Pelvic Exams: Inspection and Palpation

Pelvic Exams

• Consists of both patient education and knowing what to inspect for

External Inspection and Palpation

• Examine the clitoris, labia, and perineum
• Inspect for maturity, lesions indicating STIs, childbirth trauma, and healed scars

Internal Examination

• Examine the cervix for position, color, lesions, bleeding, and discharge
• Check the vaginal wall for color, lesions, rugae, fistulas, and bulging
• Check the uterus for position, size, shape, consistency, motility, lesions, masses, and tenderness

Bimanual Palpation

• Palpate the vagina, cervix, and uterus
• Note the position, size, shape, consistency, motility, lesions, masses, and tenderness

Retrovaginal Palpation

• Palpate the rectovaginal septum, posterior surface of the uterus, the region behind the cervix, and the rectum
• Check for rectal tenderness or masses

Speculum Use

• Used to keep the vaginal walls open for testing and inspections
• Contains two blades and a handle
• Placed on the back of the vagina wall and locked to keep an open passage for testing

Pap Smears

• Used to diagnose cancerous conditions on the cervix
• Screening not needed for women under 21
• From 21 to 65: every 3 years
• From 30 to 65: every 5 years, if Pap plus HPV test results are both negative

Colposcopy

• Examination of the cervix with a stereoscopic binocular to magnify the view
• A 3% acetic acid solution is applied to visualize areas for biopsy

STIs

• Refer to symptoms, clinical findings, labs, treatment, and patient education

Bacterial Infections: Chlamydia

• Caused by Chlamydia trachomatis
• Spread through genital contact
• Untreated, it can lead to PID or premature rupture of membranes, post partum endometriosis
• Transmitted to newborns cause pneumonia and conjunctivitis
• Unprotected sex and multiple sex partners increases risk
• Can be asymptomatic
• Gray-white discharge, dysuria and vulvar itching may be present
• Mucopurulent endocervical discharge, easy induced endocervical bleeding, and testicular edema or pain may occur
• Endocervical swab and UE diagnose the condition
• Doxycycline (contraindicated in pregnancy), azithromycin, or amoxicillin are administered for treatment
• Erythromycin is used to treat infants after delivery
• Instruct patients to take the entire prescription, identify sexual partners for testing and treatment
• Pregnant clients should be retested in 3 weeks after completing prescriptions

Gonorrhea

• Bacterial infection caused by Neisseria gonorrhea
• Spread through genital, anal contact, or to a newborn during delivery, causing blindness.
• Multiple sex partners, unprotected sex, and being under 25 increase risk
• Anal itching/irritation, rectal bleeding, diarrhea, and painful defecation occurs
• Oral lesions on the lips and pharyngitis also occurs
• Additional symptoms: sensitive gums, dysuria, testicular edema, white/green/yellow discharge, vaginal bleeding, dysmenorrhea, and easy induced endocervical bleeding
• Diagnosed via cervical and anal cultures, and UE tests
• Treated with DOXYCICLINE or Ceftriaxone IM Rocephin
• Azithromycin is also used PO
• The patient should take medication as prescribed
• Repeat culture within 3 to 4 weeks to assess medication effectiveness
• Antibiotic therapy reduces the effectiveness of oral contraceptives
• Complications during pregnancy: preterm birth, PROM, postpartum sepsis, endometritis, chorioamnionitis, and neonatal sepsis

Syphilis

• Bacterial infection caused by Treponema Pallidum
• Transmitted through oral, vaginal, or anal sex
• Multiple partners and unprotected sex increases risk
• Has 3 stages
• Primary Stage: chancre sores on hands and genitalia, females inguinal edema, and enlarged lymph nodes
• Secondary Stage: skin rashes, especially on hands and feet
• Tertiary Stage: causes damage to internal organs, difficulties coordinating muscle movements, or blindness

Diagnosing Syphilis

• Via lab tests: serology test non treponemal and treponemal
• Also detected using Microscopic examinations of lesions
• Penicillin G IM treats condition
• Doxycycline and tetracycline is used if allergic to penicillin (not safe in pregnancy)

Group B Strep (GBS)

• Bacterial infection passed to the fetus during labor and delivery
• Often an expected part of the vaginal flora for nonpregnant clients
• Can cause pneumonia, respiratory distress syndrome, sepsis, and meningitis if transmitted to the newborn
• Age, medical conditions, and race increases risk
• Positive GBS culture performed between 35 and 38 weeks indicates
• Intrapartum antibiotic administrations ampicillin or penicillin G treats condition

Bacterial Vaginosis

• Bacterial infection caused by Gardnerella Vaginalis, not related to sexual activity
• Superinfection that presents when lactobacilli in the vagina flora are reduced
• Untreated can cause preterm labor in pregnancy
• Multiple sex partners, douching, antibiotic use, IUD, and hormonal changes increase risk
• Fishy odor or clear thinner discharge symptoms
• Confirmed through wet smear test, and whiff test

Viral Infections: HPV

• Spread through oral, vaginal, and anal sex; causing genital wards and cervical cancer
• Wards can become large during pregnancy that can occlude the birth canal, interfere with the ability of the fetus to descend, or make it difficult for the patient to urinate or defecate
• Multiple sex partners and unprotected sex increase risk
• Signs: painless bumps in the genitalia, vaginal discharge, dysuria, bleeding after intercourse, and cauliflower-like warts
• Testing includes PAP test, colposcopy or biopsy
• Treated with a vaccine, or prescription of valacyclovir (Valtrex)
• There is no cure, but patients can go through phases active or dormant infection
• Abstinence is required to limit disease spreading during active infection phase

Parasitic Infection: Trichomoniasis

• Infection caused by the parasite Trichomonas vaginalis
• Spread through vaginal intercourse, if untreated can leave to preterm birth during pregnancy and PID
• Multiple partners increase risk
• Symptoms: itching, burning, urethral draining, dysuria, pain during ejaculation
• Frothy vaginal discharge with foul odor, strawberry spots on the cervix, or bleeding also indicates
• Testing includes PAP test and wet mount test
• Meds: Metronidazole or Tinidazole
• Both meds are teratogenic and not given during pregnancy

Fungal Infections: Candidiasis

• Caused by Candida Albican
• Superinfection that can manifest when changes in the vaginal flora occur and through direct contact of an infected subject
• Multiple sexual partners or unprotected sex increases risk
• Symptoms: vulvar and vaginal pruritis, painful urination, excoriation from itching, and thick creamy discharge
• Tested for by wet mount test, or Ph test

Treatments for Candidiasis

• Fluconazole
• Clotrimazole OTC
• Probiotics

TORCH Infections

• Infections that cross the placenta and have teratogenic effects
• Includes toxoplasmosis, hepatitis, rubella, cytomegalovirus, and varicella

HIV in Pregnancy

• Transmitted through placenta and breast milk
• Early testing and treatment decreases perinatal transmission
• Testing is recommended in the third trimester
• Amniocentesis/episiotomy, internal fetal monitors, vacuum extraction, and forceps should be avoided
• Newborn administrations of injections and blood testing should be delayed
• ART taken orally throughout pregnancy
• HAART therapy intrapartum includes IV zidovudine 3 hrs prior to scheduled cesarean until birth
• Infants receive zidovudine at delivery and for 6 weeks following birth
• Breastfeeding is avoided

PID (Pelvic Inflammatory Disease)

• Infection of the uterine tubes, uterus, and ovaries/peritoneal surfaces
• Nulliparity, multiple partners, and a history of STI increase risk
• Experiencing dull cramping, infertility, ectopic pregnancy, and chronic pelvic pain indicates
• Dyspareunia, tubo-ovarian abscess, or pelvic adhesions may also occur
• Antibiotics combination taken prenatally treats disease

Breast Self-Exams (BSE)

• Should be performed 5 to 7 days after menstruation stops, when breasts are not tender or swollen
• Use finger pads to feel for lumps or thickenings with circular motions
• Use light, medium, and firm pressure to feel tissue under skin
• Check for dimpling of skin, changes to nipple, redness, or swelling

Fibrocystic Breast Changes

• Characterized by lumpiness with/without tenderness
• Appears in women between 20 to 50
• Estrogen and progesterone contribute
• Occurs a week before menstruation and subsides a week after
• Physical exams may reveal excessive nodularity

Breast Cancer

• Mammography begins at age 40
• Gold standard diagnosis is mammography
• MRI used with difficult-to-find masses

Treatment for Breast Cancer

• Surgery: breast conserving or mastectomy, partial or total
• Radiation and hormonal therapy given
• Adjuvant system therapy (chemotherapy)

Oral Contraception

• Side Effects: Abdominal pain indicates a liver or gallbladder problem, chest pain indicates clot, headache may mean cardiovascular accident or hypertension, eye issues may mean hypertension, leg pain indicates thromboembolic process
• Pro for OC pills: decreased blood loss, decreased anemia, regulation of menorrhagia, reduced dysmenorrhea
• Cons: not recommended for history of thromboembolic disorders, stroke, heart attack, CAD, liver tumors, headache, HTN, breast/ estrogen related cancers, pregnancy, breast feeding
• Effectiveness can decrease when taking meds that affect liver enzymes

Progestin-Only Pills

• Oral progestin decreases likelihood of fertilization/implantation
• Take pill at same time daily
• Less effective in suppressing ovulation, risks of bleeding, headache, nausea, and breast tenderness
• Effectiveness lowers when taking meds that target liver enzymes, caution with weight loss surgery, lupus, and liver issues

IUD (Intrauterine Device)

• T-shaped device inserted to damage sperm in uterus
• STI risks, irregular menses, bacterial vaginosis, PID, risks of uterine perforation

Condoms

• Placed on the erect penis leaving space at sperm tip
• Latex/polyurethane condoms protect STIS
• Effectiveness decreases nonadherence, decreased sensation, spontaneity

Diaphragm

• Dome with flexible rim to fit over cervix
• Inserted vaginally over cervix with spermicidal jelly, spermicide reapplied each time used
• Not recommended with history of TSS, bladder issues or frequent UTI
• Proper hygiene in prevention of TSS

Basal Temperature

• Before ovulation, temperature drops slightly the increases
• Take temperature immediately after waking

Emergency Contraception

• Morning after pill prevents fertilization
• Take pill within 72 hours of unprotected sex
• Counseling about contraception and risky sex is key
• A copper IUD can be implemented up to 5 days after sex for prescription

Infertility for Females

• Age over 35
• Medical history should include hormonal/adrenal gland disorders and surgical history in pelvic area
• Past obstetric history needs to be assessed
• Diagnostic procedures should include pelvic exam, hormone analysis, laparoscopy

Therapeutic Procedures to Treat Infertility

• Lifestyle, nutritional, and medical changes
• Medical therapy includes stimulation and therapy for preexisting infections
• Assisted reproduction via IUI, IVF, donor oocyte

Genetic Counseling

• Recommended if family history, genetic counseling needed, older than 35
• Complications during pregnancy include ectopic or birth defects
• Evaluate the parents emotional and physical needs

Labs Tested in Pregnancy

• Blood type
• CBC
• Hgb Electrophoresis
• Rubella
• Hepatitis B
• Group B Strep (GBS)

Urinalysis

• Used for determination of possible health problems when pregnant such as renal disease or infection

Glucose Analysis

• Used to determine possible diabetes issues in mother and gestational diabetes

PAP Test analysis

• Used as tool to distinguish possible cancers in cervix and determine HPV presence

PPD Test Analysis

• Used for discovering exposure to Tuberculosis

HIV

• Screens and detects for HIV infection to protect infant in utero and after delivery.

TORCH Analysis

• Screens for possible fetal development abnormalities

Conception and Pregnancy Timelines

• Occurs directly after sperm and egg meet
• Implantation roughly 6 to 10 days after pregnancy
• Embryo after 15 days after conception ends after 8 weeks
• Fetus period begins after 9 weeks ends after pregnancy completes

Signs of Pregnancy

• Presumptive, changes is a sign on possible health problems
• Probable, changes that make the examiner aware of pregnancy
• Positively only explained by pregnancy

Physical Changes in Pregnancy

• Cardiovascular, Respiratory rate increases

Hormonal Changes in Pregnancy

HCG

• Maintains progesterone

Progesterone

• Suppresses secretion, maintains pregnancy by relaxing muscles

Estrogen

• Increased enlargement of genitals, uterus, can influence mood

Relaxin

• Promotes pelvis flexibility

Prolactin

• Prepares breasts for lactation

Oxytocin

• Stimulates uterine contractions and milk ejection

Thyroid and Parathyroid

• Increase of body fat
• Provides bone support

Insulin Increase

• Compensates for placental issues and any issues caused with bodily changes

Cortisol and Aldosterone

• Stimulates reabsorption and excess sodium and increases blood circulation

Exercise in Pregnancy and Kegels

• Walking and stretching should have 30 minutes a day
• Kegel Exercises used to strengthen muscles

Calculating Expected Due Date

• 1st day of the last month, minus 3 months, plus 7 days

Weight gain related to BMI

• 25-35 pounds with normal BMI score
• Overweight; 15-35 pounds

Measuring the Fundal height

• Measure after symphysis pubis, height equals women's amount of weeks of gestation

Nutrition

• Protein and fiber and nutrients for baby development

Calorie Increase

• 340 calories per week in second trimester and 452 calories in third trimester

Mineral Intake

• Iron and Folic Acid should be taken and increased to prevent potential anemia and or issues with infant development

Fluid Intake

• 8-10 glasses of water a day approximately 2.3 liters

Foods to Avoid

• Caffeine and Alcohol to prevent and or lower risks

Immunizations

• Live viruses not recommended
• Needs for pregnancy Tdap, hepatitis B and inactivated influenza shot

Rhogam Shot

• Prevents and assist the production of antibodies
• 300 Ug to woman around 26-30 weeks after giving birth

Pregnancy Risk Factors

• Adolescents and mature women

Other Risks

• Multiple fetuses and genetic abnormalities