes of post-coital bleeding
Similar to intermenstrual bleeding, as well as:
Vaginal infection with Chlamydia, gonorrhoea, trichomaniasis or yeast. Also cervicitis.
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Amenorrhoea
This is the absence of periods and may be ‘primary’ or ‘secondary’.
Primary: failure to menstruate by 16 years of age in the presence of normal secondary sexual development or failure to menstruate by 14 years in the absence of secondary sexual characteristics.
Secondary: normal menarche, then cessation of menstruation with no periods for at least 6 months.
â–¶ Amenorrhoea is a normal feature in prepubertal girls, pregnancy, during lactation, postmenopausal females, and in some women using hormonal contraception.
History-taking
A full and detailed history should be taken as described on p.446, and Chapter 2. Ask especially about:
Childhood growth and development.
If secondary amenorrhoea:
Age of menarche.
Cycle days.
Day and date of LM P.
Presence or absence of breast soreness.
Mood change immediately before menses.
Chronic illnesses.
Previous surgery (including cervical surgery with can cause stenosis and more obviously oophorectomy and hysterectomy).
Prescribed medications known to cause amenorrhoea such as phenothiazines, domperidone and metoclopramide (produce either hyperprolactinaemia or ovarian failure).
Illicit or ‘recreational’ drugs.
Sexual history.
SHx including any emotional stress at school/work/home, exercise and diet—include here any weight gain or weight loss.
Systems enquiry: include vasomotor symptoms, hot flushes, virilizing changes (e.g. ↑ body hair, greasy skin etc), galactorrhoea, headaches, visual field disturbance, palpitations, nervousness, hearing loss.
Postmenopausal bleeding
This is vaginal bleeding occurring >6 months after the menopause. It requires reassurance and prompt investigation as it could indicate the presence of malignancy.
As well as all the points outlined above, ask about:
Local symptoms of oestrogen deficiency such as vaginal dryness, soreness, and superficial dyspareunia ( p.452).
Itching (pruritus vulvae—more likely in non-neoplastic disorders).
Presence of lumps or swellings at the vulva.
Cervical or endometrial malignancy
Often present with profuse or continuous vaginal bleeding or with a bloodstained offensive discharge.
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Box 14.5 Some causes of amenorrhoea
Hypothalamic: idiopathic, weight loss, intense exercise.
Hypogonadism from hypothalamic or pituitary damage: tumours, craniopharyngiomas, cranial irradiation, head injuries.
Pituitary: hyperprolactinaemia, hypopituitarism.
Delayed puberty: constitutional delay.
Systemic: chronic illness, weight loss, endocrine disorders (e.g. Cushing's syndrome, thyroid disorders).
Uterine: mullerian agenesis.
Ovarian: PCOS, premature ovarian failure (e.g. Turner's syndrome, autoimmune disease, surgery, chemotherapy, pelvic irradiation, infection).
Psychological: emotional stress at school/home/work.
Box 14.6 Some causes of post-menopausal bleeding
Cervical carcinoma.
Uterine sarcoma.
Vaginal carcinoma.
Endometrial hyperplasia/carcinoma/polyps.
Cervical polyps.
Trauma.
Hormone replacement therapy.
Bleeding disorder.
Vaginal atrophy.
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Other symptoms in gynaecology
Pelvic pain and dyspareunia
As with any type of pain, pelvic pain may be acute or chronic. Chronic pelvic pain is often associated with dyspareunia.
Dyspareunia is painful sexual intercourse and may be experienced superficially at the area of the vulva and introitus on penetration or deep within the pelvis. Dyspareunia can lead to failure to reach orgasm, the avoidance of sexual activity and relationship problems.
Box 14.7 Gynaecological versus gastrointestinal pain
Distinguishing between pain of gynaecological and gastrointestinal origin is often difficult. This is because the uterus, cervix, and adnexa share the same visceral innervation as the lower ileum, sigmoid colon, and rectum. You should be careful in your history to rule out a gastrointestinal problem and keep an open mind.
When taking a history of pelvic pain or dyspareunia, you should obtain a detailed history as for any type of pain ( p.39) including site, radiation, character, severity, mode and rate of onset, duration, frequency, exacerbating factors, relieving factors, and associated symptoms.
You also need to establish the relationship of the pain to the menstrual cycle. Ask also about:
Date of LMP.
Cervical smears.
Intermenstrual or post-coital bleeding.
Previous gynaecological procedures (e.g. IUCD, hysteroscopy).
Previous pelvic inflammatory disease or genitourinary infections.
Previous gynaecological surgery (adhesion formation?).
Vulval discharge.
Bowel habit, nausea, and vomiting ( p.226).
A detailed sexual history ( p.408) should also include contraceptive use and the degree of impact the symptoms have on the patient's normal life, and psychological health.
Vaginal discharge
Vaginal discharge is a common complaint during the child-bearing years. As well as the standard questions ( p.446) ask about:
Colour, volume, odour, and presence of blood.
Irritation.
▶ Don't forget to ask about diabetes and obtain a full DHx including recent antibiotic use—both of which may precipitate candidal infection.
Obtain a full sexual history ( p.408). A full gynaecological history should include history of cervical smear testing, use of ring pessaries, and recent history of surgery (↑ risk of vesicovaginal fistulae).
â–¶ Lower abdominal pain, backache, and dyspareunia suggest PID.
â–¶ Weight loss and anorexia may indicate underlying malignancy.
P.453

Physiological vaginal discharge
Physiological discharge is usually scanty, mucoid, and odourless. It occurs with the changing oestrogen levels during the menstrual cycle (discharge ↑ in quantity mid-cycle and is a physiological sign of ovulation) and pregnancy.
It may arise from vestibular gland secretions, vaginal transudate, cervical mucus, and residual menstrual fluid.
Pathological vaginal discharge
This usually represents infection (trichomonal or candidal vaginitis) and may be associated with pruritus or burning of the vulval area.
Candida albicans: the discharge is typically thick and causes itching.
Bacterial vaginitis: the discharge is grey and watery with a fishy smell. Seen especially after intercourse.
Trichomonas vaginalis: the discharge is typically profuse, opaque, cream-coloured and frothy. It also has a characteristic ‘fishy’ smell. This may also be accompanied by urinary symptoms, such as dysuria and frequency.
Box 14.8 Some causes of dyspareunia
Scars from episiotomy.
Vaginal atrophy.
Vulvitis.
Vulvar vestibulitis.
PID.
Ovarian cysts.
Endometriosis.
Varicose veins in pelvis.
Ectopic pregnancy.
Infections (STIs).
Bladder or urinary tract disorder.
Cancer in the reproductive organs or pelvic region.
P.454

Vulval symptoms
The main symptom to be aware of is itching or irritation of the vulva (pruritis vulvae). It can be debilitating and socially embarrassing. Embarrassment often delays the woman seeking advice.
Causes include infection, vulval dystrophy, neoplasia, and other dermatological conditions. Ask especially about:
The nature of onset, exacerbating and relieving factors.
Abnormal vaginal discharge.
History of cervical intraepithelial neoplasia—CIN (thought to share a common aetiology with vulval intraepithelial neoplasia—VIN).
Sexual history.
Dermatological conditions such as psoriasis and eczema.
Symptoms suggestive of renal or liver problems ( p.234).
Diabetes.
Urinary incontinence
This is an objectively demonstrable involuntary loss of urine that can be both a social and hygienic problem.
The two most common causes of urinary incontinence in females are genuine stress incontinence (GSI) and detruser over-activity (DO). Other less commonly encountered causes include mixed GSI and DO, sensory urgency, chronic voiding problems and fistulae.
When taking a history of urinary incontinence, ascertain under what circumstances they experience the symptom. See also p.236. Remember to ask about the functional consequences on the patient's daily life.
Genuine stress incontinence
Patients notice small amounts of urinary leakage with a cough, sneeze, or exercise. One third may also admit to symptoms of DO.
Ask about:
Number of children (↑ risk with ↑ parity).
Genital prolapse.
Previous pelvic floor surgery.
Detruser over-activity
Urge incontinence, urgency, frequency and nocturia (see p.236). Ask about:
History of nocturnal enuresis.
Previous neurological problems.
Previous incontinence surgery.
Incontinence during sexual intercourse.
DHx (see note under ‘the elderly patient’ p.484).
Overflow incontinence
Voiding disorders can result in chronic retention leading to overflow incontinence and ↑ predisposition to infection. The patient may complain of hesitancy, straining, poor flow, and incomplete emptying in addition to urgency and frequency.
Fistulae
Suspect if incontinence is continuous during the day and night.
P.455

Genital prolapse
Genital prolapse is descent of the pelvic organs through the pelvic floor into the vaginal canal. In the female genital tract, the type of prolapse is named according to the pelvic organ involved. Some examples include:
Uterine: uterus.
Cystocoele: bladder.
Vaginal vault prolapse: apex of vagina after hysterectomy.
Enterocoele: small bowel.
Rectocoele: rectum.
Mild degrees of genital prolapse are often asymptomatic. More extensive prolapse may cause vaginal pressure or pain, introital bulging, a feeling of ‘something coming down’, as well as impaired sexual function.
Uterine descent often gives symptoms of backache especially in older patients.
There might be associated symptoms of incomplete bowel emptying (rectocoele) or urinary symptoms such as frequency or incomplete emptying (cystocoele or cysto-urethrocoele).
Box 14.9 Some causes of genital prolapse
Oestrogen deficiency states: such as advancing age and the menopause (atrophy and weakness of the pelvic support structures).
Childbirth: prolonged labour, instrumental delivery, fetal macrosomia, ↑ parity.
Genetic factors: e.g. spina bifida.
Chronic raised intra-abdominal pressure: e.g. chronic cough, constipation.
Box 14.10 Some other common vulval conditions
Dermatitis: atopic, seborrhoeic, irritant, allergic, steroid-induced (itch, burning, erythema, scale, fissures, lichenification).
Vulvovaginal candidiasis: itch, burning, erythema, vaginal discharge.
Lichen sclerosus: itch, burning, dyspareunia, white plaques, atrophic wrinkled surface.
Psoriasis: remember to look for other areas of psoriasis; scalp, natal cleft, nails.
Vulval intraepithelial neoplasia: itch, burning, multifocal plaques.
Erosive vulvovaginitis: erosive lichen planus, pemphigoid, pemphigus vulgaris, fixed drug eruption (chronic painful erosion and ulcers with superficial bleeding).
Atrophic vaginitis: secondary to oestrogen deficiency (thin, pale, dry vaginal epithelium. Superficial dyspareunia, minor vaginal bleeding and pain).
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Outline gynaecological examination
The gynaecological examination should include a full abdominal examination before proceeding to the pelvic, speculum, and bimanual examinations.
Explain to the patient that you would like to examine their genitalia and reproductive organs and reassure them that the procedure will be quick and gentle.
You should have a chaperone present, particularly if you are male*.
As always, ensure that the room is warm and well lit, preferably with a moveable light source and that you will not be disturbed.
The examination should follow an orderly routine. The authors' suggestion is shown below. It is standard practice to start with the cardiovascular and respiratory systems—this not only gives a measure of the general health of the patient but establishes a ‘physical rapport’ before you examine more delicate or embarrassing areas.
Box 14.11 Framework for the gynaecological examination
General inspection.
Cardiorespiratory examination.
Abdominal examination.
Pelvic examination
External genitalia—inspection.
External genitalia—palpation.
Speculum examination.
Bimanual examination (‘PV’ examination).
â–¶ Perform bedside urinalysis, if able.
* This is controversial at the time of writing—attitudes vary between countries. In the UK, official advice is that all doctors should have a chaperone when performing an intimate examination and the chaperone should be the same sex as the patient. In practice, male doctors performing an examination on a female and females performing an examination on a male should always have a chaperone present whilst the need for a chaperone in other situations is judged at the time.
General inspection and other systems
Always begin with a general examination of the patient (as described in Chapter 3) including temperature, hydration, coloration, nutritional status, lymph nodes, and blood pressure. Note especially:
Distribution of facial and body hair, as hirsutism may be a presenting symptom of various endocrine disorders.
Height and weight.
Examine the cardiovascular and respiratory systems in turn (see Chapters 7 and 8).
Breast examination is a routine part of the procedure in gynaecology in many countries. In the UK, it should be performed ( Chapter 13) if there are symptoms or at first consultation in women over 45 years.
P.457

Abdominal examination
A full abdominal examination should be performed (see Chapter 9). Look especially in the periumbilical region for scars from previous laparoscopies and in the suprapubic region where transverse incisions from caesarean sections and most gynaecological operations are found.
P.458

Pelvic examination
The patient should be allowed to undress in privacy and, if necessary, to empty her bladder first.
Set-up and positioning
Before starting the examination, always explain to the patient what will be involved. Ensure the abdomen is covered. Ensure good lighting and remember to wear disposable gloves.
Ask the patient to lie on her back on an examination couch with both knees bent up and let her knees fall apart—either with her heels together in the middle or separated.
The lithotomy position, in which both thighs are abducted and feet suspended from lithotomy stirrups is usually adopted when performing vaginal surgery.
Examination of the external genitalia
Uncover the mons to expose the external genitalia making note of the pattern of hair distribution.
Apply a lubricating gel to the examining finger.
Separate the labia from above with the forefinger and thumb of your left hand.
Inspect the clitoris, urethral meatus, and vaginal opening.
Look especially for any:
Discharge.
Redness.
Ulceration.
Atrophy.
Old scars.
Ask the patient to cough or strain down and look at the vaginal walls for any prolapse.
Palpation
Palpate the length of the labia majora between the index finger and thumb.
The tissue should feel pliant and fleshy.
Palpate for Bartholin's gland with the index finger of the right hand just inside the introitus and the thumb on the outer aspect of the labium majora.
Batholin's glands are only palpable if the duct becomes obstructed resulting in a painless cystic mass or an acute Bartholin's abscess. The latter is seen as a hot, red, tender swelling in the posterolateral labia majora.
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P.460

Speculum examination
Speculum examination is carried out to see further inside the vagina and to visualize the cervix. It also allows the examiner to take a cervical smear or swabs.
There are different types of vaginal specula (see Fig. 14.1) but the commonest is the Cusco's or bivalve speculum. It is important that you familiarize yourself with the operation of the speculum before examining a patient so that you can concentrate on the findings.
Inserting the speculum
Explain to the patient that you are about to insert the speculum into the vagina and provide reassurance that this should not be painful.
Warm the speculum under running water and lubricate it with a water-based lubricant.
Using the left hand, open the lips of the labia minora to obtain a good view of the introitus.
Hold the speculum in the right hand with the main body of the speculum in the palm (see Fig. 14.2) and the closed blades projecting between index and middle fingers.
Gently insert the speculum into the vagina held with your wrist turned such that the blades are in line with the opening between the labia.
The speculum should be angled downwards and backwards due to the angle of the vagina.
Maintain a posterior angulation and rotate the speculum through 90° to position handles anteriorly.
When it cannot be advanced further, maintain a downward pressure and press on the thumb piece to hinge the blades open exposing the cervix and vaginal walls.
Once the optimum position is achieved, tighten the thumbscrew.
Findings
Inspect the cervix which is usually pink, smooth and regular.
Look for the external os (central opening) which is round in the nulliparous female and slit-shaped after childbirth.
Look for cervical erosions which appear as strawberry-red areas spreading circumferentially around the os and represent extension of the endocervical epithelium onto the surface of the cervix.
Identify any ulceration or growths which may suggest cancer.
Cervicitis may give a mucopurulent discharge associated with a red, inflamed cervix which bleeds on contact. Take swabs for culture.
Removing the speculum
â–¶ This should be conducted with as much care as insertion. You should still be examining the vaginal walls as the speculum is withdrawn.
Undo the thumbscrew and withdraw the speculum.
The blades should be held open until their ends are visible distal to the cervix to avoid causing pain.
Rotate the open blades in an anticlockwise direction to ensure that the anterior and posterior walls of the vagina can be inspected.
Near the introitus, allow the blades to close taking care not to pinch the labia or hairs.
P.461


Fig. 14.1 (a) Sim's speculum—used mainly in the examination of women with vaginal prolapse. (b) Cusco's speculum.


Fig. 14.2 Hold the speculum in the right hand such that the handles lie in the palm and the blades project between the index and middle fingers.

Box 14.12 A word about specula
Many departments and clinical areas now used plastic/disposable specula. These do not have a thumb-screw but a ratchet to open/close the blades. Take care to familiarize yourself with the operation of the speculum before starting the examination.
P.462

Bimanual examination
Digital examination helps identify the pelvic organs. Ideally the bladder should be emptied, if not already done so by this stage.
This examination is often known as per vaginam or simply ‘PV’.
Getting started
Explain again to the patient that you are about to perform an internal examination of the vagina, uterus, tubes, and ovaries and obtain verbal consent.
The patient should be positioned as described on p.457.
Expose the introitus by separating the labia with the thumb and forefinger of the gloved left hand.
Gently introduce the lubricated index and middle fingers of the right hand into the vagina.
Insert your fingers with the palm facing laterally and then rotate 90° so that the palm faces upwards.
The thumb should be abducted and the ring and little finger flexed into the palm (see Fig. 14.3).
Vagina, cervix and fornices
Feel the walls of the vagina which are slightly rugose, supple and moist.
Locate the cervix—usually pointing downwards in the upper vagina.
The normal cervix has a similar consistency to the cartilage in the tip of the nose.
Assess the mobility of the cervix by moving it from side to side and note any tenderness (‘excitation’) which suggests infection.
Gently palpate the fornices either side of the cervix.
Uterus
Place your left hand on the lower anterior abdominal wall about 4cm above the symphysis pubis.
Move the fingers of your right ‘internal’ hand to push the cervix upwards and simultaneously press the fingertips of your left ‘external’ hand towards the internal fingers.
You should be able to capture the uterus between your 2 hands.
Note the following features of the uterine body:
Size: a uniformly enlarged uterus may represent a pregnancy, fibroid or endometrial tumour.
Shape: multiple fibroids tend to give the uterus a lobulated feel.
Position.
Surface characteristics.
Any tenderness.
â–¶ Remember that an anteverted uterus is easily palpable bimanually but a retroverted uterus may not be.
Assess a retroverted uterus with the internal fingers positioned in the posterior fornix.
Ovaries and fallopian tubes
Position the internal fingers in each lateral fornix (finger pulps facing the anterior abdominal wall) and place your external fingers over each iliac fossa in turn.
P.463

Press the external hand inwards and downwards and the internal fingers upwards and laterally.
Feel the adnexal structures (ovaries and fallopian tubes), assessing size, shape, mobility and tenderness.
Ovaries are firm, ovoid and often palpable. If there is unilateral or bilateral ovarian enlargement, consider benign cysts (smooth and compressible) and malignant ovarian tumours.
Normal fallopian tubes are impalpable.
There may be marked tenderness of the lateral fornices and cervix in acute infection of the fallopian tubes (salpingitis).
Masses
It is often not possible to differentiate between adnexal and uterine masses. However, there are some general rules:
Uterine masses may be felt to move with the cervix when the uterus is shifted upwards while adnexal masses will not.
If suspecting an adnexal mass, there should be a line of separation between the uterus and the mass and the mass should be felt distinctly from the uterus.
Whilst the consistency of the mass may help to distinguish its origin in certain cases, an ultrasound may be necessary.
Finishing the examination
Withdraw your fingers from the vagina.
Inspect the glove for blood or discharge.
Re-drape the genital area and allow the patient to re-dress in privacy-offer them assistance if needed.

Fig. 14.3 Correct position of the fingers of the right hand for per vaginam examination.


Fig. 14.4 Bimanual examination of the uterus.

P.464

Taking a cervical smear
Theory
The UK has a National Screening Program to detect pre-malignant conditions of the cervix. Women between the ages of 20 and 65 years receive an invitation to attend for screening every 3 years. A sample of cells from the squamo-columnar junction are obtained and a cytological examination performed to look for evidence of cerival intraepithelial neoplasia (CIN). This stage of the condition is easily and successfully treated.
The majority of Units are now using liquid based cytology (LBC) in order to minimize the number of inadequate samples.
Equipment
Specula of different sizes.
Disposable gloves.
Request form.
Sampling device-plastic broom (Cervex-Brush®).
Liquid-based cytology vial-preservative for sample.
Patient information leaflet.
Before you start
Ensure the woman understands purpose of examination.
Discuss how and when she will receive the results.
Provide a patient information leaflet.
Document the date of last menstrual period.
Document the use of hormonal treatment (e.g. contraception, HRT).
Record the details of last smear and previous abnormal results.
Ask about irregular bleeding (e.g. post-coital or post-menopausal).
Where appropriate, offer screening for Chlamydia infection (under 25 years, symptomatic).
Procedure
Prepare woman as for vaginal examination remembering to make her comfortable and allow privacy—see p.460.
Write the patient's identification details on LBC vial.
Insert Cusco speculum to identify and visualize cervix as on p.460. Record any abnormal features of the cervix
Insert the plastic broom so that the central bristles of the brush are in the endocervical canal and the outer bristles in contact with the ectocervix (see fig. 14.5).
Using pencil pressure, rotate the brush 5 times in a clockwise direction.
The bristles are bevelled to scrape cells only on clockwise rotation.
Rinse the brush thoroughly in the preservative (ThinPrep®) or break off brush into the preservative (SurePath®).
Place in transport packaging with completed request form.
Remove the speculum as p.460.
Allow the patient to re-dress in privacy.
P.465


Fig. 14.5 The end of a typical cervex-brush®.


Fig. 14.6 Representation of how to use a cervex-brush®. Note that the longer, central bristles are within the cervical canal whist the outer bristles are in contact with the ectocervix.

Box 14.13 Cervical smears in pregnancy
Cervical smears should not be performed during pregnancy. The increase in cervical mucus (and resultant ↓ in the number of cells obtained) usually renders the sample inadequate and the results unreliable.
P.466

History-taking in obstetrics
Although there are parts particular to this history, most is the same as the basic outline described in Chapter 2 and we suggest that readers review that chapter before going on.
The parts of the history detail below are only those that differ from those described in Chapter 2 and earlier in this chapter ( p.446).
Demographic details
Name, age, and date of birth.
Gravidity and parity—see Box 14.15.
Estimated date of delivery (EDD)
The EDD can be calculated from the last menstrual period (LMP) by Naegele's rule*, which assumes a 28-day menstrual cycle.
Box 14.14 Calculating the EDD
Subtract 3 months from the first day of the LMP.
Add on 7 days and 1 year.
If the normal menstrual cycle is <28 days, or >28 days, then an appropriate number of days should be subtracted from or added to the EDD. For example, if the normal cycle is 35 days, 7 days should be added to the EDD.
It is important to also consider at this point any detail that may influence the validity of the EDD as calculated from the LMP; such as:
Was the last period normal?
What is the usual cycle length?
Are the patient's periods usually regular or irregular?
Was the patient using the oral contraceptive pill in the 3 months prior to conception? If so, calculations based on her LMP are unreliable.
* Named after the German Obstetritian, Franz Naegele following its publication in his Lehrbuch der Geburtshuelfe published for midwives in 1830. The formula was actually developed by Harmanni Boerhaave. Boerhaave H. (1744) Praelectiones Academicae in Propias Institutiones Rei Medicae. Von Haller A, ed. Göttingen: Vandehoeck. 5 (part 2): 437.
Current pregnancy
About the patient's general health and that of her fetus. If there is a presenting complaint, the details should be documented in full as on p.38. and p.446. Also ask about:
Fetal movements.
Not usually noticed until 20 weeks' gestation in the first pregnancy and 18 weeks' in the second or subsequent pregnancies.
Any important laboratory tests or ultrasound scans.
Include dates and details of all the scans, especially the first scan (dating or nuchal translucency scan).
P.467

Box 14.15 Gravidity and parity
These terms can be confusing and, although it is worth knowing the definitions and how to use them, they should be supplemented with a detailed history and not relied on alone as you may miss subtleties which alter your outlook on the case.
Gravidity
The number of pregnancies (including the present one) to any stage.
Parity
The number of live births (at any stage of gestation) and stillbirths after 24 weeks' gestation.
Pregnancies terminating before 24 weeks' gestation can be written after this number with a plus sign.
Examples
A woman who is currently 20 weeks pregnant and has had 2 normal deliveries:
Gravida 3, Para 2.
A woman who is not pregnant and has had a single live birth and one miscarriage at 17 weeks:
Gravida 2, Para 1+1.
A woman who is currently 25 weeks pregnant, has had 3 normal deliveries, one miscarriage at 9 weeks and a termination at 7 weeks:
Gravida 6, Para 3+2.
Twins
There is some controversy as to how to express twin pregnancies. Most people suggest that they should count as 1 for gravidity and 2 for parity—but you should check your local practice on this.
P.468

Past obstetric history
Ask about all of her previous pregnancies including miscarriages, terminations and ectopic pregnancies.
For each pregnancy, note:
Age of the mother when pregnant.
Antenatal complications.
Duration of pregnancy.
Details of induction of labour.
Duration of labour.
Presentation and method of delivery.
Birth weight and sex of infant.
â–¶ Also enquire about any complications of the puerperal period. The puerperium is the period from the end of the 3rd stage of labour until involution of the uterus is complete (about 6 weeks).
Possible complications include:
Postpartum haemorrhage.
Infections of the genital and urinary tracts.
Deep vein thrombosis.
Perineal complications such as breakdown of the perineal wounds.
Psychological complications (e.g. postnatal depression).
Past gynaecological history
Record all previous gynaecological problems with full details of how the diagnosis was made, treatments received, and the success or otherwise of that treatment.
Record the date of the last cervical smear and any previous abnormal results.
Take a full contraceptive history.
Past medical history
Take a full PMH as on p.42. Note especially those conditions which may have an impact on the pregnancy including:
Diabetes.
Thyroid disorders.
Addison's disease.
Asthma.
Epilepsy.
Hypertension.
Heart disease.
Renal disease.
Infectious diseases such as TB, HIV, syphilis, and hepatitis.
Identification of such conditions will allow the obstetrician to consider early referral to a specialist for shared care.
All previous operative procedures.
Blood transfusions and receipt of other blood products.
Psychiatric history—may extend beyond ‘simple’ post-natal depression.
P.469

Drug history
Take a full DHx ( p.44) which should include all prescribed medication, over-the-counter medicines, and illicit drugs.
Record any drug allergies and their nature.
If currently pregnant, ensure the patient is taking 400mcg of folic acid daily until 12 weeks' gestation to reduce the incidence of spina bifida.
Smoking and alcohol
A full history should be taken, as always ( p.46).
Family history
FHx is an important aspect of the obstetric history and should not be overlooked.
Ask about any pregnancy-related conditions such as congenital abnormalities, problems following delivery etc.
Ask also about a FHx of diabetes.
â–¶ Ask especially if there are any known hereditary illnesses. Appropriate counselling and investigations such as chorionic villus sampling or amniocentesis may need to be offered.
Social history
A full standard SHx ( p.48) should be taken. Ask about:
Her partner—age, occupation, health.
How stable the relationship is.
If she is not in a relationship, who will give her support during and after the pregnancy?
Ask if the pregnancy was planned or not.
If she works, enquire about her job and if she has any plans to return to work.
You may also use this opportunity to give advice on regular exercises and the avoidance of certain foods. e.g. tuna (high Mg content) soft cheeses (risk of listeria) calf's liver (high vitamin A content). See the Oxford Handbook of Obstetrics and Gynaecology1 for more details.
1 Arulkumaran (2005). Oxford Handbook of Obstetrics and Gynaecology. Oxford University Press, Oxford.
Box 14.16 A word about deliveries
The verb ‘to deliver’ is often misused by students of obstetrics as it is often misused by the population at large.
Babies are not delivered.
In fact, the mothers are ‘delivered of’ the child-as in being relieved of a burden.
Check your nearest dictionary!
P.470

Presenting symptoms in obstetrics
Bleeding—during pregnancy
Treat as any symptom. In addition, you should build a clear picture of how much blood is being lost, when and how it is affecting the current pregnancy.
After establishing an exact time-line and other details about the symptom, ask about:
Exact nature of the bleeding (fresh/old).
Amount of blood lost.
Number of sanitary pads used daily.
Presence of clots (and, if present, size of those clots).
Presence of pieces of tissue in the blood.
Presence of mucoid discharge.
Fetal movement.
Associated symptoms such as abdominal pain (associated with placental abruption; placenta praevia is painless).
Possible trigger factors—recent intercourse, injuries.
Any history of cervical abnormalities—and the result of the last smear.
Abdominal pain
A full pain history should be taken as on p.39 including site, radiation, character, severity, mode and rate of onset, duration, frequency, exacerbating factors, relieving factors, and associated symptoms.
Take a full obstetric history and systems enquiry. Ask especially about a past history of pre-eclampsia, pre-term labour, peptic ulcer disease, gallstones, appendicectomy, cholecystectomy.
Remember that the pain may be unrelated to the pregnancy so keep an open mind! Causes of abdominal pain in pregnancy include:
Obstetric: preterm/term labour, placental abruption, ligament pain, symphysis pubis dysfunction, pre-eclampsia/HELLP syndrome, acute fatty liver of pregnancy.
Gynaecological: ovarian cyst rupture, torsion, haemorrhage, uterine fibroid degeneration.
Gastrointestinal: constipation, appendicitis, gallstones, cholecystitis, pancreatitis, peptic ulceration.
Genitourinary: cystitis, pyelonephritis, renal stones, renal colic.
Labour pain
This is usually intermittent, regular in frequency and associated with tightening of the abdominal wall.
P.471

Box 14.17 Some causes of vaginal bleeding in early pregnancy
We suggest the reader turns to the Oxford Handbook of Obstetrics and Gynaecology1 for more detail.
Ectopic pregnancy
Symptoms: light bleeding, abdominal pain, fainting if pain and blood loss is severe.
Signs: closed cervix, uterus slightly larger and softer than normal, tender adnexal mass, cervical motion tenderness.
Threatened miscarriage
Symptoms: light bleeding. Sometimes: cramping, lower abdominal pain.
Signs: closed cervix, uterus corresponds to dates. Sometimes, uterus is softer than normal.
Complete miscarriage
Symptoms: light bleeding. Sometimes: light cramping, lower abdominal pain and a history of expulsion of products of conception.
Signs: uterus smaller than dates and softer than normal. Closed cervix.
Incomplete miscarriage
Symptoms: heavy bleeding. Sometimes: cramping lower abdominal pain, partial expulsion of products of conception.
Signs: uterus smaller than dates and cervix dilated.
Molar pregnancy
Symptoms: heavy bleeding, partial expulsion of products of conception which resemble grapes. Sometimes: nausea and vomiting, cramping lower abdominal pain, history of ovarian cysts.
Signs: dilated cervix, uterus larger than dates and softer than normal.
Information adapted from the WHO department of reproductive health research publication, ‘Vaginal bleeding in early pregnancy’.
1 Arulkumaran (2005). Oxford Handbook of Obstetrics and Gynaecology. Oxford University Press, Oxford.
P.472

Bleeding-after pregnancy
This is called ‘post-partum haemorrhage’ or PPH.
Primary PPH: >500ml of blood loss within 24 hours following delivery.
Secondary PPH: any excess bleeding between 24 hours and 6 weeks post delivery. (No amount of blood is specified in the definition).
▶ Take a full history as for bleeding during pregnancy on p.470. Ask also about symptoms of infection—an important cause of secondary PPH.
Hypertension
Hypertension is a common and important problem in pregnancy and you should be alert to the possible symptoms which can result from it such as headache, blurred vision, vomiting and epigastric pain after 24 weeks, convulsions or loss of consciousness.
Pregnancy-induced hypertension
Two readings of diastolic blood pressure 90-110, 4 hours apart after 20 weeks gestation. No proteinuria.
Mild proteinuric pregnancy-induced hypertension
Two readings of diastolic blood pressure 90-110, 4 hours apart after 20 weeks gestation and proteinuria 2+.
Severe proteinuric pregnancy-induced hypertension
Diastolic blood pressure 110 or greater after 20 weeks' gestation and proteinuria 3+. Other symptoms may include: hyper-reflexia, headache, clouding of vision, oligura, abdominal pain, pulmonary oedema.
Eclampsia
Convulsions associated with raised blood pressure and/or proteinuria beyond 20 weeks gestation. May be unconscious.
P.473

Box 14.18 Some causes of bleeding in 2nd/3rd trimesters (>24 weeks)
This is known as ‘antepartum haemorrhage’ (APH). See the Oxford Handbook of Obstetrics and Gynaecology1 for more detail.
Placenta praevia
The placenta is positioned over the lower pole of the uterus, obscuring the cervix. Bleeding is usually after 28 weeks and often precipitated by intercourse. Findings may include a relaxed uterus, fetal presentation not in pelvis and normal fetal condition.
Placental abruption
This is detachment of a normally located placenta from the uterus before the fetus is delivered. Bleeding can occur at any stage of the pregnancy. Possible findings include a tense, tender uterus, ↓ or absent fetal movements, fetal distress, or absent fetal heart sounds.
Box 14.19 Some causes of post-partum haemorrhage
Primary
Uterine atony (most frequent cause).
Genital tract trauma.
Coagulation disorders.
Retained placenta.
Uterine inversion.
Uterine rupture.
Secondary
Retained products of conception.
Endometritis.
Infection.
Box 14.20 Risk factors for post-partum haemorrhage
Nulliparity, multiparity, polyhydramnios, prolonged labour, multiple gestation, previous PPH or APH, pre-eclampsia, coagulation abnormalities, genital tract lacerations, Asian or Hispanic ethnicity.
P.474

Box 14.21 Minor symptoms of pregnancy
These so-called ‘minor’ symptoms of pregnancy are often experienced by a number of woman as normal, physiological changes occur. This is not to say that they should be ignored as they may point to pathology.
Nausea and vomiting
The severity varies greatly and is more common in multiple pregnancies and molar pregnancies. Persistence of vomiting may suggest pathology such as infections, gastritis, biliary tract disease or hepatitis.
Heartburn/gastro-oesophageal reflux
Heartburn is a frequent complaint during pregnancy due partially to compression of the stomach by the gravid uterus. See p.228.
Constipation
Often secondary to ↑ progesterone. Improves with gestation ( p.230).
Shortness of breath
Due to dilatation of the bronchial tree secondary to ↑ progesterone. Peaks at 20-24 weeks. The growing uterus also has an impact. Other possible causes (such as PE) need to be considered. See p.198.
Fatigue
Very common in early pregnancy, peaking at the end of the first trimester. Fatigue in late pregnancy may be due to anaemia.
Insomnia
Due to anxiety, hormonal changes and physical discomfort.
Pruritus
Generalized itching in the third trimester may resolve after delivery. Biliary problems should be excluded ( p.234).
Haemorrhoids
May resolve after delivery.
Varicose veins
Especially at the feet and ankles.
Vaginal discharge
Exclude infection and spontaneous rupture of the membranes.
Pelvic pain
Stretching of pelvic structures can cause ligament pain which resolves in the second half of the pregnancy. Symphysis-pubis dysfunction causes pain on abduction and rotation at the hips and on mobilization.
Backache
Often first develops during the 5-7th months of pregnancy.
Peripheral paraesthesiae
Fluid retention can lead to compression of peripheral nerves such as carpal tunnel syndrome. Other nerves can be affected, e.g. lateral cutaneous nerve of the thigh.
P.475

P.476

Outline obstetric examination
Explain to the patient that you would like to examine their womb and baby and reassure them that the procedure will be quick and gentle.
You should have a chaperone present, particularly if you are male.
As always, ensure that the room is warm and well lit, preferably with a moveable light source and that you will not be disturbed.
As for the gynaecological examination, you should follow an orderly routine. The authors' suggestion is shown below. It is standard practice to start with the cardiovascular and respiratory systems-this not only gives a measure of the general health of the patient but establishes a ‘physical rapport’ before you examine more delicate or embarrassing areas.
Box 14.22 Framework for the obstetric examination
General inspection.
Cardiorespiratory examination.
Abdominal inspection.
Abdominal palpation.
Uterine size.
Fetal lie.
Fetal presentation.
Engagement.
Amniotic fluid estimation.
Auscultation of the fetal heart.
Vaginal examination.
â–¶ Perform bedside urinalysis (particularly protein) if able.
General inspection
Always begin with a general examination of the patient (as in Chapter 3) including temperature, hydration, coloration, nutritional status, lymph nodes, and blood pressure. Note especially:
Any brownish pigmentation over the forehead and cheeks known as chloasma.
Distribution of facial and body hair, as hirsutism may be a presenting symptom of various endocrine disorders.
Height, weight, and calculate BMI ( p.66).
▶ Blood pressure should be measured in the left lateral position at 45° to avoid compression of the IVC by the gravid uterus.
Anaemia is a common complication of pregnancy so examine the mucosal surfaces and conjunctivae carefully ( p.58).
Examine the cardiovascular and respiratory systems in turn (see Chapters 7 and 8).
Flow murmurs are common in pregnancy and, although usually of no clinical significance, must be recorded in detail.
A routine breast examination is not normally indicated unless a female patient complains of breast symptoms, in which case you must carefully look for any pathology such as cysts or solid nodules.
P.477

P.478

Abdominal examination
Inspection
Look for the abdominal distension caused by the gravid uterus rising from the pelvis. Look also for:
Asymmetry.
Fetal movements.
Surgical scars.
Pubic hairline (transverse suprapubic Pfannenstiel incision).
Paraumbilical region (laparoscopic scars).
Cutaneous signs of pregnancy including:
Linea nigra (black line) which stretches from the pubic symphysis upwards in the midline.
Red stretch marks of current pregnancy (striae gravidarum).
White stretch marks (striae albicans) from a previous pregnancy.
Other areas that can undergo pigmentation in pregnancy include the nipples, vulva, umbilicus and recent abdominal scars.
Umbilical changes:
Flattening as pregnancy advances.
Eversion secondary to ↑ intra-abdominal pressure (e.g. caused by multiple pregnancies or polyhydraminios).
Palpation
Before palpating the abdomen, always enquire about any areas of tenderness and visit those areas last.
Palpation should start as for any standard abdominal examination (Chapter 9) before proceeding to more specific manoeuvres in an obstetric examination.
Uterine size
This provides an estimation of gestational age in weeks and is objectively measured and expressed in centimetres as the symphysial-fundal height (the distance from the symphysis pubis to the upper edge of the uterus).
Box 14.23 The symphysial-fundal height (cm) ≈ weeks of gestation
Between 16-36 weeks, there is a margin of error of ±2cm, ±3cm at 36-40 weeks, and ±4cm at 40 weeks onwards.
You need a tape-measure for this-don't start without it!
Use the ulnar border of the left hand to press firmly into the abdomen just below the sternum.
Move the hand down the abdomen in small steps until you can feel the fundus of the uterus.
Locate the upper border of the bony pubic symphysis by palpating downward in the midline starting from a few centimetres above the pubic hair margin.
Measure the distance between the two points that you have found in centimetres using a flexible tape-measure.
P.479


Fig. 14.7 The distance between the fundus (upper border of the uterus) and the pubic symphysis can be used as a guide to the number of weeks' gestation. You can also, therefore, judge whetherthe uterus is smaller or largerthan expected which may point to problems with the pregnancy.

Box 14.24 Uterine size—milestones
The uterus first becomes palpable at 12 weeks' gestation.
20 weeks' gestation = at the level of the umbilicus.
36 weeks' gestation = at the level of the xiphisternum.
P.480

Fetal lie
This describes the relationship between the long axis of the fetus and the long axis of the uterus and, in general, can be:
Longitudinal: the long axis of the fetus matches the long axis of the uterus. Either the head or the breech will be palpable over the pelvic inlet.
Transverse: the fetus lies at right angles to the uterus and the fetal poles are palpable in the flanks.
Oblique: the long axis of the fetus lies at an angle of 45° to the long axis of the uterus, the presenting part will be palpable in one of the iliac fossae.
Examination technique
The best position is to stand at the mother's right side, facing her feet.
Put your left hand along the left side of the uterus.
Put your right hand on the right side of the uterus.
Palpate systematically towards the midline with one and then the other hand—use ‘dipping’ movements with flexion of the MCP joints to feel the fetus within the amniotic fluid.
You should feel the fetal back as firm resistance or the irregular shape of the limbs.
You should now palpate more widely using the 2-handed technique above to stabilize the uterus and attempt to locate the head and the breech.
The head can be felt as a smooth, round object that is ballotable—that is, it can be ‘bounced’ (gently) between your hands.
The breech is softer, less discrete and is not ballotable.
Fetal presentation
This is the part of the fetus that presents to the mother's pelvis. Possible presenting parts include:
Head: ‘cepahalic’ presentation. One option in a longitudinal lie.
Breech: ‘podalic’ presentation. The other option in a longitudinal lie.
Shoulder: seen in a transverse lie.
Examination technique
Stand at the mother's right side, facing her feet.
Place both hands on either side of the lower part of the uterus
Bring the hands together firmly but gently.
You should be able to feel either the head, breech, or other part as described above under ‘fetal lie’.
It is also possible to use a one-handed technique (Paulik's grip) to feel for the presenting part—this is best left to obstetricians. In this, you use a cupped right hand to hold the lower pole of the uterus. This is possible in ~95% of pregnancies at about 40 weeks.
P.481


Fig. 14.8 Some examples of fetal lie.

P.482

Engagement
When the widest part of the fetal skull is within the pelvic inlet, the fetal head is said to be ‘engaged’.
In a cephalic presentation, palpation of the head is assessed and expressed as the number of fifths of the skull palpable above the pelvic brim. A fifth of a fetal skull is roughly equal to a finger breath on an adult hand.
The head is engaged when 3 or more fifths are within the pelvic inlet—that is when 2 or less fifths are palpable.
When 3 or more fifths are palpable, the head is not engaged.
Number of fetuses
The number of fetuses present can be calculated by assessing the number of fetal poles (head or breech) present.
If there is one fetus present, 2 poles should be palpable (unless the presenting part is deeply engaged).
In a multiple pregnancy, you should be able to feel all the poles except one—as one is usually tucked away out of reach.
Amniotic fluid/liquor volume estimation
The ease with which fetal parts are palpable can give an indication as to the possibility of ↓ or ↑ amniotic fluid volume.
↑ volume will give a large-for-dates uterus that is smooth and rounded. The fetal parts may be almost impossible to palpate.
↓ volume may give a small-for-dates uterus. The fetus will be easily palpable giving an irregular, firm outline to the uterus.
Percussion
This is usually unhelpful in an obstetric examination unless you suspect polyhydramnios (increased amniotic fluid volume), in which case, you may wish to attempt to elicit a fluid thrill ( p.260).
Auscultation
Auscultation is used to listen to the fetal heart rate (FHR). This is usually performed using an electronic hand-held Doppler fetal heart rate monitor and can be used as early as 14 weeks.
Using Pinard's fetal stethoscope
A Pinard's fetal stethoscope is not useful until 28 weeks' gestation. It is a simple-looking device rather like an old-fashioned ear-trumpet (Fig. 14.9).
Place the bell of the instrument over the anterior fetal shoulder—where the fetal heart sounds are best heard.
Press your left ear against the stethoscope so as to hold it between your head and the mother's abdomen in a ‘hands-free’ position or hold the instrument lightly with one hand.
Press against the opposite side of the mother's abdomen with your other hand so as to stabilize the uterus.
It should sound like a distant ticking noise. The rate varies between 110 and 150/minute at term and should be regular.
â–¶ Record the rate and rhythm of the fetal heart.
P.483

Vaginal examination
Vaginal examination allows you to assess cervical status before induction of labour. You should attempt this only under adequate supervision if you are unsure of the procedure.
This examination allows you to assess the degree of cervical dilatation (in centimetres) using the examining fingers.
Examination of the vagina and cervix should be performed under aseptic conditions in the presence of ruptured membranes or in cases with abnormal vaginal discharge.
Technique
The examination should be performed as described on p.462. The findings take experience to recognize. The student should not shy away from this examination due to its intimate nature.
Findings
Assess:
Degree of dilation.
Full dilation of the cervix is equivalent to 10cm.
Most obstetric departments will have plastic models of cervices in various stages of dilatation which you can practice feeling.
The length of the cervix.
Normal ~3cm but shortens as the cervix effaces secondary to uterine contraction.
The consistency of the cervix which can be described as:
Firm.
Mid-consistency.
Soft (this consistency facilitates effacement and dilatation).
Position.
As the cervix undergoes effacement and dilatation it tends to be pulled from a posterior to an anterior position.
Station of the presenting part.
The level of the head above or below the ischial spines which may be estimated in centimetres.

Fig. 14.9 A Pinard's stethoscope.

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The elderly patient
It is easy to be seduced into thinking that the principal focus should be on very ‘medical’ diagnoses such as urinary tract infections, which contribute to significant morbidity (and mortality) in older people.
Continence issues are sadly overlooked in most clinical assessments—despite costing the UK National Health Service £424m per annum (on figures from 2000). Large-scale surveys of prevalence have shown up to 20% of women over 40 reporting difficulties with continence; so whilst more common in older people, you should always be mindful of problems in younger adults too.
Although continence issues are one of the ‘Geriatric Giants’ of disease presentation, it is important to recall the physiology of the post menopausal changes—such as vaginal atrophy and loss of secretions—which can complicate urinary tract infections, continence and utero-vaginal prolapse in older patients.
Assessment
Tact and understanding: although problems are common, patients may be reluctant to discuss them, or have them discussed in front of others. Engaging in a discussion about bladder and/or sexual function can seem daunting—but if done empathetically, remembering never to appear to judge, or be embarrassed—you may reveal problems that have seriously affected your patient's quality of life. Treating problems such as these, even with very simple interventions, can be of immeasurable value to the patient.
Holistic assessment of urinary problems: learn to think when asking about bladder function, and work out a pattern of dysfunction—e.g. bladder instability or stress incontinence. Remember that bladder function may be disrupted by drugs, pain, lack of privacy. Continence issues may reflect poor mobility, visual and cognitive decline.
Genital symptoms: never forget to consider vaginal or uterine pathology—view postmenopausal bleeding with suspicion. Discharges may represent active infection (if candida—consider diabetes) or atrophic vaginitis (see opposite).
Past medical history: pregnancies and previous surgery in particular may help point to a diagnosis of stress incontinence. Are urinary tract infections recurrent—has bladder pathology been excluded?
Drugs: many are obvious—diuretics and anticholinergics; some are more subtle—sedatives may provoke nocturnal loss of continence; Does your patient drink tea or coffee?
Tailored functional history: the cornerstone of these pages—and of any assessment you perform. This largely relates to bladder function—is the lavatory up or down? How are the stairs? Does your patient already have continence aids—bottles/commodes/pads, and do they manage with them?
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Box 14.25 A word on atrophic vaginitis
Up to 40% of postmenopausal women will have symptoms and signs of atrophic vaginitis and the vast majority will be elderly and may be reluctant to discuss this with their doctors. A result of oestrogen deficiency, the subsequent ↑ vaginal pH and thinned endometrium lead to both genital and urinary symptoms and signs. ↓ in vaginal lubrication presents with dryness, pruritus, and discharges, accompanied by an ↑ rate of prolapse. Urinary complications can result in frequency, stress incontinence, and infections.
Careful physical examination often makes the diagnosis clear with labial dryness, loss of skin turgidity, and smooth, shiny vaginal epithelium. A range of treatment options including topical oestrogens, simple lubricants, and continued sexual activity when appropriate are all key interventions to manage this common condition.
We thank Dr Richard Fuller for providing this page.