RWAMAGANA SCHOOL OF NURSING AND MIDWIFERY PO.BOX 2 RWAMAGANA COURSE OF GYNECOLOGY 2nd year nursing &midwifery FACILITATOR: MUSENGIMANA 1 INFORMATIONS RELATED TO THE COURSE 1. COURSE DESCRIPTION Throughout this course different variations of structure and functions of female reproductive system will be discussed, it is important for a nurse and midwife to be familiar with various terminologies used in gynecology. Common problems encountered in gynecology will be discussed in detail in terms of prevention of risk and treatment. 2. BACKGROUND & PURPOSE OF COURSE The course aim is to enable the learner to understand and manage problems which can occur in female. 3. Course objectives At the end of this course, student will be able to: • To define gynecological conditions and diseases • To identify their etiologies • To explain their pathogenesis • To enumerate principal signs and symptoms of gynecological problems • To diagnose gynecology diseases • To manage client with gynecological diseases 4. TEACHING/LEARNING METHODS Lecturing Group discussions Presentations Case studies 5. REFERENCES Coad. (2008), Anatomy and physiology for midwives, 2nd edition, Churchill Livingstone, 2 London, U.K Dictionary of nursing (2007), 2nd edition, Black publisher ltd, London Elisabeth A Gangar (2001) Gynecological nursing, a practical guide, Churchill Livingstone, London, U.K Ellis Q. Y .Marcia S.D (2004) Women’s health, a primary care clinical guide, 3rd edition. Pearson Education, Inc. Fraser D& Cooper M. (2003).Myles textbook for midwives, Churchill Livingstone, London, U.K Kerri D S and Frances E.L (2006) Women’s gynecologic health, Jones and Bartlett, USA UNIT I. INTRODUCTION 3 I.0.DEFINITION 1. Gynecology The branch of medicine particularly concerned with the health of the female organs of reproduction and diseases thereof. The word "gynecology" comes from the Greek gyno, gynaikos meaning woman + logia meaning study, so gynecology literally is the study of women. However, these days gynecology does not address all of women's medicine but focuses on disorders of the female reproductive organs. 2. REVIEW OF FEMALE REPRODUCTIVE ORGANS Areas of special concentration for gynecologists include disorders of the uterus, or womb: the organ where an unborn fetus develops; ovaries: the organs that produce ova, or eggs, which are the female sex cells; fallopian tubes: the channels connecting the uterus and ovaries; cervix: the organ that connects the vagina and uterus; vagina: the canal between the cervix and vulva, or external female organs; and breasts. It is very necessary to know that gynecology study the woman in her four periods of genital life: Pre-puberty Puberty : The stage in a person's life when they develop from a child into an adult because of changes in their body that make them able to have children: At puberty, pubic hair develops and girls begin Reproduction Menopause : The time in a woman's life when she gradually stops having periods(mostly between the ages of 40 and 50 ) Midwife’s role in gynecological consultation 4 - Welcoming the client - Screening and orientation - Make client’s file available - Empty the bladder and anus before any gynecological exam - Install the client…………………. I.1.Investigations in gynecology PHYSICAL EXAM It starts by taking a history: because you can’t examine a person to whom you don’t have his history (personal, or of his disease).Taking history and physical examination go together and they are parts of clinical examination. Personal data: name, age, marital status, social status, address… Symptoms: complaint and duration, Obstetric history: number of pregnancy, antenatal care, premature birth, stillbirth, abortion, Gynaecological history: menstruation: age of onset, length of cycle, amount of blood loss, pain… Vaginal discharge: character, color, purulent, quantity. Bowels: constipation, pain, difficulty on defecation… Sexual history: dyspareunia, post-coital bleeding… Past medical and surgical history: ask for a written report of treatment received from other hospital… Social history: home condition, work condition. Family history: hereditary diseases, health. Current treatment: note this in detail for it may affect the course of management of the condition Summary: allow the patient to explain her symptoms freely; in this way it is possible to assess her character and whether she tends to exaggerate or underrate her complaints. 5 General While some physicians perform each of these evaluations at every routine gynecologic visit, some perform only those which focus on specific issues for the specific patient. 1. Weight the patient Make an assessment of how her weight fits with standards for good health. Too much and too little weight is both problems. Compare the weight with previous weights to assess the trend. Make an assessment of how her weight fits with standards for good health. Too much and too little weight is both problems. Compare the weight with previous weights to assess the trend. 2. Blood Pressure Measure the blood pressure and the other vital signs, particularly among older women, elevated blood pressure is a common problem and one that may be effectively controlled or treated. Uncontrolled hypertension is associated with a number of serious medical consequences. A single elevation of blood pressure is usually not significant, particularly if the patient has some anxiety about being seen and examined. Blood pressure that is persistently ≥ 140 (systolic)or ≥ 90 (diastolic) is considered elevated. About 90% of hypertension is "primary" or "essential" hypertension. 5-10% is caused by chronic renal disease, and only 1-2% is caused by a curable condition. If hypertension is found, a basic laboratory workup to identify underlying illness might include: Urinalysis Creatinine Potassium Sodium Glucose Lipoproteins(Total cholesterol) 3. Inspection Look in their hair, eyes, Face. 6 Check distribution of body hair, anaemia, oedema, Watch they eyes for symmetry, focus, and movement. Look for any facial muscle weakness appearing as a droop or asymmetry. Eye movements should be coordinated. The ability to read a sentence with each eye suggests intact ophthalmic, neurologic and higher brain function. Facial muscles should have symmetry. If she can read text off a page, you have confirmed the essential elements of neurologic function related to vision. Look in their ears While not always necessary, a quick look in the ears will confirm pearly-white drums, the absence of fluid behind the drum, clean canals and the absence of pain while pulling on the external ear to straighten the canal. Note any redness, drainage, or tenderness. She should be able to hear your whispering voice or the ticking of your watch. Inspect from the head to foot: the state of the mouth, axillaries adenopathy, chest (asymmetry), abdomen (ballonement,ligne blanche,..),varices and oedma (legs) 4. Palpation Feel the thyroid Checks the thyroid gland, many gynecologists routinely feel the thyroid for enlargement, tenderness or lumps which might suggest a thyroid nodule. Thyroid disease is more common among women than men, and increases in incidence with advancing age. Some menstrual abnormalities are associated with thyroid dysfunction and many hypothyroid patients, for example, have infrequent menstrual periods in addition to their fatigue and cold intolerance. Hyperthyroid patients are more likely to have heavy, frequent menstrual cycles. 5. Auscultate Listen to the lungs Listen for wheezes suggesting asthma, diminished breath sounds, or fine crackles, suggesting pneumonia or heart failure. Some apparently abnormal sounds will clear if the patient coughs. 7 Listen alternately in mirror image areas from one side of the chest to the other. Asymmetry in breath sounds will attract your attention. Listen to the heart Heart Note the regularity of the rhythm. Listen over the aortic, pulmonic, tricuspid and mitral valve areas for abnormal sounds such as clicks or murmurs. Any hyper dynamic state, such as pregnancy, leads to increased flow across the heart valves and leads, in many patients, to soft flow murmurs that are not ordinarily heard. The commonness with which these murmurs are heard during pregnancy should not lull the examiner into assuming all murmurs heard during pregnancy are innocent. GYNECOLOGICAL EXAM a) Breast examination Inspect and palpate for lumps, masses, tenderness, nipple discharge, or skin changes such as dimpling, retraction or crusting, dominant masses need further evaluation, sometimes with mammography, ultrasound and/or fine needle aspiration, bilateral nipple discharge may indicate hyperprolactinemia, unilateral nipple discharge, if bloody, may be the presenting finding with an intraductal papilloma. Most breasts can demonstrate a drop or two of clear to white or greenish fluid if the ducts are stripped. b) Abdomen Inspection, Palpation, percussion and auscultation of the abdomen. On abdomen it is not only to palpate, you inspect, palpate, precut and auscultate, ask to empty her bladder before examination of her abdomen and pelvis, it should be soft, and non-tender, with no masses. The liver may be just barely palpable below the rib cage and should not be tender. Have the patient take a deep breath while you press your examining hand down beneath the ribs on her right side. While she exhales, keep pressure on your hand. With her next deep breath, you will feel the liver edge descend down to or just past the costal margin. If it is tender, that suggests 8 swelling or inflammation of the liver. The gall bladder is normally not tender, but if diseased, it may be. c) Pelvic Evaluate the pelvis systematically, position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. If she is not down far enough, the exam will be more difficult for you and more uncomfortable for her. Pad the stirrups to avoid the stirrups digging into her feet. Kitchen pot-holders work well for this, but almost any soft material can be used. Use a bright light to visually inspect the vulva, vagina and cervix. Most examiners find it easiest to look just over the light to get the best view.