University of Hargeisa
College of Medicine and health science
Faculty of Nursing and Midwifery
Gynecology Nursing course
BSM And BSN 4th year
Prepared by Haliima Saed Ali
MSc of Obstetric and Gynecology Nursing
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Introduction of Gynaecology
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Definition of Gynecology
Gynecology A branch of medicine that deals with the diseases and
routine physical care of the reproductive system of women.
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Gynecological history
Gynecological history taking has a number of questions that are not part
of the standard history taking format and therefore it’s important to
understand what information you are expected to gain when taking a
gynecological history.
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Gynecological history
1- General information: 2- Date of admission + date of
• Name. examination.
• Age.
• Occupation. 3- Chief compliant:
• Residence. A brief statement of the general
nature and duration of the main
• Blood group. complaints.
• Educational background.
• Husband information.
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Gynecological history
History of presenting illness:
This will differ slightly depending on the presenting complaint but
follows a vague structure:
• If pain is involved ascertain site, radiation (if any) and character
• Onset
• Periodicity
• Duration
• Recurrence?
• Aggravating & relieving factors
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Gynecological history
Pelvic pain:
• Site, nature, severity.
• Aggravates or relieves the pain – specifically enquire about
relationship to menstrual cycle and intercourse.
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Gynecological history
Vaginal discharge:
• Amount, color, odor, presence of blood.
• Relationship to the menstrual cycle.
• Any history of sexually transmitted diseases (STDs) or recent tests.
• Any vaginal dryness (post-menopausal).
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Gynecological history
Menstrual history:
• Age of menarche.
• Usual duration of each period and length of cycle e.g. 5/28.
• LMP : First day of the last period.
• Regularity
• Amount of blood loss : more or less than usual, number of sanitary
towels or tampons used.
• Passage of clots or flooding.
• Any inter-menstrual .
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Gynecological history
• Any pain relating to the period
• Any medication taken during the period including over-the counter
preparations.
• If post-menopausal:
Date of last period ,
Any post-menopausal bleeding.
Any menopausal symptoms (hot flushes, vaginal
dryness, irregular periods).
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Gynecological history
Past Gynaecological History:
• Previous gynaecological symptoms, diagnosis, treatment (medical,
surgical).
• Previous cervical smears :date of last, abnormal results, treatments
• Current contraception .
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Gynecological history
Previous obstetric history:
• G: gravida :Number of all pregnancies (delivered or aborted).
• P: para or parity : number of deliveries after 24 weeks (live or dead).
• A: abortion : number of expulsions of products of conception before 24
weeks (normal or ectopic or hydatidiform)
• Each Pregnancy : Current age of child, Birth weight, Complications of
pregnancy and labor and after birth (puerperium).
• Ask sensitively regarding miscarriages / terminations / ectopic
pregnancies
• Number, cause, complication of each.
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Gynecological history
Sexual and contraceptive history:
• The type of contraception used and any problems with it.
• Establish whether the patient is sexually active and whether there are
any difficulties or pain during intercourse.
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Gynecological history
Drug History:
• Regular medication example: tranexamic acid (Treating heavy
menstrual bleeding), hormone replacement therapy (HRT).
• Over the counter drugs.
• Non-prescribed medications/herbal remedies.
• Contraception : COCP / POP / Coil / Implant / Depot.
• Allergens.
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Gynecological Examination
The gynecologic examination includes:
Examination of the breasts, abdomen, and pelvic organs.
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Gynecological Examination
Abdominal examination
General notes:
• The patient should empty her bladder before the abdominal
examination.
• The patient should be comfortable and lying semi-recumbent.
• The patient is covered with a sheet from the waist down, but the area
from the xiphisternum to the symphysis pubis should be left exposed.
It is usual to examine the women from her right hand side.
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Gynecological Examination
Inspection:
• Shape and size of the abdomen.
• Abdominal distention : gradual distention is caused by benign conditions like
fibroid or ovarian cyst.
• Abdominal mass.
• The presence of surgical scars (laparoscopy scars).
• Dilated veins or striae gravidarum (stretch marks) should be noted.
• Hernia (the patient should be asked to raise her head or cough and any hernias
or divarication of the rectus muscles will be evident).
• Pubic hair distribution (absent or reduced in conditions that cause adrenal
insufficiency such as hypopituitarism, Turner's syndrome, Alopecia and Delayed
Puberty).
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Gynecological Examination
Palpation:
• First, if the patient has any abdominal pain she should be asked to
point to the site of pain.
• Palpation using the right hand and start at left lower quadrant and
proceeding to the other quadrants.
• Palpation should include examination for masses, the liver, spleen and
kidneys.
• Mass (abdominal mass can palpate below it, pelvic mass cannot
palpate below it).
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Gynecological Examination
• Examine the inguinal hernias and lymph nodes.
• Look for signs of peritonism (guarding and rebound tenderness).
• Tenderness localized to the abdominal wall will typically worsen with
this maneuver.
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Gynecological Examination
Percussion:
• Ascites (shifting dullness, fluid thrill).
• An enlarged bladder due to urinary retention will also be dull to
percussion (many pelvic masses have disappeared after
catheterization).
• Percussion is utilized to determine the size of abdominal and pelvic
structures such as the liver and masses.
• Percussion is also useful for assessing abdominal and pelvic
tenderness.
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Gynecological Examination
Auscultation:
• This method is not specifically useful for the gynecological
examination.
• Auscultation aids in the assessment of intestinal peristalsis (bowel
sounds).
• Detection of abdominal bruits.
• Helpful in acute abdomen with bowel obstruction or a postoperative
patient with ileus.
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Pelvic examination
Pelvic examination
Inspection
• The patient in the dorsal position, the hips flexed and abducted and
knees flexed.
• The left lateral position can also be used.
• Examine the external genitalia and surrounding skin, including the
peri-anal area.
• Patient is asked to strain down to enable detection of any prolapse.
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Pelvic examination
• Patient is asked to cough, as this may show the sign of stress
incontinence.
• Any lesions or developmental abnormalities are noted.
• The urethra is inspected for the presence of caruncle and other
findings.
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Speculum
A speculum is an instrument which is inserted into the vagina to obtain a
clearer view of part of the vagina or pelvic organs.
There are two types:
1- Bi-valve or Cusco’s speculum : allows visualization of the cervix, take
sample from the cervix, e.g. smear or swab.
2- Sim’s speculum : useful for examination of prolapse as it allows
inspection of the vaginal walls.
There is plastic disposable speculums, but a metal one can be warmed to
make the examination more comfortable for the patient.
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• Excessive lubrication should be avoided and if a smear is being taken,
lubrication with anything other than water should be avoided.
• The vagina and cervix are inspected for lesions. The vagina is also
inspected for the presence or absence of rugae to assess the level of
estrogen present.
• The examiner assesses any vaginal discharge that is present for normal
in appearance, color, consistency, and odor.
• The pH of the normal vagina is less than 4.2. Normal cervical mucus
is clear
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Bimanual examination
Bimanual examination This is usually performed after the speculum
examination and is performed to assess the pelvic organs.
• It is customary to use the left hand to part the labia and expose the vestibule
and then insert one or two fingers of the right hand into the vagina.
• The fingers are passed upwards and backwards to reach the cervix
• The cervix is palpated any irregularity, hardness or tenderness noted.
• The left hand is now placed on the abdomen below the umbilicus and
pressed down into the pelvis to palpate the fundus of the uterus.
• The fundus : size, shape, position, mobility, consistency and tenderness are
noted.
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Bimanual examination
• The normal uterus is pear shaped and about 9 cm in length. It is
usually anterior (antiverted) or posterior (retroverted) and freely
mobile and non-tender.
• The tips of the fingers are then placed into each lateral fornix to
palpate the adenexae (tubes and ovaries) on each side.
• The fingers are pushed backwards and upwards, while at the same
time pushing down in the corresponding area with the fingers of the
abdominal hand.
• It is unusual to be able to feel normal ovaries, except in very thin
women.
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• Ovaries Any swelling or tenderness is noted, although remember that
normal ovaries can be very tender when directly palpated.
• The posterior fornix should also be palpated to identify the uterosacral
ligaments which may be tender or scarred in women with
endometriosis.
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Rectal examination
• A rectovaginal examination may be useful to identify a lesion in the
rectovaginal septum and when one suspects endometriosis or a pelvic
mass.
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Breast examination
Breast examination:
• Systemic way (setting, inspection, palpation, examine L.N).
• Changes in pregnancy (enlargement, secondary areola).
• Nipple (retraction, cracking, discharge).
• Breast lump examination.
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Instruments
1: Bi-valve or Cusco’s speculum :
• Consist of upper and lower plates.
• Used to examine the vaginal wall, visualization of the cervix, and take
biopsy.
• At the beginning close the speculum and put it at 9 o'clock degree,
then start to enter it through the vestibule until reach the vagina, then
rotate it to 6 o'clock or 12 o'clock, then open it and fixed it by screw,
complete the examination and investigations, then start to remove the
speculum, close the upper and lower plate by using the screw, rotate to
9 o'clock then remove it from the vagina.
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Bi-valve or Cusco’s speculum
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Instruments
When the speculum inside the vagina, see the following:
• Cervix: color, ulcer, abnormal discharge, nodules, erosions.
• Fornices: fullness.
• Lateral vaginal wall: rogue.
• At same time of examination do some investigations like:
• Cotton for high vaginal swap : put the cotton on the posterior fornix (site of
discharge accumulation) then remove the cotton without touching the
vaginal wall, then put it in container and send it to the lab
• swap for culture and sensitivity.
• Pap smear : use the spatula.
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Instruments
Advantages:
• It is self-retaining speculum.
• It is easy to use.
• The vaginal walls can be retracted to a variable extent.
• It gives a good exposure of the cervix.
• Both anterior and posterior vaginal walls can be retracted with a
single instrument.
• It causes least discomfort to the patient.
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Instruments
Disadvantages: the space available for carrying out any procedure is
limited by the rim of instrument.
Uses:
• When the biopsy is to be taken from the cervix.
• For cauterization of cervical erosions.
• For insertion of IUCD
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Instruments
2: Sim’s speculum:
• Need for assistance by nurse.
• Used for diagnosis to see the anterior and posterior vaginal wall.
• Same procedure of Cusco's speculum, but we should press sim's
speculum downward to see the anterior vaginal wall or pull it upward
to see the posterior vaginal wall.
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Sim’s speculum
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Instruments
Uses:
• See the Bulging of bladder (cystocele): due to weakness of anterior vaginal wall, you can
examine it by asking the patient to come with full bladder or ask the patient to cough so the
bulging become more obvious, and see some fluid.
• Bulging of the rectum (rectocele)
• Cystorectocele.
• Used for retracting the posterior vaginal wall during dilatation & curettage (D & C) and during
dilatation & evacuation (D & E).
• For taking biopsy .
• For routine per speculum examination.
• Outdoor cauterization of erosion.
Disadvantages:
• An assistant is required.
• An05/02/2025
anterior vaginal retractor is required to get a good view 41
Instruments
3: Ferguson's speculum:
• It is a tubular speculum having no valves.
Advantages: it is protect the vaginal wall during examination.
Uses:
• Taking biopsy or smear from the cervix.
• For cauterization of cervical erosions.
• For schiller's test ( medical test in which iodine solution is applied to the
cervix in order to diagnose cervical cancer).
• To protect the vaginal walls during decapitation operation with Gigli's wire
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Ferguson's speculum
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Instruments
4: Spatula :
• Used for Pap smear
• Done it annually to screening for cancer.
• Could be woody or plastic.
• Use it with Cusco's speculum, enter it to the vagina and take the smear.
• At the top of the spatula there is lingual part (put it in the inner part of the cervix)
and shoulder part (put it in the ectocervix).
• Rotate the spatula and take columnar cells (by lingual part) and squamous cells (by
shoulder part).
• Put the spatula on the slide and do fixation.
• Send the slide to the lab for cytology. 5
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Spatula
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Instruments
5: Sponge (swab) holding forceps:
• It has ring shapes tips, which may be serrated or smooth.
Uses:
It used for holding the sponges to swab out cavities (vagina for
example).
• For applying antiseptics over vulva, vagina or abdominal skin before
operation.
6: Uterine curette
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Sponge (swab) holding forceps:
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Instruments
6: Uterine curette:
• Used for dilatation and curettage (D & C).
• It is used under general anesthesia.
• Hormonal disturbances lead to increase thickness to 7 cm and this
could be pathological or cancer.
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Instruments
Types :
1.Sim's curette, Sharp & blunt curette,
2.Goldstein curette (nowadays it is not used due to the risk of fluid embolism).
Uses:
• To curette out the products of conception in cases of missed or incomplete conception.
• To curette out endometrium in cases of endometrial diseases for diagnostic and
therapeutic purposes (in case of infertility, postmenopausal bleeding, endometrial
cancer).
• For checking curettage: done 1 week after evacuation of H.mole.
Complications : Hemorrhage, sepsis, perforation of the uterus, vigorous curettage lead
to amenorrhea due to total removal of endometrium (Asherman's syndrome).
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Uterine curette
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Instruments
7: Cervical dilator:
Types:
1. Hegar's dilator,
2. Hawkins Ambler's dilator.
Uses:
• Dilatation & curettage (D & C).
• Dilatation & evacuation (D & E).
• To diagnose incompetence os of cervix by passing Hegar's dilator in non-gravid uterus.
• In operation of cervix
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Instruments
• amputation of cervix, repair and cauterization of cervix.
• For insufflations tests
• Insufflate means to deliver air or gas under pressure to a cavity of
chamber of the body.
• To relive some causes of spasmodic dysmenorrhea.
Complications:
sepsis, haemorrhage, perforation of the uterus, cervical tear which cause
cervical incompetence or cervical dystocia at a later date.
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Cervical dilator
Hawkins Ambler's dilator Hegar's dilator
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Instruments
8: Anterior vaginal wall retractor:
It has 2 loop-shaped ends with transverse serrations.
Uses :
It used with Sim's speculum to retract the anterior vaginal wall for
visualizing the cervix and anterior fornix. Hegar's dilator Hawkins
Ambler's dilator
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Anterior vaginal wall retractor
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Instruments
9: Simpson's uterine sound:
• It is a granulated metallic rod about 12 inches long.
• The distal end is curved at an angle of 60 degree and it is 2 inches long (normal
cervical length) and the tip of the instrument is blunt.
Uses:
• To ascertain the size and direction of the uterus before passing the cervical
dilator.
• To ascertain the position of abnormal uterine content like tumor, polyp, etc.
• For correction of the a mobile retroverted uterus (with precaution).
• For insufflations tests.
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Instruments
• The uterus is sounded routinely before operations on uterus or cervix.
• It is not used when pregnancy is suspected, cervical infection is
present.
Complications :
sepsis, perforation of the uterus.
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Simpson's uterine sound
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Instruments
10: Volsellum forceps:
• It is used to hold the anterior lip of the cervix when it is not friable that is in
gynecological conditions.
• It has got sharp teeth at the end which provide firm grip.
Uses:
• For holding the anterior or posterior lip of cervix in various operations
• D & C, cauterization of cervix.
• To test the mobility of cervix and laxity of ligaments in prolapse.
• To bring down fundus of uterus in vaginal hysterectomy.
• For small fibroids in myomectomy..
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Volsellum forceps
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Instruments
11: Self-retained retractor:
Used for retraction of abdominal wall.
Not need surgeon assistance
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Instruments
12: Killund forceps:
Has only one curve.
Cannot be locked.
Used for the rotation of the baby.
Need good experience physician.
It is not used widely nowadays because of its
severe complications
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Instruments
13: Long curved forceps:
• Has two curves, one for cephalic
presentation, the other for breech.
• Can be locked.
• Cannot be used for rotation.
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