Obstetrics History taking/ Examination

obstetrics examination, HISTORY TAKING,

1. EXAMINATION OF AN OBSTETRICS CASE MODERATOR: DR. A.V.RAJESHWAR RAO, H.O.D & ASSISTANT PROFESSOR OF DEPARTMENT OF GYNECOLOGY AND OBSTETRICS . DATE: 16-03-2016 PRESENTER: DR. VAMSHIKRISHNA DUSSA, P.G XVIII BATCH, MD-PART-1 DEPARTMENT OF HOMOEOPATHIC PHARMACY.

2. CONTENTS Introduction Aims and objectives History taking Examination Part: Keywords Before Examination General physical examination General systemic review Obstetrical Examination: A- Abdominal. B- Vaginal & Cervical.

3. Introduction Systematic supervision (Examination and Advice) of a woman during pregnancy is called Antenatal (prenatal care) care. The supervision should be of a regular and periodic nature in accordance with the principles laid down or more frequently according to the need of the individual.

4. The care should start from the beginning of the pregnancy and end at delivery. Careful History Taking and Examination (General and Obstetrical) is a part of Antenatal care.

5. Aims & Objectives: To screen the High risk cases. To treat the complications detected early by examination. To educate mother by demonstrating the labour. To ensure continued Medical Surveillance and Prophylaxis.

6. To remove the fear about the delivery and to gain confidence before labour. To ensure normal pregnancy with delivery of healthy baby. To motive the couple about to need of family planning. To give appropriate advice to couple seeking MTP.

7. History Taking: AN OBSTETRIC CASE SHOULD INCLUDE Vital statistics. Complaints. History of present illness. History of Current/Present pregnancy. Obstetric history. Past gynecological history.

8. Past medical and surgical history. Drug history and allergies. Social history. Personal history. Family history.

9. VITAL STATISTICS: Name: Date of first examination: Address: Age: A woman having her first pregnancy at the age of 30 or above (FIGO-35 YEARS) is called Elderly primigravida. - Extremes of age (Teenage and Elderly) are obstetrics risk factors.

10. Gravida & Parity : Gravida: Denotes a pregnant state both present and past , irrespective of the period of gestation. Parity : Denotes a state of previous pregnancy beyond the period of viability. Gravida and Para refer to pregnancies and not to babies. As such, a women who delivers twins in first pregnancy is still a Gravida one and Para one.

11. A pregnant woman with a history of two abortions and one term delivery can be referred as fourth Gravida but first primipara . It is customary in clinical practice to summarize the past obstetric history by two digits affixing the letter P (doesn’t denote parity here). Eg : P(2+1)= 2 denotes two viable births, 1 is one abortion.

12. But in some centers it is expressed by 4 digits. Example: P(A-B-C-D) A = Number of TERM PREGNANCIES(37-42 Wks) B = Number of PRETERM PREGNANCIES (28 weeks to < 37 weeks) C = Number of MISCARRIAGES (< 28 weeks) D = Number of BABIES ALIVE at present.

13. Duration of marriage: This is relevant when dealing with pregnancy Helps in noting fertility or fecundity of a woman. Pregnancy early after marriage - High fecundity. Pregnancy lately after marriage - Low fecundity.

14. Religion: Occupation: Helps in dealing occupational hazards. Occupation of husband : Gives fair idea about the socio-economic status of the patient. By this we can know likely complications with her status like anemia, prematurity, preeclampsia.

15. Period of Gestation: - The duration of pregnancy is to expressed in terms of completed weeks. A fraction of a week of more than 3 days is to be considered as completed week. In calculation the weeks of gestation in early part of pregnancy , counting is to be done from the first day of Last Normal Menstrual Period ( L.N.M.P) and later months of pregnancy, counting is to be done from expected date of delivery (E.D.D)

16. Most reliable clinical parameter of gestational age assessment is an Accurate LMP . In case of persons who had used oral contraceptives(OC) LMP may be inaccurate. In case of OC use, ovulation may not have occurred 2 weeks after the LMP. In such situation the estimation of gestational age is more accurate with ultrasonography in the first trimester.

17. COMPLAINTS: Categorically, the genesis of complaints are to be noted. Even if there is no complaint, enquiry is to be made about the sleep, appetite, bowel habit and urination.

18. HISTORY OF PRESENT ILLNESS: - Elaboration of the chief complaints as regard their onset, duration, severity, use of medication and progress is to be made.

19. HISTORY OF CURRENT PREGNANCY: Shall be noted in following ways: First Trimester Second Trimester Third Trimester

20. HISTORY OF IST TRIMESTER: ( First 12 weeks) Amenorrhea during the reproductive period in an otherwise healthy individual having previous normal periods, is likely due to pregnancy unless proved otherwise. If H/o Amenorrhea (6-8 weeks), Bleeding p/v (dark, continuous) is associated with lower abdominal pain (acute, colicky) (on sides initially and later whole abdomen) chances of Ectopic pregnancy .

21. Placental sign- Cyclic bleeding till 12 weeks of pregnancy. (This happens until Decidual space is obliterated by the fusion of D. vera with D. capsularis ) Tiredness, Malaise Other normal physiological symptoms: Nausea/Vomiting- if severe- Hyper-emesis Gravidarum. Heart-burn, Constipation, Insomnia.

22. Increased frequency in urination- noted between 8-11th weeks of gestation. Cannot be seen after 12 th week due to straightening of uterus (again seen in 3 rd trimester when uterus pressure increases due to engagement of fetal head)

23. HISTORY OF SECOND & THIRD TRIMESTER: History of fetal movements- Quickening- 18 th week (2 weeks early in Multigravidae)- more in 3 rd trimester. Symptoms of Anemia, Miscarriage, Hyper emesis gravidarum. If H/o Amenorrhea, Bleeding p/v (slight, bright red), painless (dull lower back pain), and if bleeding first and pain later- suggestive of Abortion.

24. If H/o Amenorrhea, bleeding p/v ( recurrent, sudden), painless- Placenta previae . If Symptoms of heavy bleeding, partial expulsion of products of conception which resemble grapes with nausea and vomiting, cramping lower abdominal pain, history of ovarian cysts- Molar pregnancy. Ask for vaccination H/o ( Tetanus and Rh. Immunization)

25. 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).

26. Note: Remember that the pain may be unrelated to the pregnancy so keep an open mind! Causes of abdominal pain in pregnancy include: Obstetric: Preterm/Term Labour, Placental Abruption, Ligament Pain, Symphysis Pubis Dysfunction, Pre- eclampsia /HELLP Syndrome, Acute Fatty Liver Of Pregnancy. Gynaecological : Ovarian cyst rupture, Torsion, Uterine fibroid degeneration.

27. Gastrointestinal : Constipation, Appendicitis, Gallstones, Cholecystitis, Pancreatitis, Peptic Ulceration. Genitourinary: Cystitis, Pyelonephritis, Renal stone pain & Ureteric Colic.

28. OBSTETRICS HISTORY: Related to multigravida Previous obstetrics events are to be recorded chronologically as per the proforma . Proforma in next slide To be relevent , enquiry is to be made whether she had antenatal and intranatal care before.

29. No. Year And Date Pregnancy Events Labour Events Methods Of Delivery Puerperium Baby Weight, Sex Condition At Birth, Duration Of Breast Feeding Immunization 1 2 3

30. For each pregnancy, note: Age of the mother when pregnant. Antenatal complications. Duration of pregnancy. Details of induction of labour. Duration of labour. Presentation and method of delivery. Birth weight and sex of infant.

31. Also enquire about any complications of the puerperal period. Possible complications include: Postpartum hemorrhage. Infections of the genital and urinary tracts. Deep vein thrombosis. Perineal complications such as breakdown of the perineal wounds. Psychological complications (e.g. postnatal depression).

32. Obstetrics H/o can be summed up as: Status of Gravida, Parity, Number of deliveries (Term, Preterm), Miscarriage, Pregnancy, Termination (MTP) and Living issue. E.g.: Mrs. R.L, ( P 2+0+1+2 ), G4, P2, Miscarriage 1, Living 2 at 36 weeks of present pregnancy. 2 = Number of TERM PREGNANCIES . = Number of PRETERM PREGNANCIES . 1 = Number of MISCARRIAGES . 2 = Number of BABIES ALIVE at present.

33. PAST GYNAECOLOGICAL HISTORY Method of contraception before conception. Cervical smear history. Coital problems. Any sexually transmitted diseases Menstrual History .

34. Menstrual history: Cycle, duration, amount of blood flow and first day of the last normal menstrual period ( L.N.M.P) are to be noted. From the L.N.M.P., the expected date of the delivery (E.D.D) has to be calculated. Calculation of the expected date of delivery ( E.D.D). THIS IS DONE BY NAEGELE’S FORMULA.

35. NAEGELE’S FORMULA: Calculation of the expected date of delivery (EDD): this is done accordingly Adding 9 months and 7 days to the first day of the last normal (28 day cycle) period. Alternatively one can count back 3 calendar months from the first day of the last period and then add 7 days to get the expected date of the delivery. Former method is more commonly employed.

36. Ex: The patient had her first day of last menstrual period on 1 ST jan. By adding 9 Calendar months it comes to 1 st October and then add 7 days i.e. 8 th October which becomes the E.D.D For IVF pregnancy, date of L.M.P IS 14 DAYS PRIOR TO THE DATE OF EMBRYO TRANSFER ( 266 DAYS)

37. Obstetrics calendar

38. PAST MEDICAL/ SURGICAL HISTORY Some medical conditions may have impact on the course of the pregnancy or the pregnancy may have an impact on the medical condition examples: Heart disease. Hypertension. Diabetes. Epilepsy. Thyroid diseases. B Asthma. Any previous surgery.

39. Kidney disease. UTI. Autoimmune disease. Psychiatric disorders. Hepatitis. Venereal diseases. Blood transfusion.

40. DRUG HISTORY AND ALLERGY Current medications. Medications taken at any time during the pregnancy. If currently pregnant, ensure the patient is taking 400mcg of folic acid daily until 12 weeks gestation to reduce the incidence of Spina Bifida . Any allergies and their severity (Anaphylaxis or a rash?)

41. 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 thrombophilias. Previously affected pregnancies with any chromosomal or genetic disorders in maternal side. Multiple gestations. Consanguinity.

42. PERSONAL HISTORY : Contraceptive history prior to pregnancy: - LMP may be a withdrawal bleed following pill usage. The first ovulation may be delayed by 4-6 weeks Smoking and Alcohol habits: They have got some relation with their low birth weight of the baby Previous history of blood transfusion, corticosteroid therapy, immunization against tetanus, prophylactic administration of anti-D immunoglobulin are to be enquired.

43. SOCIAL HISTORY: Ask about: Her partner age, occupation, health. How stable the relationship is. Any domestic violence. If she is not in a relationship, who will give her support during and after the pregnancy? Ask if the pregnancy was planned or not. If she works, enquire about her job and if she has any plans to return to work.

44. EXAMINATION PART

45. Keywords Before Examination Before examination, explain to the patient the need and the nature of the proposed examination. Obtain a verbal consent. The examiner (either male or female) should be accompanied by another female. Respect her privacy and examine in a private room.

46. Keywords Before Examination Expose only relevant parts of her anatomy for examination . Ensure the patient is comfortable and warm. Ask patient to empty the bladder . Patient should lie in the dorsal position with thighs slightly flexed. Stand right to her.

47. Keywords Before Examination She is slightly rolled to the left side to prevent compression of the inferior vena cava by the enlarged uterus (inferior venacaval syndrome or supine hypotensive syndrome ). Ask for any tender area before palpating the abdomen.

48. Dorsal position/Supine position with thighs slightly flexed

49. General Examination VITAL DATA NUTRITIONAL STATUS HEIGHT FACIAL FEATURE/EXPRESSION SKIN ICTERUS LEGS NECK BREAS T

50. General Examination VITAL DATA: Blood pressure : Record while she is in sitting and Semi-Recumbent ( 45 degrees) posture. Record in every visit.

51. Usually unaffected or Slightly lower than normal due to SVR ( SYSTEMIC VASCULAR RESISTANCE). If BP > 140/90 mm Hg on 2 separate occasions 6 Hrs apart: Chronic Hypertension: if recorded before 20 weeks of pregnancy or may be persisted before pregnancy. With + family history. Gestational Hypertension : if recorded after 20 weeks of pregnancy.

52. Pulse rate: Slightly increased Heart rate : Increased. Murmurs heard- normal- continuous hissing murmur- systolic type-also called mammary murmur- at left tricuspid area over 2 nd and 3 rd intercostal spaces. Respiratory rate: usually unaffected. feels shortness of breath with slight exertion due to elevated diaphragm.

53. 5- Temperature: may rise by 0.4 ºF i.e..98.6 ºF to 99 ºF  Due to increased metabolic rate

54. NUTRITIONAL STATUS: Nails - white spots in zinc deficiency, brittle nails in magnesium deficiency. Tongue - May be Large in iodine or niacin deficiency. May be pallor in Fe++ deficiency. Cyanotic in CHD. Site- dorsum of tongue. WEIGHT - The abnormal nutritional status can be described as obesity and emaciation. Check weight in every visit . Parameter- Body mass index (BMI)

55. Weight gain for a woman with normal BMI ( 20-26) is 11-16 kgs. Weight gain for a obese woman ( BMI > 29 ) should be less than 7kgs. Weight gain for a under weight woman ( BMI < 19 ) is 18 kgs. Parameters helps in early intervention of preeclampsia ( in obese ) and IUGR of fetus ( in under weight ).

56. HEIGHT Short stature women are mostly to suffer with small pelvis. May cause IUGR OF FETUS.

57. FACIAL FEATURE/EXPRESSION Some facial appearances are pathognomonic of disease. Here the patient may be having thyrotoxicosis. The appearance of the patient’s face may also provide information regarding psychological makeup: is the person happy, sad, angry or anxious

58. SKIN : Extreme pigmentation around neck, face, forehead. Common in pregnancy Palmar erythema – due to high estrogen Hirsutism – mild common, if more – Cushing syndrome . ICTERUS- Bulbar conjunctiva, under surface of tongue, Hard palate- to rule out any LIVER pathology LEGS-EDEMA – common- physiological other causes- Preeclampsia, Anemia, Cardiac Failure, Nephrotic Syndrome

59. Pigmentation of Neck, cheeks oedema of feet

60. NECK - Neck veins, Thyroid gland ( diffuse enlargement common in pregnancy-50 % of cases), Lymph gland enlargement ( any H/o of Kochs / other pathologies of lymph nodes). BREAST- Examination of breast is mandatory not only to note presence of pregnancy changes ,but also to note the nipples/skin around areola. The breast changes are evident between 6-8 weeks.

61. The nipple and the areola become more pigmented specially in dark women. Montgomery’s tubercles are prominent. Thick yellowish secretion ( colostrum ) can be expressed as early as 12 th week. Breasts are enlarged with vascular engorgement evidenced by the delicate veins visible under the skin.

62. Breast changes are valuable only in primigravidae, as in multigravidae the breasts are enlarged and often contain milk for years. **Purpose is to correct the abnormalities (cracks/fissures) early so that to make easy breast feeding more safely too infant after delivery.

63. Neck - Diffuse swelling - common- 50 % cases of pregnancy Abnormal swelling

64. BREAST Normal in pregnancy Abnormal in pregnancy

65. General Systemic Review CNS GIT GENITALIA URINARY SYSTEM LOCOMOTORY SYSTEM

66. CNS : following finding are checked sleeplessness, mental irritability due to some psychological background Any depression/psychosis Anaesthesia of the thighs – due to compression of Lateral Cutaneous Nerve. Carpel tunnel syndrome- median nerve compression in later months of pregnancy.

67. GIT: Gums –usually congested and spongy Esophageal reflux- due to relaxed sphincter- by progesterone. Constipation- due to atony Other signs of any disturbances should noted clearly. Chances of gall stones- due to raised cholesterol- advise USG if pain in Rt hypochondria.

68. ABDOMINAL EXAMINATION Can be examined in three parts 1- INSPECTION 2- PALPATION 3- AUSCULTATION

69. INSPECTION - Size of the uterus: If the length & breadth are both increased  multiple pregnancies, polyhydramnios If the length is increased only  large baby - Shape of the uterus : Length should be larger than broad this indicates longitudinal lie. But if the uterus is low and broad indicates transverse fetus lie. Pendulous abdomen- in primigravidae is sign of inlet contraction.

70. INSPECTION If there is lateral implantation of the placenta then the uterus enlargement will be asymmetrical- piskacek’s sign . - Look for fetal movements. ( More prominently seen in 3 rd trimester / Less in oligohydramnios ) Look for scars. Herniations.

71. INSPECTION CUTANEOUS SIGNS - Linea nigra, Striae gravidarum, Striae albicans, Umbilicus flat or everted, Superficial veins. SKIN CONDITIONS- Ringworm/Scabies LINEA NIGRA EVERTED UMBILICUS FETAL PARTS

72. STRIAE ALBICANS

73. PALPATION Aim : Palpation of fetal parts Active fetal movements Height of the uterus (symphysis- fundal height) Gestational age Foetal poles Foetal lie Presentation part- cephalic(head), breech,etc Attitude

74. Level of engagement of presenting part. Uterine contractions. Estimate fetal weight. Amniotic fluid. Any cephalo -pelvic disproportion Of the above parameters To assess FETAL POLE, FETAL LIE, FETAL PRESENTING PART, ATTITUDE AND ENGAGEMENT OF FETAL HEAD- LEOPOLD’S MANOUEVRE IS FOLLOWED

75. 1) Palpation of fetal parts Distinctly felt after 20 th week Usually done to estimate the fetal pole/presenting part. 2) Active fetal movements Gives positive evidence of pregnancy. Felt at intervals by placing the hand over the uterus as early as 20 th week. Indicates live fetus. Intensity more in last trimester.

76. 3) Height of the uterus (Symphysis-Fundal Height): The distance from the symphysis pubis to the uterine fundus (top of the uterus)- size of the uterus directly related to the size of the fetus. Technique: Place ulnar border of the left hand on the highest part of the uterus (fundus). Mark this point with a pen after obtaining her permission. The distance between the upper border of the symphysis pubis upto the marked point is measured by tape. This corresponds to gestational age

77. FUNDAL REGION SYMPHYSEAL REGION TAPE

78. 4) Gestational age : The distance from the symphysis pubis to the uterine fundus (top of the uterus) corresponds to the gestational age/duration of pregnancy . After 24 weeks of pregnancy, the distance measured in cm normally corresponds to the period of gestation in weeks.

79. 5 ) Fetal Pole, Lie , Presenting Part , Engagement And Attitude Of Fetal Head are assessed by LEOPOLD’S MANOUEVRE. LEOPOLD’S MANOUEVRE: Done by four obstetric grips 1- Fundal grip - To assess fetal pole 2- Lateral grip - To assess fetal lie 3- Pawliks grip - To assess presenting part 4- Deep pelvic grip – To assess engagement and attitude of fetal head.

80. 1) Fundal grip: Both hands placed over the fundus and the contents of the fundus determined. A hard smooth, round pole indicates a fetal head . Broad, soft and irregular mass suggestive of breech . In transverse lie no parts are palpated.

81. 2) Lateral Grip or umbilical grip: Move both hands in a downward direction from the fundus along the sides of the uterus to determine the "lie" of the fetus. "Lie" is the relationship btw the longitudinal axis of the fetus and the longitudinal axis of the mother. The "lie" is usually longitudinal, hence baby is lying length-wise in the same direction as mother's longitudinal axis.

82. Lateral Grip

83. Other "lies" are : Transverse Lie: fetus lies across the longitudinal axis of mother and oblique lie: fetus lies at an oblique angle to the mother's longitudinal axis. Can also determine which side the foetal back is situated by feeling the firm regular surface of the foetal back on one side and the irregular, lumpy surface as the foetal limbs on the other side.

84. Longitudinal Lie Transverse Lie

85. 3) Pawliks grip: (second pelvic grip ) The thumb and four fingers of the right hand are placed over the lower pole of uterus keeping the ulnar border of palm on the upper border of the suprapubic area to determine the presenting part . Presenting part of fetus is the lowest most part of the fetus at the inlet of the pelvis .

86. Presentation : Presenting part of fetus occupying the lower pole of uterus i.e. Cephalic. Breech. Shoulder.

87. Pawliks grip:

88. In transverse lie, pawliks grip is empty. If not engaged the presenting part can be grasped and moved side to side. Presenting Part- cephalic Presenting Part- breech

89. 4) Deep pelvic grip: ( first pelvic grip ) Determines two points about the fetus 1) The attitude of the fetal head 2) Engagement of the fetal head 1) The attitude of the fetal head : The examiner turns around to face patients feet. Each hand placed on either side of the fetal trunk lower down. The hands moved downwards towards the fetal head.

90. Note made as to which hand first touches the fetal head (This point called cephalic prominence). Cephalic prominence helps determine the attitude (i.e. flexion, deflexed or extended) of fetal head.

91. If cephalic prominence (sinciput) is on the opposite side of fetal back, fetal head is well flexed (Normal Position). If cephalic prominence ( occiput ) on the same side as fetal back, fetal head is extended (abnormal position). If examiners hands reach the fetal head equally on both sides (both sinciput and occiput ), fetal head is deflexed (Military position, indicating mal-position)

92. 2)Engagement of the fetal head: Engagement of the fetal head defined as having occurred once the widest transverse diameter of the fetal head (bi-parietal diameter) has passed through the pelvic inlet into the true pelvis. Procedure : Continue moving both hands down around the fetal head, determine how far around the head you can get. Examiner should be able to palpate part of fetal head still in the lower abdomen (also called the 'false' pelvis but cannot palpate the part of fetal head in the true pelvis).

93. Abdominal palpation to determine engagement of the head A- Divergence of fingers- Engaged Head B- Convergence of fingers- Not Engaged

94. If you divide the fetal head into five-fifths, you estimate how many fifths of the fetal head can be felt. If 5,4 or 3 fifths can still be palpated, most of the head is still up, hence the widest part of the head has not engaged into the pelvis. If only 2,1 or 0 fifths of fetal head felt, the widest part of the head has engaged into the pelvis.

95. Diagrammatic representation showing the difference between an engaged and a fixed head by use of egg cups and eggs.

96. 6) Amniotic fluid : Useful in assessing the well being and maturity of fetus Excess or less volume of liquor amnii is assessed by AMNIOTIC FLUID INDEX (AFI ) AFI : Maternal abdomen is divided into 4 quadrants taking the umbilicus, symphysis pubis and the fundus as the reference points. With ultrasound, the largest vertical pocket in each quadrant is measured. The sum of the four measurements(cm) is AFI.

97. AFI helps to diagnose the clinical conditions called oligohydramnios and polyhydramnios. Normal level of amniotic fluid at Term- 40 weeks is 600-800 ml. Other values: at 12 weeks: 50 ml, at 20 weeks: 400 ml, at 36-38 weeks: 1 liter . There is gradual decrease in levels after 38 weeks

98. 7)Uterine contractions: Braxton-Hicks: Felt bimanually. During early months of pregnancy- usually in 2nd trimester begin. Irregular, Infrequent, Spasmodic, Painless Increases by near term. Elicited by rubbing the uterus. Absent in abdominal pregnancy.

99. Palmer Sign In early weeks of pregnancy palmer sign is elicited to diagnose the pregnancy. This method is done to note the uterine contractions. Done by- cupping uterus between internal fingers and external fingers for about 2-3 mins . During contraction- uterus is firm and well defined. During relaxation – soft and ill defined

100. 8) Estimate foetal weight: Difficult and requires practice. Approximate prediction of the fetal weight is more important than the mere estimation of the uterine size. This is more important prior to induction of labour or elective caesarian section. Following methods are useful : 1- Fetal Growth Velocity : 2- Johnsons Formula:

101. 1- Fetal Growth Velocity : Normal growth-26.9 gm/ day More during 32-36 weeks Declines by 24 gm/day after 36 weeks ** individual fetal growth varies.

102. 2- Johnson's formula: Applicable only in vertex presentation Fundal height (cm) noted above the pubic symphysis Fundal height (cm )- 12 (if Vertex above Ischial Spine ) × 155 = weight Fundal height (cm )- 11 (if vertex below Ischial Spine) × 155 = weight This will be fetal weight in grams. • e.g., 32 (Fundal height)-12(constant) x155( constant) => 20 x 155=3100gms.

103. 8) Cephalo-pelvic disproportion: - State were the normal proportion between fetal size and size of the pelvis is disturbed. Two methods: Abdominal method . Abdomino -vaginal method . (explained in vaginal examination)

104. Abdominal method- Patient is placed in dorsal position with the thighs slightly flexed and separated. The head is grasped by the left head Two fingers, index and middle fingers, of the right hand are placed above the symphysis pubis keeping the inner surface of the fingers in line with the anterior surface of the symphysis pubis to note the degree of overlapping, if any, when the head is pushed downwards and backwards.

105. No disproportion- if the head can be pushed down in the pelvis without pelvis overlapping of the parietal bone on the symphysis pubis. Disproportion - if the head cannot be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the fingers. Abdominal method is difficult to elicit in deflexed head. It can be used as screening method.

106. AUSCULTATION Importance: for monitoring FETAL HEART SOUNDS Helps in diagnosis of live baby but its location of maximum intensity can resolve doubt about the presentation of the fetus. FHS are best audible through back in vertex and breech presentation where the convex portion of the back is in contact with the uterine wall. How ever in face presentation, FHS are heard through fetal chest.

107. FHS is maximum below the umbilicus in cephalic presentation and FHS is maximum around the umbilicus in breech. Location of FHS depends on the position of the head and degree of decent of the head even in cephalic presentation.

108. In Occipito anterior position, FHS is heard in middle of the spino -umbilical line. In occipito -posterior –> towards the mother flank on same side In occipito -lateral -> towards laterally . In left occipito -posterior position –> FHS is most difficult to locate.

109. Types of monitoring: Pinnard stethoscope : The heartbeat of the baby may be checked by a simple instrument which looks like a short trumpet that is held against the pregnant tummy. This is called a Pinnard stethoscope (or fetoscope) and can be used by a midwife or doctor to listen to the heartbeat periodically. A fetoscope can detect and transmit fetal heart sounds at 18 to 20 weeks and beyond.

110. Pinnard's Foetal Stethoscope

111. 2. Regular stethoscope : useful in monitoring heart beat after 18 to 20 weeks (same as pinnards fetoscope)

112. 3. Ultrasound fetoscope: Toward the end of the first trimester, usually around the 10th or 11th week of gestation, it is possible to hear fetal heart tones. It is possible only by ultrasound fetoscope.

113. 4. Doppler: Doptone machine Doppler machines may be very simple and report only the rate and rhythm of the beat, but more sophisticated models will provide additional information about blood flow in the umbilical artery .

114. Vaginal Examination A vaginal examination (speculum or digital examination) is not part of a routine obstetric examination but may be indicated to diagnose the pregnancy, to see any rupture of membranes, onset of labour by checking cervix, cephalopelvic disproportion. Can be done bimanually by hands and by speculum.

115. Bimanual examination

116. Speculum Examination

117. Technique of vaginal examination: Mother in Supine, Hips Flexed And Abducted, Knees Flexed. Aseptic technique as much as possible. Note: In Placenta previae & Abruptio placentae- usually vaginal examination is avoided. Only vulval examination done.

118. Diagnosing pregnancy: Osianders sign- increased pulsation felt in the lateral fornices – 8 th week. Walls- softened. Jacquemiers sign: Dusky Hue discoloration of the vaginal walls- anterior- 8 th week.

119. Premature rupture of membranes: Check the collected fluid in posterior fornix (vaginal pool). Cephalopelvic disproportion : Done by Muller-Munro Kerr method . It is a bimanual examination It is superficial to abdominal method Two fingers are introduced into vagina with the finger tips placed over the ischial spines and thumb is placed over the symphysis pubis.

120. The head is grasped by the left hand and is pushed in a downward and backward direction into the pelvis. No disproportion- if the head can be pushed down up to the level of ischial spines and there is no overlapping of the parietal bone on the symphysis pubis. Disproportion - if the head cannot be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the thumb.

121. Negatives for vaginal examination: warning signs

122. Cervical examination : - Done simultaneously in vaginal examination Helps in diagnosing the pregnancy in early weeks- Goodells sign- (soft cervix-6 th week) To check the dilatation of cervix, effacement of cervix in labour. Hegars sign: Gently done- Bimanual examination- two fingers in the anterior fornix and two abdominal fingers behind the uterus. + Ve sign- cervix is firm.

123. Thank you

124. References : TEXT BOOK OF OBSTETRICS- D.C DUTTA, sixth edition-2004. D.C. DUTTA’S TEXBOOK OF OBSTETRICS, 8 th edition-2015- Google eBook MUDALIAR AND MENONS CLINICAL OBSTETRICS- 9 TH edition. OXFORD HANDBOOK OF CLINICAL EXAMINATION AND PRACTICAL SKILLS, 1 st edition (vishal). GOOGLE IMAGES