Obstetrics - History taking and Physical exam Flashcards
Outline Obstetrics history taking questions
Demographics: Name, Age, Occupation, Martial status
HPI: Symptoms, associated symptoms, current visit purpose
History of present pregnancy:
- Estimated date of condinement
- Order of pregnancy: single/ multiple/ chronicity
- Antenatal care: prior booking visits, metrics and health, later screening tests
- Previous hospitalization
- Planned or unplanned, natural or assisted pregnancy
Past obstetric history:
- Gravida/ Parity, Date and outcome
- Pregnancy conditions
- Delivery method and complications
- Puerperium complications
- Newborn metrics and development
Past gynaecological history:
- Previous conditions
- Surgeries
- Last gynaecological exam
- Last cervical smear and result
- Contraception and infertility
Past health:
- Medical and surgical conditions
- Psychiatric conditions
- Drug history and KDA
Social history:
- Smoking, alcohol, illicit drug use
- Marital status, consanguinity
- Home and family situation
- Occupation
- Family history of psychiatric, medical and inherited condition
Reduced fetal movement
- Definition
- Physiological causes
- Criteria for high-risk case
- Approach
Definition: Change in fetal movement from previous level, movement detectable from >20 weeks
Physiological causes:
- Increase FM: after eating/ activity/ evening
- Decrease FM: sleeping cycle
High risk: <10 FM in 2 hours
Approach:
- Full Hx - gestational age, suspicion of IUGR, RFs, drug use
- Urgent NST stat - consult MO beforehand if <30w
- Further tests - if NST abnormal, clinical RFs or repeated ↓FM
Detail of HPI in Obstetric history
CC/HPI
- Symptom - nature, duration, course
- Associating symptoms
○ Symptoms of labour - bloody show, ROM, painful contractions
○ Fetal movement - active? Freq (no routine counting, ≥10/2h lying on side)? Changes?
- Current visit: booking (meticulous Hx)? Routine? Problems (esp in late preg)?
Methods of dating present pregnancy/ Estimated date of confinement (EDC)
How to establish reliability of LMP
By LMP: EDC = LMP + 280d = LMP + 9mo + 7d (Naegele’s rule)
Assumed Basis:
- cycle length = 28d
- ovulation occurs on d14
- normal cycle i.e. not straight after stopping OC or prev pregnancy
- If cycle >28d, then add cycle length - 28d
By dating scan: accurate if before 20w (variable growth rate afterwards)
- Crown-rump length - up to 13w +6
- Head circumference - 14-20w
Establish reliability of LMP by
- Regularity and length of cycle
- Hx of recent OCP use
- USG assessment of gestational age
- Date of +ve preg test
Details of antenatal care and antenatal screening tests in Obstetric history
AN care
- Any prior to booking - eg. private, other HA Obs units, MCHC, outside HK
- Model of AN care - exclusive hospital, shared care with MCHC/primary care, primary care only
* Dating - gestational age
* Screening - ABO/Rh, rubella Ab, HBsAg, VDRL, HIV, Hb/MCV
- To date: regular visits? BP? Fetal growth?
Later screening tests:
- Down syndrome: usu offer 1st trim, 2nd trim if book late (some may opt for NIPT)
□ 1st trim - nuchal translucency, PAPP-A, free b-HCG at 11-(13+6)w
□ 2nd trim - AFP, HCG, uE3, inhibin A at 16-(19+6)w
- GDM - OGTT/spot sugar (飲糖水) in booking - 16w (↑risk) or 28-32w (routine)
- Anomaly scan (結構) - 18-20w, ask specifically on fetal structure and placenta
- Pre-eclampsia - BP, urinalysis every AN visit
- GBS - screening by low vaginal swab + rectal swab in 35-37w
Last USG - presentation (胎位), viability, placenta location (praevia 胎盤前置), fetal size
Details of past obstetric history
For each past pregnancy, record
- Date and outcome: 之前有無試過懷孕？有無試過人工流產小產宮外孕？
- Abortion and type if any, eg. spontaneous (小產), therapeutic (墮胎), ectopic pregnancy (宮外孕)
- Delivery, eg. preterm delivery (早產), full term birth (足月), stillbirth (死產), intrauterine death (宮內死亡)
Pregnancy:
- Complications: eg. early onset pre-eclampsia (妊娠毒血症), placenta abruption, unexplained stillbirth, miscarriage, macrosomia, IUGR
- Delivery method (順產定開刀), gestational age at delivery (足月), any problems, eg. difficult vaginal delivery, PPH, significant perineal trauma
- Puerperium: any complications, eg. postpartum blues, 2o PPH
- Newborn: weight and sex, well-being now, any problems, eg. congenital abnormalities, …
Define Gravidarity and parity
Gravida (G): total number of pregnancies regardless of how they ended
Parity (P): number of live births at any gestation or stillbirths after 24w (need to ask gender)
- Note that twins count as two
Another way is number after para = number of pregnancies that did not result in parity
Examples:
- No prev preg, 12w current preg = G1P0 + 0
- Delivered a twins, then came back next time at 12w = G2P2 + 0
- 6 prev miscarriage, one born in 25w, currently pregnant = G8P1 + 6
Details of past gynaecological history
Previous gynaecological conditions
- Eg. STDs and PID → ↑risk of ectopic pregnancy
- Eg. endometriosis → ↑risk of infertility, ectopic pregnancy
- Eg. pelvic mass → implication on delivery
Previous gynaecological surgeries/procedures
- Eg. those involving uterus → implication for delivery
- Eg. for cervical changes:
§ Knife cone Bx a/w ↑cervical incompetence and stenosis
§ Loop excision of transformation zone → small ↑risk of preterm birth
Last gynaecological exam
Last cervical smear (子宮頸柏氏抹片): date and result
- Screening guidelines = 25y/start of sex life → Q3y after 2× consecutive normal annual smears (25, 26, 29, 32…) till 65
- Smear in pregnancy = safe in 1st trim (no ↑risk of miscarriage), but often prefer to be deferred
Contraception/infertility
- Length tried to conceive, planned pregnancy
- Contraception - method used, duration (Prior OCP may invalidate dating by LMP; IUD still in situ may increase risk of miscarriage)
- In/subfertility - duration, method tried, assisted reproduction? (Donor egg/sperm a/w ↑risk of pre-eclampsia, ↑rate of preterm delivery in assisated conception pregnancy)
Details of past health in obstetric history
Details of social and family history in obstetric history
Outline general obstetrics physical exam for first antenatal visit
For first antenatal visit,
- General - general inspection, maternal height/weight/BMI, BP, urinalysis (protein/glucose)
- LN and thyroid
- Oedema - feet, lower legs, sacral
- CVS - auscultation only, esp with Hx of CVS disease, murmur, S/S
○ Flow murmur present in 80% at the end of 1st trim
- Resp - auscultation
- Breast - palpation only, any lumps
For subsequent visits,
- Maternal weight
- BP - pre-existing HTN (<20w), pre-eclampsia (>20w)
Urinalysis - protein (≥2+, pre-eclampsia), glucose (GDM)
Outline Abdominal obstetrics exam
Inspection
- Abdomen is grossly distended
- Size/shape of fetus (uniform/asymmetrical) and fetal movements
- Scars - look for scar tenderness if prev LSCS (dehiscence, rupture)
- Linea nigra and striae gravidarum
Measurements:
- Symphysial-fundal height (SFH)
- Abdominal girth - alternative (>100cm abnormal)
Palpation:
- Number of fetal poles (if >30w): singleton or multiple
- Lie (if >34-36w): Longitudinal/ Oblique/ Transverse
- Presentation (if longitudinal lie + ≥34w): Cephalic or Podalic
- Stations and engagement
- Amniotic fluid/ Liquor volume
Auscultation: Pinard fetal stethoscope, handheld Doppler
- Position: Cephalic or Breech
- Record: Rate, rhythm while palpating radial artery
Symphysial-fundal height (SFH)
- Definition
- Measurement method
- Interpretation
- Alternative
Symphysial-fundal height (SFH)
- palpable by 12w, umbilicus 20w, xiphisternum 36w (then may be stable or come down)
§ Rarely at midline!
Method:
- Palpate for fundus with ulnar border of left hand
- Palpate for top of pubic symphysis with right hand
- Measure - use inch side and turn over to read the reading
Interpretation
- usually number of weeks in cm (from 20-36w) but should prefer using charts (±3 in Chinese, ±2 in Caucasians)
- Large SFH - wrong dates, polyhydramnios, multiple pregnancy, macrosomia, (full bladder, fibroid)
- Small SFH - IUGR (esp if <4w diff), wrong dates, oligohydramnios, intrauterine death, transverse lie, molar pregnancy, PROM (if Hx of leaking)
Fetal poles, lies and presentations
Measurement and interpretation
Fetal stations and engagement, liquor volume
Measurement and interpretation
General physical signs of pregnancy
Signs of pregnancy
- Cardiac - flow murmur at apex, mammary souffle at 2nd ICS (from internal mammary vessels, disappear with pressure from stethoscope)
- H&N - cholasma (brownish pigmentation over forehead and cheeks)
- Breast - Montgomery tubercles, ↑pigmentation of areola
- Abdomen - striae gravidarum (purplish → white), linea nigra
Auscultation for fetal position and heart rate
- Method
- Interpretation
Auscultation
Apparatus - Pinard fetal stethoscope, handheld Doppler (Doptone)
Position - over left or anterior fetal shoulder (cephalic end of fetal back)
- Cephalic - 1/2 between ASIS and umbilicus
- Breech - above umbilicus
Record - rate, rhythm while palpating radial artery (d/dx uterine artery bruit)
- Normal FHS = 110-160bpm, heard USG from 6w, clinically 18-20w
- Twins - 2 distinct FHS heard ≥10cm with diff of ≥10bpm by 2 observers
- Note - whoosh (Doppler flow from umbilical cord) vs dub (fetal heart)
Fetal position and descend
- Metrics
- Method of measurement
- Interpretations
Position: relationship of denominator to pelvic inlet
e.g.
Presentation - Vertex, Denominator - Occiput (vertex)
Presentation - Face, Denominator - Chin (mento)
Presentation - Breech, Denominator - Sacrum (sacro)
Presentation - Shoulder, Denominator - Acromion
Measurement:
- Abdominal palpation by palpating anterior shoulder of fetus
- Vaginal examination by palpating suture lines and fontanelles
Types: Left or right side+
- Occipito-anterior (LOA/ ROA)
- Occipitotransverse (LOT/ROT)
- Occipitoposterior (LOP/ROP)
Pelvic examination for obstetrics
- Indication
- Process
Indications:
- Excessive or offensive discharge
- Vaginal bleeding - C/I in late preg until placenta previa excluded!
- Cervical smear
- Confirm ROM
Process:
- Wash hands and put on gloves
- Position patient semi-recumbent with knees drawn up and ankle together
- Prepare Cusco bivalve speculum of appropriate size, warm it and apply sterile lubricant
- Gently part the labia
- Introduce the speculum with blade in vertical plane
→ aim for sacral promontory
→ then rotate speculum to horizontal position
- Slowly open blade until cervix visualized
- Assess cervix and take necessary samples
Gently close blades and remove speculum by reversing maneouver
Digital examination for obstetrics
- Indication
- Contraindication
- Process
Indications
- Membrane sweep at term prior to induction of labour
- Assessment of cervix: consistency and effacement of cervix for calculation of Bishop score
C/I -
- Known placental praevia or vaginal bleeding when placental site is unknown and presenting site unengaged
- Prelabour rupture of membrane (↑risk of ascending infection)
Process
○ Same position as pelvic exam in semi-recumbent position
○ Insert two gloved fingers of RH until cervix is palpated
Clinical Pelvimetry
- Indication
- Measurements
- ## Formula for estimating fetal weight
Indications
- Delayed progress in labour
- Previous trauma or abnormal development of bony pelvis
Measurement:
Pelvic inlet - only diagonal conjugates can be measured:
- True conjugate - mid-pt of sacral promontory to sup border of pubic symphysis
- Obstetric conjugate - mid-pt of sac prom to nearest pt of pub symph (most clinically relevant)
- Diagonal conjugate - mid-pt of sac prom to inferior margin of pubic symphysis (usu 1.5cm greater than obs conjug)
Plane of greatest pelvic dimensions
Plane of least pelvic dimensions
- Interspinous diameter - narrowest in pelvis, ~10cm
- AP diameter
Pelvic outlet
- Intertuberous diameter - place knuckles of clenched fist between ischial tuberosities
