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When you have completed this section you should be able to:
The purpose of taking a gynaecological history is to find out more about the woman’s presenting complaint and to assess past and present gynaecological problems. It is also an opportunity to assist a woman in talking about her reproductive health, to educate her about reproductive health risks and how to reduce them, and to support her in taking responsibility for her health.
The first step is to find out why she has come to see the nurse or doctor. Important questions to ask are:
The following questions are part of a routine gynaecological history:
Even if a woman is not pregnant she should briefly be asked how many times she has been pregnant and what the outcome of each pregnancy was. Ask about the mode of delivery.
A woman should be asked about any significant illnesses, admissions to hospital or operations which she may have had. Asking about allergies and medication often brings to light a problem which the patient may have forgotten, or thought not to be of significance.
The social history is very important as it may have a big influence on a woman’s health. Poor social circumstances can increase the risk of many conditions including unwanted pregnancy, sexual abuse and late detection of cancers. Poor lifestyle such as poor diet, obesity, or substance abuse (smoking, alcohol, drugs) is also associated with many general health and reproductive health problems. Difficult social circumstances may prevent women from attending appointments or from being fully compliant with medical interventions.
The examination of a woman, including the gynaecological examination, should be conducted in a private area and in a respectful, sensitive manner. The nature of the examination should be explained to her and why the examination is important. Always preserve her dignity and provide suitable cover such as a gown or blanket. Ideally you should have a chaperone (someone else with you) when performing a gynaecological examination, especially if a male doctor or nurse does the examination.
A woman has the right to decline the examination, but the implications need to be carefully explained to her. She should never be forced to have an examination, nor should a natural degree of discomfort be used by the health worker as an excuse not to conduct an examination. A vaginal examination in a woman who is menstruating should only be postponed if you can be confident that the bleeding is not part of her problem (she may have cervical cancer or a miscarriage). You also need to be confident that she will come back for follow up in order to have another examination in the near future.
The following should be assessed:
This can be difficult when the patient has a short, thick neck, or when she is obese. Look for an obviously enlarged thyroid gland (a goitre). She should be referred for further investigation when there is obvious enlargement of the thyroid, the thyroid feels nodular or a single nodule can be felt.
The patient must be undressed in order for the breasts to be examined properly. The breasts should be examined with the patient both sitting and lying on her back, with her hands above her head.
When the thyroid is examined, the neck should also be thoroughly examined for enlarged lymph nodes. The areas above the clavicles and behind the ears must be palpated. The axillae and inguinal areas should also be examined for enlarged lymph nodes.
Patients with HIV infection usually have painless, enlarged lymph nodes in all these areas.
The patient must be undressed. Look for any of the following signs:
The aim of a speculum examination is to examine the vagina and cervix. It also provides an opportunity to take a Pap smear.
Ask the patient to lie on her back and bend her knees. Her hands should rest next to her sides as this helps to relax the abdomen. Make sure that she is appropriately covered. Always explain what you are doing.
Look at the vulva for any discharge or blood coming from the vagina. Check for any lesions, ulcers or swellings.
Lubricate the bivalve speculum. Close the valves and turn it 90 degrees into a vertical position. Part the labia gently and ask the patient to bear down. Gently insert the closed speculum aiming slightly posterior towards the woman’s sacrum. Advance the speculum and then turn it into the horizontal position. Make sure that the handles of the speculum do not hurt the patient. Gently open the valves and look for the cervix. See if the cervix looks healthy or if you notice any discharge, blood, ulcers, or tumors.
When gently withdrawing the speculum inspect the vaginal walls and look for any abnormality like inflammation or ulcerations.
For a bimanual examination gently introduce your gloved and lubricated right index finger into the vagina by gently pushing down posteriorly and then add your middle finger. Advance your fingers until you can feel the cervix. Feel the cervix for any irregularity or lumps. Move it from side to side to assess whether this causes any discomfort. Use your left hand to feel the abdomen at the same time. Feel for the size of the uterus between your two hands and assess whether it feels mobile, enlarged, irregular or tender. Also check if you can feel any masses or tenderness next to the uterus.
The indications for a Pap smear are:
Explain to the patient what you will be doing and why. You will need:
Get all items ready. Label the glass slide with the patient’s name and hospital or clinic number
Pass the speculum as described above. Look for the cervix and inspect it carefully for any abnormality. If using a wooden spatula introduce the long arm of the spatula gently into the external os of the cervix (the central opening of the cervix) and rotate it by 360 degrees. Remove the spatula and gently wipe it across the glass slide. Fix the slide immediately after making the smear with a fixative spray. If using a cytobrush insert the brush gently into the external os then swirl it around and remove it. Gently roll the brush across the slide, then fix the slide with the fixative spray.
Complete the cytology request form and send the slide plus form in a safe package (to avoid breaking of the slide during transport) to the laboratory.
It is very important to bring the patient back for follow up so she can be informed of her result of the Pap smear. Make sure she understands how important it is for her to get the result. Each year many Pap smears are taken in South Africa without women getting their result. This is a problem because these women are at risk of developing cervical cancer and resources are wasted in the process.
This test is usually done when a patient has missed one or more menstrual periods and when, on clinical examination, one is uncertain whether or not she is pregnant.
The test is based on the detection of human Chorionic Gonadotrophin (hCG) in the patient’s urine.
The earliest that the test can be expected to be positive is 10 days after conception. The test will be positive by the time a pregnant woman first misses her period. If the test is negative and the woman is not having her period yet, the test should be repeated after 48 hours.
The test which is described in this book is the U-TEST β-hCG STRIP FOIL. If another pregnancy test is used, the method of doing the test and reading the results must be carefully studied in the instruction booklet. All these kits can be stored at room temperature. However do not expose to direct sunlight, moisture or heat.
The patient should bring a fresh urine specimen.