History taking and examination

technique in obstetrics
Dr Sofiah Sulaiman
Dept. of Obs & Gyn Medical Faculty Univ Malaya
History

➢ Able to interview a patient and obtain relevant

information for clinical management

➢ Able to listen and ask appropriate questions for an

intended purpose during patient’s interview
Physical examination

• Able to perform physical examination and identify clinical signs

• Able to analyse and correlate symptoms and signs in order to make

a clinical diagnosis
History : introduction

• Name • Gravidity

• Age • Parity

• Occupation • LMP / EDD /gestational age

• Race • Booking status

Gravidity

• Term is used when a woman is pregnant at the time of clerking

• Refers to total number of pregnancies including the current

one.
Parity

• The number of livebirths and stillbirths delivered after

viability period (22 weeks)

• Miscarriages, ectopic, molar pregnancies – added to

parity (+)

• Multiple pregnancy – counted as 1 (not 2)

example

• A lady is currently in her 5th pregnancy and she delivered 3 children

prior to this and had 1 miscarriage.

• Gravida 5 Para 3 + 1
Exercise 1

• A lady who’s in her 8th pregnancy. She had 3 miscarriages and 1

ectopic pregnancy. She delivered 3 healthy children at term.

• Answer :

• Gravida 8
• Para 3 + 4
Exercise 2

1. A lady is currently in her 3rd pregnancy and she had 2 fetal

demised in utero; at 28 weeks gestation and 20 weeks gestation
• Answer : Gravida 3 Para 1 + 1

2. Pregnant for the 1st time with twins

• Answer : Gravida 1 Para 0
History : introduction

• LMP
EDD = LNMP + 9 mth + 7 days

• 1st day of last menstrual period ( Naegele’s rule ) if

regular cycle and sure of date

• Add 1 year and 7 days and subtract 3 months

History : introduction

• Dating scan EDD (1st trimester)

• Long cycles

• Irregular periods

• Using hormonal contraception

Period of gestation

• Terminology describes gestational age at clerking.

• Eg: LMP: 1/6/16

• Clerking at 1/1/17
• 7 months difference (28 weeks)
• Add a week for every 3 months (+2 weeks)
• = 30 weeks gestation
Presenting/chief complaint

• The symptoms or problem that brings the patient to the

hospital or to see a doctor.

• In patient own words

• If more than one, should be arranged in chronological

order
History of presenting illness

• Elaboration of chief complaint

• Describes the onset, nature, aggravating or relieving

factors

• The progression of illness/complaints

History of present pregnancy

• Details of pregnancy from the time of diagnosis.

• Eg planned or unplanned/ positive urinary pregnancy test

/ 1st visit to hospital(booking) / routine antenatal
invstigations results

• Screening for risk factors Screen for Hpt,GDM,STD



Past obstetrics history

If MANY babies
“From 1995-2017,she had 11 normal per
veginal bleeding, birth weight ranging from
2.15-3.56, at UMMC”

• Year • Antenatal problems

• Onset/Mode of delivery
• Complications – intra/post
partum
• Gestational age

• Place of birth • Baby details – gender/weight/

abn/livebirth
Past gynaecological history

• Age of menarche • Intermenstrual bleeding/

dysmenorrhea
• Menstruation history
• history of sepsis/PID/
gynaecological surgery
• Cycle
12 7–8
28 • PAP smear
• Flow
12:first age of menarche
7-8 flow period
28: cycle period
Past medical history

• DM / Hypertension /Chronic illnesses

• Important and relevant to the management of current

pregnancy

• Assessment of risk to the pregnancy and risk of pregnancy

to the disease
Past surgical history

• Appendisectomy

• tonsilectomy

Laparotomy :in case of emergency c-section

Drug history / allergies

• What medication - details

• Allergies – rashes/swollen

• Contraindicated in pregnancy?

• Change to other medications

Family history

• DM

• Hypertension

• Chromosomal/structural anomalies

• Multiple pregnancy
Social history

• Working hours

• Environment

• Support

Smoking hx
Drinking
Systemic review

• Description of other symptoms experience

• Not to missed - sytematic

Summary

• At the end

• One sentence

• Age/gravida/parity/period of gestation/chief complain

• Important/relevant history
Important!!!

• List of possible differential diagnosis

• Looking for certain signs during physical examination.

physical examination

• stand on the right side

• general examination

• specific examination
general examination

• well / distress / happy / sad

• height / weight

• calculate BMI
Hands

• pallor

• palmar erythema

• koilonychias - iron deficiency

• clubbing

• pulse rate/rhythm/volume
Blood pressure

• sitting

• arm - heart level and supported

• cuff - 2/3rd of arm and

encircling
• systolic - korotkoff 1
• diastolic - korotkoff 4 (muffling) Or propped up, left lateral: 3rd trimester
Bc false low BP dt << venous return
 Face / neck

• eyes - conjunctiva (pallor) / sclera (jaundice)

• mouth - angular stomatitis (IDA) / central cyanosis / mucous

membrane

• Thyroid - exophthalmos / goitre Physiological thyroid enlargement

Legs

• peripheral oedema

• press on the skin over tibia x 10 secs fluid retention

• could be physiological esp in 3rd trimester
• may be pathological if involve face / sacral (preclampsia)
Abdominal examination (obstetrics)

• lie flat on one pillow or slight left lateral if has difficulty in

breathing (supine hypotension)

• exposure : xiphisternum to symphysis pubis

• inspection / palpation / auscultation of fatal heart

• +- percussion
inspection

• enlargement of gravid uterus

purplish silvery white

• presence of linea nigra / striae gravidarum / striae albicans

• presence of surgical scar

• fetal movements (type / length / site )

• others (abn vessels / hernias )

Palpation

• Gentle and not causing pain

• keep glancing at her face

• cautious : placenta previa / premature contraction

• superficial and deep

superficial palpation

• To elicit whether the abdomen is soft and non tender (rigid and
tender)

• use the flat of your hands

• feel the whole abdomen in quadrants

• contractions can be felt

deep palpation

• palpate the uterus (anterior wall)

• to assess the fetal lie / presentation / liquor volume

• liver / spleen / kidneys / inguinal region

• site / size / shape / margin / mobility / tenderness / consistency

symphysio-fundal height

• clinical assessment

• 12 weeks - symphysis pubis

16 weeks - in between

• 22 weeks - umbilicus

• 36 weeks - xiphisternum
Symphysio-fundal height

• measured in centimetres

• measuring tape from fundus to symphysis pubis

• fundus is located by using the left hand (ulna side) from
xiphisternum downwards
• after 20 weeks

• = no of weeks (+-2 cm or 3 cm after 36 weeks)

Symphysio-fundal height (SFH)
fetal examination

• number of fetus - number of fetal poles (Head or bottom)

fetal pole is a thickening on the margin of the yolk sac of a fetus during pregnancy.
It is usually identified at 8 weeks with abdominal ultrasound imaging

• single fetus has 2 poles

• more than 2 poles may indicate multiple pregnancy or singleton

with uterine fibroid/ovarian mass
Fetal examination

• Leopold’s manoeuvre -

• fundal grip
• lateral grip
• pelvic grip

Head/bottom:harder,ballotable,rounde
r
Fetal lie

• longitudinal axis of the foetus in relation to the longitudinal axis of

the uterus

• longitudinal / transverse / oblique RUQ—>LIF

fetal presentation

• The lowest fatal part of the foetus in the uterus - above or

entering the pelvic brim

• cephalic / breech (longitudinal lie)

• head - pole feels harder / rounder and ballotable
• fixed / mobile - engagement
Cinciput/occiput
• oblique / transverse lie - shoulder / arm
Engagement

• Widest diameter of the fetal head (BPD) entered the pelvic brim

• described in fifths palpable above the symphysis pubis

<3/5th
• 2/5th, 1/5th and 0/5th palpable - engaged
• 3/5th, 4/5th and 5/5th palpable - not engaged
Fetal parts/back

• Palpable during lateral grip

• placement of cardio probe/fetoscope/pinard - fetal heart

• back - feels firm

• fetal parts - irregular / limbs movement

Liquor volume
Symphysial fundal height

• adequate - corresponding SFH/poles and parts felt

• polyhydramnios - uterus larger than dates

• difficult to feel fetal parts
• fluid thrill

• oligohydramnios - uterus smaller than dates

Auscultation

• Fetal heart - rate and rhythm

• placement of fetoscope - anterior shoulder/fetal back

• cephalic - lower right/left maternal abdomen
• breech - upper right/left maternal abdomen
Summary

• inspection:
• distended abdomen
• striae gravidarum/albicans
• linea nigra
• surgical scars
• fetal movement
summary : palpation/auscultation

• superficial-consistency/tenderness
• deep- irritable/contracting uterus
• singleton estimated fetal weight
• lie amount of liquor
• presentation fetal heart rate/rhythm
• engagement
• fetal parts
Thank you and good luck!