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Obstetrics history & examination

Aug 25, 20258 min read

Table of Contents

  • History Taking In Obstetrics
  • Obstetric Abdominal Examination
  • General Examination
  • General Systemic Review
  • Abdominal Examination
  • Palpation
  • Leopold Maneuvers
  • Vaginal Examination (PV)
  • Indications for Vaginal Examination in Pregnancy
  • Suspicion of Multiple Pregnancy on Abdominal Examination
  • Summary of Abdominal Examination
  • Conclusion

History Taking In Obstetrics

Introduction

By Dr. Mona Ahmed

Learning Outcomes

  • Systemic supervision (examination & advice) of a woman during pregnancy is called ANC (prenatal care).
  • Started with the beginning of pregnancy & ends by delivery.
  • Aiming to:
    • Screen high-risk pregnancy.
    • Treat complications detected by early examination.
    • Educate the mother by demonstrating labor.
    • Ensure continuous medical surveillance and prophylaxis.

Case Study: Mrs. Hanaa Ahmed

Mrs. Hanaa Ahmed is 38 years old, G v P ii + ii, came to the antenatal clinic to follow her pregnancy. LMP 16/8/2023. What are the questions you will focus on in history?

How to Take History?

Steps

  1. Identification
  2. Past Medical History
  3. Family History
  4. Drug History
  5. Social History
  6. Obstetrical History (current & previous)
  7. Gynaecological History
  8. Complain of & History of presenting illness
  9. Summary

Remember

  • Obstetrical History (if obstetrical case in detail) & Gynae History will be in brief.
  • In gynae history, vice versa; Gynae history will be in detail, and obstetrical history will be in brief.

Identification

  • Name (at least three names)
  • Age
  • Occupation
  • Blood grouping
  • Husband’s name, age, BG, occupation, consanguinity
  • Address
  • Date of marriage
  • Date of first examination

Notes

Women who have their first pregnancy at the age of 35 or more are called elderly primigravida.

Extremes of age (teenagers & elderly) are obstetric risk factors.

Past Medical History, Family History, Drug History, and Social History

Past Medical History

  • DM
  • ASTHMA
  • HEART DISEASES
  • HTN
  • RENAL DISEASES
  • (OTHERS)

Family History

  • DM
  • ASTHMA
  • HEART DISEASES
  • HTN
  • RENAL DISEASES
  • CONGENITAL ANOMALIES

Drug History

  • Chronic medications
  • Allergy

Social History

Obstetric History

Gravidity Parity LMP EDD History of current pregnancy:

  • 1st trimester
  • 2nd trimester
  • 3rd trimester
  • History of previous pregnancies

Risks Associated with Grand Multiparity

  • Anaemia
  • Increase risk of miscarriage
  • Abnormal Fetal presentation
  • Preterm delivery
  • Uterine atony
  • Placenta praevia
  • Uterine rupture
  • Amniotic fluid embolism
  • Postpartum haemorrhage
  • Stress incontinence and urinary urgency symptoms

Example: Gravidity and Parity

Ex: A woman who has had six miscarriages with only one live baby born at 32 weeks and is pregnant again will be: gravida 8, para 1. (para 1+6.)(G viii P i+ iv)

OR to say  ‘Mrs Wafaa is in her eighth pregnancy. She has had six miscarriages at gestations of 8–12 weeks and one spontaneous delivery of a live baby boy at 32 weeks. Baby Ahmed is now 2 years old and healthy.

LMP and EDD

  • Use LMP to date pregnancy if the cycle was a normal cycle.
  • The EDD is calculated by taking the date of the LMP, counting forward by 9 months, and adding 7 days.

Calculation of the Estimated Delivery Date

MonthDayYear
Month of period - 3 monthsLast Period + 7 days+ 1 year

EDD (by Naegele’s Rule)

  • The expected date of pregnancy.
  • The median duration of pregnancy is 280 days (40 weeks), and this gives the estimated date of delivery (EDD).

How to Calculate EDD

  1. Add 7 to days.
  2. Subtract 3 (or add 9) to months.
  3. Add 1 to the year if (month is bigger than 3rd month).

EX:

  • LMP 7/7/2021AD
  • EDD 14/4/202AD
  • GA(gestational age) calculate the pregnancy age today

In previous ex GA 34 weeks.

History of Current Pregnancy

1st Trimester (0-13 weeks)

  • Folic acid (drug history - teratogens)
  • NVP
  • Dating scan
  • Downs syndrome screening

2nd Trimester (14-26 weeks)

  • Quickening
  • Vaccination
  • Anomaly scan
  • Iron supplementation

3rd Trimester (27-40 weeks)

  • Baby’s movement

  • Assessment scan

  • Mode of delivery

  • Puerperium & breastfeeding

Don’t Forget

☐ In all trimesters:

Bleeding UTI Signs of anaemia

Previous Obstetric History

  • It is helpful to list the pregnancies in date order and to discover what the outcome was in each pregnancy.
    • For each pregnancy, note:
      • Antenatal complications
      • Duration of pregnancy
      • Labour duration method complications
      • Hx of PPH
      • Birth weight and sex of infant; its age now; is he/she alive and well?
      • Complications of puerperium

Possible Complications of Puerperium

  • PPH
  • Urinary tract infections
  • DVT
  • Perineal wound
  • Psychological complications (e.g., postpartum depression)

Gynaecological History in Current Pregnancy

  • Ask about cycle regularity
  • Vaginal discharge (colour, odour, itching)
  • Cervical smear
  • Contraceptives (prior to conception)
  • Gynaecological operations
  • Assisted conception

Complain of & History of Presenting Illness

  • If no complaint, ask her about:
    • Sleep
    • Appetite
    • Bowel habit
    • Urination

Gynaecological History (for Gynae Case)

Steps

  1. Identification
  2. Past Medical History
  3. Family History
  4. Drug History
  5. Social History
  6. Obstetrical History (in brief)
  7. Gynaecological History
  8. Complain of & History of presenting illness
  9. Summary

Gynaecological History Details

  • Cycle
  • Menarche
  • Kata
  • Regularity
  • Amount
  • Dysmenorrhoea
  • Bleeding PCB IMB
  • Vaginal discharge (amount, colour, odour, itching, time)
  • Dyspareunia
  • Cervical smear
  • Contraceptives
  • Gynaecological operations
  • Assisted conception

Summary

  • Summarise your history

Obstetric Abdominal Examination

Before Examination

  • Explain to the patient the need, nature, and purpose of the examination.
  • Obtain verbal consent.
  • The examiner should be accompanied by another female.
  • Respect her privacy and examine in a private room.
  • Expose only the relevant part of the examination.
  • Ensure the patient is comfortable and warm.
  • Ask the patient to empty her bladder.

Patient Positioning

  • Patient should lie in the dorsal position.
  • Stand to her right.
  • Roll her slightly to the left (to decrease vena cava compression).
  • Ask about any tender area before palpation.

General Examination

  • Vital signs
  • Weight
  • Height
  • Face
  • Skin
  • Eyes
  • Neck
  • Breast
  • Hands
  • Legs

Vital Signs

  1. Blood pressure: Chronic hypertension, Gestational hypertension.
  2. Pulse rate
  3. Heart rate (increased): Haemic murmur.
  4. Respiratory rate: Usually unaffected, slight increase (diaphragm raise).
  5. Temperature (increase due to increase MR)

Weight and Height

  • Weight: Abnormal (obesity, underweight, overweight, emaciation). Check every visit. Weight gain (11-16 kgs).

  • Height: Short stature (small pelvis).

Skin, Face, and Eyes

Face:

  • Appearance
  • Psychological status
  • Diseases (thyrotoxicosis).
  • Hyperpigmentation (chloasma).

Eyes

  • Pallor
  • jaundice cyanosis.

Tongue

  • Pallor
  • dehydration
  • stomatitis
  • jaundice

Neck, Breast, Hands, and Legs

  • Neck: JVP, Thyroid, Hyperpigmentation (acanthosis nigricans), Dilated veins, Lymph nodes.
  • Breast: Enlarged in size, 2ry areola, Montgomery’s gland, Redness, Vascular engorgement, Colostrum, Cracked or fissure nipple.
  • Hands: Nails (clubbing, spooning (koilonychia), cyanosis), Palms (Pallor, Palmer erythema, spider navi).
  • Legs: Varicose vein, Oedema ± causes; (Physiological, Preeclampsia, Anaemia, Heart failure, Nephrotic syndrome).

General Systemic Review

  • CNS
  • GIT
  • Urinary system
  • Locomotor system

Abdominal Examination

Can be examined in three parts:

  1. Inspection
  2. Palpation
  3. Auscultation

Inspection

  • Skin of the abdomen
  • Linea nigra
  • Striae gravidarum
  • Dilated veins
  • Umbilicus (flat, inverted, everted)
  • Fetal parts
  • Skin conditions

Inspection Details

  • Size of uterus
  • Shape of uterus
  • Fetal movement
  • Scars
  • Herniation

Palpation

  1. Superficial palpation: AF, Organomegaly, Uterine contractions.
  2. Deep palpation

What the Examiner Should Identify

  1. First fundal grip
  2. Second fundal grip
  3. Lateral grip
  4. Fetal heart auscultation
  5. First pelvic grip
  6. Second pelvic grip
  7. Vaginal examination (if indicated)

1. Fundal Height (1st Fundal Grip)

  • Keep the ulnar border of the curved left hand on the woman’s abdomen parallel to the symphysis pubis.

  • Start from the xiphisternum and gradually proceed towards the symphysis pubis, lifting the hand between each step till a bulge/resistance of the uterine fundus is felt.

  • Mark the level of the fundus.

Estimating Gestational Age from Fundal Height

  • Measurement of fundal height: Divide the abdomen by imaginary lines passing through the umbilicus.
  • Divide the lower abdomen into 3 parts with 2 equidistant lines between the pubic symphysis and the umbilicus.
  • Divide the upper abdomen into 3 parts again with 2 imaginary equidistant lines between the umbilicus and xiphisternum.

Significance of Fundal Height

Indicates:

  • Duration of pregnancy
  • Fetal growth
  • Any abnormality in the pregnancy

Reasons for Fundal Height Less or More Than Date

  • Less than date: Wrong date, IUGR, Missed abortion, IUD, Transverse lie, Deep engagement, Oligohydramnios.
  • More than date: Wrong date, Polyhydramnios, Macrosomia, Multiple pregnancy, Placenta previa, Tumours, Hydrocephalus, Molar pregnancy.

Leopold Maneuvers

2. 2nd Fundal Grip (Leopold I)

Using two hands and compressing the maternal abdomen till a sense of the fetal part is reached.

This determines which part of the baby is occupying the fundus.

How to identify head? Hard smooth , rounded .

How to identify breech? Soft irregular broad.

3. Lateral Grip (Leopold II)

  • To detect the lie.
  • To detect the fetal back (hard, regular).

why?

  • To determine the scapula to
  • know where to put the sonic aid
  • (hearing Fetal heart sound).

How ?

  • The sides of the uterus are palpated to determine the
  • position of the Fetal back.(hard regular)

4. Detect Fetal Heart

  • Below umbilicus if cephalic presentation.
  • Above umbilicus if breech presentation.

How to measure?

  • Pinnards stethoscope.
  • Regular sthesoscope.
  • Ultrasound.
  • Doppler machine.
  • CTG machine.

5. First Pelvic Grip and 6. Second Pelvic Grip

  • To determine which part of the fetus is occupying the pelvis.
  • To determine engagement.

Vaginal Examination (PV)

  • Patient should be in the lithotomy position.

How to Perform

  • Bimanual examination.
  • Speculum examination.

Vaginal Examination In Pregnancy

 Bimanual examination is no longer a routine part of antenatal examination but still sometimes required:  1. To assess maturity in early pregnancy 

  1. To exclude suspected abnormalities such as incarcerated retroversion of the uterus or ovarian tumor. 

  2. To identify a presenting part this cannot be confidently identified abdominally. 

  3. To exclude or confirm gross degrees of contraction (in very small patients).

 5. To assess the ripeness of the cervix near term.

 6. To assess pelvic cavity.

Suspicion of multiple pregnancy - an abdominal examination

  • An unexpectedly large uterus for the estimated gestational age

  • Multiple Fetal parts felt on abdominal palpation

  • FHS is heard at more than one place.

  • Poly hydramnios.

To Summarize

Abdominal Examination is done for:

  • Fundal height
  • Fetal lie and presentation
  • Fetal movement
  • Fetal heart sounds
  • Any other abdominal finding

Graph View

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