HISTORY & EXAMINATION

1. Obstetric history and
examination
DR. AHMED WALID ANWAR MORAD
ASSISTANT PROFESSOR OF OBSTETRICS &GYNECOLOGY
FACULTY OF MEDECINE
BENHA UNIVERISITY
2013

2. Key points
 Introduce yourself using the full name . انت مين
 Explain what would you like to do and gain her consent. هتعمل اية
 Ensure the patient is comfortable and warm. المريض مستريح
 Do not do vaginal or breast exam. alone. لزمم ممرضة
 All information's are confidential. المعلومات سرية

3. APPROACH TO AN OBSTETRIC PATIENT
INVESTIGATIONS
EXAMINATION
HISTORY

4. HISTORY
 History taking is an ART :
- Logical sequence
- Avoid inadvertent omission of important details.
- Guide examination.
 Since pregnancy is a “normal” occurrence, the usual
format of the clinical history should be modified.
 History of past pregnancy may alter the outcome of
current pregnancy.

5. Personal History- 1
 NN→→ NNaammee
 AA→→ AAggee
 SS→→ sseexx XXXXXXXXXXXXXXXXXXXXXXXXXX
 OO →→ OOccccuuppaattiioonn
 MM→→ MMaarriittaall ssttaattuuss
 RR→→ RReessiiddeennccyy ((AAddddrreessss))
 HH→→ SSppeecciiaall HHaabbiittss
 GG→→ Gravidity
 P→ Parity

6. Terminology
Gravida x, para a+ b
x = total number of pregnancies including this one
a = number of births beyond 24 weeks
b= number of pregnancies terminated befor 24 weeks

7. CCHHIIEEFF CCOOMMPPLLAAIINNTTSS-- 22
CChhiieeff ccoommppllaaiinntt wwiitthh
dduurraattiioonn iinn cchhrroonnoollooggiiccaall oorrddeerr
iinn ppaattiieenntt oowwnn wwoorrddss

8. HHIISSTTOORRYY OOFF PPRREESSEENNTT IILLLLNNEESSSS-- 33
11.. AAMMEENNOORRRRHHOOEEAA::
EExxpprreesssseedd iinn wweeeekkss,, CCaallccuullaatteedd ffrroomm LLMMPP
DDiiaaggnnoossiiss ooff pprreeggnnaannccyy ccoonnffiirrmmeedd??????
DDAATTIINNGG
 Naegele ̕s rule (EDD= LMP +9M+7D)
For accurate estimation:
- Menses – regular, average length, sure
- No recent use of COC pills.
 Obstetric calendar (wheel)
 First trimester ultrasound scan
 Later ultrasound scan

9. (Obstetric calendar (wheel

10. HHIISSTTOORRYY OOFF PPRREESSEENNTT IILLLLNNEESSSS-- 33
22.. SSYYMMPPTTOOMMSS RREELLAATTEEDD TTOO PPRREEGGNNAANNCCYY::
 NAUSEA & VOMITING
 FREQUENCY OF MICTURATION
 CONSTIPATION
 HEAVINESS IN THE BREAST
 RISE OF TEMPERATURE
3. AANNKKLLEE OOEEDDEEMMAA::
PRESSURE DUE TO GRAVID UTERUS
? HTN, ??? Protein Urea

11. HHIISSTTOORRYY OOFF PPRREESSEENNTT IILLLLNNEESSSS-- 33
44.. PPAAIINN AABBDDOOMMEENN::
LABOUR PAIN
ABRUPTIO PLACENTAE
PRE-ECLAMPSIA TOXEMIA
DEGENERATION OF MYOMA
ACUTE URINARY RETENSION
TORSION OF OVARIAN CYST
AACCUUTTEE CCHHOOLLEECCYYSSTTIITTIISS

12. HHIISSTTOORRYY OOFF PPRREESSEENNTT IILLLLNNEESSSS-- 33
55..BBAACCKKAACCHHEE::
Increase in body weight
Hyperextension of the spine
Laxity of joints in pelvis and spine
66.. VVAAGGIINNAALL BBLLEEEEDDIINNGG::
-- IImmppllaannttaattiioonn HHeemmoorrrrhhaaggee,,
-- EEaarrllyy pprreeggnnaannccyy :: AAbboorrttiioonn,, EEccttooppiicc PPrreeggnnaannccyy,, VV..mmoollee,,
-- LLaattee pprreeggnnaannccyy:: PPllaacceennttaa PPrreevviiaa,, AAbbrruuppttiioo PPllaacceennttaa,, VVaassaa pprreevviiaa

13. HHIISSTTOORRYY OOFF PPRREESSEENNTT IILLLLNNEESSSS-- 33
77.. DDeeccrreeaasseedd FFEETTAALL MMOOVVEEMMEENNTT:: 1100// 1122 hhrrss
PRIMI: 18 weeks
MULTI: 16 weeks
8..EExxcceessssiivvee EENNLLAARRGGEEMMEENNTT OOFF TTHHEE AABBDDOOMMEENN::
Multiple pregnancy ,
Hydramnios,
accidental hemorrhage,
Macrocosmia,
Miscalculation.

14. HHIISSTTOORRYY OOFF PPRREESSEENNTT IILLLLNNEESSSS-- 33
99..VVAAGGIINNAALL DDIISSCCHHAARRGGEE::
RUPTURE OF MEMBRANE
PHYSIOLOGICAL LEUCORRHOEA
CANDIDIASIS
CERVICITIS
10. HHIISSTTOORRYY OOFF TTTT// IIRROONN++ CCAA SSUUPPPPLLIIMMEENNTT

15. HISTORY OF PRESENT ILLNESS- 3
ديباجة
 Pregnant female for ( weeks) as her LNMP ( / / ) and EDD ( / / ) and
pregnancy is confirmed by pregnancy test since( / / )
 Analysis of the complaint ( onset, course duration)
 History of current pregnancy
 details of the 1st ,2nd & 3rd trimester
 admission and examination
 Investigations : lab tests & U/S scans pattern
 the expected management
 System review ( ( لتننسى

16. Menstrual & gynecological history- 4
 Cycle :
- 1st day of LNMP ( was it conform to the usual in terms of
timing, volume, and appearance)
- Regularity
- Length
- OCP use.
 Surgical procedures
 Hx of infertility
 Sexually transmitted diseases
 Uterine anomalies

17. Past obstetric history-5
Gravidity, Parity
Outcomes
 Gestational age: abortion, preterm, term
 Delivery
 Date
 Mode
 Place
 Infant : sex ,weight, wellbeing
 Complications

18. Past medical/ surgical H-6
- 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
 Dm
 Epilepsy
 Thyroid disease
 B asthma
 Any previous surgery.
 Kidney disease
 UTI
 Autoimmune disease
 Psychiatric disorders
 Hepatitis
 Venereal diseases
 Blood transfusion

19. OBSTETRIC HISTORY
 7- Drug history and allergy.
 8- Social Hx → Cigarette smoking, illegal drug use, domestic
violence, psychiatric illness specially in postnatal period.
 9- Family Hx
- Hereditary illness → DM., Hpt., thalassemia, sickle cell
disease, hemophilia
-Congenital defects eg. neural tube defects, Down
syndrome
-Twins

20. OBESTETRIC PHYSICAL EXAM

21. Key points
 Wash your hands
 Introduce yourself using the full name . انت مين
 Explain what would you like to do and gain her consent. هتعملتعمل
اية
 Ask patient to empty the bladder .
 Do not do vaginal or breast exam. alone. لزمم ممرضة
 Ensure the patient is comfortable and warm. المريض مستريح

22. Key points
 For abdominal exam: Uncover the patient’s abdomen
from the xiphi sternum to the pubic hairline, .
Abdominal wall relaxation is maximized by (arms
along side and hips slightly flexed)
 Advise the mother to indicate if she should feel weak
or nauseous.
 All information's are confidential. المعلومات سرية

23. EXAMINATION
 General
 General of the general
 Local of the general
 Breast
 Chest
 Abdominal
 Heart
 Back
 Lower limbs
 Specific
 Abdominal ( ???)
 Pelvic

25. General exam
 GGEENNEERRAALL PPHHYYSSIICCAALL EEXXAAMMIINNAATTIIOONN ::
AAPPPPEEAARRAANNCCEE,, HHEEIIGGHHTT,, WWEEIIGGHHTT ,,BBooddyy MMaassss IInnddeexx
MMOODDEE,, MMEEMMOORRYY,, IINNTTEELLEEGGEENNCCEE,,
OORRIINNTTAATTIIOONN ((TTIIMMEE ,,PPLLAACCEE AANNDD PPEERRSSOONNSS))
GGAAIITT
DDEECCUUBBEETTUUSS ,, cchhllooaassmmaa
HHeeaadd,, eeyyeess,, eeaarrss,, nnoossee && tthhrrooaatt → nnoo cchhaannggeess
TThhyyrrooiidd → ddiiffffuussee eennllaarrggeemmeenntt
 PPAALLLLOORR,, IICCTTEERRUUSS,, LLYYMMPPHH NNOODDEESS,, CCYYAANNOOSSIISS,,
CCLLUUBBBBIINNGG,, OOEEDDEEMMAA,, DDEEHHYYDDRRAATTIIOONN

26. General exam
 VVIITTAALL SSIIGGNNSS ::
PPUULLSSEE
BBLLOOOODD PPRREESSSSUURREE
RREESSPPIIRRAATTOORRYY RRAATTEE
TTEEMMPPEERRAATTUURREE
 BBRREEAASSTT EEXXAAMMIINNAATTIIOONN
 CChheesstt ,,hheeaarrtt
 Ophthalmoscopy hypertensive /diabetic women

27. Blood pressure
Blood pressure: seated, semi-recombent.
each visit.
HTN : BP > 140/90 mm Hg on 2 separate
occasions 6 H apart and less than 7 days using 5th
Korotkoff sounds .
< 20 wks Chronic HTN .
> 20 wks Gestational HTN.
PET.

28. Abdominal exam
 Semi-recumbent position.
 Cover legs with sheet.
 Inspection:
- Shape of uterus .
- Any asymmetry.
- Look for fetal movements.
- Look for scars
- Hernia orifices.
- Cutaneous signs of pregnancy → linea nigra,
striae gravidarum, striae albicans, umbilicus flat or
everted, superficial veins

29. Abdominal exam
2-Palpation:
Superficial palpation: Temperature, Tenderness,
Gardening.
Specific palpation:
 Lie
 Presentation
 Engagement
 Fetal back
 Liquor
 Contractions

30. : Specific palpation
* Fundal height → Palpate before 20 wks( fundal level) +
→ Measure after 20 wks (Symphysis-fundal height)
* Leopold's maneuvers
1. Fundal grip
2. Lateral grip
3. First pelvic grip. PAWLIK’S GRIP
4. Second pelvic grip :

31. Symphysis-fundal height

32. Symphysis-fundal height
MMEEAASSUURREEMMEENNTT

33.  A), First maneuver. One or both hands are placed over fundus and the fetal part
identified.
 (B), Second maneuver. The palmar surface of one hand is used to locate the back of
the fetus and the other hand to feel the irregularities, such as hands and feet.
 (C), Third maneuver. Thumb and third finger are used to grasp presenting part over
the pubic symphysis.
 (D), Fourth maneuver. Both hands are used to outline the fetal head.

34. Abdominal exam
3-Ascultation of fetal heart 
*Site: anterior fetal shoulder .
*Time:
- 12 wks by sonicade ( US Doppler device)
- 24 wks by Pinard steoscope
* Duration: rate ,rhythm over 1 min.
4-Percussion polyhydramnious ballotment & fluid
thrill

35. :Vaginal examination
PPRREE--RREEQQUUIISSIITTSS::
 EEXXPPLLAANNAATTIIOONN
 EEMMPPTTYY BBLLAADDDDEERR
 DDOORRSSAALL PPOOSSIITTIIOONN
 FFUULLLL AASSEEPPSSIISS
 EEqquuiippmmeenntt aarree pprreesseenntt
CCoonnttrraaiinnddiiccaattiioonnss ::
 PPllaacceennttaa pprraaeevviiaa..
 PPrreellaabboouurr rruuppttuurree ooff
mmeemmbbrraanneess

36. Vaginal examination
Vulva and perineum:
 Hyper pigmentation
 Look for abnormalities  Varicose veins/ hemorrhoids,
Warts or herpes
 Cx : Softer, pigmented with  thick ,  yellowish
mucous secretions
 Uterus : enlarged

37. Pelvic assessment
 Check ischial spines if prominent or not
 Diagonal conjugate distance from lower border of the
symphysis pubis to the sacral promontery (pelvic inlet)
 Shape of the sacrum
 Side walls of the pelvis
 Distance between the two sacral promonteries

38. Bishop score

39. Provisional Diagnosis
Name …….., age ……. y, Gx Pa+b , ………. Gestational weeks,
complains of………., most probably……….., complicated or not,
for further investigations and management.

40. E.mail:::ahwalid2004@yahoo.com