History, Examination and Antenatal Care

Question 1

Antenatal Hx Overview

Answer 1

Personal details, presenting complaint, hx of current pregnancy, past obstetric hx, past gynae hx, past medical hx, drugs and allergies, family hx and social hx.

Question 2

Antenatal Hx - Dates

Answer 2

• Naegele’s rule - subtract 3 months from date of LMP and add a year plus 7 days +/- days of cycle if normally more or less than 28 days.
• Obstetric wheel - uses a precise 280 days from the date of the LMP.
• Ultrasound EDD - uses crown-rump length between 7-14 weeks or biparietal diameter or femur length between 14-20 weeks.

Question 3

Antenatal Hx - Complications

Answer 3

For example - bleeding, hypertension, anaemia, diabetes, concerns about fetal growth or UTIs.

Has the pt been admitted to hospital?

Question 4

Antenatal Hx - Parity

Answer 4

The no of times a women has delivered a potentially viable baby (UK law states post 24 weeks).

A suffix denotes the number of pregnancies that have miscarried or been terminated before 24 weeks.

Para 3 + 2 - a women who is pregnant and has had 3 term pregnancies and 2 miscarriages at 12 weeks.

Question 5

Antenatal Hx - Gravida

Answer 5

The number of times a women has been pregnant.

Gravida 6 - a women who is pregnant and has had 3 term pregnancies and 2 miscarriages at 12 weeks.

Question 6

Antenatal Hx - Family Hx

Answer 6

Ask about twins, diabetes, hypertension, pre-eclampsia, autoimmune disease, VTE, thomphilia or any other inherited disorders.

Question 7

Antenatal Hx - Social Hx

Answer 7

Ask about smoking, alcohol, drugs, relationship status, support network and accomodation.

Question 8

Postnatal Hx Overview

Answer 8

Ask about delivery, infant, puerperium so far, plans for the puerperium and social history.

Question 9

Postnatal Hx - Delivery

Answer 9

Gestation, mode of delivery, if instrumental or Caesarian why, mode of onset, length of labour, analgesua or any procedures afterwards?

Question 10

Postnatal Hx - Infant

Answer 10

Ask about sex, birth weight, Apgar score, mode and success of feeding and whether vitamin K was given after birth.

Question 11

Postnatal Hx - Puerperium so far

Answer 11

Ask about lochia (volume and odour), bowel and bladder function post delivery, any dysuria or urine leaking and any pain.

Question 12

Postnatal Hx - Puerperium Plans

Answer 12

Ask about contraception - pop can be used when breastfeeding or cocp can be started after 6 weeks.

Ask about relationships and accomodation.

Question 13

Obstetric Examination Overview

Answer 13

General examination, urinalysis, blood pressure, abdominal exam - inspect, palpate and auscultate.

Question 14

Abdo Exam - Inspection

Answer 14

Look for 5 things - swelling consistant with pregnancy, striae gravidarum, linea nigra (vertical black line), scars and in the later stages fetal movements.

Question 15

Abdo Exam - Fundo-symphysis Height

Answer 15

Measure from the fundus of the uterus to the pubic symphysis. The fundus is palpable at 12 wks, at the umbilicus at 20 wks and the xiphisternum at 36 wks.

After 24 weeks the fundo-symphysis height corresponds to the gestation +/- 2cm.

Question 16

Abdo Exam - Lie

Answer 16

Palpate from the fundus downwards towards the pelvis - if longitudinal lie the head and buttocks are palpable at each end, if transverse lie the pelvis is empty and if oblique lie the head or buttocks are palpable in the right or left iliac fossa.

Question 17

Abdo Exam - Presentation

Answer 17

Press the fingers of both hands just above the pubic symphysis and determine the fetal part that occupies the lower pelvis.

Presentation will be breech in 30% at 28 weeks and just 3% after 37 weeks.

Question 18

Abdo Exam - Engagement

Answer 18

The head is engaged when 2 fifths or less of the head of the fetus is palpable in the pelvis.

Question 19

Abdo Exam - Ausultation

Answer 19

Listen over the anterior shoulder (usually between the fetal head and the umbilicus) with a doppler and the heart rate should be 110-160 bpm.

Question 20

The Booking Visit

Answer 20

Occurs between 9-11 weeks - antenatal hx, height and weight, baseline BP, urinlysis and abdo exam.

Bloods - FBC, serum antibodies e.g. anti-D, blood glucose, syphilis, rubella immunity and offer screening for HIV and hepatitis B.

Question 21

Booking Ultrasound

Answer 21

USS between 11-13 weeks - to confirm gestation, viability and to rule out multiple pregnancy.

Question 22

Combined Test

Answer 22

To look for chromosomal abnormalities - nuchal translucency measured during the initial USS, B-hCG and PAPPA (pregnancy associated plasma protein A).

Question 23

Triple Test

Answer 23

Can be performed after 14 weeks if combined test missed between 11-13 weeks but less sensitive.

Measures - AFP, BhCG and oestridiol.

Question 24

Anomaly Scan

Answer 24

Normally performed at 20 weeks but can be rescheduled for later if low lying placenta.

Question 25

Anti-D

Answer 25

Given to rhesus negative women at 28 weeks and again at 36 weeks

Question 26

Treat minor conditions

Answer 26

• Heartburn - Ranitidine
• Constipation - diet changes or Docusate
• Vagnitis - Clotrimazole pessary

Question 27

Amniocentesis

Answer 27

• A fine gauge needle is used to remove amniotic fluid under ultrasound guidance.
• Can be used to diagnose chromosomal abnormalities, infections e.g. CMV or toxoplasmosis and inherited disorders.
• Safest after 16 weeks, 1% risk of miscarriage.

Question 28

Chorionic Villus Sampling

Answer 28

• A needle passed through cervix or abdo wall and into placenta to remove trophoblast cells.
• FISH or PCR can be used to diagnose chromosomal abnormalities.
• Can be performed after 11 weeks but slightly higher rate of misscarriage than amniocentesis.

Question 29

Neural Tube Defects

Answer 29

• Occurs in 1 in 200 pregnancies.
• E.g. spina bifida causes severe disablity and anencephaly is incompatible with life.
• Folic acid 0.4mg a day should be taken for 3 months prior to pregnancy to reduce the risk.
• Causes raised AFP levels.
• 95% detected at the 20 week anomaly scan.

Question 30

Cardiac Anomalies

Answer 30

• Occur in 1% of pregnancies.
• In 50% the nuchal translucency is increased at the 11-13 week scan.
• However < third are diagnosed prenatally.

Question 31

Exomphalos

Answer 31

• Partial extrusion of abdominal contents into the peritoneal sac.
• 50% will have chromosomal abnormality so amniocentesis is offered in these cases.

Question 32

Gastroschisis

Answer 32

There are free loops of bowel in the amniotic sac but not associated with chromosomal abnormalities.