HIstory taking and Examinations for obtetric

for medical students

1. OBSTETRIC HISTORY TAKING AND EXAMINATION CHAPTER 5

2. Greeting the patient. ❑ Introduce yourself: give your name and your job (e.g. Dr. Farah Imad , at ward doctor) ❑ Identity: confirm you’re speaking to the correct patient (name and date of birth) ❑ Permission: confirm the reason for seeing the patient (“I’m going to ask you some questions about your pregnancy, is that OK?”) ❑ Positioning: patient sitting in chair approximately a metre away from you. Ensure you are sitting at the same level as them and ideally not behind a desk.

3. Demographic Details ❑ Triple Name : ❑ Age : Women have the best chance of getting pregnant in their 20s (21-29 years). This is the time have the: ❖ Highest number of good quality of eggs available. ❖ Less pregnancy risks.

4. Advanced maternal age: is usually defined as age 35 or more. It's effects in pregnancy : ➢ risk of early pregnancy loss. ➢ risk of chromosomal abnormalities like Down's syndrome. ➢ incidence of stillbirths. ➢ pre-existing medical diseases like diabetes, hypertension. ➢ incidence of twins. ➢ incidence of operative delivery.

5. Teenage pregnancy : is a pregnancy in a woman 19 years of age or younger. It's effects in pregnancy: ❖ Higher risk for anemia. ❖ Pregnancy-induced hypertension ❖ Lower genital tract infections. ❖ low birth weight babies. ❖ Premature birth (PTL). ❖ Surgical, increase incidence of caesarean section. ❖ Assistant operative delivery.

6. ❑ Address. ❑ Religion. ❑ Marital status: ❑ The husband's personal history: ✓ Should be taken as it reflects some important social and health issues. ✓ Ask about: Name of the husband, age, consanguinity, occupation , residence , blood group and Rh. and ethnic background.

7. ❑ Gravida and Parity : Gravida : Describes the number of pregnancies. Nulligravida : Describes a woman who is not now and never has been pregnant. Parity : Describes a woman who has delivered a fetus. Nulliparous : Describes a woman who has never delivered a fetus. Primipara : Describes a woman who has delivered only once. Multipara : Describes a woman who delivered more than once. Abortion : Expulsion of an embryo or fetus before 24 week of gestational age

8. ❑ Date of admission: ❑ Time of admission to the hospital: ❑ Duration of the current pregnancy (GA) : ✓ The first complaint in any obstetric case should be cessation of menstruation since the last menstrual period (LMP). If the LMP was uncertain, we can say “cessation of menstruation … Months ago”. ✓ Gestational age can be calculated in weeks using different methods:

9. A. Menstruation delivery interval: ( Naegele’sformula ): Used when the first day of the last menstrual period (LMP) is certainly known. The expected date of delivery (assuming that human pregnancy is 40 weeks) is calculated by adding seven to the first day of the last menstrual period and counting back three months the expected date of confinement is reached. The characters of the LMP are should be normal in characters, preceded by 3 consecutive normal cycles, and not preceded by hormonal contraception's

10. B. Expected dates can be calculated by ultrasound < 20 weeks by: ➢ The crown–rump length is used between 10 weeks 0 days and 13 weeks 6 days. ➢ Head circumference from 14 to 20 weeks. ✓ It is important to define the EDD at the booking visit, as accurate dating is important in later pregnancy for assessing fetal growth. In addition, accurate dating reduces the risk of premature elective deliveries, such as induction of labour for post-mature pregnancies and elective caesarean sections

11. C. Other methods of calculating GA: ❖ Ovulation-delivery interval: EDD= ovulation date – 7days + 9 months ❖ Single coitus- delivery interval: EDD= date of coitus- 7 days + 9 months ❖ Date of embryo transfer: EDD= date of ET – 5 days + 9 months ❖ Date of quickening : EDD = date of quickening + 20 w in primipara , or + 18 w in multipara

12. Chief Complaint (CC) : First ask open question: what brought you in? "Then ask the below questions if it wasn't mentioned in patient's story“ ✓ Time of admission: When did you come to the hospital? Which day & what time? ✓ Route of admission: Were you admitted through ER, Electively' through OPC, or referral? ✓ The duration : ( since when? for how long?) of each symptom alone. ✓ Complaining of: What are you complaining of? What did you feel, for each symptom alone (record the answer in the patient's own words)

13. History Of Present Illness (HPI) : " Ask close question to narrow the list of possible diagnosis " ✓ When did it start? What was the first thing noticed? ✓ Ever had it before? ✓ To evaluate abdominal/pelvic pain, use the SOCRATES Questions: ❑ Site: ❑ Onset: Rapid? Gradual? Continuous? Intermittent? ❑ Character: Stabbing? Burning? Cramp? Amount? color?

14. ❑ Radiation (if the symptom is pain or discomfort) ❑ Alleviating factors: Movement? Eating? Coughing? ❑ Timing: Noticed when? Better or worse in night or day? ❑ Exacerbating factors: Movement? Eating? Coughing? ❑ Severity: Interfere with normal activity

15. ✓ To evaluate reduced or absence fetal movement: Can be associated with fetal distress and absent fetal movements may indicate early fetal demise. ✓ To evaluate vaginal bleeding: Causes include cervical bleeding (e.g. ectropium , cervical cancer), placenta praevia and placental abruption (typically associated with abdominal pain). ✓ To evaluate abdominal pain: Causes may include urinary tract infection, constipation, pelvic girdle pain and placental abruption. ✓ To evaluate vaginal discharge or loss of fluid: Abnormal vaginal discharge may be caused by sexually transmitted infections such as gonorrhoea and the loss of fluid from the vagina indicates rupture of the amniotic membranes.

16. ✓ To evaluate headache, visual disturbance, epigastric pain and oedema : These are typical clinical features of pre-eclampsia. Mild oedema is common and normal in the later stages of pregnancy. ✓ To evaluate pruritis : Associated with obstetric cholestasis (typically affecting the palms and soles of the feet) ✓ To evaluate unilateral leg swelling: Consider and rule out deep vein thrombosis. ✓ To evaluate chest pain and shortness of breath: Pregnant women are at increased risk of developing pulmonary emboli. ✓ To evaluate systemic symptoms: Fatigue (e.g. anaemia ), fever ( chorioamnionitis ) and weight loss (e.g. hyperemesis gravidarum ).

17. ✓ Associated symptoms related to the same system as the CC. ✓ Constitutional symptoms: fever, cough, night sweats, loss of appetite, weight loss In HPI you should come up with the system involved, pathology, and the severity

18. History Of Current Pregnancy : Ask about: • The gestational age of the pregnancy and expected day of delivery. • Using of folate supplementation prior to conception and currently pregnancy. • Singleton or multiple gestation. • Regular/ irregular ANC. • History of teratogenic drug taking .

19. • Prenatal diagnostic results (ex: previous ultrasound findings) • History of maternal infectious diseases and immunization.(ex: congenital TORCH infections). • History of vaginal bleeding or fluid leakage during the current pregnancy. • Presence and frequency of fetal movement and uterine contractions . • Any associated GIT& Urinary symptoms

20. Questions in every trimester of pregnancy First trimester ➢ Morning sickness. ➢ Drugs , radiation, febrile illnesses. ➢ Pain, bleeding, discharge. ❖ Second trimester ➢ Pain, bleeding, discharge. ➢ Edema, UTI. ➢ Quickening.

21. ❖ Third trimester ➢ Pain, bleeding, discharge. ➢ Fetal movement. ➢ Febrile illnesses. ➢ Symptoms of labour .

22. Complications of the Current Pregnancy a) Pregnancy induced : Pre-eclampsia, ante- partum hemorrhage, PROM, fetal malformation, fetal death, Rh- iso - immunization,… etc b) b) Pregnancy aggrevated : RHD, SLE, HTN,GDM Previous Diseases or Surgical procedures that can affect the management of the Current Pregnancy : e.g., Maternal cardiac disease, diabetes mellitus, uterine anomalies or fibroids, previous uterine scar, … etc

23. Menstrual History : I. Date of the LMP II. Age of menarche III. Rhythm and length of cycle. IV. Duration, regularity, flow and associated symptoms (e.g., dysmenorrhea , mittelschmerz ) V. Inter-menstrual period.

24. Past Obstetric History : ❖ Duration of Marriage: This is important when dealing with pregnancy and helps in noticing a woman's fertility. ✓ Past obstetric history is one of the most important areas for establishing risk in the current pregnancy. ✓ Ask about the number of children the patient is given birth , miscarriages, stillbirths, ectopic pregnancy or termination.

25. For each prior pregnancy, the following information should be obtained: 1. Estimated gestational age at the time of delivery. 2. Weight of infant. 3. Anesthesia. 4. Mode of delivery: a. SVD: spontaneous vaginal delivery . b. VAVD: vacuum-assisted vaginal delivery . c. FAVD: forceps - assisted vaginal delivery .

26. d. Cesarean section, including indication and type of uterine incision : ❑ Low transverse: incision in the lower uterine segment in transverse fashion . ❑ Classical: vertical incision through the muscular portion of the uterus : ❑ Low transverse: incision in the lower uterine segment in transverse fashion . ❑ Classical: vertical incision through the muscular portion of the uterus

27. The features that are likely to have impact future pregnancies include: ❑ Recurrent miscarriage (increased risk of miscarriage, fetal growth restriction [FGR]). ❑ Preterm delivery (increased risk of preterm delivery). ❑ Early-onset pre-eclampsia (increased risk of pre-eclampsia/FGR). ❑ Abruption (increased risk of recurrence). ❑ Congenital abnormality (recurrence risk depends on type of abnormality). ❑ Macrosomic baby (may be related to gestational diabetes). ❑ Unexplained stillbirth

28. In every pregnancy the following should be noted ❑ The age of the mother when she becomes pregnant. ❑ Duration of pregnancy. ❑ Antenatal and postpartum complications. ❑ Details of labor induction and the duration of labor. ❑ Delivery method. ❑ Fetal birth weight and gender of the baby

29. Possible postpartum complications that may include : ❑ Postpartum hemorrhage. ❑ Urinary and genital tract infections. ❑ Deep vein thrombosis (DVT). ❑ Perineal complications such as perineal wound collapse. ❑ Psychological complications (such as postpartum depression)

30. GynaecologicalHistory : Periods: menarche, regularity. ➢ Contraceptive history. ➢ Previous infections and their treatment. ➢ When was the last cervical smear? Was it normal? ➢ Previous gynaecological surgery. ➢ Previous ectopic pregnancy. ➢ Recurrent miscarriage. ➢ Previous history of sub-fertility and IVF

31. Past Medical and Surgical History : ❑ Diabetes mellitus. ❑ Hypertension. ❑ Bronchial asthma. ❑ Renal disease. ❑ Epilepsy. ❑ Venousthromboembolic disease.

32. ❑ Human immunodeficiency virus infection. ❑ Connective tissue diseases , SLE ❑ Any previous surgery. ❑ Psychiatric history: ❑ Postpartum blues or depression. ❑ Depression unrelated to pregnancy. ❑ Domestic violence

33. Family and Social History: Diabetes, hypertension, genetic problems, psychiatric problems, etc. ➢ Thromboembolic disorders and pre-eclampsia . ➢ Congenital anomalies. ➢ Haemoglobinopathies . ➢ Tuberculosis (TB). ➢ Multiple pregnancy.(twin, triple )

34. ➢ Malignancies (e.g. Breast). ➢ Allergies , smoking/alcohol/drugs ➢ Occupation, partner’s occupation. ➢ Who is available to help at home? ➢ Are there any housing problems?

35. Drug History: ➢ Folate supplementation. ➢ Any regular medications. ➢ Allergies Systematic Review: Query about other systems. ➢ Central Nervous System.

36. ➢ Respiratory System. ➢ Cardio vascular System. ➢ Gastrointestinal System. ➢ Musculoskeletal System

37. Warning Features During Pregnancy ➢ Any vaginal bleeding during pregnancy. ➢ Any gush of fluid per vaginum . ➢ Abdominal cramping. ➢ It persistent headache especially in 2 nd and 3 rd trimester. ➢ Any blurring of vision. ➢ Oedema of hands or face . ➢ Persistent vomiting.(hyperemesis gravidarum ) ➢ Any decrease or absent fetal movements

38. Bad Obstetric History (BOH) ❑ The term bad obstetric history (BOH) is used loosely to signify that a woman has previously had problems with previous pregnancies. ❑ This may include miscarriage, stillbirth, or other adverse and undesirable conditions. ❑ The details about it are important to prevent similar situations and increase the chances of a successful pregnancy and a live birth

39. obstetric examination The obstetric examination is a type of abdominal examination performed in pregnancy. It is unique in the fact that the clinician is simultaneously trying to assess the health of two individuals – the mother and the fetus. In this article, we shall look at how to perform an obstetric examination in an OSCE-style setting

40. Introduction Introduce yourself to the patient Wash your hands Explain to the patient what the examination involves and why it is necessary Obtain verbal consent

41. Preparation Measure the patient’s height and weight In the UK, this is performed at the booking appointment, and is not routinely recommended at subsequent visits Patient should have an empty bladder Expose the abdomen from the xiphisternum to the pubic symphysis

42. Cover above and below where appropriate Ask the patient to lie in the supine position with the head of the bed raised to 15 degrees Prepare your equipment: measuring tape, pinnard stethoscope or doppler transducer, ultrasound gel General Inspection General wellbeing – at ease or distressed by physical pain. Hands – palpate the radial pulse. Head and neck – melasma , conjunctival pallor, jaundice, oedema . Legs and feet – calf swelling, oedema and varicose veins.

43. Abdominal Inspection In the obstetric examination, inspect the abdomen for: Distension compatible with pregnancy Fetal movement (>24 weeks) Surgical scars – previous Caesarean section, laproscopic port scars Skin changes indicative of pregnancy – linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum (‘stretch marks’), striae albicans (old, silvery-white striae )

44. Fig 1 – Skin changes in pregnancy. A) Linea nigra . B) Striae gravidarum and albicans .

45. Palpation Ask the patient to comment on any tenderness and observe her facial and verbal responses throughout. Note any guarding. Fundal Height Use the medial edge of the left hand to press down at the xiphisternum , working downwards to locate the fundus. Measure from here to the pubic symphysis in both cm and inches. Turn the measuring tape so that the numbers face the abdomen (to avoid bias in your measurements ).

46. Uterus should be palpable after 12 weeks, near the umbilicus at 20 weeks and near the xiphisternum at 36 weeks (these measurements are often slightly different if the woman is tall or short). The distance should be similar to gestational age in weeks (+/- 2 cm).

47. Lie Facing the patient’s head, place hands on either side of the top of the uterus and gently apply pressure Move the hands and palpate down the abdomen One side will feel fuller and firmer – this is the back. Fetal limbs may be palpable on the opposing side

48. Fig 2 – Assessing fetal lie and presentation

49. Presentation Palpate the lower uterus (below the umbilicus) to find the presenting part. Firm and round signifies cephalic, soft and/or non-round suggests breech. If breech presentation is suspected, the fetal head can be often be palpated in the upper uterus. Ballot head by pushing it gently from one side to the other. Liquor Volume Palpate and ballot fluid to approximate volume to determine if there is oligohydraminos /polyhydramnios When assessing the lie, only feeling fetal parts on deep palpation suggests large amounts of fluid

50. Engagement Fetal engagement refers to whether the presenting part has entered the bony pelvis Note how much of the head is palpable – if the entire head is palpable, the fetus is unengaged. Engagement is measured in 1/5s

51. Fig 3 – Assessing fetal engagement

52. Fetal Auscultation Locate the back of the fetus to listen for the fetal heart, aim to put your instrument between the fetal scapulae to aim toward the heart. Hand-held Doppler machine >16 weeks (trying before this gestation often leads to anxiety if the heart cannot be auscultated). Pinard stethoscope over the anterior shoulder >28 weeks Feel the mother’s pulse at the same time Measure fetal HR for one minute Should be 110-160bpm (>24 weeks )

53. Completing the Examination Palpate the ankles for oedema and test for hyperreflexia (pre-eclampsia) Thank the patient and allow them to dress in private Wash your hands Summarise findings

54. Perform: Blood pressure Urine dipstick