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1. History Taking and Physical Examination in OBGY Samuel Bezabih Yekatit 2008 DB

2. Identification Name (use initials when reporting for wider audience) Age * Occupation, Marital Status** Religion Address * ad olescents (< 18 ) and the elderly gravida (> 35) are at particular risk for adverse pregnancy outcome ** Information on marital status and occupation help assess the socioeconomic status of the pregnant woman. Low socioeconomic status is associated with several poor pregnanacy outcomes Eg preterm labor, PROM, low birth weight, anemia, Pre- eclampasia , Eclampsia 7/26/2021 SAMUEL BEZABIH 2

3. Chief Complaint Most pregnant women come for routine ANC May have minor routine complaints eg abdominal discomfort, morning sickness, back pain, leg pain, urinary frequency and urgency, Some complaints may mark a serious problem and warrant Eg - vaginal bleeding, ↓fetal movement, headache, headache, visual disturbance leakage of liquor, 7/26/2021 SAMUEL BEZABIH 3

4. History of Present Pregnancy (HPP ) HPP is the most important part of obstetric history and is composed of 1.Summary of reproductive performance Gravidity - refers to all previous pregnancies i.e. term, preterm, live birth, stillbirth, abortion, ectopic pregnancy, molar pregnancy Primigravidity (1 st pregnancy) is associated with increased risk of PIH, labor abnormalities, CPD and obstructed labor Parity - all previous pregnancies that have reached fetal viablity and delivered dead or alive ( i.e. at or beyond 28 weeks of gestational age for Ethiopia and UK , 28 weeks according to other western countries) 7/26/2021 SAMUEL BEZABIH 4

5. HPP Parity - all previous pregnancies that have reached fetal viablity and delivered dead or alive ( i.e. at or beyond 28 weeks of gestational age for Ethiopia and UK , 28 weeks according to other western countries) Primipara - 01 previous delivery Multipara - > 02 previous deliveries Grand multipara - > 5 previous deliveries 7/26/2021 SAMUEL BEZABIH 5

6. HPP 2. Last normal menstrual Period (LNMP), Expected Date of Delivery (EDD) and Gestational age (GA) LNMP - 1 st day of last menses For LNMP to be reliable, It should be regular ( cycle length vary among idividuals ranging b/n 21 to 35 days) It Should be similar to previous cycles in volume and duration of flow If the woman was on OCPs it should be discontinued for at least 03 months ahead of LMP Lactating women should have 03 regular cycles before LMP 7/26/2021 SAMUEL BEZABIH 6

7. HPP Expected Date Of Delivery (EDD)- 280 days after LMP EDD calculation Naegel’s Rule Subtract 03 months from LNMP and add 07days Eg If LNMP is February 12 then EDD will be on November 19 Calculation according to the Ethiopian calendar ( 12 months of 30 days and pagume 5days/ 6 days with each leap year) LMP+ 9mths + 10days- if EDD doesn’t cross a year LMP+ 9mths + 5 days- if EDD crosses a year and pagume is 05 days LMP + 09 mths + 04 days- if EDD crosses a year and pagume is 6 days 7/26/2021 SAMUEL BEZABIH 7

8. HPP Gestational age GA is calculated in completed weeks Preterm pregnanacy - GA below 37completed wks Early Term pregnancy: 37 – 38 6/7 Week Full Term Pregnancy: 39- 41 6/7 Post-term pregnancy: > 42 weeks GA calculation is based on the assumption a 28 day regular cycle length- ovulation on the 14 th day 7/26/2021 SAMUEL BEZABIH 8

9. HPP In addition to LMP other methods are used to estimate GA Early US  before 20 weeks Ultrasonography may be considered to confirm menstrual dates if there is a GA agreement within 1 week by CRL obtained in the 1 st trimester or within 10 days by an average of multiple fetal biometric measurements ( eg,CRL , BPD, HC, AC,FL) obtained in the 2 nd (up to 20 weeks GA) . ACOG-2008 Quakening date – around the 17 th week for multipara ( experience from previous pregnancies) Around the 19 th week for primipara Fundal height at umbilicus~20 weeks 7/26/2021 SAMUEL BEZABIH 9

10. HPP ANC if no ANC or delayed start – reason Details of ANC Prepregnancy weight /BMI and weight at booking and on subsequent visits Blood pressure recordings Lab investigation results Blood group, Rh , hemoglobin level UA for bacteruria , infection and hCG RVI, RPR/ VDRL test HBsAg 7/26/2021 SAMUEL BEZABIH 10

11. HPP Health education about nutrition, sanitation, labor, breast feeding and contraception Iron supplementation, malaria prophylaxis, TT immunization, Any drug use- prescription, over-the-counter or herbal medications Significant symptoms of illness early in pregnancy like excessive nausea and vomiting, Vaginal bleeding 7/26/2021 SAMUEL BEZABIH 11

12. HPP Detailed discussion of the presenting complaint Always ask about the common danger signs of pregnancy Head ache (severe, persistent, not responsive for analgesia) Visual disturbance Epigastric / RUQ pain Vaginal bleeding Leakage of liquor per vagina Fetal movement status 7/26/2021 SAMUEL BEZABIH 12

13. HPP Positive and negative statements directed at possible DDx to the presenting complaint NB: Relevant informations should be switched from other sections ( past ob Hx , Medical and surgical hx , family hx etc. ) to the HPP. 7/26/2021 SAMUEL BEZABIH 13

14. Nutritional Hx Detailed enquiry whether the woman takes adequate amount of carbohydrates, fat, proteins , minerals and vitamins Look for any food restrictions for cultural reasons or taboos 7/26/2021 SAMUEL BEZABIH 14

15. Past obstetric History Detailed chronological documentation of all previous pregnancies i.e. year, gestation length, labor duration, presentation, fetal outcome ( weight, alive/ dead), mode of delivery Any antepartum , intrapartum or postpartum complications Eg APH, PPH, IUGR, PROM, Malpresentations , macrosomia , congenital anomalies, molar pregnancy, GDM, Hypertensive disorder NB- most of these complications have a significant recurrence risk 7/26/2021 SAMUEL BEZABIH 15

16. Gynecologic History Menstrual history Age at menarchae Regular, irregular , intermenstrual bleeding/ spotting Amount and duration of flow Discomfort during menses ( Dysmenorrhoea ) Premenstrual symptoms (cyclic affective and somatic symptoms in the luteal phase) Contraception use history 7/26/2021 SAMUEL BEZABIH 16

17. Past medical and surgical History Episodes of acute/ chronic illnesses, duration, treatment outcome , followup , current status Such chronic illnesses as DM, HTN, Thyroid disease ( thyrotoxicosis and hypothyroidism), cardiac and renal disease that affect pregnancy outcome need to be integrated with the HPP Hx of blood transfusion- possibility of minor blood group incompatibility and Rh isoimmunization STI Hx and treatment Hx of pelvic surgery Eg – myomectomy , hysterectomy, metroplasty - cause uterine scarring and may dehisce during pregnancy and labor Hx of surgery involving other organ systems 7/26/2021 SAMUEL BEZABIH 17

18. Personal and Family History Place of birth and bringing up Education, occupation, income Habit of smoking, alcohol , caffein or illicit drug use siblings- Number of sisters and brothers Alive Dead – cause of death Parents Age Health status If deceased- age when dying and cause of death Family history of chronic illnesses ( eg DM, Hypertension Epilepsy etc.) or any hereditary disease Family history of twining 7/26/2021 SAMUEL BEZABIH 18

19. Review of System (Functional enquiry) Detailed orderly search for any symptoms pertaining to each organ system 7/26/2021 SAMUEL BEZABIH 19

20. Physical Examination General Appearance Comfortable, in CRD, acutely/ chronically sick looking, body habitus ( obese, malnourished), stature ( extremely short?), skeletal deformities Facial features- chloasma of pregnancy, puffy face NB . some of the above descriptions can be placed at the respective systemic examinations 7/26/2021 SAMUEL BEZABIH 20

21. PE-Vital Signs BP Measured in the left lateral ( usually for inpatients) or sitting positions The right arm should be used consistently, in a roughly horizontal position at heart level. For DBP, both phases ( IV-muffling and V-disappearance of sound) should be recorded. PR, RR, T are taken the same way as in any medical patient- NB- physiologic changes caused by pregnancy should be taken into account while interprating results 7/26/2021 SAMUEL BEZABIH 21

22. PE HEENT look for chloasma , Cnjunctival pallor, icteric sclera Hair distribution Buccal mucosa- wet or dry ? Gingival hypertrophy, gingivitis? Oral thrush? LGS- Breast (engorgement, areolar pigmentation , montgomery tubercles….), thyroid and all accessible LN areas are examined Chest CVS PMI displacement lateral to the MCL, S3 and systolic murmurs < Grade III are usual non pathologic findings Look for varicose veins in the lower extremities and vulva 7/26/2021 SAMUEL BEZABIH 22

23. Physical Examination Abdomen Exposure The patient should be supine with a comfortable pillow, the arms lie by her sides The abdomen should be exposed from just below breasts to the symphisis pubis just below the pubic hairline ( not to miss pfannenstel scar) NB- the woman is often asked to expose the abdomen by herself 7/26/2021 SAMUEL BEZABIH 23

24. PE-Abdomen Inspection Grossly distended abdomen? Protuberence - central or localized tone area Movemnt of abdomen with respiration Flank fullness Uterine dextrorotation ( abdomen tilted more to the right) Black line ( linea Nigra ) more prominent in the midline b/n umbilicus and and symphysis pubis. Striae gravidarum - stretch marks due to disruption of collagen fibers of dermis ( breasts and thighs can also be involved) NEW- purplish, few Old ( straie albicantes )- whitish, multiple Umbilicus-flat, inverted, everted ? Scar- location, size and thickness distended veins and ascitis  portal hypertension Abdominal wall edema with peau -d-orange appearance  part of ana sarca 7/26/2021 SAMUEL BEZABIH 24

25. PE-Abdomen Superficial palpation In each quadrant – areas of rigidity, tenderness, abd wall masses Location of appendix base in advanced pregnancies at higher level than McBurneys point ( pushed up by the gravid uterus) Diffuse tenderness and rigidity / generalized peritonitis chorioamnionitis abruptio placentae , ruptured appendicitis, perforated PUD 7/26/2021 SAMUEL BEZABIH 25

26. PE-Abdomen Deep Palpation Detection of hepatomegally and splenomegally 7/26/2021 SAMUEL BEZABIH 26

27. PE- Abdomen Obstetric Palpations (Leopold’s maneuvers) Four sequential maneuvers Performed on the gravid uterus i.e. the fundal , lateral, pelvic palpations and the Pawlik’s grip. NB before 28 weeks of gestation fundal height determination is the only palpation possible as the fetus is too small to determine lie or presentation Fetal heart beat can be ascultated from 20 th week of gestation 7/26/2021 SAMUEL BEZABIH 27

28. PE- Abdomen 1- Fundal Palpation Objectives :Determination of Height of fundus ( Gestational Age) and what occupies the fundus Abdominal assymetry need to be corrected first ( if dextro or levorotation is there) and the bladder should be empty before starting examination A.Fundal Height determination- two methods ie Tape measurement of symphysis fundal height (SFH) in cms or Finger method 7/26/2021 SAMUEL BEZABIH 28

29. PE- Abdomen I.SFH tape measurement (tape measurement) In the midline along the linea nigra traversing the umbilicus The fundal height in cm accurately matches to the gestational age b/n 18- 34 weeks More reliable method than the finger method 7/26/2021 SAMUEL BEZABIH 29

30. PE-Abdomen II. Finger method Fundus just palpable at Spubis  12 weeks Midway b/ Spubis and umbilicus 16 weeks At Umbilicus 20 weeks Generally 1 finger above umbilicus represents 2 weeks At Xyphisternum  38 weeks/term 36 week by finger is comparale to 40 weeks of GA due to decrease in fundal height after engagement 7/26/2021 SAMUEL BEZABIH 30

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33. PE- Abdomen NB a fundal height to GA discripancy of upto 02 weeks is acceptable. A positive or negative discripancy of more than 02 week mandates further investigation to identify the possible underlying cause. The commonest cause of both + ve and – ve discrepancies (large for date and small for date respectively) is wrong dating Other possible causes + ve Discrepancy  multiple gestation, polyhydramnios , macrosomia , GTD, leiomyoma , ovarian tumor, - ve discripancy  IUGR, oligohydramnios , PROM, transverse lie, IUFD, missed abortion 7/26/2021 SAMUEL BEZABIH 33

34. PE- Abdomen B- determining what occupies the fundus Palpate and ballot the fundal area with both hands Head  hard, round, ballotable structure Breech soft,bulky , irregular, non ballotable 7/26/2021 SAMUEL BEZABIH 34

35. PE- Abdomen 2- Lateral Palpation Objective- determination of fetal lie and identification of the side of the back Lie  orientation of the fetal longtudinal axis with respevt to that of the mother ie longtudinal , Transverse or Oblique Lateral palpation is performed alternatively on both sidesusing one hand to stabilize the uterus. The back feels like hard, straight/ flat structure while the extremities on the opposite side feel like multiple nodular parts Fetal heart beat can be easily auscultated on the side of the back 7/26/2021 SAMUEL BEZABIH 35

36. PE- Abdomen 3- pelvic palpation Objectives- identification of fetal presentation and attitude ( if cephalic)  Cephalic prominence The examiner faces the patient's feet and places a hand on either side of the uterus, just above the pelvic inlet. When pressure is exerted in the direction of the inlet, one hand can descend farther than the other. The part of the fetus that prevents the deep descent of one hand is called the cephalic prominence. Presentation can be Cephalic , breech or shoulder Attitude- flexed-the cephalic prominence is on the same side as the small parts. Extended,-the cephalic prominence is on the same side as the back. military Desscent - from 5/5 ( floating) to 0/5 Engagement- minimum of 2/5 descent 7/26/2021 SAMUEL BEZABIH 36

37. 7/26/2021 SAMUEL BEZABIH 37 Desscent - b/n 5/5 ( floating) and 0/5 Engagement- minimum of 2/5 descent

38. PE- Abdomen 4- Pawlik’s Grip Objective- identification what fetal part lies in the lower segment ( presentation) and its mobility A single examining hand is placed just above the symphysis . The fetal part that overrides the symphysis is grasped between the thumb and third finger. If the head is unengaged, it is readily recognized as a round, hard object that frequently can be displaced upward. After engagement, the back of the head or a shoulder is felt as a relatively fixed, knoblike part. In breech presentations, the irregular, nodular breech is felt in direct continuity with the fetal back 7/26/2021 SAMUEL BEZABIH 38

39. PE- Abdomen Abdominal Findings in multiple gestation multiple fetal poles 2 fetal heart beats at 2 sites , a difference of > 10 bpm , FHR auscultated simultaneously by two examiners ie for twin pregnancy 7/26/2021 SAMUEL BEZABIH 39

40. PE- GUS Inspection Look for Normal development of the external genitals(The Vulva)- Mons pubis ( Veneris ), Labia majora and minora , urethra, Skene ( paraurethral ) Glands,Vestibule , Bartholins (Great vestibular) glands, The Hymen, Fossa Navicularis Hair distribution- Normal findings-I Inverted triangle pattern with a base over the mons Pubis. The labia majora are also covered Extension of hair to the abdomen is abnormal for females ( Hirsuitism ) Look for skin lesions( warts), discharge (vaginal or urethral),Scars, Swelling and Prolapse ( descent with or without exertion) 7/26/2021 SAMUEL BEZABIH 40

41. PE-GUS Speculum Examination Speculum Types Bivalved ( Pederson’s, Cusco’s, Grave’s Univalved (Sims , Auvard )  7/26/2021 SAMUEL BEZABIH 41

42. 7/26/2021 SAMUEL BEZABIH 42 Grave’s Speculum Sims Speculum Cusco’s Speculum

43. PE- GUS Speculum Examination Position- dorso lithilomy Warm and lubricate the speculum ( clean speculum for most gynecologic examinations) Insert the speculum with the transverse diameter of the blades anteroposteriorly and guide the blades through the introitus in a downward motion with the tips pointing toward the rectum Then turn the blades so that their transverse axis is along with the transverse axis of the vagina Open the blades after full length insertion of the speculum- the cervix should be visible b/n the blades 7/26/2021 SAMUEL BEZABIH 43

44. PE- GUS Speculum Examination Inspect the vagina and Cervix Vagina Discharge , inflammation ( erythema ), Mass ( eg Gatner’s cyst) Cervix- External OS ( shape, discharge from), SCJ, Nabothian cysts, Lesions (polyp, ulceration, nodularity , inflammation), bleeding NB- Cervical Ca screening ( Cytology via Pap smear or visual methods via VIA / VILI) can be performed if indicated and possible. Discharge specimen is taken for wet mount and KOH test 7/26/2021 SAMUEL BEZABIH 44

45. PE- GUS, Pelvic Examination Bimanual Examination - palpation of the uterus and the adnexa . Gloved and lubricated index and middle fingers of the dominant hand are inserted deeply into the vagina so that they rest beneath the cervix in the posterior fornix. The opposite hand is placed on the patient's abdomen above the pubic symphysis . The flat of the fingers are used for palpation. The vaginal hand then elevates the uterus by pressing up on the cervix and delivering the uterus to the abdominal hand so that the uterus may be placed between the two hands, Both adnexa are also examined in the same way through the lateral fornices Bimanual Examination helps identify Position ( often anteverted and anteflexed ) , size, shape, consistency, and mobility of the uterus Whether the adnexa are papable or not The presence or absence of uterine or adnexal masses 7/26/2021 SAMUEL BEZABIH 45

46. Bimanual examination of the Uterus 7/26/2021 SAMUEL BEZABIH 46 Bimanual examination of the Adnexa

47. PE- GUS, Pelvic Examination Notice the following while performing Bimanual Exam- ሀ Cervix • Excitation / motion tenderness – Move the cervix gently to each side with one finger. Pain points at a tuboovarian mass (ectopic, abscess) or inflammation. • Consistency A normal cervix is firm (tip of nose) but not hard, in pregnancy it is softer with a firmer core. In cervical cancer the cervix can be hard, broad, with an irregular surface. 7/26/2021 SAMUEL BEZABIH 47

48. PE- GUS, Pelvic Examination ለ. Uterus Axis/ position Anteverted - anteflexed (most common), retroverted or straight Size Enlarged size  pregnancy, leiomyoma , sarcoma etc A large tubo -ovarian mass can be mistaken for an enlarged uterus. Uterne mass moves with the cervix but not adnexal masses Consistency Normally firm , A gravid uterus is soft, uterine fibroids are hard or at least firm; advanced uterine or cervical malignancy is often hard but endometrium carcinoma can present as a soft enlarged uterus as well. 7/26/2021 SAMUEL BEZABIH 48

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50. PE- GUS- Pelvic Examiation ሐ - Adnexa Mass Ovaries normally impalpable unless the woman is too slim Normal tubes are impalpable too even in slim women Adnexal masses can arise from ovarian cysts, solid benign tumors, ovarian malignancy, hydrosalpinx , ectopic pregnancy, tubo -ovarian abscess or rarely tubal malignancy. Tenderness pain in the adnexa can point to adnexitis or pelvic inflammatory disease (PID) (most often bilateral), ectopic pregnancy (unilateral) or ovarian cysts or hydrosalpinx ( uni - or bilateral). Mobility – benign ovarian tumors such as a dermoid or ovarian cysts can be freely moved TOA in frozen pelvis,advanced malignant ovarian tumors - immobile 7/26/2021 SAMUEL BEZABIH 50

51. Rectovaginal examination The rectovaginal palpation is not necessary in every patient Often done in cases when there is suspicion of malignancy, endometriosis or any process located in the pouch of Douglas. It helps to assess the structures between the vagina and rectum. Eg Rectovaginal septum,Uterosacral ligaments Mass, thickenig , tenderness of these structures may be caused by malignancy, inflammation or endometriosis Retroverted uterus can also be examined ( size, shape, consistency) through the RV route 7/26/2021 SAMUEL BEZABIH 51

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53. Rectal Examination In virgins, a vaginal examination is avoided. Instead a well-lubricated finger inserted into the rectum can be used for a bimanual assessment of the pelvic structures. Today, practically all gynaecologists prefer ultrasonic scanning to rectal examination, which, apart from being unpleasant, is not that accurate. A rectal examination is a very useful additional examination whenever there is any palpable pathology in the pouch of Douglas. It often allows the ovaries to be more easily identified. In parametritis and endometriosis, the uterosacral ligaments are often thickened, nodular and tender. It confirms the swelling to be anterior to the rectum, and if the rectum is adherent to that swelling. This is important in case of carcinoma of the cervix to determine the extent of its posterior spread. A rectal examination is mandatory in women having rectal symptoms. This should begin by inspecting the anus in a good light, when lesions like fissures, fistula-in- ano , polyps and piles may come to light. Introduction of a well-lubricated proctoscope to inspect the rectum and anal canal helps to complete the examination. Ultrasound today has reduced the importance of rectal examination except in cancer cervix and pelvic endometriosis . 7/26/2021 SAMUEL BEZABIH 53