History and Examination Flashcards
What are the components of obstetric hx?
Current pregnancy Past obstetric histories - term and other PMHx PSHx PGHx DHx FHx SHx
What should you ask about current pregnancy?
Name Age Relationship status Gravidity Parity LMP EDD
Gestational age (weeks + days) - Naegele’s rule - first day of LMP, add 1 year, subtract 3 months, add 7 days
Crown-rump length measured by USS
Irregular cycles, long cycles and hormonal contraception make dating by LMP inaccurate
Ask about general health and symptoms
Fetal movements if > 20 weeks
Admissions or problems in this pregnancy
Tests and scans:
Routing bloods
1st trimester scan
Anomaly scan at 20 weeks
Folate use? EDD (date when woman will be 40+0 Singleton or multiple gestation Down's syndrome screening results Fetal anomalies scan results
What are findings of fetal anomaly scan?
Fetal anomalies
Placenta position - clear of internal os?
Amniotic fluid index - oligohydramnios, polyhydramnios
Estimated fetal weight - growth parameter
Past Obstetric History?
Term pregnancies:
Gestation - previous preterm labour?
Mode of delivery - spontaneous vaginal, assisted vaginal, Caesarean?
Gender
Birth weight - SGA?
Complications - Pre-eclampsia, genstational HTN, diabetes, obstetric anal sphincter injury, PPH
Assisted reproductive therapies - ovulation induction with clomiphene, IVF
Care providers
Other pregnancies:
gestations - miscarriages can be classified into early pregnancy (12 weeks) or second trimester (13-24 weeks)
Miscarriages - outcome (spontaneous, medical/surgical management)
Terminations - reason, method of management
Identified causes of miscarriage, stillbirth - fetal anomaly?
Ectopic pregnancies?
Site of ectopic
Management: expectant (serum hCG levels)
Medical (methotrexate injection), surgical (laparotomy, salpingectomy)
PMHx?
Asthma CF Epilepsy HTN Congenital heart disease DM Systemic autoimmunde disease Haemoglobin disorders Blood borne viruses - HIV, hep B/C
Contraception Pre-conception Difficulties with conception smear history Previous gynaecologist problems and procedures
Psychiatric history important:
Recent change in mental state or new symptoms
New thoughts or acts of violent self-harm
New and persistent expressions of incompetency as a mother
Surgical history
Ddx?
Allergies and intolerances
Regular medications
OTC drugs
Illicit drugs and alcohol
Folic acid 400micrograms per day for first 12 weeks of preganncy
FHx
Congenital diseases
Six
Smoking - how long, what, how many per day Alcohol Occupation Thoughts of pregnancy Home circumstances Financial circumstances Domestic abuse?
What is gravidity?
Total number of pregnancies regardless of outcome including the current one
G3 P2 - patient currently pregnant, 2 previous deliveries
What is parity
Pregnancies that resulted in delivery beyond 24 weeks gestation
G3 P1+1 - patient currently pregnant, one previous delivery and one previous miscarriage
What are the components of obstetric examination?
Introduction Preparation General Inspection Abdominal inspection Palpation Fetal auscultations Completion
Introduction
Introduce
Wash hands
Explain and consent
Preparation
Measure height and weight
Patient should have empty bladder
Expose the abdomen from the xiphisternum to the pubic symphysis
As patient to lie supine with head of bed raised 15
Prepare your equipment - measuring tape, pinnard stethoscope/doppler transducer and ultrasound gel
General inspection
General well being
Hands - palpate radial pulse
Head and neck - melanoma, conjunctival pallor, jaundice, oedema
Legs, feet - calf swelling, oedema, varicose veins
Abdominal Inspection
Distention compatible with pregnancy
Asymmetry
Surgical scars - previous C-section, laparoscopic ports
Fetal movement (>24 weeks)
Skin changes indicative of pregnancy:
Linea nigra - dark vertical line from umbilicus to pubis
Striae gravidarum - stretch marks
Striae albicans - old silvery-white stretch marks
Palpation
Fundal height
Measure from fundus to pubic symphysis in both cm and inches
Turn measuring tape face down to avoid bias
SFH should be gestational age in weeks (cm) ± 2cm
Estimate number of fetuses
Lie
Facing patient head, pale hands on either side of top of uterus and apply pressure
Move hands and palpate down abdomen
Fuller and firmer side is back
- Longitudinal, oblique, transverse in relation to uterus
Presentation Palpate lower uterus Firm and round = cephalic Soft and/or non-round = breech Ballot head by pushing from one side to the otters
Liquor volume
When assessing lie, only feeling fetal parts on deep palpation suggests large amounts of fluid
Engagement
Whether presenting part has entered the bony pelvis
Measured in 1/5ths
Pawlick grip
Auscultation
Lovate back of fetus to listen to fetal heart
Aim instrument between fetal scapulae
Pinnard stethoscope from > 24 weeks
Doppler > 16 weeks
Feel mothers pulse
Measure fetal HR for one minute - should be 110-160 bpm irregular
When are fetal movement s noted?
18-20 weeks
Movements increase til 32 weeks then plateau
What is position of fetus?
Which way fetus is facing
Occipitoanteiror - back of fetus to front of mother
Occipitolateral - side of fetus for front of mother
Occipitoposteiror - front of fetus to front of mother
Completion?
Palpate ankles for oedema Hyperreflexia for pre-eclampsia Thank patient and allow to dress Wash hands Summarise
BP
Urine dipstick
