History taking in obstetrics and - PowerPoint Presentation

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History taking in obstetrics and obsterical examination

Essential etiquettes

Seek permission to enter the area where the patient is

Be very careful with the dress code

Make sure you are wearing your identity badge

Be courteous ,sensitive and gentle

Always have a chaperone present

Switch off your mobile

Template of an obstetric history

Personal history

Presenting complaints

History of presenting complaints

Course in the hospital

History of present pregnancy

Past obstetric history

Menstrual history

Contraceptive history

Past medical &surgical history

Drug history and allergies

Family history.

Social history

Systemic review

Summary

1-Personal and social history

Name ,age ,nationality ,occupation ,marital status and adress.Hasband name ,age ,occupation ,consanguity.

Blood groups and Rh for both.

Gravida :is the number of times the woman has been pregnant regardless of the out come of the pregnancy.

Parity is the total number of deliveries either live or still birth after the viability (24 weeks)

LMP/EDD/Duration of gestation

LMP=First day of the last menstrual period .Establish the patients certainty of date, the regularity of cycle and the use of contraception.

EDD=expected date of delivery

Naegles rule

EDD=+7 days – 3monthes +1 to the year or

EDD=LMP+9months +7days or it calculated from obstetric wheel

Chief complaint

Main complaint and duration of the symptoms that make the patient seek medical help

Common obstetric symptoms are :bleeding per vagina , abdominal pain , urinary symptoms ,headache , reduced fetal movement , contractions , PROM

etcetera .

History of present illness

Onset , course , severity , duration .

What increase /decreases the symptoms .

Associated other symptoms .

Investigations done (date ,place &results)

Treatment received (details &response)

Any complications .

History of present pregnancy

Planned / unplanned pregnancy .

Antenatal care –

number

of visits ,any high risk factors identified , results of investigations including early US , any problems in

each

trimesters , what medication is being taken

Adequate weight gain , BP , Protein urea

.History of vaccination.

Past obstetrical history

State the

gravida

and parity status and then give the following details of all her

pregnancies

:Date , place , mode of delivery (normal or CS )

Maturity , fetal sex , weight .,onset of labor any complications ,breast feeding .If long obstetrical history one may

summaries e.g.

she had 8 children ,all are normal vaginal deliveries ,breast feeding ,no complications

Gynecological history

Menarche ,her cycle regular or not .dysmenorrhea , intermenstrual bleeding .

Any contraception used before ,type .

Any gynecological operation she had .

Any vaginal discharge .

Family history

Family history of chronic illness like HT , DM. Any inherited disease ,family history of congenital anomalies , multiple pregnancy .

Social history :occupation ,income ,level of educations , smoking, drugs abuse .

Drugs history :any drugs used ,allergy

Past medical history :

Past surgical history :

Review of system

Examination :

Consent, privacy , female nurse present.

General examination :color , examination of pallor in the palm and congectiva and mucous membrane of the tongue .

Cloasma

of face .the presence of edema .

Vital sign (pulse ,BP ,Temp ,respiratory rate )

Systemic examination of head and neck ,cardiovascular ,respiratory system.

Obstetric examination

Inspection of the abdomen for distension ,symmetry , striae

gravid arum

,lina nigra ,scars of previous operation , edema ,fetal movement if present .

Palpation for any tenderness .

Examination for fundal height by ulner border of left hand starting from xiphysternum

downward

till you feel the

fundus

.

Symphysis fundal height measurement by tape measure in cm ,the measurement equal to gestational age in weeks .A large SFH may be due to wrong date ,macrosomia ,multiple pregnancy ,polyhydramnios .A small SFH may be due to oligohydramnios .

Fundal grip palpate the fundal region by the two hand to feel what occupy the fundal region .

Lateral examination to feel the back on which side ,estimate the amount of liquor and determine the fetal lie .

Pelvic maneuver by using the two hand to feel the presenting part ,the head is hard round while the breech is soft .

Pawlick grip try to hold the head between the thumb and index to see is it fix to pelvis or free .

Auscultation : Try to listen to fetal heart by fetal stethoscope or sonic aid usually on fetal back in one of iliac fossa bellow the umbilicus while in breech F H above umbilicus .

Vaginal examination :

Inspect the vulva for any abnormality

Vaginal examination for cervical dilatation ,cervical consistency ,effacement ,position of cervix (bishop score ) and station (level of presenting part to ischial spine