OBSTETRIC HISTORY TAKING AND EXAMINATION.pdf

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1. OBSTETRIC HISTORY TAKING AND
EXAMINATION
Moderator : Dr. Saritha Shamsunder
Presenter:- Dr. Tahmeena Khatoon
Dr. Purnima Singh

2. CHECKLIST
•Demographic data- from both partners
•Chief complaints
•History of Present Pregnancy (trimester wise)
•Menstrual history
•Marital history
•Past obstetric history
•Contraception used prior to pregnancy
•Past medical history and drug history
•Past surgical history
•Family history
•Personal history
•Physical examination- GPE, Systemic and Obstetric examination

3. DEMOGRAPHIC DATA
•From both partners
•Name
•Age
•Address
•Education
•Occupation
•Socioeconomic class

4. IMPORTANCE OF AGE
Elderly gravida(>35 yrs )
•Chromosomal anomalies
•Miscarriage
•Chronic HTN/ gestational HTN/ PE
•Diabetes
•Abnormal Labour- Malpresentation,
obstructed labour
•Abruptio placentae
•Increased chances of operative delivery
•PPH
Teenage pregnancy (<19yrs)
•Anaemia
•Abortion
•CPD
•PE/ Abruption
•Preterm delivery
•FGR/ LBW
•Psychological problems

5. ANC Visits
Recommended :
•Every 4 weekly till 28 weeks
•Every 2 weeks till 36 weeks
•Twice a week after that
WHO recommendation: ( at least 4 visits)
•1
st before 12 weeks for registration
•2
nd between 14 to 26 weeks
•3
rd between 28 to 32 weeks
•4
th at 36 to 40 weeks

6. History
Chief complaints to be noted in chronological order
Complaints should be elaborated with regard to :
▪Onset
▪Duration
▪Severity
▪Relieving and aggravating factors, if present
▪Associated symptoms

7. History of Present Pregnancy
•How long after marriage conception occurred?
•Whether conception occurred spontaneously?
•Any contraception practiced and if so, when it was stopped?
•If there is history of infertility, details regarding investigations for the
same
•Whether conception occurred after induction of ovulation or other
assisted reproductive technique

8. Trimester history
•FIRST
TRIMES
TER
•How and when pregnancy confirmed?
•H/o dating scan
•Morning sickness, hyperemesis
•Fever with rashes, drug intake
•Folic acid intake
•Exposure to irradiation and teratogenic drugs
•Bleeding PV
•SECOND
TRIMES
TER
•Quickening
•Immunization
•Anomaly scan
•Intake of iron, folic acid and calcium
•GCT
•H/O polyuria, polydipsia, polyphagia
•h/o epigastric pain,headache, blurring of vision, dec UO
•THIRD
TRIMES
TER
•Perception of fetal movements
•Growth scan
•Discharge or LPV
•Bleeding PV
•h/o epigastric pain, headache, blurring of vision, dec UO

9. Relavance of first trimester history
•Excess
vomiting
•Vesicular mole
•Multiple pregnancy
•Jaundice
•gastritis
•Bleeding
•Threatened abortion
• Missed abortion
• Vesicular mole
• Inevitable abortion
• Incomplete abortion
• Ectopic gestation
•Radiatio
n
•Upto 5
rads
permissib
le
•Fever with
rash
•Measles
•Viral infections with
teratogenic effects

10. Second and Third trimesters
•PATHOLOGICAL
OEDEMA
•Anemia
•PE
•Heart disease
•Renal disease
•hypoproteinemia
•BLEEDING PV
•Abruptio Placentae
•Placenta previa
• FETAL
MOVEMENTS
•Excessive in
multiple pregnancy
•Diminished in
oligohydramnios,
FGR
•Absent in IUD
•If pathological
edema present, H/o
blurring of vision,
decreased urine
output, epigastric
pain to be elicited to
rule out imminent
eclampsia

11. Menstrual History
•Menstrual Cycle – regularity, frequency, duration, amount of blood loss
•Last Menstrual Period- useful to calculate EDD
•Applicable when cycles occur in 28-30 days and the women should not
have taken OCPs 2 months before conception
•Only 4% will deliver on EDD
Naegele’s rule - add 9 months and add 7 days or go back 3 months and add 7 days to
LMP to arrive at EDD

12. Corrected EDD (Knane’s rule)
➢EDD can be corrected upto 14 days only
Suppose if menstrual cycle is
once in 21 days, the corrected
EDD will be 7 days less
If the cycle is once in 40 days,
for corrected EDD, add 12 days
to calculated EDD

13. Determination of GA when LMP not known
•Date of single coitus
•Date of ovulation induction with drugs like clomiphene, HCG
•Date of quickening- add 20 weeks in primigarvida and 22 weeks in
multigravida
•Per vaginal examination in first trimester
•Height of uterus in second trimester
•UPT date
•Dating scan by USG

14. Importance of GA
•Timing of investigations
▪First trimester screening for Down syndrome
▪Second trimester screening for Down syndrome
▪Screening for gestational diabetes
➢Calculating preterm or postdates
➢Timing of interventions
➢Monitoring fetal growth

15. Marital History
•Duration of marriage
•Whether consanguineous marriage or not
•Contraception and it’s type
•h/o infertility, investigations done and treatment taken should be
elicited

16. Past Obstetric History
•PREVIOUS PREGNANCY – GA at delivery, hospital or home
delivery, spontaneous or induced labour, prolonged labour, with or
without episiotomy, natural vaginal/forceps/vaccum/assisted vaginal
breech delivery, h/o PPH , BT, weight of baby, live/IUD/early neonatal
death, H/o anti-D
•ABORTION- GA, spontaneous/ induced abortion, curettage done or not,
postabortal fever, BT, preceding events, h/o recurrent abortion, h/o anti-
Din Rh-ve women

17. LACTATION – start of lactation. Sore/retracted nipple/ breast abscess, duration
of lactation
POSTPARTUM PERIOD- PPH, BT, fever, pain, lochia, UTI, DVT, resumption
of periods after delivery
PRETERM- precipitating factors, spontaneous/ induced, newborn details,
milestones
LSCS – emergency/elective, indication, place of prev lscs, H/o BT or postop
complications, details of baby, interval between previous LSCS and
subsequent pregnancy

18. Past Medical History
•Diabetes - insulin dependent or not
•Heart disease –RHD or congenital, H/o cardiac surgery/prosthetic valve/pacemaker/
cardiac drugs and anti-coagulants
•Thyroid – hypo or hyperthyroidism
•Epilepsy – duration and therapy
•Hypertension (25% risk of PE)
•SLE/APLA
•Bronchial asthma
•Tuberculosis
•H/o allergy
•Blood transfusion

19. Past surgical History
•Cholecystectomy
•Appendicectomy can cause dense adhesion in abdomen
•Laparotomy
•General surgery
•Laparoscopy/myomectomy/ uterine adhesion
•CPT repair/VVF repair anal incontinence/miscarriage
•Amputation of cervix, Fothergill’s operation, cervical stenosis/preterm labor
• Any problems with anaesthesia in previous surgery
•Gynecological Surgery

20. Family History
•H/o Diabetes ( High risk category for screening)
•Hypertension
•H/o of pre eclampsia in mother (20-25%), siblings (3- 40%)
•H/o twins (family h/o mother supercedes that of father)
•Hereditary diseases like hemoglobinopathies, genetic disorders,
congenital anamolies

21. Personal History
•H/o drug abuse/smoking- may lead to FGR
•Alcohol- may lead to fetal alcohol syndrome
•History regarding bowel habits, micturition, sleep pattern, appetite
should be taken
•Dietary history
•Socio economic status

22. Basic investigations at booking:
•MBG
•Heamogram
•TSH
•HIV
•HBsAg
•VDRL
•OGTT
•Urine routine microscopy
•Urine culture
Radiological investigations
NT /NB scan (11-13+6 weeks)
Anomaly scan (18-22 weeks)

23. General Examination
•Stature –average/short/tall, short stature is ≤145cm
•Nourishment – thin built/moderate/obese
•Weight
▪Pre-pregnancy weight to be noted to calculate weight
gain during pregnancy
▪BMI= weight in kg/height in square metres
< 18.5 Underweight
18.5 – 24.9Normal
25 – 29.9 Overweight
> 30 Obesity

24. Total weight gain during pregnancy: 9-12 kg
Trimesteric wise weight gain-
▪First trimester: 1 kg
▪Second trimester: 3-4 kg
▪Third trimester: 4-6 kg

25. Underweight women Should gain 12-14 kg
Average weight women Should gain 10-12 kg
Overweight women Should gain 8-10 kg
Obese Should gain < 8 kg
Increased BMI
Pre-eclampsia
Polyhydramnios
Gestational Diabetes
Hypertension
Shoulder dystocia
Dysfunctional labor
Caesarean section
Decreased BMI
FGR
Anemia
Malnutrition
Low birth weight
Preterm delivery

26. •Pallor – lower palpebral conjunctiva, nail beds, tip of tongue, soft
palate, palms and soles
•Cyanosis – Heart disease, corpulmonale
▪Peripheral cyanosis – hands, feet, fingers, toes and nail beds
▪Central cyanosis – tongue, lips
➢Icterus – upper bulbar conjunctiva, undersurface of tongue, soft
palate, sole, palm and skin
➢Clubbing – Congenital heart disease/sub-acute bacterial endocarditis/
atrial myxoma/lung disease/ gastrointestinal and hepatobiliary disease

27. ➢Edema – bilateral or unilateral, pitting or non- pitting, over medial malleolus
for atleast 30 secs, anterior surface of lower third of shin, dorsum of foot,
other sites – face, dorsum of hand, sacrum, abdominal wall, vulva.
Visible edema over ankles on rising from bed in morning is pathological
edema. Sudden and generalised edma may indicate imminent eclampsia.
physiological edema subsides on rest alone unlike pathological edema.

GRADES of edema-
grade1- edema upto ankle
grade2- edema till knees
grade3- above thighs or in two separate sites on body
grade4- generalised edema or anasarca

28. •Breast examination – asymmetry, areola, nipples, masses
•Thyroid examination
•Tongue, teeth, gum – glossitis, stomatitis, caries teeth, gingivitis
•Spine examination
•Temperature
•Pulse – rate, rhythm, volume, radiofemoral delay (normal rate in
pregnancy:- 85-90bpm)
•Blood pressure – measured in sitting/ semi-recumbent posture with
arm at the level of heart & not in lying as supine hypotension may
result as gravid uterus can impair venous return via the inferior vena
cava. In pregnant women korotkoff 5 is taken instead of korotkoff 4 as
a measure of diastolic BP.

29. *
SYSTEMIC EXAMINATION:-
RS, CVS, CNS
Abdominal examination –
empty the bladder
stand on the right side
examined in dorsal position with semi-flexed thigh
abdomen exposed from xiphisternum to pubic symphysis
*

30. Physiological changes seen in pregnancy:-
Cardiovascular system-
cardiac output increases by 40%
heart rate increases by 20% (18bpm above baseline)
BP:- decrease in DBP>SBP- 2
nd trimester onward pt begin to rise in
3
rd trimester
heart moves upward, rotated internally & apex beat is located in
4
th I/C space
loud heart sounds are heard, splitting of S1, presence of S3,systolic
murmur upto grade 2

31. Respiratory system-
Elevation of diaphragm by 4cm
Total lung capacity reduced by 5% due to elevation
Diaphragmatic excursion is increased by 1-2cm & breathing becomes
diaphragmatic
Transverse diameter of chest expands by by 2cm & chest circumference
increases by 5-7cm
State of hyperventilation occurs during pregnancy leading to leading to
increase in tidal volume

32. Signs in pregnancy which mimic disease:-
•Vascular spider & palmar erythema (inc estrogen)
•Varicosities in leg
•Nausea, vomiting,mental irritability & sleeplessness

33. Inspection
•Striae gravidarum
•Linea nigra
•Abdominal wall oedema
•Umbilicus
•Scars
•Keloid
•Sinuses
•Presence of umbilical/incisional hernia

34. Palpation
•Should be gentle
•Dextrorotation to be corrected
•Assessing fundal height – using the ulnar aspect of hand, moving
downwards from xiphisternum
Height of uterus bigger than period of amenorrhea:
Wrong dates
Full bladder
Multiple pregnancy
Polyhydramnios
Big baby
Pelvic tumours – ovrian/fibroid
Vesicular mole
Height of uterus lesser than period of amenorrhea:
Oligohydramnios
Transverse lie
IUD
FGR
Missed abortion
Mistaken dates
Delayed conception – in rregular periods

35. Fundal height at different weeks of pregnancy

36. •Symphysio-fundal height – between 20-32 weeks, SFH in cm roughly
corresponds to weeks of gestation
▪Distance between the upper border of pubic symphysis and top of fundus
▪A difference of ± 2 cm is normal
▪Persistent deviation above 90
th centile or below 10
th centile from the normal
needs further evaluation
▪Gravidogram or metogram is a simple, inexpensive screening method in low-
resource setting, recommended by WHO
➢Abdominal girth – at the level of umbilicus after 30 weeks, at term 90-100 cm

38. Gravidogram

39. Leopold’s manoeuvres

40. Uses of second pelvic grip:
•Confirms the first pelvic grip
•Whether head is engaged or not
•Attitude of head, whether well-flexed, deflexed or extended
▪If sinciput is at higher level than occiput – flexed head – vertex
presentation
▪Both occiput and sinciput at same level – deflexed head
▪Occiput higher than sinciput – brow/ face presentation
➢If hands diverge – head is engaged, if hands converge – head is
unengaged

42. Fetal attitude

43. Auscultation
•FHS with bell or diaphragm of stethoscope or Pinard’s fetoscope or
hand held Doppler
Cephalic presentation below the umbilicus
Occipito-anterior positionSpinoumbilical line
Occipito-posterior More towards flanks
Breech presentation Above umbilicus
Transverse lie At the level of umbilicus
Multiple gestation Two FHS with difference of 10 beats/min

44. Fetal weight estimation:


Johnson’s formula in cephalic presentation
▪Unengaged head, fetal weight=
fundal height in cm – 12 x 155 g
•Engaged head, fetal weight=
fundal height in cm – 11 x 155 g

45. McDonald’s rule – to assess GA
•Height of fundus in cm x 2/7 = duration of pregnancy in lunar months
•Height of fundus in cm x 8/7 = duration of pregnancy in weeks

46. Per vaginal examination
•To diagnose pregnancy
•H/o first trimester bleeding
•Assess pelvis and CPD at 38weeks in primigravida
In labour
•Assess length of cervix with h/o preterm labour
•Assess Bishop’s score if induction of labour is contemplated
CONTRAINDICATIONS
Suspected placenta previa
Suspected rupture d membranes- a speculum examination to be done

48. BISHOP SCORE( CONTINUED)

49. Pelvic assessment:-
Ask patient to empty her bladder before examination
Inform the patient about the procedure
Take patient at the edge of the table. Clean the external genitalia with
betadine solution then gently insert 2 fingers into vagina and assess the
pelvis.

50. The points to note are:-
INLET- sacral promontory (normally not tipped)
diagonal conjugate (normal-12cm)
MID-PELVIS- bay of sacrum well curved or not
lateral pelvic wall ( straight, convergent or divergent)
ischial spine ( normally should not be prominent)
sacro-iliac notch ( should admit 2 fingers)
interspinous diameter {if both ischial spines touched on spanning
finger}
(normally-10.5cm)
OUTLET- subpubic angle ( acute or obtuse)
inter-tuberous diameter { 4 knuckle test} (normally-11cm)

51. Munro Kerr Muller’s method