OBSTETRICS AND

GYNECOLOGY OSCE

Bimanual Vaginal (PV) Examination

Bimanual or PV examinations are performed for a number of clinical reasons e.g. problems relating to
menstruation, irregular bleeding, dyspareunia, abnormal vaginal discharge or pelvic pain.

For the purpose of examinations you will be provided with a mannequin, however you should pretend it is a
real patient and talk to it as such, which will also form part of the marking scheme.

Subject steps
1. Introduce yourself to the patient and clarify her identity. Explain what you would like to do and
obtain consent.

Explain she should feel little, if any, discomfort and that the examination should be over fairly quickly.

A chaperone is required for this examination

2. The patient should be exposed from the waist down. Ask her to lie on her back, ankles together and
to let her knees fall apart as much as possible. You should try and remain some of her modesty by
putting a cover over her.

o Patient exposed from the waist down

3. Wash your hands, put on some gloves and inspect the outside of the vagina. Check the labia and
clitoris looking for any obvious abnormalities such as erosions.
o Inspect the outside of the vagina

4. Lubricate the index and middle finger of your right hand. Explain to the patient that you are about to
start the procedure.

o Lubricate the index and middle finger

5. Use the thumb and index finger of your left hand to separate the labia majora and firstly insert your
index finger, checking for any cervical excitation. If none is present, then insert your middle finger.

o Separate the labia majora and firstly insert your index

finger

6. Palpate all of the vaginal walls as you advance your fingers feeling for any obvious abnormalities.

7. Using your fingertips, palpate the cervix, feel for its size, shape and mobility check with the
patient if it is tender.

8. At this point palpate the uterus by pressing it between your right middle and index fingers and your
left hand placed on the lower abdomen. Feel for any masses
o Palpate the patients uterus

9. You should also try to palpate each of the ovaries. This is done by placing your internal fingers in the
right fornix and trying to press the ovary between them and your left hand placed in the right iliac fossa.

Do the same for the left ovary.

Note any tenderness or masses which you may feel.

o Palpate the patients right ovary

o Palpate the left ovary

10. Once complete, remove your fingers, check your glove for any discharge or blood, and then discard
your gloves in the clinical waste bin.

o Check your glove for any discharge or blood

11. Offer the patient a tissue, cover them up and thank them. You should now report your findings back
to the examiner.

Pregnant Abdomen Examination

Examination of the pregnant abdomen is performed routinely throughout pregnancy. Expectant
mothers attend ante-natal check-ups regularly throughout their pregnancy where this is performed
by both doctors and midwives. You will get the chance to practice this skill during your obstetrics
and gynaecology placement in medical school, however as you will likely encounter pregnant
women in whatever area you specialise in (ok there are a few exceptions) it is an essential skill to be
able to perform, as such it IS commonly examined on in OSCEs.

This skill demonstrates two areas; your communication skills with the mother, and your examination
technique. There will usually be real patient volunteers for this station so remember to be gentle as
your patient may have had her bump examined many times before your turn. Like most stations this
still follows the general rule of inspection, palpation, auscultation.

Subject steps
1. Introduce yourself and clarify the patients identity. Wash your hands. Explain what you
would like to do and gain her consent.

For this station the patient should be lying on the bed, as flat as possible but in reality
whatever is most comfortable for her. She should ideally be exposed from the pubic bone to
below her breasts.

2. Try and put mum at ease. A few simple but friendly questions to help her gain your trust
includes:

o how are you feeling?

o do you know what you are having?
o is this your first pregnancy?

This shows the examiner that you can be caring, rather than jumping in hands first. As you
become more skilled at this station you can incorporate these types of questions into your
examination technique along the way.
 Perform a general inspection of mum and her bump. Comment if she looks
comfortable, does she have any abdominal striations or Linea Nigra, and whether she has
previous operative scars e.g. previous caesarean section.

If greater than 24 weeks you can expect some foetal movements, comment if so. This shows
you really are observing her closely.

Measure fundal height. Do this with a tape measure (disposable if

available). Measure from the pubic symphysis to the top of her bump (fundus).

The length in centimetres roughly corresponds to how far along she is in weeks; i.e. 36cm
roughly equals 36 weeks.

Check the lie of the baby by examining her bump. Remember to be gentle and
warm your hands if they are cold. Here you are assessing which way the baby is lying this
can be longitudinal, transverse or oblique.

Use both hands, one on each side of her bump and gently press. Remember to face mum
while you are doing this.

Check the presentation of the baby to determine which end of the baby is
presenting. This should be cephalic but may be breech.

Place both hands at the base of her uterus, just above the pubic bone and apply quite firm
pressure. Again face mum and warn her that this bit may be slightly uncomfortable. Hopefully
the baby will be head down and may even be engaged in the pelvis. If you are very
confident in this skill you may wish to offer the examiner how much the baby is engaged.

Auscultating the babys heart. This is best heard over the babys shoulder. If you
have correctly identified the lie you should roughly know where this is. Put either your Doppler
ultrasound or Pinard stethoscope over this area and listen. The babys heart rate should be
between 120-140bpm (ensure you are not incorrectly hearing the transmission of mums,
remember hers will be slower).

Cover mum up and thank her at this stage. Wash your hands.
 Inform your examiner that for completeness you would like to check her blood
pressure, and also perform urinalysis. If you have any concerns regarding the babys heart
rate you should suggest that a CTG should also be performed. You will not usually be asked
to perform these extra skills as part of this station.

An extension to this station could be discussions regarding glucosuria or

proteinuria, and/or elevated blood pressure. You should therefore be familiar with conditions
such as gestational diabetes and pre-eclampsia.

Newborn Baby Examination

This examination is performed on all newborn babies, ideally within 48 hours of birth. It is also
rechecked by the babys general practitioner at the 8 week check. It is basically a top-to-toe
examination of a baby and therefore has many parts to it.

It is not often examined in OSCEs as you would not be able to use real babies as patients, however
some medical schools do have dummy babies to practice these skills on. Every medical student will
however have a paediatric placement and it is here that you can practice these skills. In addition,
helping the doctors with their baby checks on the post-natal wards will also gain you brownie points!
All of the following steps have to be performed but its up to you which order you do them, this is the
order I [Laura] personally use in my work as a GP.

Subject steps
1. Equipment required for this station:

o Neonatal stethoscope
o Opthalmoscope
o Oxygen saturation monitor/pulse oximeter

Introduce yourself to mum and clarify her, and babys identity. Explain what you
would like to do, i.e. full examination of her new baby(s) and gain her consent. Congratulate
her on the birth as this will put her at ease and help gain your trust. New mums are protective
of their babies so trust and rapport is essential.

Whilst washing your hands you could ask mum to strip her baby down to its nappy.
Ensure you have a changing mat to do the examination on.

Start by asking mum a few questions:

 How was the birth?

Good to know as forcep deliveries can cause facial bruising, c-sections can occasionally cut
the babys skin. Babys born by c-section are usually more mucusy too.

Did your baby need any help after birth with breathing?

i.e. did the midwives or paediatric doctors have to give oxygen/rescue breaths.

How are you feeding your baby? Breast or bottle?

If breast feeding ask her

How is it going/baby latching ok, etc?

If bottle feeding ask

Which milk are you giving your baby/is baby taking bottles ok, etc?

Dont criticise if mum has not opted to breast feed, this is an individual decision.

Are there any conditions that run in you or dads family e.g. congenital heart problems?

Has anyone in your family (especially females) had problems with their hips at birth?

Female babies are more likely to have clicky or dislocated hips due to the hormones that are
in mums body during pregnancy, these are the hormones which help to open up mums pelvis
prior to and during birth.

Has your baby passed its sticky black stool yet?

Parents often dont know the term meconium

 Start by observing the baby. Does it look and behave normally, i.e. colour e.g.
jaundice, activity and posture. Is there any obvious bruising or marks from birth. Are there any
other marks such as strawberry naevus, stork marks or Mongolian blue spot. Remember to
turn the baby over and inspect its back too.

With the baby lying on its back feel the fontanelle gently with your hand. It should
be nice and soft, a tense/bulging or sunken fontanelle can suggest the baby is unwell.

Using both your hands gently feel the babys bones checking they are symmetrical
on both sides. Face, around ears, clavicles (these can be injured during birth if shoulder
dystocia occurs), both arms (e.g. Erbs palsy) down to legs and feet. Open up the babys hand
and look at the palm for normal palmar creases, count the fingers on each hand. Look at the
feet, is there any signs of a sandal gap or talipes and count the toes on each foot.

If the baby has its eyes open at this point check for the red reflex using your
opthalmoscope. An absent reflex could suggest congenital cataracts.

Auscultate the babys heart using a neonatal/paediatric stethoscope. The normal

rate is 120-150 so you will have to listen much more carefully for any murmurs as there is less
time between heartbeats to hear them. If you do pick up any murmurs assess whether it
radiates anywhere.

Ausculate the lung fields. The normal respiratory rate is 30-60 in newborns. Are
there any extra sounds e.g. grunting or stridor.

Palpate the abdomen and check the umbilical stump/clamp to ensure no signs of
infection.

Turn the baby over and check down its spine and between buttock cheeks for the
sacral dimple.

At this point undo the babys nappy. Look for any obvious genital abnormalities. If
its a male infant you should check the scrotum to see if the testicles have descended. If not
you may be able to palpate them in the spermatic cord and gently bring them down yourself.
Check the patency of the anus at this point too.

Test the babys hips. This is done by two techniques, Ortolani and Barlow tests.
Essentially cup the babys hips in the palm of your hand and gently abduct the hips, this
should be smooth with no clicks. Next move your hands to the front of the baby and with their
knees flexed push gently downwards into the bed, again this should be smooth with no clunks.
 At this point redo the nappy and again wash your hands. With your hands freshly
washed you now want to assess inside the babys mouth. Use your little finger to feel the
palate of the mouth. Look to see if there is a tongue tie.

Again wash your hands. Attach the pulse/oxygen monitor to the babys foot.
Remember if a baby is sleeping or crying the heartrate may be higher or lower than the
normal range.

There are a number of primitive reflexes present in newborns which you should
elicit. Moro, grasp and sucking.

Thank mum, offer to dress the baby, although she will usually wish to do this
herself. Answer any questions she may have.

Again wash your hands and report your findings, if any, to the examiner, or doctor if
on a ward. Should you notice any abnormalities you may wish to suggest how to investigate
these further.