This document outlines the process for taking a thorough obstetric history and conducting a physical examination of a pregnant patient. It discusses taking a full biodata, obstetric, medical, and social history. The physical exam involves inspection of general appearance and systems, as well as specific obstetric examination including fetal lie, presentation and position using Leopold's maneuvers, and fundal height measurement. Proper rapport, explanation of procedures, and patient comfort are emphasized.

1. History Taking & Examination
in Obstetrics
Dr. Igbodike Emeka P
Senior/Specialist Registrar OBGYN ,Cert. MAS

2. Outline
• Segment I – History taking in Obstetrics
• Segment II – General physical examination
• Segment III- Abdominal Examination

3. Introduction
• History and physical examination forms the basis for patients
evaluation and clinical management
• Both the mother and the foetus are assessed
• Provides an insight on the quality of management during the
course of her pregnancy
• Rapport is established
• Opportunity for counselling may arise

4. History taking in Obstetrics
Segment I

5. Tips for good history
• Ensure privacy and confidentiality
• Greet the patient
• Explain to the patient what you want to do
• Obtain a verbal consent
• Use patients own words
• Be chronologic
• Be in charge
• Do not be in a hurry!

6. History taking
• Biodata – NASORAM
• Obstetric summary
• Menstrual history
• Presenting complaint
• History of presenting complaint [ 5cs]
• History of index pregnancy
• Past obstetric history
• Gynaecological history

7. History taking
• Past medical and surgical history
• Drug history
• Family and social history
• Systemic review
• Summary

8. Biodata
• Full name/title
• Age at her last birthday
• Occupation – be specific
• Residential address
• Religion – denomination
• Marital status – may affect the social and support system
• Tribe / Ethnic group
• Educational status – effective communication / social status

9. Menstrual history –
• Gravidity – total number of pregnancies irrespective of
outcome - normal, abortions, ectopic pregnancies etc,
current pregnancy
• Parity – total number of previous pregnancies carried to
viability
• LMP – EDD [280 days/ 40weeks/ 9months and 7 days] -
EGA
• Naegele’s Rule
• Add 7 to the LMP
• Add 9 months
• Subtract 3 months and add 1 year

10. Presenting complaint
• There may not be any
• May have come for ANC booking
• Routine antenatal follow up visit
• List the complaints in chronology order- the one that started
first to the latest with duration

11. History of presenting complaint [PC]
• Details of PC
• EGA at onset
• 5Cs

12. History of Index Pregnancy
• When she first knew she was pregnant
• What investigations she did to confirm the pregnancy
• Any details of any illness during this period / treatment./ hospital
admissions
• If she was booked? If yes where … if not why?
• Results of her booking investigations
• Height, weight, Blood pressure, Urinalysis, Blood Group, Genotype, HIV I & II
status, HBSAg.
• She may not know details/ were they normal ?

13. • Total number of ANC visits prior to presentation
• Routine drugs
• Tetanus Toxoid and the EGA at which they were taken
• IPTp-SP and the EGA at which they were taken
• Haematinics
• Ultrasound – Dating and Latest

14. Special notes
• Unsure date
• Twin gestation
• One previous Caesarean section
• Two or previous Caesarean section
• HBSAg positive
• HIV Positive
• Rhesus Negative
• HbSS

15. Special consideration
• Diabetics mellitus

16. Past Obstetric history
• Year of delivery
• Place of delivery
• Duration of labour
• Mode / method of delivery
• Birth weight
• Sex

17. Past Obstetric history
• Apgar?? Any neonatal complication
• Puerperium
• Breastfeeding - duration
• Immunization
• Alive and well

18. Gynaecological history
• Age at menarche
• Menstrual cycle length
• Number of days of menstruation
• Regular?
• Associated symptoms – menorrhagia or dysmenorrhea
• Previous contraceptive use- type and duration

19. Gynaecological history
• Any previous gynaecological complaints or treatment?
• Any abortions? Or gynaecological surgery?
• Any history of STD?
• History of Cervical smear
• Has she done smear?
• Date
• Result of the latest smear- normal or abnormal
• Due date for the next smear

20. Past medical and Surgical History
• Any medical illness requiring treatment and/or
hospitalisation
• Personal history of Diabetics mellitus, hypertension, sickle
cell disease, cardiac disease, chronic renal disease, asthma,
epilepsy, TB.
• Any surgical operation in the past
• Any previous blood transfusion

21. Drug history
• Chronic use
• Current use
• Allergies

22. Family history and social history
• Marital setting – poly/monogamous
• Age of husband
• Husband’s occupation
• Husbands educational status – think finances
• Family history of
• Twinning
• DM
• SCD
• Cancers

23. Social history
• Intake of alcohol
• Tobacco
• Stimulants
• Sedatives
• Other medications

24. Systemic Review
• General- Headache, fever, etc.
• Cardiorespiratory - chest pain, cough, palpitations
• GI – abdominal pain, dyspepsia, appetite, nausea/vomiting
• GU – frequency, dysuria, nocturia, haematuria
• Locomotor – joint pain, muscle cramps
• Neurological – dizziness, eyesight, paraesthesia

25. Summary
• Two or three sentences
• Patient’s name
• Age
• EGA
• Current problem/situation
• Actions taken – investigations and plan

26. Summary example
• I have presented MRS AK a 32 year old booked
G3P2+0 [2A] primary school teacher with 1 previous
caesarean section 3 years ago for persistent breech at
term. She presented today for routine antenatal clinic
visit at EGA of 20 weeks and has no complaints. She
has commenced haematinics.

27. Physical examination of an
Obstetrics patient
Section II

28. Physical examination
•General
•Systemic

29. Essentials
• Aesthetical environment – colourful/cheerful
• Physician should be warm and professional
• Chaperone should prepare the patient
• *assuming is a continuum , otherwise – greet, introduce,
obtain permission and screen]
• Explain what you want to do
• Run commentary please
• Be audible and clear!!!

30. • Patient in anatomical position
• Head gear off
• Expose legs up to knee [ beware of ladies on tight jean
trousers]
• Educate her on what to do before your examiners arrive [
may no be possible in osce]
• Height , weight and Bp , BMI*, urinalysis – protein, glucose
and acetone

31. • INSPECTION!!! – general state, demeanour, healthy
/acute/chronic ill looking, dressing….. Skin colour, height*
• Febrile – 3 step motion
• Jaundice – 2 step motion, one instruction
• Pallor - 2 step motion, one instruction

32. • Mouth – 5 instructions [ open, stick out your tongue, roll it
upwards, take your tongue in, close your mouth]
• Open : mouth hygiene , caries, dentures,
• Dorsum of the tongue – dehydration, leucoplakia
• Tip of the tongue – central cyanosis
• Ventral surface of the tongue- buccal mucosal pallor

33. • Hands – on the midline
• Pallor while supinated
• Drop the contralateral hand carefully
• Pronate the other hand and check for capillary refill
[prompt>2sec of refill]
• Repeat on the contralateral arm

34. • Oedema
• Posterior aspect of the lateral malleolus
• Press for 15 secs
• Check for dimpling
• If dimpling – move to the pretibial, if dimpling move to
knee, sacrum, note [pinard sign]
• Breast examination
• Thyroid examination

35. Breast Exam
• Note masses
• Prepare the mother for breast feeding post partum
• Examine initially sitting , then in supine position
• While sitting
• Inspect – size, shape, symmetry, skin changes, dimpling, retraction ,
nipples
• Palpate in supine – Any pain? palpate by quadrant – tenderness,
masses, axillary tail

36. Thyroid examination
• IPPA
• Aim – check for enlargement , tenderness or lumps
• Inspect the neck from the front – any obvious swelling?
• Ask patient to swallow- observe the neck for any swelling
• Thyroid swelling or thyroglossal cysts moves up upon swallowing
• While standing behind the patient, Give fluids to sip
• The thyroid gland is examined as it moves – noting the size, shape,
contour, consistency, feel for thrill
• Listen for bruit

37. Abdominal Examination
Segment III

38. • Urinary bladder should be empty
• Greet , introduce, explain, consent, screen, expose
• Abdominal exam/ Uterus and its content/ Obstetrics exam
• Exposure
• Tuck in your blouse below your brassieres
• Pull your skirt from behind in such a manner that can see
your pubic hairline a bit.
• Use cover cloth to screen from her hairline up to her toes

39. • Inspect – shape an size of the abdomen , moves with
respiration
• Linea nigra, striae gravidarium, scarification marks,
surgical scars (well healed?), foetal movements
• Palpation
• Any site painful?
• 9 quadrants – light palpation
• Liver, spleen, kidneys – deep palpation

40. • Liver – right iliac fossa and move upwards,
inspiration/expiration at the subcoastal margins , then right
lobe - inspiration/expiration at the subcoastal margins
• Spleen – diagonal ? No – left iliac fossa longitudinal upwards,
inspiration/expiration at the subcoastal margins
• Ballot for the kidneys – abdominal/watching – balloting
hands

41. Measurement of height of fundus
• Symphysio-fundal height [SFH] with tape in cm
• Use of anatomical landmarks method

42. Using anatomical landmarks
• A standard finger breath is assumed to be 2cm = 2 weeks
• Fundus just above pubic symphysis – 12 weeks
• Fundus at the lower margin of the umbilicus – 20 weeks
• Fundus at the upper margin of the umbilicus – 22 weeks
• Fundus at the tip of xiphisternum – 36 weeks
• Fundal heights at any point below or above the landmarks ,
is assessed by adding the finger breath to the immediate
landmark

43. SFH using measuring tape [Mc Donald
Technique]
• Determine the fundal region
• Start off from the xiphisternum using 2 curved ulnar
borders of the hands
• Move 2cm downwards until the fundus is reached
• With the tip of the measuring tape at the “0” level with
inches side facing upwards
• Stretch the tape in the midline to meet the supra pubic
region, then palpate with the index finger of the non-
dominant hand to determine the upper border of the
pubic symphysis

44. • Terminate the measurement at this point
• Turn the inches part of the measuring tape over to read
the cm part
• Report as follows: The SFH is 32cm which corresponds to
an intra uterine gestation of 32 weeks plus or minus 2
weeks and is compatible / less or greater than her EGA of
** today.

45. Leopolds
• Determination of foetal lie, presentation and position
• Palpation / better after 24 weeks / 4 manoeuvres
• Use palm for palpation not fingers
• Uterine fundus – what occupies it?
• Each side of the maternal abdomen – spine/back or
extremities – stabilizing the other side and vice versa
• Area above the pubic symphysis, what occupies it?
• Decent ?

46. • Listen to the foetal heart tone
• Pinard foetal stethoscope – 20 weeks better from weeks
26weeks
• Sonicaid @ 14 weeks
• Stay on patients right side
• Listen with the left ear facing the patients feet with one hand
at the patients pulse and the other stabilizing the
contralateral side of the maternal abdomen
• Summarize your findings:

47. • Determine lie and presentation and position
• By applying gentle pressure at the fundus and finger and
thumb of the other hand palpating the presenting part

48. Conclusion
• You can perfect your skills by personal efforts at the
following
• Clerk all pregnant women
• Present to everyone most especially senior colleagues
• Re-clerk to correct your mistakes
• Continue to clerk and examine !!
Obstetrics is an ART

49. Thank you