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HISTORY & CLINICAL
EXAMINATION IN OBSTETRICS


   DR.SHABNAM NAZ
      ASSISTANT PROFESSOR
             OBGYN
      CMC,SMBBMU LARKANA
HISTORY IN
OBSTETRIC
 AN OBSTETRIC HISTORY SHOULD INCLUDE:


  Current pregnancy details.
  Past obstetric history.
  Past gynecological history.
  Past medical and surgical history.
  Drug history and allergies.
  Family history-especially multiple
   pregnancy, diabetes, hypertension, chromosome or
   congenital malformations.
  Social history.
  History of systemic review
  Case summary
 CURRENT PREGNANCY

BIODATA
  Name
  Age
  Occupation
  Relationship status
  Booking status
  Gravidity (i.e. number of pregnancies including the
   current one).
  Parity (i.e. number of births beyond 24 weeks
   gestation)
  LMP
  EDD
 The expected date of delivery (EDD) can be
    calculated from the last menstrual period (LMP)
    using Naegele’s rule (add 1 year and 7 days to the
    LMP and subtract 3 months)
   Long cycles
   Irregular periods
   Relevant use of the combined oral contraceptive pill
    (COCP)
   Ist trimester scan is more reliable as compare to
    LMP in these case
 GRAVIDITY AND PARITY EXPLAINED


 The terminology used is gravida x, Para a+b:
   X is the total number of pregnancies (including this one).
   A is the number of births beyond 24 weeks gestation.
   B 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 termination at 9 weeks and 1
   miscarriage at 16 weeks would be gravida 4, Para 1+2.
HISTORY OF CURRENT PREGNANCY
 Ist trimester
 Second trimester
 Third trimester
 History of labor
   HISTORY OF IST TRIMESTER
   method of confirmation of pregnancy,LMP
  General health (tiredness, malaise, and other non-specific
  symptoms)
  Bleeding ,pain.( Ectopic pregnancy,misscariage)
  Vaginal discharge
  Hyperemesis
  Urinary problems
  Investigations( ultrasound,blood and urine test )
   drug history (treatment)
  vaccination
HISTORY OF SECOND & THIRD
TRIMESTER
History of fetal movements
Symptoms of anemia, Miscarriage ,Ectopic
pregnancy,Vaginal discharge,UTI,hyper emesis
gravidarum
Symptoms of aph,pih.diabetes,preterm labor
Ask for vaccination
 Results of all antenatal blood tests-routine and specific.
  Results of anomaly and other scans (details of results
  can be cross checked with the notes).


 IF SHE IS POSTNATAL:

  Labor and delivery
  History of the postnatal period.
PAST OBSTETRIC HISTORY INCLUDES:

  Details of all previous pregnancies (including
  miscarriages and terminations).

  Length of gestation.


  Date and place of delivery.


  Onset of labor (including details of induction of labor).
 Mode of delivery.
 Sex and birth weight.
 Fetal and neonatal life.
 Clear details of any complications or adverse
 outcomes (such as shoulder dystocia, postpartum
 hemorrhage, or stillbirth).
 History often repeats itself, so previous
    antenatal, intrapartum, or postpartum complications
    should influence the management of this pregnancy.


   GYNAECOLOGICAL HISTORY

     Method of contraception before conception.
      Menstrual history
     Cervical smear history.
     Coital problems
 PAST HISTORY             (MEDICAL & SURGICAL)
Medical conditions such as hypertension, epilepsy, or
diabetes.
 Details of any consultations with other physicians
  (neurologist or endocrinologist).
 Involvement of multidisciplinary teams.
 Details of any previous surgery.
 DRUG AND ALLERGY HISTORY


 Current medications


 Medications taken at any time
 during the pregnancy.


 Any allergies and their severity
 (anaphylaxis or a rash?).
 FAMILY HISTORY


 Any history of hereditary illnesses or congenital defects
 is important and is required to ensure adequate
 counseling and screening is offered.

   Familial disorders such as thrombophilia's.


   Previously affected pregnancies
   with any chromosomal or genetic disorders.
   multiple gestations


   Consanguinity.
SOCIAL HISTORY
 living status
 total family members
 earning members
 Planes for breast feeding
 Domestic violence screening

PERSONAL HISTORY


     Smoking, other narcotics.
     History of drug or alcohol abuse.
     Sleep
     Diet
     Bowel habits..
HISTORY OF SYSTEMIC
REVIEW
 CNC
 CVS
 RESPIRATORY SYSTEM
 GIT
 GENITALIA
 URINARY SYSTEM
 LOCOMOTORY SYSTEM
EXAMINATION IN
 OBSTETRICS
GENERAL EXAMINATION
 Body mass index (BMI) calculated [weight
  (kg)/height (m)2].
  Pregnancy complications are increased with a BMI <
  18.5 and > 25.
VITALS ( B.P, PULSE, TEMP, R.R)

 Blood pressure measured in the
 semi-recumbent position (450 tilt).
  Use an appropriate size cuff:
too small a cuff gives a falsely high BP.
   Anemia
   Jaundice
   Cyanosis
   Dehydration
   Edema
   Clubbing
   Koilonychias
   Thyroid gland

 Breasts (exclude any lumps).

 Varicose veins and skeletal abnormalities (kyphosis or
    scoliosis):
     Normal pregnancy is associated with an increase in lumbar
      lordosis which can lead to lower backache.
History and clinical examination in obstetrics
 Auscultation of the heart and lungs:


   Flow murmurs are common in pregnancy and are
    not significant.
   Cardiac murmurs may be detected for the firs time
    in pregnancy.
ABDOMINAL EXAMINATION

 -INSPECTION.


  Note the apparent size of the abdominal distension.
  Note any asymmetry.
  Fetal movements.
 Cutaneous signs of pregnancy:


  Linea nigra (dark pigmented line stretching from the
   xiphi sternum through the umbilicus to the suprapubic
   area).
  Striae gravidarum (recent stretch marks are purplish in
   color).
  Striae albicans (old stretch marks are silvery-white).
  Flattening/eversion of umbilicus (due to intra-abdominal
   pressure).
 Superficial veins (alternate paths of venous
 drainage due to pressure on the inferior vena
 cava by a gravid uterus).

 Surgical scars (a low pfannenstiel incision may
 be obscured by pubic hair, and laparoscopy scars
 hidden within the umbilicus).
 ABDOMINAL EXAMINATION-
 PALPATION.
  Symphysis-fundal height (SFH):
    Palpated < 20 weeks.
    Measured in cm > 20 weeks.


  Estimation of number of fetuses:
    ? Multiple fetal poles.
History and clinical examination in obstetrics
History and clinical examination in obstetrics
History and clinical examination in obstetrics
PAWLIC GRIP
PELVIC GRIP
 NORMAL UTERINE SIZE


  The uterus normally becomes palpable at 12 weeks
   gestation.
  It reaches the level of the umbilicus at 20 weeks
   gestation.
  It is at the xiphi sternum at 36 weeks gestation.
 SYMPHYSIS-FUNDAL HEIGHT
 The SFH detects approximately 40-60% of small-
 for-gestational age fetuses but its predictive value
 in detecting large-for-dates fetuses is
 considerably less.

 The uterine size is objectively measured with a
 tape measure from the highest point of the fundus
 to the upper margin of the symphysis pubis.
 Appropriate growth is usually estimated to be the
 number of weeks gestation in centimeters (at 30
 weeks the SFH should be 30 cm + 2 cm):

 + 2 cm from 20 until 36 weeks gestation.
 + 3 cm between 36 and 40 weeks.
 + 4 cm at 40 weeks.
 FETAL LIE (relationship of longitudinal axis of
 fetus to that of the uterus):

   Longitudinal-fetal head or breech palpable over
    pelvic inlet.
   Oblique-the head or breech is palpable in the iliac
    fossa
   Transverse-fetal poles felt in flanks
 PRESENTATION (part of the fetus overlying the
 pelvic brim):
   Cephalic
   Breech
   Other (shoulder, compound)


 AMNIOTIC FLUID VOLUME:
   Tense abdomen with fetal parts not easily palpated.
   Compact abdomen with fetal parts easily palpable.
PALPATION OF UTERINE
CONTRACTION
 AUSCULTATION OF THE FETAL HEART
 The fetal heart is best heard at the anterior shoulder
    of the fetus using:
   A doppler ultrasound device (Sonicaid) from about
    12 weeks gestation.
   A fetal stethoscope (Pinard) from about 24 weeks
    gestation.
   In a breech presentation it is often heard at, or
    above, the level of the maternal umbilicus.
   The rate and the rhythm of the fetal heart should be
    determined over 1 minute.
FHR monitoring
by fetoscope
History and clinical examination in obstetrics
Listening with a doppler
ENGAGEMENT( maximum diameter pass through
pelvic inlet)

 Conventionally, engagement or the passage of the
 maximal diameter of the presenting part beyond the
 pelvic inlet, is estimated using the palm width of the
 five fingers of the hand. If five fingers are needed to
 cover the head above the pelvic brim, it is five-fifths
 palpable, and if no head is palpable, it is zero-fifths
 palpable.
 Normally, the fetus engages in an attitude of flexion
  in the transverse diameter of the pelvic inlet, unless
  the pelvis is very roomy where it may engage in any
  diameter.
 In nulliparous women, engagement usually occurs
  by 37 weeks but in multiparous women it may not
  occur until the onset of labour.
 Rare causes of non-engagement should always be
  considered and investigated with an ultrasound scan
  (USS) (including placenta praevia and fetal
  abnormality)
 In women of Afro-Caribbean origin, engagement may
  only occur at the onset or during the course of
  labour, even in nulliparous women.
 Paulik’s grip
 This is a one-handed technique that uses a cupped
  right hand to grasp and assess the lower pole of the
  uterus (usually the fetal head).
 This can be very uncomfortable and is not necessary
  if the head can be palpated using two hands.
 ENGAGEMENT


 A head that is only two-fifths palpable is usually
  considered to be engaged (and therefore fixed in the
  pelvis).
 Put simply: an easily palpable head is not
  engaged, whereas a head more difficult to palpate is
  more likely to be deeply engaged.
   Care must be taken, as a breech presentation can
  some times be mistaken for a deeply engaged head.
 VAGINAL EXAMINATION
 A vaginal examination (speculum or digital
 examination) is not part of a routine obstetric
 examination but may be indicated to diagnose
 rupture of membranes or onset of labour.
Thanks…



THANKS

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History and clinical examination in obstetrics

  • 1. HISTORY & CLINICAL EXAMINATION IN OBSTETRICS DR.SHABNAM NAZ ASSISTANT PROFESSOR OBGYN CMC,SMBBMU LARKANA
  • 3.  AN OBSTETRIC HISTORY SHOULD INCLUDE:  Current pregnancy details.  Past obstetric history.  Past gynecological history.  Past medical and surgical history.  Drug history and allergies.  Family history-especially multiple pregnancy, diabetes, hypertension, chromosome or congenital malformations.  Social history.  History of systemic review  Case summary
  • 4.  CURRENT PREGNANCY BIODATA  Name  Age  Occupation  Relationship status  Booking status  Gravidity (i.e. number of pregnancies including the current one).  Parity (i.e. number of births beyond 24 weeks gestation)  LMP  EDD
  • 5.  The expected date of delivery (EDD) can be calculated from the last menstrual period (LMP) using Naegele’s rule (add 1 year and 7 days to the LMP and subtract 3 months)  Long cycles  Irregular periods  Relevant use of the combined oral contraceptive pill (COCP)  Ist trimester scan is more reliable as compare to LMP in these case
  • 6.  GRAVIDITY AND PARITY EXPLAINED  The terminology used is gravida x, Para a+b:  X is the total number of pregnancies (including this one).  A is the number of births beyond 24 weeks gestation.  B 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 termination at 9 weeks and 1 miscarriage at 16 weeks would be gravida 4, Para 1+2.
  • 7. HISTORY OF CURRENT PREGNANCY  Ist trimester  Second trimester  Third trimester  History of labor HISTORY OF IST TRIMESTER method of confirmation of pregnancy,LMP General health (tiredness, malaise, and other non-specific symptoms) Bleeding ,pain.( Ectopic pregnancy,misscariage) Vaginal discharge Hyperemesis Urinary problems Investigations( ultrasound,blood and urine test ) drug history (treatment) vaccination
  • 8. HISTORY OF SECOND & THIRD TRIMESTER History of fetal movements Symptoms of anemia, Miscarriage ,Ectopic pregnancy,Vaginal discharge,UTI,hyper emesis gravidarum Symptoms of aph,pih.diabetes,preterm labor Ask for vaccination
  • 9.  Results of all antenatal blood tests-routine and specific.  Results of anomaly and other scans (details of results can be cross checked with the notes).  IF SHE IS POSTNATAL:  Labor and delivery  History of the postnatal period.
  • 10. PAST OBSTETRIC HISTORY INCLUDES:  Details of all previous pregnancies (including miscarriages and terminations).  Length of gestation.  Date and place of delivery.  Onset of labor (including details of induction of labor).
  • 11.  Mode of delivery.  Sex and birth weight.  Fetal and neonatal life.  Clear details of any complications or adverse outcomes (such as shoulder dystocia, postpartum hemorrhage, or stillbirth).
  • 12.  History often repeats itself, so previous antenatal, intrapartum, or postpartum complications should influence the management of this pregnancy.  GYNAECOLOGICAL HISTORY  Method of contraception before conception. Menstrual history  Cervical smear history.  Coital problems
  • 13.  PAST HISTORY (MEDICAL & SURGICAL) Medical conditions such as hypertension, epilepsy, or diabetes.  Details of any consultations with other physicians (neurologist or endocrinologist).  Involvement of multidisciplinary teams.  Details of any previous surgery.
  • 14.  DRUG AND ALLERGY HISTORY  Current medications  Medications taken at any time  during the pregnancy.  Any allergies and their severity  (anaphylaxis or a rash?).
  • 15.  FAMILY HISTORY  Any history of hereditary illnesses or congenital defects is important and is required to ensure adequate counseling and screening is offered.  Familial disorders such as thrombophilia's.  Previously affected pregnancies  with any chromosomal or genetic disorders.  multiple gestations  Consanguinity.
  • 16. SOCIAL HISTORY  living status  total family members  earning members  Planes for breast feeding  Domestic violence screening PERSONAL HISTORY  Smoking, other narcotics.  History of drug or alcohol abuse.  Sleep  Diet  Bowel habits..
  • 17. HISTORY OF SYSTEMIC REVIEW  CNC  CVS  RESPIRATORY SYSTEM  GIT  GENITALIA  URINARY SYSTEM  LOCOMOTORY SYSTEM
  • 19. GENERAL EXAMINATION  Body mass index (BMI) calculated [weight (kg)/height (m)2]. Pregnancy complications are increased with a BMI < 18.5 and > 25. VITALS ( B.P, PULSE, TEMP, R.R)  Blood pressure measured in the semi-recumbent position (450 tilt). Use an appropriate size cuff: too small a cuff gives a falsely high BP.
  • 20. Anemia  Jaundice  Cyanosis  Dehydration  Edema  Clubbing  Koilonychias  Thyroid gland  Breasts (exclude any lumps).  Varicose veins and skeletal abnormalities (kyphosis or scoliosis):  Normal pregnancy is associated with an increase in lumbar lordosis which can lead to lower backache.
  • 22.  Auscultation of the heart and lungs:  Flow murmurs are common in pregnancy and are not significant.  Cardiac murmurs may be detected for the firs time in pregnancy.
  • 23. ABDOMINAL EXAMINATION  -INSPECTION.  Note the apparent size of the abdominal distension.  Note any asymmetry.  Fetal movements.
  • 24.  Cutaneous signs of pregnancy:  Linea nigra (dark pigmented line stretching from the xiphi sternum through the umbilicus to the suprapubic area).  Striae gravidarum (recent stretch marks are purplish in color).  Striae albicans (old stretch marks are silvery-white).  Flattening/eversion of umbilicus (due to intra-abdominal pressure).
  • 25.  Superficial veins (alternate paths of venous drainage due to pressure on the inferior vena cava by a gravid uterus).  Surgical scars (a low pfannenstiel incision may be obscured by pubic hair, and laparoscopy scars hidden within the umbilicus).
  • 26.  ABDOMINAL EXAMINATION-  PALPATION.  Symphysis-fundal height (SFH):  Palpated < 20 weeks.  Measured in cm > 20 weeks.  Estimation of number of fetuses:  ? Multiple fetal poles.
  • 32.  NORMAL UTERINE SIZE  The uterus normally becomes palpable at 12 weeks gestation.  It reaches the level of the umbilicus at 20 weeks gestation.  It is at the xiphi sternum at 36 weeks gestation.
  • 33.  SYMPHYSIS-FUNDAL HEIGHT  The SFH detects approximately 40-60% of small- for-gestational age fetuses but its predictive value in detecting large-for-dates fetuses is considerably less.  The uterine size is objectively measured with a tape measure from the highest point of the fundus to the upper margin of the symphysis pubis.
  • 34.  Appropriate growth is usually estimated to be the number of weeks gestation in centimeters (at 30 weeks the SFH should be 30 cm + 2 cm):  + 2 cm from 20 until 36 weeks gestation.  + 3 cm between 36 and 40 weeks.  + 4 cm at 40 weeks.
  • 35.  FETAL LIE (relationship of longitudinal axis of fetus to that of the uterus):  Longitudinal-fetal head or breech palpable over pelvic inlet.  Oblique-the head or breech is palpable in the iliac fossa  Transverse-fetal poles felt in flanks
  • 36.  PRESENTATION (part of the fetus overlying the pelvic brim):  Cephalic  Breech  Other (shoulder, compound)  AMNIOTIC FLUID VOLUME:  Tense abdomen with fetal parts not easily palpated.  Compact abdomen with fetal parts easily palpable.
  • 38.  AUSCULTATION OF THE FETAL HEART  The fetal heart is best heard at the anterior shoulder of the fetus using:  A doppler ultrasound device (Sonicaid) from about 12 weeks gestation.  A fetal stethoscope (Pinard) from about 24 weeks gestation.  In a breech presentation it is often heard at, or above, the level of the maternal umbilicus.  The rate and the rhythm of the fetal heart should be determined over 1 minute.
  • 41. Listening with a doppler
  • 42. ENGAGEMENT( maximum diameter pass through pelvic inlet)  Conventionally, engagement or the passage of the maximal diameter of the presenting part beyond the pelvic inlet, is estimated using the palm width of the five fingers of the hand. If five fingers are needed to cover the head above the pelvic brim, it is five-fifths palpable, and if no head is palpable, it is zero-fifths palpable.
  • 43.  Normally, the fetus engages in an attitude of flexion in the transverse diameter of the pelvic inlet, unless the pelvis is very roomy where it may engage in any diameter.  In nulliparous women, engagement usually occurs by 37 weeks but in multiparous women it may not occur until the onset of labour.  Rare causes of non-engagement should always be considered and investigated with an ultrasound scan (USS) (including placenta praevia and fetal abnormality)
  • 44.  In women of Afro-Caribbean origin, engagement may only occur at the onset or during the course of labour, even in nulliparous women.  Paulik’s grip  This is a one-handed technique that uses a cupped right hand to grasp and assess the lower pole of the uterus (usually the fetal head).  This can be very uncomfortable and is not necessary if the head can be palpated using two hands.
  • 45.  ENGAGEMENT  A head that is only two-fifths palpable is usually considered to be engaged (and therefore fixed in the pelvis).  Put simply: an easily palpable head is not engaged, whereas a head more difficult to palpate is more likely to be deeply engaged. Care must be taken, as a breech presentation can some times be mistaken for a deeply engaged head.
  • 46.  VAGINAL EXAMINATION  A vaginal examination (speculum or digital examination) is not part of a routine obstetric examination but may be indicated to diagnose rupture of membranes or onset of labour.