Chapter 23: The Gynecologic Examination and Prenatal Care

How are chlamydial and gonorrheal infections usually diagnosed?

Chlamydia and gonorrheal infections are usually diagnosed by using a nucleic acid amplification test (NAAT) or a DNA probe test.

Why is a pregnant woman tested for group B streptococcus (GBS)? When is the woman tested for GBS?

A pregnant woman is tested for group B streptococcus (GBS) between 35 to 37 weeks of gestation because it can cause life threatening infections in the newborn. The newborn can become infected with the bacteria carried by the mother when passing through the birth canal and may develop an infection of the blood (septicemia), pneumonia, or meningitis.

What conditions might warrant performing an amniocentesis?

Amniocentesis is offered only to women whose pregnancies are at risk for fetal abnormalities. This includes women who are 35 and older, women who have a child with a genetic or neural tube defect, women who have multiple marker test results, women who have or whose partner has a chromosomal abnormality, and women who are carriers or whose partner is a carrier for a metabolic disease.

What is the purpose of the return prenatal visit? List the usual schedule for return prenatal visits.

The purpose of the return prenatal visit is for continuous assessment of health and fetus. The usual schedule is every 4 weeks from 0 to 28 weeks of gestation, every two weeks from 29 to 35 weeks of gestation, and every week from 36 weeks of gestation until delivery.

Describe the laboratory procedure that can be used to identify Candida albicans in the medical office.

Candida may be identified microscopically in the medical office by placing a specimen of the vaginal discharge on a slide using a sterile swab and adding a drop of a 10% solution of potassium hydroxide (KOH).

Why should the medical assistant instruct the patient not to douche or insert vaginal medications for 2 days before coming to the medical office to have a Pap test?

Douching and tampon insertion reduce the number of cells available for analysis, and vaginal medications and spermicides change the pH of the vagina, making the specimen nonrepresentative or invalid.

What tests are performed on the patient's urine specimen at each return visit and why is each performed?

During each prenatal visit, urine specimens are tested for glucose and protein.

What position is generally used for the pelvic examination?

For the pelvic examination, the patient is positioned in the lithotomy position.

What is the normal range for the fetal heart rate?

The normal range for the fetal heart rate is between 120 to 160 bpm.

What is the importance of assessing the Rh factor and ABO blood type of a pregnant woman?

It is important to assess the Rh factor and ABO blood type to anticipate incompatibilities because an increased antibody level could be dangerous to the fetus and could result in severe anemia, jaundice, brain damage, heart failure, and sometimes the death of the fetus.

What is the importance of making sure that a pregnant woman does not have gonorrhea before delivery of the infant?

It is important to make sure that the pregnant woman does not have gonorrhea before the delivery of the infant because the N. gonorrhoeae organism could infect the infant's eyes during passage through the birth canal that can result in ophthalmia neonatorum which could result in blindness if not treated.

What causes most cervical cancers?

Most cervical cancers are caused by the human papillomavirus (HPV).

What conditions might warrant performing a fetal heart rate monitoring test?

Specific conditions that may warrant this procedure are fetal growth that is not progressing well, decreased amniotic fluid, decreased fetal activity, elevation of the mother's blood pressure, gestational diabetes, and an overdue infant.

Describe the schedule for having a Pap test as recommended by the American Cancer Society.

The American Cancer Society recommends that women begin cervical cancer screening at 21 years of age and then every 3 years after until they are 29 years old. Beginning at age 30, ACS guidelines recommend testing every 2 to 3 years after 3 or more negative results.

Why is the Bethesda System recommended for reporting the results of the Pap test?

The Bethesda System is recommended for reporting the results of the Pap test because it provides a detailed cytologic description rather than a numerical result, it is also a more effective means of communicating the results of the Pap test to the physician.

Why does the Centers for Disease Control and Prevention recommend that pregnant women have a blood test to screen for exposure to the hepatitis B virus?

The CDC recommends that pregnant women have a blood test to screen for exposure to the hepatitis B virus because women who have positive HBsAg test results have an increased risk of spontaneous abortion or preterm labor. In addition, the woman may transmit hepatitis B to the infant, particularly during delivery or in the first few days of life.

What are the advantages of using the liquid-based Pap test method?

The advantages of using the liquid based Pap test method are that it preserves most of the specimen to allow the laboratory to evaluate it better, an automated processor is used that removes a large portion of debris from the specimen and transfers cells to a slide in a thin even layer that provides a clear view of the cells that is spread out and easier to evaluate.

List the four components of the first prenatal visit.

The four components of the first prenatal visit are usually the completion of a prenatal record form, an initial prenatal examination, consisting of a complete physical examination, prenatal patient education, and laboratory tests.

What is the function of a vaginal speculum?

The function of a vaginal speculum is to hold the walls of the vagina apart to allow visual inspection of the vagina and cervix.

Explain the importance of performing a physical examination on the prenatal patient.

The importance of performing a physical examination on the prenatal patient is to establish a baseline for the woman's general state of health and in identifying high risk prenatal patients.

List three conditions that the maturation index can help to evaluate.

The maturation index helps evaluate the cause of infertility, menopausal or postmenopausal bleeding, or amenorrhea and can help assess the results of treatments of hormones.

How can the medical assistant help the patient to relax during the pelvic examination?

The medical assistant can help the patient relax during the examination by telling her to breathe deeply, slowly, and evenly through the mouth.

List two types of information included in the past medical history (of the prenatal record).

The past medical history part of the prenatal record includes conditions that could affect the mother and fetus such as hypertension and Rh sensitization and immunizations and childhood diseases to assess antibody protection against diseases.

What are the components of the pelvic examination?

The pelvic examination consists of inspection of the external genitalia, vagina, and cervix, it also involves a collection of a specimen for a pap test, bimanual pelvic examination, and a rectal-vaginal examination.

List three types of information included in the present pregnancy history.

The present pregnancy history part of the prenatal record includes presence of warning signs of pregnancy, prescriptions or OTC medications, and calculation of the expected date of delivery.

What is the purpose of the gynecologic examination?

The purpose of a gynecologic examination is to assess the health of the female reproductive organs to detect early signs of disease, leading to early diagnosis and treatment.

What is the purpose of performing a breast examination?

The purpose of performing a breast examination is to check for abnormalities or lumps that might indicate breast cancer.

What is the purpose of performing a glucose challenge test on a pregnant woman?

The purpose of performing a glucose challenge test on a pregnant woman is to screen for gestational diabetes mellitus (GDM).

What is the purpose of performing a hemoglobin and hematocrit evaluation on a prenatal patient?

The purpose of performing a hemoglobin and hematocrit evaluation on a prenatal visit is to detect anemia because prenatal patients have a tendency to have low values because there is an increased demand for and correlating increased production of red blood cells during pregnancy.

What is the purpose of performing a rubella titer test on a pregnant woman?

The purpose of performing a rubella titer test on a pregnant woman is to determine if the woman is immune to rubella. If the mother contracts rubella during pregnancy, serious congenital abnormalities can result in the fetus.

What is the purpose of performing a vaginal examination as the patient nears term?

The purpose of performing a vaginal examination as the patient nears term is to confirm the presenting part and determine the degree of cervical dilation and effacement. The purpose of dilation and effacement is to permit the passage of the infant from the uterus into the birth canal.

What is the purpose of performing a visual examination of the vagina and the cervix?

The purpose of performing a visual examination of the vagina and the cervix to inspect for color, lacerations, ulcerations, tenderness, nodules and discharge. If there is an abnormal condition present, the physician will obtain a specimen for laboratory evaluation and test for pathologic conditions such as trichomoniasis, candidiasis, chlamydia, and gonorrhea.

What is the purpose of performing the bimanual pelvic examination?

The purpose of performing the bimanual pelvic examination is to allow the physician to palpate the uterus and ovaries for size, shape, position, and detection of tenderness or lumps.

What is the purpose of prenatal care?

The purpose of prenatal care is to promote the health of the mother and fetus through prevention of disease and early detection, diagnosis, and treatment of problems common to pregnancy.

What is the purpose of performing a Pap test?

The purpose of the Pap test is for early detection of cervical cancer, detection of abnormal (atypical) cells of the cervix, and detection of cancer of the endometrium.

What is the purpose of the interval prenatal history?

The purpose of the interval prenatal history is to update the record. It assists in planning, implementing, and evaluating the individual needs of the patient.

What is the purpose of the prenatal record?

The purpose of the prenatal record is to provide information regarding the past and present health of the patient and serves as a database and flow sheet for subsequent prenatal visits and is essential for helping identify high-risk patients.

What is the purpose of the rectal-vaginal examination?

The purpose of the rectal-vaginal examination is to provide a view of the tone and alignment of the pelvic organs and adnexal region, and note the presence of hemorrhoids, fistulas, and fissures for early detection of colorectal cancer.

Why must the slides be fixed immediately after collection of a specimen for the direct-smear Pap test method?

The slides must be fixed immediately after collection to maintain the normal appearance of cells, protect slides from contaminants, and to ensure the smear firmly attaches to the slide, they should also be allowed to dry to avoid inaccurate results.

What are the symptoms of PID? What complications can occur from PID?

The symptoms of PID include lower abdominal pain, fever, nausea, and vomiting, dyspareunia, vaginal discharge, and bleeding between periods. Complications of PID are serious and include chronic pelvic pain, scarring of the fallopian tubes, ectopic pregnancy, and infertility.

List the three categories of medical office visits for provision of prenatal and postnatal care to the pregnant woman.

The three categories of prenatal and postnatal office visits are the first prenatal visit, return prenatal visits, and the 6 weeks postpartum visit.

What are the three types of specimens that may be obtained for a Pap test? Where is each collected?

The three types of specimens are vaginal, cervical, and endocervical. The vaginal specimen is collected from the vaginal pool in the posterior fornix of the vagina. The cervical specimen is collected from just inside the cervical canal and the external os, over the surface of the ectocervix. The endocervical specimen is collected from the endocervix.

What are the warning signs of a spontaneous abortion?

The warning signs of a spontaneous abortion are vaginal bleeding, persistent lower back pain, abdominal pain and cramping.

What are the warning signs of preeclampsia?

The warning signs of preeclampsia are severe, persistent headache, dizziness, blurred vision, sudden swelling of hands, feet, or face, sudden rapid weight gain, and abdominal pain.

Describe the laboratory procedure that can be used to identify Trichomonas vaginalis in the medical office.

Trichomonas may be identified in the medical office by a wet preparation, which involves using a sterile swab to place a small amount of the discharge on a microscope slide, adding a drop of isotonic saline to it, and placing a coverslip over the mixture to protect it. The slide is examined under the microscope and observed for presence of the lashing movements of the flagella and motility of the organism.

List two purposes of measuring the fundal height.

Two purposes of measuring the fundal height are as a rough estimate of duration of pregnancy during the first and second trimesters and assess whether fetal development is progressing normally.

What are three examples of vaginal infections that cause a discharge?

Vaginal infections that cause a discharge are chlamydia, gonorrhea, and trichomoniasis.

3. How often should a woman perform a breast self-examination at home? When should it be performed in relation to the menstrual cycle and why?

Women 20 years of age or older should examine their breasts once every month. If a woman has regular periods, examinations should be done approximately 2 to 3 days after the menstrual period has ended. This is because the breasts are least likely to be tender or swollen, which make it easier to perform the examination.

What is the purpose for performing each of the following special tests and procedures? a. Multiple marker test: b. Obstetric ultrasound scan: c. Amniocentesis: d. Fetal heart rate monitoring:

a. Multiple marker test: Performed to screen for the presence of certain fetal abnormalities, which include neural tube defects, down syndrome, trisomy 18, and ventral wall defect. b. Obstetric ultrasound scan: Performed to evaluate the health of the fetus and to determine gestational age. c. Amniocentesis: Performed to diagnose certain genetically transmitted errors of metabolism, congenital abnormalities, chromosomal disorders, detect fetal jeopardy or distress, assess fetal lung maturity, and determine if the fetus is a boy or girl. d. Fetal heart rate monitoring: Performed to obtain information on the physical condition of the fetus.

List the symptoms of each of the following sexually transmitted diseases: a. Trichomoniasis in the female: b. Candidiasis in the female: c. Chlamydia Female: Male: d. Gonorrhea Female: Male:

a. Trichomoniasis in the female: Symptoms include a profuse, frothy vaginal discharge that is usually yellowish green and has an unpleasant odor; itching and irritation of the vulva and vagina; dyspareunia; and dysuria. The cervix may exhibit small red spots, a condition known as "strawberry cervix". b. Candidiasis in the female: Symptoms include white patches on the mucous membrane of the vagina; a thick, odorless, cottage cheese-like discharge; vulval irritation; and dysuria. The discharge is extremely irritating and usually results in burning and intense itching. c. Chlamydia Female: Most women with chlamydia have no symptoms, if symptoms do occur, they may include dysuria, itching and irritation of the genital area, and a yellowish, odorless vaginal discharge. Male: Symptoms include mild dysuria and a thin, watery discharge from the penis. d. Gonorrhea Female: May have no symptoms or may exhibit dysuria and a yellow vaginal discharge. Male: Symptoms include dysuria and a whitish discharge from the penis, which may progress to a thick and creamy discharge. The burning and pain experienced during urination are often severe.