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Clinical Approach to

Obstetric Patient
Remah M. Kamel, PhD, MRCOG, FICS.
Ass. Prof. Obstetrics & Gynaecology
Faculty of Medicine, J.U.

Personal History

2010

Name.
Age.
Sex ?
Race.
Address.
Occupation.
Marital Status ?
Special Habits of Medical importance.

Prof. Dr. Remah Kamel

Health Effects of Smoking on Mother

2010

Conception delay.
Reduced fertility.
Ectopic pregnancy.
Premature rupture of membranes.
Spontaneous abortion.
Placenta Previa.
Placental abruption.

Prof. Dr. Remah Kamel

Health Effects of Smoking on Fetus

2010

Preterm delivery.
Low birth weight.
Stillbirth Baby.
Perinatal mortality.
Small head circumference.
Low APGAR score.
Respiratory illnesses
Pneumonia.
Prof. Dr. Remah Kamel

Complaint
Give proper time for your patient to tell you about
her problem/s without any interruption.
This is best written down in the patient's own
words and phrases.
In many cases the patient may not complain of
anything except amenorrhea of certain duration
and she is coming for antenatal care.

2010

Prof. Dr. Remah Kamel

Common Complaints in The 1st Trimester


1- Cessation of Menses.
2- Nausea, Vomiting, Excessive salivation Ptyalism,
Bleeding gums with tooth-brushing.
3- Frequency of Micturition, Nocturia, Dysuria, Incomplete
emptying, Incontinence, Urgency.
4- Increased breast size with associated dark pigmentation,
tenderness and tingling sensation.
5- Fatigue, Weakness and Lack of Concentration. Feeling of
Warmth, and nasal obstruction/bleeding.
6- Changes in the Appetite.
7- Sleep Disturbances.
2010

Prof. Dr. Remah Kamel

Common Complaints in The 2nd / 3rd Trimester


1- Progressive Abdominal Enlargement, Indigestion,

Flatulence, Constipation.
2- Perception of Fetal Movements (Quickening).
3- Visualization of Fetal Movements.
4- Skin pigmentation.
5- Headache, Leg Cramps, Low backache, and
Fainting Attacks upon lying-down on bed.

2010

Prof. Dr. Remah Kamel

Even if no complaint is given ask about the


warning symptoms as:
1. Vaginal bleeding.
2. Gush of fluid per vagina.
3. Abdominal pain.
4. Persistent headache.
5. Blurring of vision.
6. Edema of hands or face.
7. Persistent vomiting.
8. Diminshed or absent fetal movements.
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Prof. Dr. Remah Kamel

Present History
Analysis of the present complaint/s:
Onset.
Course.
Duration.
The relation of various complaints to each other.
Referral sites of pain.
Factors aggravating it.
Factors relieving it.

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Prof. Dr. Remah Kamel

Menstrual History

Age at Menarche.
Regularity of the menstrual cycles.
Characters of menstrual blood loss.
Associated Symptoms.
Any recent changes in the cycle pattern.
Inter-menstrual Discharges / Pain.
Date of the last menstrual period (LMP).

2010

Prof. Dr. Remah Kamel

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Sexual History

Availability of the husband.


Frequency of Intercourse.
Dyspareunia.
Coital Positions.
Occurrence of Orgasm.
Use of Vaginal Lubricants.
Post-coital Vaginal Douching.

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Obstetric History

Number of the Living Dead Children.


Duration of each Pregnancy & Labour.
Date, Place, and Mode of each Delivery.
Number of Abortions, Duration, and the possible
Causes, any Surgical Intervention.
Last Delivery / Last Abortion.
Puerperium and Post-abortive periods: History of
Haemorrhage / Sepsis.
Breast feeding / Bottle feeding.
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Contraceptive History

Physiological Methods.
Barrier Methods.
Mechanical Methods.
Hormonal Methods.
Chemical Methods.
Sterilization ?

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Past History
Medical History: as syphilis, gonorrhoea,
diabetes, hypertension, chronic nephritis, heart
disease etc.....
Surgical History: specially involving the uterus as
myomectomy, C.S.
Any trauma to the pelvis, spine and lower limbs.
Hormonal Replacement Therapy ?

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Socio-Economic History

Work of the Husband and Wife.


Current living conditions.
Level of education.
Average family income.

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Family History

Diabetes.
Hypertension.
Genetic diseases.
Twins delivery.
Breast Cancer.

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Immunization History
Tetanus-Diphtheria booster x10 years.
High-risk groups: Pre-conceptional
Vaccination:
MMR vaccine.
Hepatitis-B vaccine.
Influenza vaccine.
Pneumococcal vaccine.

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History related to Other Systems

Autonomic / C.N.S.
Eye / Ear / Nose / Throat / Teeth / Gums.
Chest.
Breast.
Cardio-Vascular System.
Gastrointestinal Tract.
Urinary System.
Musculo-Skeletal System.

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General Examination
Patient Gait.
Body Height in Cm and Weight in Kg.
Vital Signs: Pulse, Blood Pressure,
Temperature, and Respiratory Rate.
Body Hair Distribution.
Secondary Sexual Characters.
Upper / Lower Limbs: for oedema,
varicose veins & deformities.
The back, for lordosis and any deformity.
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Head & neck examined for:


Eyes for jaundice & edema of the eye-lids.
Pallor, pigmentations & septic foci in the
teeth or tonsils.
The neck for goiter, enlarged lymph
nodes & congested neck veins.

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Breast Examination

1. Approximately every 3 minutes a woman is


diagnosed with breast cancer.
2. Approximately every 12 minutes breast
cancer claims another life.
3. 70% of breast cancer cases occur in
women who have no risk factors.
4. An estimated 40,600 deaths (40,200
women, 400 men) from breast cancer are
expected next year.
5. Breast cancer ranks the 2nd among cancer
deaths in women.
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Breast Signs of Pregnancy

It is more pronounced in Primigravidas:


Increased in size and vascularity.
Increased pigmentation of the nipple & areola.
Appearance of the secondary areola.
Montgomery's tubercles on the areola (dilated
sebaceous glands).
Expression of clostrum-like fluid from the nipple.

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Chest / Heart Examination

Inspection.
Palpation.
Percussion.
Auscultation.

The enlarged uterus displaces the diaphragm up to 4 cm.


This result in :
1. The diaphragmatic mobility is reduced and respiration
becomes mainly thoracic.
2. Widen the subcostal angle and increases the
transverse diameter of the chest.
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Change in cardiac outline that occurs in pregnancy. The


light lines represent the relations between the heart and
thorax in the non-pregnant woman, and the heavy lines
represent the conditions existing in pregnancy.
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The 1st heart sound becomes louder before midpregnancy.


Systolic functional murmurs develop in most of
women, usually early systolic, but mid-systolic
murmurs may occur and heard over the left sternal
edge.
The main features of ECG may be attributed to the
changes in the position of the heart: the axis
undergoes left shift by 15-28, the QRS complex
becomes of low voltage, and T-wave becomes
flattened.

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Abdominal Examination

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Inspection.
Palpation.
Percussion.
Auscultation.

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Abdominal Inspection:
The size of abdomen & whether over-sized or undersized.
Pendulous abdomen is detected in the standing
position.
Abdominal Contour: (vertical swelling in longitudinal lie,
and transverse swelling in oblique lie).
Localized bulge in the hypochondrium e.g. the head of
a breech presentation.
Fetal limb movements.
Scars as a cesarean section scar.
Striae gravidarum (rubra/alba) and pigmentations as
linea nigra.
Masses as umbilical hernia.
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Abdominal Palpation:

During palpation the examiner should stand on


the right side of the patient facing her face.
Superficial palpation, for tenderness &
rigidity.
Deep palpation to examine the abdominal
organs and the enlarged gravid uterus.

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Obstetric Palpation (Maneuvers of Leopold)

1. Fundal Level:
It is done by the ulnar border of the left hand
starting at the xiphisternum after centralizing
the uterus to correct its dextro-rotation. After
engagement, the fundal level descends to the
level of 32 weeks.

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The differences between


The 32 weeks and term (40 weeks):
1. The period of amenorrhea suggests the
gestational age.
2. The date of quickening.
3. Engagement of fetal head suggests a term fetus.
4. Lightening & pelvic pressure symptoms: At 40
weeks, the fundus of the uterus is felt broader,
and shelving (due to slight forward fall of fundus).
5. The size of the fetus & the fundus of the uterus
also helps.
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2. Fundal Grip:
The fundus of the uterus is palpated
by both hands to detect the part of
the fetus occupying the fundus i.e.
breech in 96% or head in 3.5%.
Breech is large, soft, irregular,
does not ballot and there is no
groove between it and the back.
Head is small, hard, globular,
ballots, there is a groove between it
and the back and it may be tender.
The fundus is empty in transverse lie.
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3- Lateral (Umbilical) Grip:


The uterus is fixed by one hand at the
level of the umbilicus while the other
hand perform palpation then both
hands are alternated:
1. To palpate the back which is felt
smooth, firm and convex.
2. To palpate the limbs which are felt
as mobile knobs.
3. In transverse lie the head is felt on
one side and the breech on the other.
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If the back is posterior it is felt with


difficulty away from the middle line and
the limbs are felt with ease near or on
both sides of the middle line. Follow the
back to reach the head, the 1st. bony
prominence before the head is the
anterior shoulder.

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4- First Pelvic Grip (Pawlick Grip):


The hand is placed on the
symphysis pubis with the thumb
parallel to one inguinal ligament &
the 4 fingers parallel to the other. It
is done for:
1. Detection of the part of the fetus
occupying the lower part of the
uterus.
2. Detection of engagement: It is not
felt if engaged.

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5- Second Pelvic Grip:


Facing the patient's feet both hands
are pushed towards the pelvis:
1. To detect the degree of flexion of
the head (if the occiput is at a lower
level than the sinciput, the head is
flexed).
2. To detect the engaged head of an
un-suspected twin.

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In addition to the above;


(1) We palpate the abdomen systematically by
superficial and deep palpation to detect any
abnormality.
(2) We examine for fluid thrill by the palm of the
hand placed on one side of the middle line of
the uterus. The uterus is tapped on the other
side by one finger of the other hand. The
ulnar border of one of the patient's hands is
put on the middle line of the uterus.

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Auscultation of Fetal Heart Sounds (FHS)


FHS is heard by Pinard's stethoscope or the sonicaide.
Normally the FHS are 120-160 b/m, regular tic-tac rhythm.
The point of maximum intensity of the FHS is heard through
the anterior scapula & is determined by the fetal position e.g.
1. In occipito-anterior (OA) FHS are heard below the
umbilicus near the midline at the middle of a line joining
the umbilicus & anterior superior iliac spine
2. In occipito-posterior (OP) FHS are heard below the
umbilicus in the flank.
3. In breech presentation FHS are heard above umbilicus
4. In transverse lie on one side of umbilicus towards head
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Values of auscultations of FHS:


1. It is a sure sign of pregnancy.
2. It gives an idea of the fetal position &
presentation.
3. Diagnosis of intrauterine fetal death (IUFD).
4. Diagnosis of fetal distress (FHR above 160
or below 100 or irregular indicates foetal
distress).
5. Diagnosis of twins.

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Differential diagnosis of the FHS:

1. Uterine Souffle: It is a soft blowing murmur sound


coinciding with the maternal pulse. It is due to
increased blood flow in the dilated maternal
uterine vessels.
2. Umbilical Souffle: It is a soft blowing sound
coinciding with the fetal pulse. It is due to blood
flow in the umbilical vessels.
3. Sounds of fetal movements.
4. Aortic pulsations: coinciding with maternal
pulsations.
5. Intestinal sounds: irregular slow sounds.
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Pelvic Examination
Prerequisites

The presence of a third party, preferably


a female relative or a nurse.
The consent of the patient. If she is less
than 18 years of age, take a consent from
her husband/parents.
The patient's bladder must be empty.

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Vaginal Examination
Gloves and instruments, if not disposable,
should be sterilized by autoclaving before
being used again.
Washing and boiling offer inadequate
protection against the real risk of transferring
Trichomonas & Monilia organisms from one
woman to another.

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Positioning the Patient

Raise the patients head so that eye contact


is possible.
Drape the sheet around her legs and arrange
so that you can see the patient and only the
perineum is visible.
Dont say things like spread your legs or it
looks good. Say let your legs relax out to
here and show her how, and say
everything looks healthy

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Indications of vaginal examination

1. Any complication during early pregnancy e.g.


bleeding or discharge.
2. At the 36th week to perform Cephalo-Pelvic
Disproportion tests (Examination of bony pelvis
+ Measure diagonal conjugate diameter + doing
Muller-Kerr Test) if the head is not engaged in a
primigravida.
3. During labor: to assess the stage and progress
of labour.

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1- Inspection:
Any anatomical abnormality in the Vulva.
Any abnormal swelling / mass / tumour.
Examine the orifices of Bartholin's glands and
external urethral meatus for any redness or
abnormal discharges.
The patient is then asked to cough to detect
stress incontinence.
The perineum is next examined for old tear,
presence or absence of piles, fissures, or fistulae.
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2- Digital Palpation:
The cervix: noting its size; shape; consistency;
mobility; level; dilatation; direction of the external
os; any bleeding when the finger comes in contact
with the cervix.
The vaginal walls: palpated for any mass or ulcer.
The structures in relation to the vagina: can be
felt by deeper palpation. The bladder and urethra
can be palpated through the anterior vaginal wall,
and the rectum and pouch of Douglas through the
posterior vaginal wall.
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Bartholin's glands: are palpated to detect any


swelling.
The condition of the levator ani muscles can
be determined by two fingers in the vagina, and
the thumb on the perineum, and asking the
patient to cough to feel the muscle as it contracts.
The amount and character of discharges on
the examining fingers are noted.

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3- Bimanual Examination:
Two fingers of the right hand are placed in the
anterior vaginal fornix, while the left hand is
placed flat on the lower abdomen. On pressing
both hands together, the uterus can be palpated
between the fingers of the two hands.
After palpating the uterus, the vaginal fingers are
placed in one of the lateral fornices, while the left
hand is placed lateral to the uterus, and an
attempt is made to palpate the adnexa between
the fingers of both hands.
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4- Speculum Examination:
The next step is inspection of the cervix and
vaginal walls by the aid of a speculum.
The one commonly used is Cusco's bivalve
Speculum, which has the advantage of being
self-retaining, and gives a good exposure of
the cervix and a large part of the vagina.

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5- Rectal Examination:
Rectal examination is indicated in:
1. Any patient complaining of rectal symptoms.
2. Cases with piles or anal fissures.
3. Chronic Constipation.
4. Assessment of pelvic floor muscles.
5. Cases with complete perineal tear.

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DIAGNOSIS
(1) Gravidity and Partity.
(2) Duration of pregnancy in Weeks.
(3) Lie, Presentation and Position.
(4) Engagement.
(5) Degree of flexion of the head.
(6) Associated medical complications.
(7) Any previous Operation/s.
Sometimes, 4 digits code are written which are: No. of
term deliveries; No. of preterm deliveries; No. of
abortions; and No. of living children. e.g. Para 2 0 1 2
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Differential Diagnosis of Early Pregnancy


Other causes of Amenorrhoea.
Causes of diffuse enlargement of uterus: as
single submucous or single interstitial fundal
Fibroid, Metropathia haemorrhagica, diffuse
Adenomyosis, Haematometra, pyometra,
subinvoluted uterus.
Extra-uterine Swellings: as Ovarian or Tubal
swellings, Pelvic haematocele, Full-bladder.

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Differential Diagnosis of Late Pregnancy

2010

Fibroids.
Ovarian Tumours: androgenic tumours.
Ascites.
Pseudocyesis.
Other causes of Pelvi-abdominal swellings:
as vesicular mole, encysted tuberculous
peritonitis, advanced uterine body tumours.

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Thank You

Remah M. Kamel, PhD, MRCOG, FICS.


Ass. Prof. Obstetrics & Gynaecology
Faculty of Medicine, J.U.

2010

Prof. Dr. Remah Kamel

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