OBSTETRIC HISTORY AND EXAMINATIONRAJEEV BAHALL

OBSTETRIC HISTORY

OBJECTIVES• Patient demographics• Current pregnancy details and complaints• Past obstetric history• Past gynecological history• Past medical and surgical history• Drug history and allergies• Family history• Social history• Systemic review• Case summary

PATEINT DEMOGRAPHICS• Name• Age• Occupation• Relationship status• Booking status• Gravidity• Parity• Last Menstrual Period (LMP)• Estimated Date of Delivery (EDD)

• EDD can be calculated from the LMP using Nagele’s rule (add 1 year and 7 days to the LMP and subtract 3 months)

• If a cycle is >28 days, the EDD will be later and needs to be adjusted: the number of days by which the cycle is longer than 28 days is added to the date calculated in Nagele’s rule

• If a patient recently stopped combined oral contraceptive pill, her cycles can be anovulatory and LMP is less useful

GRAVIDITY AND PARITY• Terminology: Gravida x, Para y+z:• X is the total number of pregnancies (including this one)• Y is the number of births beyond 24 weeks gestation• Z is the number of miscarriages or termination of

pregnancies before 24 weeks gestation

• Example: A woman who is pregnant for the 4th time with 1 normal delivery at term, 1 TOP at 9 weeks and 1 miscarriage at 16 weeks would be G4, P1+2

CHIEF COMPLAINTS• What brings you in today?• Tell me what has been going on?• What seems to be the problem?

• Common reasons for admission are hypertension, pain, antepartum heamorrhage, unstable lie and possible ruptured membranes.

• S.O.C.R.A.T.E.S

HISTORY OF PRESENT ILLNESS- 1ST TRIMESTER• Planned/Unplanned• Method of confirmation of pregnancy• General health (tiredness, malaise and other non specific

symptoms)• Booking (when, where, how many visits)• Early booking investigations and result (FBC, Hb

electrophoresis, Blood group and Rh, VDRL, HIV)• History of vaginal discharge, vaginal bleeding, urinary

problems and flu like symptoms• Imaging (crown rump length usually between 9-14 weeks)

2nd TRIMESTER• History of foetal movements• Symptoms of anemia, miscarriage, ectopic pregnancy

(classic triad- amennorhea, abdominal pain, vaginal bleeding), vaginal discharge, UTI

• Symptoms of preterm labour, diabetes• Imaging (head circumference)• Anomaly scanning? (when, where, why)• Blood pressure check up• Changes in weight

3rd TRIMESTER• Any medication due to HTN, DM, EPILEPSY• Any labour pains, vaginal discharge, bleeding, urinary

problems• Hospital stays?• Any plans of delivery?

PAST OBSTETRIC HISTORY• Details of all previous pregnancies (including miscarriages

and terminations)• Length of gestation• Date and place of delivery• Onset of labour (including details of induction of labour)• Mode of delivery• Sex and birth weight• Fetal and neonatal life• Clear details of complications or adverse outcomes

(shoulder dystocia, post partum heamorrhage, still birth)

GYNAECOLOGICAL HISTORY• Age of menarche• Regular/irregular cycles• LMP, duration of menses, cycle length• Cervical smear history (last smear, when, where, what

was the result, awareness and follow up plans)• Methods of contraception• Difficulties in conceiving?

PAST MEDICAL AND SURGICAL HISTORY

• Any illness in childhood or adult life (DM, HTN, Hepatitis, Psychiatric illnesses, epilepsy)

• Previous hospitalizations (when, where, why, how long)

• Past surgery: Any past surgical procedures, particularly any abdominal or gynaecological operations as well as any associated complications or reaction to anaesthesia

DRUG HISTORY

• Current medications before and after conception (prescribed, over the counter, herbal)

-Name -Dosage -Purpose -Route -Frequency• Pregnancy related medication (folic acid, iron, antiemetic)• Allergies (what exactly happened)• Don’t forget vitamins and nutritional supplements

FAMILY HISTORY• Major illness in the immediate family members (DM, HTN,

carcinoma of breast, ovary, colon, endometrium)• Family history of preeclampsia, eclampsia, DM• Genetic disorders: sickle cell disease, cystic fibrosis,

chromosomal anomalies• Previously affected pregnancies• History of twin

SOCIAL HISTORY• Personal status (smoking and alcohol: amount, duration

and type)• Occupation• Educational background • Socioeconomic status (home conditions, water supply,

sanitation)• Financial earning of support system• How many people live in the household• Domestic violence screening• Plans for breastfeeding

SYSTEMIC REVIEW• General • Appearance • CVS (chest pain, SOB, palpitations, orthopnea)• GI • Genital (pain, discomfort, itch, discharge, bleeding)• Urinary (frequency, urgency, dysuria, nocturia,

incontinence, character of urine)• CNS • MSK (pain, swelling, weakness, gait)

EXAMINATION INTRO• Introduce yourself and gain consent• Explain the need and nature of the proposed exam• Examiner should be accompanied by chaperone• Respect patient’s privacy at all times• Patient should be covered at all times and relevant parts

of her anatomy only exposed• Ensure room is well lit and comfortabe• Patient should empty bladder before exam• Should lie supine with pillow under her head and arms at

the side• Ask for any tenderness before palpation

GENERAL• Measure BMI (Body Mass Index) [weight (kg)/height (m)2]

• Pregnancy complications are increased with BMI <18.5 and >25

• Measure vitals (BP, Temperature, Pulse, Resp rate)

• Blood glucose levels

INSPECTION• Distention• Fetal movements• Scars (especially lower segment transverse/longitudinal in

the event of previous C section)• Skin changes-Linea nigra-Striae Gravidarum-Striae Albicans-Distended Superficial Veins (increased IVC pressure due to gravid uterus)

LINEA NIGRA• Dark vertical line appearing on the abdomen from the

pubis to above the umbilicus during pregnancy due to increase melanocyte stimulating hormone made by the placenta

STRIAE GRAVIDARUM• Specific scarring of the skin due to sudden weight gain

during pregnancy. Caused by tearing of the dermis and results in atrophy

SYMPHYSIS FUNDAL HEIGHT• Distance from the symphysis pubis to the uterine fundus

(top of the uterus). The size of the uterus is directly related to the size of the foetus.

• Technique: palpate down from xiphi-sternum to determine the fundus and mark that point. A tape measure is then placed from the mid-point on the uppermost border of the symphysis pubis, over the curve of the uterus to the marked highest point and the measurement in cm is recorded

• The SFH in cm corresponds to the gestation +or- 2cm and is the best clinical test for detecting ‘small for dates’ fetus

FOETAL POLES• Leopold maneuver 1 also known as the fundal grip

• Both hands placed over the fundus and the contents of the fundus determined.

-A hard, smooth, round pole indicates the foetal head- A softer triangular pole continuous with the foetal body is the foetal buttocks

FOETAL LIE• Leopolds second maneuver or The lateral grip

• Move hands in a downward direction along sides of the uterus from the fundus. Lie is the relationship between the longitudinal axis of the foetus and that of the mother.

• Lie is usually longitudinal, hence lying length-wise in the same direction as mother’s longitudinal axis.

• Other lies are transverse and oblique • This procedure can also determine which side is the foetal

back (firm, regular surface) and foetal limbs (lumpy and irregular)

PRESENTING PART• Leopolds third maneuver or Pawlik’s grip• The thumb and middle fingers of the right hand are placed

wide apart over the suprapubic area to determine the presenting part.

• The presenting part of the foetus is the lowest part of the foetus at the inlet of the pelvis.

• Cephalic or breech presentation can be distinguished as indicated in the previous slide

ATTITUDE AND ENGAGEMENT• Deep pelvic grip• 1) The attitude of foetal headTechnique: examiner turns around to face patient’s feet and each hand placed on either side of lower foetal trunk.Note made as to which hand touches the foetal head (called the cephalic prominence)If cephalic prominence is felt on the same side as the back, this implies the foetal head is extended (abnormal)If cephalic prominence is felt opposite side of back, head is well flexed (normal)

ENGAGEMENT• Technique: continue moving hands down and determine

how far around the head you can get.

• Engagement is defined as having the widest transverse diameter of the foetal head pass through the pelvic inlet into the true pelvis.

• Divide the head into fifths. If 5, 4 or 3 fifths can still be palpated, most of the head is up, hence the widest part has not engagedIf 2, 1 or 0 fifths can be palpated, the widest part has engagaed into the pelvis

ADDITIONAL UTERINE ASSESSMENT

• Liquor volumeAssessment is made of the volume of amniotic fluid surrounding the foetus

Reduced volme or Oligohydramnios, the foetal parts are easily felt

Increased volume or Polyhydramnios, there is difficulty in feeling the foetal parts

Note any foetal movements

AUSCULTATION• Auscultated with Pinard’s foetal stethoscope or doppler

• Best place to listen is over the foetal back, closer to the cephalic pole

• Normal foetal heart rate is between 110-160 beats per minute

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