Examination of female

reproductive system
 Connetion way

name: nancy

Email: chengmin.jjjj@yahoo.com.cn
Examination of female reproductive
system

1 General points

2 Medical history

3 Examination

4 Vaginal examination during labour

 Examination of female
reproductive system

5 Rectal Examination

6 Investigations

7 Imaging techniques

8 Test of fetal well-being

1 General points
 Presenting problems and
gynaecological history

1 Menstrual upset

2 Postcoital bleeding, Dyspareunia

3 Symptoms of bladder or pelvic

floor disturbance and backache
 Menstruation

 Definition:
The cyclical loss of sanguineous fluid from the
uterus in mature women
 The days of menstrual loss and duration of the
interval from the first day of one period to the
onset of the next,e.g.5/28
 The date of the first day of the last menstrual period
(LMP)

History
of The previous menstrual pattern before conception
current
and
previous The expected date of delivery (EDD)
pregnan
cies
The time taken for the woman to return to a normal
menstrual pattern

The course and outcome of previous pregnancies

 General points

A live
birth

The
outcome of
A neonatal Previous
pregnancies
death

A
stillbirth
 General points

A woman’s gravidity is
described by the notation
para x+y

X is Y is
the number the number of
of babies pregnancies the
delivered woman has had
2 Medical history
 Medical history

Medication
or
Treatment
history allergic reactions should
be recorded
 Medical history

 Changes in appetite

A
Volume of Change in bowel habit
urine passed G B

General and
associated Change in weight
F system C
Frequency of
urine passed assessment

E
E D

Variations in sleep patterns Change in responses to normal

exercise
 Family and social history
1
Employment

2
Home condition

the length of relationships

3

The ethnic origins of the family

4 5 a detailed
family history
3 Examination
 Examination

appearance gait

Secondary sexual
development and General demeanour
hair distribution

The level of responsiveness

intelligence and
education
 Examination

Hands

Arms
Following Eyes
a
predictable Head,neck
sequence
Breasts, chest

Abdomen

Pelvic examination
 Abdominal examination

Inspection Palpation Auscultation

Fundal height
 striae Fetal poles and fetal
Fetal heart rate

gravidarum lie
 linea nigra Presentation-
breech,head ect
 Scars Attitude
 Fetal Level of presenting
part
movement Fetal movements
Liquor volume
Four maneuvers of Leopold

(1) (2)

(3) (4)
 The size of the uterus

Fetal lie
Four
maneuvers
 Fetal presentation
of
Leopold
Fetal position

engagement of the
presentation
 The size of the uterus is
estimated from the fundal height

The fundal height is just

above the symphysis pubis 36 weeks
at 12 weeks’ gestation
30 weeks
22 weeks---at the umbilicus
22 weeks

12 weeks
30 weeks---equidistant from the
symphysis pubis and the umbilicus

36 weeks---at the xiphisternum Approximate fundal height

with changing gestation
From 36 weeks the fundal height is also dependent on
the level of the presenting part ,and will reduce as the
presenting part descends into the pelvis

 Comparative assessments can be made by measuring

either the symphsis-fundal height
or the minimal girth measured at the level of the umbilicus
  Method of
abdominal
palpation to
determine fetal lie
and location of
back

Fetal lie----the relationship of the long axis

of the fetus to the long axis of the uterus
 Once the presenting part has a relationship to the
pelvis,that relationship can be vertical or rotational

When the flexed When the face When the breech

head presents, presents the presents the
the fetal denominator denominator
occiput is termed is the chin is the sacrum
the denominator
 AtAt the
the end
end of
of labour
labour ,the
,the common
common
presenting
presenting position
position are
are left
left occipito-anterior
occipito-anterior (LOA)
(LOA)
and
and right
right occipito-anterior
occipito-anterior (ROA)
(ROA)

(60%) (30%)
ROA
LOA
 Engagement

(ischial spines)

 Engagement of the baby’head in the pelvis will

usually have occurred by the time the leading edge
reaches the level of the ischial spines(zero station)
 The vertical relationship of the presenting part to the pelvic
  Listening over the
fetal back to the
fetal heart

A record is made of the fetal heart rate(FHR),

normally at the range from 115 to 160 beats/min
 Pelvic Examination

vaginally
 The pelvic examination
may be undertaken
vaginally or rectally
Pelvic
examination
For those who cannot
use tampons or whose
rectally
hymen is intact
 Vaginally Examination

Before starting ,it is most important to

1 explain every step to the patient

A good light is required and an assistant

2 is necessary

Begin by inspecting the perineum in the

3 dorsal or left lateral position
Vaginally Examination

Inspection of vulva

Digital palpation

Speculum examination
 Inspection of vulva

Mons pubis

External urethral orifice

Hymen

Vaginal cavity

The vulva

Any inflammation, swelling, soreness,

ulceration or neoplasia of the vulva,
perineum or anus is noted
Rectocele

Uterine prolapse
 Digital vaginal examination

 With the patient in the supine position

and with her knees drawn up and
separated
 Locate cervix

bimanual palpation

pelvic tenderness
Digital
pelvic masses
palpation
Ovaries and fallopian tubes

Assessment of uterus(position,mobility)
 Bimanual examination

Two
Two fingers(index
fingers(index andand middle
middle fingers)
fingers)
of
of right hand insert into the
right hand insert into the
vigina,with
vigina,with the
the left
left hand
hand placed
placed on
on
the abdomen above the symphysis
the abdomen above the symphysis
pubis
pubis and
and below
below the
the umbilicus
umbilicus
 The size,shape,position,consistency,
and regularity of the relationship of
the fundus of the uterus to the cevix is
estimated

Bimanual
examination

When attempts are made to move the

cervix in the presence of pelvic
inflammation,particularly in
association with ectopic
pregnancy,extreme pain results
 Speculum Examination

 This is an essential part of gynaecological

examination
 The speculum should be warmed to body
temperature and lubricated with water or a
water-based jelly
Clinical instruments prepared for Cusco’s speculum used to expose
a Gynaecological examination the vaginal cavity and cervix
 Smear from uterine cervix.

There are several

abnormal squamous
cells indicating situ
carcinoma of the cervix.
Large pink-stained
normal superficial.
Squamous cells and
many inflammatory cells
are also included
 Technique for taking a cervical smear

 In order to detect cervical pre-cancer,an

Aylesbury or similar spatula ia used

 The tip of the spatula is placed firmly in

the cervical os ,so as to allow the
removal of surface cells from the whole
of the squamo-columnar junction when
the spatula is rotated through 360
degrees
 Sims’s speculum used to display
the anterior vaginal wall.

Using the left hang to

elevate the right buttock.
The blade then deflects the
rectum, exposing the
urethral meatus, anterior
vaginal wall and bladder
base
 Uterine prolapse

FIST-DEGREE SECOND-DEGREE THIRD-DEGREE

The cervix The cervix The whole of the

descends but passes to the uterus is
lies short of level of the prolapsed
the introitus introitus outside the vulva
 VAGINAL EXAMINATION
DURING LABOUR

Absence of pulsating umbilical cord,

especially if the membranes are ruptured The presence or absence of
amniotic membranes

The examination Data and effacement

The level of the
is made to of the cervix
presenting liquor
determine. .

The size and shape of the

maternal bony pelvis
The degree of moulding of the fetal head,
or the presence of the caput succedaneum
 RECTAL EXAMINTION

When vaginal examination is not possible

or not acceptable, rectal examination
permits bimanual assessment of the pelvic
viscera and is particularly valuable in
assessing problems which are located in the
pouch of Douglas, the uterosacral
ligaments, or the rectovaginal septum
 INVESTIGATIONS

1 PREGNANCY TESTING

2 BACTERIOLOGICAL AND VIRUS TESTS

3 COLPOSCOPY

4 HYSTEROSCOPY

5 ENDOMETRIAL BIOPSY

6 CYSTOSCOPY AND CYSTOMETRY

 PREGNANCY TESTING

Most pregnancy tests depend on the

demonstration of HCG in the urine, The
URINE
sensitivity of these tests varies. Very early
diagnosis of pregnancy is now possible

Even earlier detection of pregnancy is

BLOOD possible by radioimmunoassay of the
beta-subunit of HCG in blood
 BACTERIOLOGICAL AND
VIRUS TESTS

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

1 2 3

 Swabs from the Tests for toxoplasma,

Bacteriological
throat, endocervix, rubella, cytomegalovirus
mid-stream
vagina, urethra and and herpes simplex
urinalysis is
rectum may be needed cover previous
important in both
for sexually infections likely to be
Obstetrics and
transmitted diseases damaging to a
Gynaecology
pregnancy
 COLPOSCOPY

Colposcopy permits
visualization of the cervix,
vaginal vault or vulva with a
low-power binocular
microscope to detect pre-
cancerous abnormalities of
the epithelium

Colposcopy
 HYSTEROSCOPY

This is a technique for

viewing the cavity of the
uterus using small
diameter fibre-optic
telescopes and cameras,
such as endometrial
ablation or resection of
submuocus fibrods,
which can be performed
under general
anaesthetic

Hysteroscopic view of an intrauterine device in situ

 ENDOMETRIAL BIOPSY

One of the common

investigations
undertaken in
Gynaecology is
sampling of the
endometrium. The
biopsy is not always
representative and may
fail to make a diagnosis
in up to one-third of
cases

An endometrial biopsy curette, a pipette

cell sampler and fixing medium
 CYSTOSCOPY AND
CYSTOMETRY

Viewing the interior The pressure/volume

of the bladder by relationships of bladder
cystoscopy gives filling, detrusor and
information of its sphincter activity and
condition and allows urethral flow rate can be
biopsy of the mucosa assessed with a
or removal of foreign cystometrogram
bodies
 IMAGING TECHNIQUES

RADIOLOGICAL INVESTIGATIONS

1 2

HYSTEROSALPINGOGRAPHY LATERAL X-RAY PELVIMETRY

 HYSTEROSALPINGOGRAPHY

This is now used

infrequently to image
the uterine cavity and
fallopian tubes after a
radiopaque medium has
been installed into the
uterus .The fallopian
tubal lumen and patency
can also be seen. The
technique is being
replaced by
hysterosonegraphy

An abnormal hysterosalpingogram: uteri didelphys

LATERAL X-RAY PELVIMETRY

　 An indication for
this assessment is a Now MIR pelvimetry
planned breech birth, is usually used,
so that the succedent in order to limit
head can be certain to radiation exposure
pass through the
pelvis without bony
obstruction
 ULTRASOUND

Ultrasound generated form a piezo-

electric crystal transducer is propagated
through tissue at variable velocity
depending on tissue density. The echo
time and signal amplitude give an
estimate of the size and consistency of
the object scanned. Ultrasound scanning
is used in medicine assessment of
gestational age, blood flow and all
important parameters of pregnant
monitoring
 Two-dimensional imaging by "B" scanning is the
primary modality, and additional information can
be obtained by colour and pulsed Doppler which
provides information on
bloodflow.Transabdominal and transvaginal
routes can be used.The former enables a wide
field of view,greater depth of penetration and
transducers movement; the latter,with higher
frequency transducers,gives increased resolution
and diagnostic power but over a more limited
area
 In early pregnancy (5-7weeks) ,the integrity, location
and number of sacs can be viewed. At 11-13 weeks nuchal
translucency mono dichorionicity and gross fetal
abnormality can be detected. formal scanning at 18-20
weeks is performed to confirm structural normality and
some functional activity. By 24 weeks uterine and placental
blood flow can be assessed
In Gynaecology, apart from the assessment of masses,
ultrasound is useful to ascertain aspects of bladder function
such as residual volumes and bladder neck activity. It is
also helpful in the preoperative preparation of anal
sphincter deficiency
.
.
 CT SCNNING

CT scanning has proved less values in

Gynaecology than that originally
anticipated in other major and is used
mainly for staging and follow up of
malignancies
 MRI

MRI, however, offers an alternative to

ultrasound and to X-ray imaging during
pregnancy ;it uses no ionizing radiation and
magnetic field strengths (0.2-2.0 tesla) in
current application
Good images are obtained with excellent
differentiation of maternal and fetal tissues.
Although ultrasound is much cheaper, no

interactions from bone

bowel gas occur
 LAPAROSCOPY

Visualization of the pelvic and abdominal

MRI
viscera is valuable if it can be done without a
major injury to the abdominal wall
(Fig.14.17).This is achieved by using a
fibreoptic telescope illuminated by a light
source remote from the patient. It is then
possible to inflate the abdomen with carbon
dioxide under general or local anaesthesia,
so that the viscera, allowing inspection of
the abdominal and pelvic contents
 BIOLOGICAL TESTS
Chorion biopsy
This is a method of obtaining chorionic material at 9-
11 weeks of pregnancy, usually through the abdomen
so that genetic constitution or biochemical function of
fetal cellular material can be determined. It is useful
for the diagnosis of Down's syndrome, thalassaemia,
and in a number of other hereditary conditions.
Early and rapid diagnosis allows the therapeutic
termination of an abnormal pregnancy, increasing the
safety and acceptability of that procedure. There is
still an increased risk of spontaneous abortion after
the chorion biopsy and this technique is used only in
specialized centres.
 Maternal blood sampling for
fetal cells

It is possible to isolate fetal cells from the

maternal circulation which are suitable
for chromosome analysis. Trials of this
promising non-invasive test are currently
underway
 Chorion biopsy
This is a method of obtaining chorionic material
at 9-11 weeks of pregnancy, usually through
the abdomen so that genetic constitution or
biochemical function of fetal cellular material s
can be determined. It is useful for the diagnosis
of Dowm's syndrome, thalassaemia,and in a
number of other hereditary, conditary
conditions. Early and rapid diagnosis allows
the therapeutic termination of an abnormal
pregnancy, increasing the safety and
acceptability of that procedure. There is still a
increased risk of spontaneous abortion after
the chorion biopsy and this technique is used
only in specialized centres
Amniocentesis
Samples of amniotic fluid can
be used for:
 Chromosome analysis

This is undertaken at 13-18 weeks of pregnancy

and is currently much safer than chorion biopsy.
The amount of desquamated fetal cells obtained is
much smaller in quantity than chorion biopsy. The
amount of desquamated fetal cells obtained is
much smaller in quantity than that from chorion
biopsy and cell culture is necessary (which takes
about 3weeks)before a chromosomal diagnosis is
made. However, rapid preliminary results can be
obtained using the fluorescent immunostaining
method when other chromosome abnormalities are
suspected
 Bilirubin concentration

Sometimes it is measured in
amniotic fluid pool in the latter
stage of pregnancy in order to
assess the health of a baby
affected by maternal rhesus
isoimmunization
 DNA analysis
Fetal cells obtained by amniocentesis,
chorionic villus sampling or cordocentesis, (see
below) can be used for DNA analysis of
nuclear chromatin in order to directly test for a
number of genetically-determined diseases, for
example Tay-Sach's disease and Duchenne
muscular dystrophy, in families known to be at
risk. DNA testing and chromosomal studies
should both only be carried out with fully
informed parental consent, and with the help of
a genetic counselling service
 Cordocentesis

In this procedure a needle is needed to insert

through the abdominal wall and into the
amniotic sac to obtain fetal blood from the
placental insertion of the cord. It is used
when chromosomal abnormality, haemophilia
, haemoglobinopathies, inborn errors of
metabolism, fetal viral infections or fetal
anaemia are suspected. Althought the
procedure carries more risk than
amniocentesis, it is less traumatic than
fetoscopy while providing rapid diagnosis
 BIOCHEMICAL TESTS
Early pregngncy
Alpha fetoprotein
This is a normal fetal protein which passes from the
fetus into the amniotic fluid and maternal serum. Its’
maternal concentration varies in a predictable way
with gestation. At 16 weeks 'gestation, the increased
levels suggest fetal spina bifida or anencephaly
However, similar levels can be caused by several
other conditions, including threatened
abortion, multiple pregnancy and exomphalos.
Decreased levels are associated with the presence of
an infant with Down's syndrome. A computed risk of
Down's syndrome can be produced from maternal
weight, gestation, parity and race ,measured against
alpha fetoprotein, HCG and unconjugated oestriol
,and the results matched against ultrasound findings
 Labour
Fetal health in labour can be assessed by checking
the liquor for tje presence of meconium, by
checking the responsiveness of the fetal heart rate,
and by monitoring feral movements. In addition to
these simple clinical tests, fetal PH measured on a
scalp blood sample can be used to detect acidosis.
This is particularly useful if labour is prolonged
,complicated or known to be high-risk, e.g. in
diabetic mothers. The fetal scalp is displayed using
an amnioscope and a small sample of capillary
vessel is obtained. If an urgent PH of the sample is
below 7.2 then delivery is an urgent priority.
Continuous oximetry by near infrared reflectance
although useful is not in general use
 BIOPHYSICAL TESTS
Fetal movements
In some cases with placental blood supply
insufficiency, fetal movements decreases or stop
12-48 hours before the fetal heart ceases beat .In
healthy pregnancy fetal movements increase from
the 32nd week of pregnancy to term, but the 12
hour daily fetal movement count falls below 10 in
only 2.5% of normal pregnancies. Thus a variety
of counting systems which are used by mothers
to count fetal movement and fetal welfare have
been devised. These can alert the mother that a
more sophisticated and detailed surveillance is
required
 Ultrasound

Visualization by real time

Sequential ultrasonic scanning to detect the
presence of symmetrical or asymmetrical growth
retardation or changes in fetal activity, breathing,
movements, etc, can be used to assess placental
function. If it becomes clear that fetal growth has
halted or the child's survival in utero is in doubt,
then urgent delivery should be planned with
paediatric support
 Cardiotocography(CTG
)
Assessment of the fetal heart rate and its variation with fetal
and uterine activity can be recorded antenatally with
ultrasound using the Doppler principle(Fig.14.18).A pressure
transducer is attached to the abdominal wall so that variations
in uterine activity can be matched with the ultrasound
recordings. The production of an accurate recording requires
patience and considerable interpretive skills.
If with membrane rupture during labour, a more accurate of
the fetal heart rate can be produced by an electrode attached
to the fetal scalp (Figs14.19and14.20).The recording is
triggered by the fetal ECG
 Doppler blood flow and Placental volume

 Studies of the circulatory changes

in the uterine circulation may predict
fetal urgence in the umbilical, aortic
and cerebral, especially in already
compromised circumstances.
 Ultrsound measurements of
placental volume may also help in the
prediction of fetal growth retardation