A thorough history and comprehensive physical examination form the bedrock of effective clinical care in obstetrics and gynecology (OB/GYN). This systematic approach is crucial for accurate diagnosis, appropriate management, and establishing a strong patient-provider relationship.
1. Essential Obstetrics Terminology
Before delving into history taking, a solid understanding of core obstetrics terms is vital. These terms provide a standardized language for describing a woman’s reproductive history.
- Gravidity (G): The total number of times a woman has been pregnant, regardless of the outcome (including the current pregnancy, if applicable). Multiple gestations (e.g., twins) count as one pregnancy.
- Parity (P): The number of times a woman has given birth to a fetus or fetuses reaching viability (typically considered 20 weeks gestation) or greater, regardless of whether the infants were born alive or stillborn. Parity is often broken down into a four-digit code known as TPAL or FPAL:
- T (Term): Number of deliveries at 37 weeks gestation or later.
- P (Preterm): Number of deliveries between 20 weeks and 36 weeks + 6 days gestation.
- A (Abortions): Number of pregnancies ending before 20 weeks gestation. This includes spontaneous abortions (miscarriages) and induced abortions.
- L (Living): Number of living children.
- Example: A woman pregnant for the fourth time, who had one full-term delivery, one preterm delivery, and one miscarriage would be G4P1112 (if both term and preterm babies are alive). If she previously had twins at term and is currently pregnant, she would be G3P1012 (assuming both twins are alive). The notation can sometimes be simplified to G_P_ (e.g., G4P2) indicating total pregnancies and total viable births.
- Gestational Age: The age of the pregnancy, measured in weeks and days, from the first day of the woman’s last menstrual period (LMP) or by ultrasound.
- Last Menstrual Period (LMP): The first day of the woman’s most recent menstrual period. Used to calculate estimated gestational age.
- Estimated Date of Delivery (EDD) or Estimated Date of Confinement (EDC): The estimated date when the baby is due. Calculated by adding 280 days (40 weeks) to the first day of the LMP (Naegele’s Rule), or based on early ultrasound measurements.
- Nulligravida: A woman who has never been pregnant.
- Primigravida: A woman who is pregnant for the first time.
- Multigravida: A woman who has been pregnant more than once.
- Nullipara: A woman who has not completed a pregnancy to 20 weeks gestation or more.
- Primipara: A woman who has completed one pregnancy to 20 weeks gestation or more.
- Multipara: A woman who has completed two or more pregnancies to 20 weeks gestation or more.
- Lochia: Vaginal discharge after childbirth, consisting of blood, mucus, and uterine tissue.
- Episiotomy: A surgical incision made in the perineum (the tissue between the vaginal opening and the anus) during childbirth to enlarge the opening.
- Laceration: A tear in the perineum or vaginal tissue that occurs during childbirth. Graded 1st through 4th degree based on severity.
- Cesarean Section (C-section): Surgical delivery of a baby through incisions in the abdomen and uterus.
2. Taking a Comprehensive History
The history provides crucial subjective information from the patient. It should be conducted in a private, comfortable setting with sensitivity and respect.
Step 2.1: Analysis of the Main Complaint (Presenting Concern)
Begin by understanding the primary reason for the patient’s visit. This could be a routine antenatal check-up, a specific symptom (e.g., vaginal bleeding, pelvic pain), a request for contraception, or an infertility concern. Use open-ended questions initially.
- Identify the Complaint: “What brings you in today?” or “Tell me about the problem you’re experiencing.”
- Characterize the Complaint: For a specific symptom, use a structured approach like OLDCARTS (Onset, Location, Duration, Characteristics, Associated factors, Relieving factors, Timing, Severity) or a similar mnemonic.
- Onset: When did it start? Was it sudden or gradual?
- Location: Where exactly is the pain/sensation? Does it radiate?
- Duration: How long does it last? Is it constant or intermittent?
- Characteristics: Describe the symptom (e.g., pain: sharp, dull, cramping; bleeding: heavy, light, clots, color; discharge: color, odor, consistency).
- Associated Factors: Are there other symptoms occurring at the same time (e.g., fever, nausea, urinary symptoms)? Is it related to activity, time of day, or other factors?
- Relieving Factors: Does anything make it better (e.g., rest, medication)?
- Timing: When does it occur (e.g., specific time of day, relative to menstrual cycle, during or after intercourse)?
- Severity: On a scale of 0-10, how bad is it? How does it affect daily activities?
Step 2.2: History of Present Pregnancy (HPP)
If the patient is currently pregnant, gather detailed information about this specific pregnancy.
- Confirmation: How was the pregnancy confirmed (urine test, blood test, ultrasound)?
- Gestational Age & EDD: Confirm LMP and calculate EDD. Note regularity of cycles. Note if EDD is based on LMP or ultrasound (and date of ultrasound).
- Planned vs. Unplanned: Was the pregnancy planned? This can impact emotional well-being and care decisions.
- Antenatal Care: Where is she receiving care? How many visits has she had? Are there any planned visits/tests coming up?
- Symptoms: Ask about common pregnancy symptoms (e.g., nausea, vomiting, fatigue, breast tenderness, urinary frequency, constipation) and any concerning symptoms (e.g., vaginal bleeding, leakage of fluid, severe headache, visual changes, abdominal pain, decreased fetal movement – later in pregnancy).
- Medications & Supplements: List all current medications (prescription, over-the-counter), vitamins, and supplements.
- Allergies: Document any drug or other allergies.
- Lifestyle: Ask about smoking, alcohol consumption, recreational drug use during pregnancy. Inquire about diet and exercise.
- Maternal Health Conditions: Any new conditions diagnosed during this pregnancy (e.g., gestational diabetes, gestational hypertension)?
- Investigations: Has she had any antenatal blood tests (e.g., blood type, Rh factor, screening for infections like HIV, Hepatitis B, Syphilis, Rubella, screening for chromosomal abnormalities)? Any ultrasounds? Note dates and key findings if known.
- Fetal Movement: (For pregnancies > 20 weeks) Has she felt the baby move? If so, when did she first feel it? Is fetal movement regular?
Step 2.3: Past Obstetrics History (POBH)
Systematically inquire about all previous pregnancies using the defined terminology (Gravidity/Parity, TPAL).
- For each previous pregnancy (including miscarriages and abortions):
- Year/Date of outcome.
- Gestational age at outcome.
- Outcome (live birth, stillbirth, miscarriage, termination).
- Mode of delivery (vaginal, vacuum/forceps assisted vaginal, Cesarean section). If C-section, reason and type of scar (if known).
- Location of birth.
- Labor duration and any complications (e.g., induction, epidural use, hemorrhage, infection).
- Infant birth weight.
- Infant outcome (alive/deceased, any neonatal complications – e.g., prematurity issues, NICU stay).
- Any maternal complications during pregnancy, labor, or postpartum (e.g., preeclampsia, gestational diabetes, postpartum hemorrhage, infection, depression).
- Inter-pregnancy Interval: Time between pregnancies.
- History of infertility treatments?
Step 2.4: Gynecology History (PGH)
Cover relevant aspects of the patient’s gynecological health.
- Menstrual History:
- Menarche: Age at first menstrual period.
- Cycle regularity: Is it regular?
- Cycle length: Number of days from the start of one period to the start of the next (typically 21-35 days).
- Duration of flow: How many days does the bleeding last? (Typically 3-7 days).
- Flow intensity: Light, moderate, heavy? Number of pads/tampons used per day? Clotting?
- Dysmenorrhea: Painful periods? Severity? Interference with activities?
- Intermenstrual bleeding: Bleeding between periods?
- Postcoital bleeding: Bleeding after intercourse?
- Menopause status: If applicable, age at menopause, menopausal symptoms, hormone replacement therapy use.
- Sexual History:
- Currently sexually active?
- Number of partners (lifetime and recent).
- Type(s) of sexual activity.
- History of Sexually Transmitted Infections (STIs)? Diagnosis, treatment, compliance.
- History of sexual assault?
- Contraception: Current and past methods used, satisfaction, complications.
- Pap Smear History: Date of last Pap smear, result, any history of abnormal results and follow-up.
- Pelvic Pain: History of chronic pelvic pain? If so, characterize using OLDCARTS.
- Vaginal Discharge/Itching: Characterize if present.
- Breast History: Any lumps, pain, nipple discharge? History of breast disease or surgery?
- Previous Gynecological Conditions/Surgeries: Endometriosis, fibroids, ovarian cysts, PID (Pelvic Inflammatory Disease), history of surgery (e.g., hysterectomy, oophorectomy, D&C, tubal ligation).
Step 2.5: General Medical History, Family History, Social History, and Review of Systems
Complete the comprehensive history by including:
- Medical History: Chronic illnesses (diabetes, hypertension, thyroid issues), past surgeries, hospitalizations.
- Family History: Relevant conditions (e.g., breast or ovarian cancer history, genetic conditions, multiple pregnancies, preeclampsia, diabetes) in first-degree relatives.
- Social History: Occupation, living situation, support system, domestic violence screening, diet, exercise, substance use (smoking, alcohol, recreational drugs), travel history.
- Review of Systems: Ask targeted questions about other body systems to identify potential related issues.
3. Performing the Physical Examination
The physical examination complements the history, providing objective data. It must be conducted professionally, respecting patient privacy and comfort. Always explain what you are going to do before you do it. A chaperone should be offered for pelvic examinations, in accordance with local guidelines.
Step 3.1: General Examination
- Vital Signs: Blood pressure, pulse, respiratory rate, temperature. Note particularly blood pressure in pregnant patients.
- General Appearance: Overall health, nutritional status, level of distress.
- Relevant Systems:
- Heart and Lungs: Assess for any abnormalities.
- Extremities: Check for edema (swelling), varicosities.
- Skin: Look for any rashes, lesions, jaundice, or pregnancy-related changes (e.g., striae, linea nigra, chloasma).
- Thyroid: Palpate if indicated.
- Breasts: Inspection and palpation (may be part of the GYN exam depending on setting).
Step 3.2: Obstetric Examination (Performed on Pregnant Patients)
This focuses on assessing the pregnancy and the mother’s physical status related to it.
- Preparation: Ensure patient has emptied her bladder. Position her comfortably (often supine or semi-recumbent). Warm your hands and equipment.
- Inspection: Observe the abdomen for size, shape, striae, scars.
- Fundal Height Measurement: Measure the distance in centimeters from the superior edge of the pubic symphysis to the top of the uterine fundus. This measurement correlates roughly with gestational age between 20 and 36 weeks. Note any discrepancies (e.g., too large or small for dates).
- Palpation (Leopold’s Maneuvers): A systematic way to palpate the pregnant abdomen to determine fetal lie (longitudinal, transverse, oblique), presentation (part of the fetus closest to the birth canal – e.g., head, breech), position (relation of fetal presenting part to the maternal pelvis), and engagement (whether the presenting part has descended into the pelvis).
- Maneuver 1: Palpate the fundus to identify the fetal part occupying it (usually the breech).
- Maneuver 2: Palpate the sides of the abdomen to locate the fetal back (smooth, firm) and small parts (irregular).
- Maneuver 3: Palpate just above the pubic symphysis to identify the presenting part.
- Maneuver 4: (Performed facing the patient’s feet) Assess descent and engagement of the presenting part into the pelvis.
- Auscultation of Fetal Heart Rate (FHR): Use a Doppler or fetal stethoscope to locate and count the FHR. Note the rate and rhythm. Normal FHR is typically 110-160 beats per minute.
Step 3.3: Gynecology Examination (Pelvic Examination)
This examination requires sensitivity and clear communication.
- Preparation: Explain the procedure step-by-step. Ensure privacy. Offer and confirm the presence of a chaperone. Have all necessary equipment ready (speculum, light source, collection devices for Pap test or swabs, lubricant, gloves). Ask the patient to empty her bladder. Assist the patient into the lithotomy position.
- External Genitalia (Vulva) Inspection: Inspect the labia majora, labia minora, clitoris, urethral meatus, vaginal introitus, and perineum. Look for any inflammation, lesions, discharge, swelling, or structural abnormalities. Palpate for tenderness or masses (e.g., Bartholin’s glands).
- Speculum Examination:
- Warm the speculum with warm water (not hot). Use lubricant sparingly on the external aspects only if needed.
- Insert the speculum gently into the vagina, usually angled slightly downwards and backwards, applying downward pressure to avoid the urethra.
- Rotate and open the blades to visualize the cervix.
- Cervix Inspection: Observe the color, position, size, and surface characteristics. Look for lesions, discharge, or bleeding. Note the os (opening).
- Vaginal Walls: Inspect the vaginal walls as the speculum is inserted and slowly withdrawn. Note color, rugae (folds), and any lesions or discharge.
- Sample Collection: If indicated, obtain samples (e.g., Pap test from the cervix, cultures for STIs from the endocervix or vagina). Use the appropriate collection devices and techniques.
- Bimanual Examination:
- Withdraw the speculum slowly and carefully.
- Lubricate the index and middle fingers of the dominant hand and gently insert them into the vagina. Palpate the vaginal walls.
- Place the other hand on the patient’s lower abdomen, midway between the umbilicus and the pubic symphysis.
- Cervix Palpation: Gently palpate the cervix with the internal fingers. Note its position, size, consistency, and mobility. Check for cervical motion tenderness (pain with movement), which can indicate infection or inflammation.
- Uterus Palpation: Attempt to trap the uterus between your abdominal and vaginal hands. Note its size, shape, consistency, mobility, and position (anteverted/retroverted, anteflexed/retroflexed). Tenderness?
- Adnexa Palpation: Palpate the adnexal areas (ovaries and fallopian tubes) in the fornices on each side of the uterus. Note any masses (size, shape, consistency, tenderness, mobility). Ovaries are often palpable in premenopausal women but not always.
- Rectovaginal Examination (If Indicated): Insert the index finger into the vagina and the middle finger into the anus. This allows for better palpation of the posterior uterus, cul-de-sac, and rectovaginal septum, and provides information about the rectum. Indicated for assessing posterior pelvic structures, certain types of pain, or before some gynecological procedures. Use fresh lubrication and change gloves.
4. Documentation
Accurate and complete documentation of the history and physical findings is essential for patient care, communication with other providers, and legal purposes. Use clear, concise, professional language and the appropriate terminology.
Conclusion
Mastering the art of taking a comprehensive OB/GYN history and performing a skilled physical examination is fundamental to providing excellent care. It requires not only technical knowledge but also empathy, active listening, and respect for the patient’s privacy and autonomy. By following a systematic approach, practicing diligently, and continuously refining these skills, healthcare professionals can build a strong foundation for diagnosing and managing a wide range of obstetric and gynecological conditions effectively.
