Obstetrics Case Proforma Swapneel Shah

History taking

1. Name
2. Age
3. GPLAD
4. Active married life of
5. Occupation
6. Residence

7. Months of amenorrhea
8. Chief complaints
9. ODP
a. Ward course
b. Treatment given
c. Symptoms increased, decreased
d. Negative history
e. Rule out PIH, GDM, heart disease
i. History of headache, visual disturbances
ii. History of palpitations, chest pain, hemoptysis

10. Menstrual history

a. Menarche
b. LMP and EDD
c. Past menstrual cycles
i. Regularity
ii. Duration of the cycle
iii. Amount of bleeding
1. Number of days
2. Volume
iv. Associated pain.

11. Contraceptive history

a. Used/not used
b. If used
i. Type of contraceptive
ii. Duration of use
c. If conception was due to failure of contraception or stoppage of OC pills

12. Obstetric history

a. GPLDA
i. Example- No of months/years of active married life after which the patient
conceived for the 1st time and carried the pregnancy to full term without any
antenatal problems and had a spontaneous vaginal delivery of a male/female
child weighing __ kg, child alive and healthy/child died ____ months/years later
of pediatric cause.
ii. No of months/years after the first delivery patient conceived for the second
time

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Obstetrics Case Proforma Swapneel Shah
1. Amenorrhea period
2. Spontaneous abortion/live birth
a. Dilatation and Curettage done or not?
3. Hydramnios?
4. Premature delivery?
b. Weeks of gestation
c. Conception spontaneous/any treatment
d. UPT done?
e. USG done?
f. ANC registration
g. Medications, hematinics, calcium
i. If yes, how long?
h. Tetanus toxoid
i. Exposure to radiation (?)

13. Past history

a. ANC admission, similar complaints in the past
b. Medical/surgical illness
i. Drugs for chronic illnesses
c. Blood transfusion
d. HTN/DM/TB/Heart disease

14. Personal history

a. Diet
i. Vegetarian/mixed
ii. Lunch and dinner items- 2 major meals
iii. 3 subsidiary meals- breakfast, evening snack, prebedtime snack
iv. Average calorie intake
v. Average protein intake
vi. Adequate/inadequate?
b. Bowel
c. Bladder
d. Sleep
e. Appetite
f. Socioeconomic status (Kuppuswamy classification)
g. Drug allergy

General examination

1. Conscious, cooperative, well-oriented

2. Built, nourishment- good/average/poor
3. Temp, pulse, RR, BP
4. Height
5. Weight
6. Gait
7. Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
8. Platynychia, koilonychia
9. Glossitis, angular stomatitis
10. Thyroid swelling, JVP
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Obstetrics Case Proforma Swapneel Shah

Obstetric examination

1. Inspection
a. Swelling- globular/pyriform
b. Linea nigra, stria gravidarum, linea albicantes seen/not seen
c. Umbilicus vertically/transversely stretched/everted? – hydramnios/plural
pregnancy
d. Scars/sinuses
i. If present, position- vertical/midline/pfannenstiel
ii. Healing- well healed/keloid formation
2. Palpation
a. Clinical presentation of uterine size is _____ weeks (Bartholomew’s rule of fourths)
b. Fundal height is _____ cm measured along the contour of the uterus from pubic
symphysis after correction of dextrorotation of the uterus
c. Therefore, by MacDonald’s rule, gestational age in weeks= 8/7 x fundal height.
3. Leopold’s manoeuvres
a. Fundal grip
i. Firm, irregular, non-ballotable mass corresponds to fetal breech
b. Right lateral grip
i. Continuous board like resistance corresponds to fetal back
c. Left lateral grip
i. Multiple knob like structures which slip under the fingers on deep palpation-
fetal limbs
d. Pawlik’s first grip
i. Hard, globular, ballotable, non-ballotable- fetal head- floating or engaged
e. Deep pelvic grip (Pawlik’s second grip)
i. Convergence or divergence of fingers
4. Auscultation
a. Fetal heart sounds inside/outside the left spino umbilical line
b. Rhythm- regular or not.
c. Rate- ____ bpm

Breast examination
1. Development – normal or not
2. Nipple and areola- normal or not
a. No cracks, fissures or retracted nipple
b. No abnormal nipple discharge
c. No abnormal lump palpable

Respiratory system/Cardiovascular system

1. Breath sounds normal- whether rales/rhonchi are present

2. Heart sounds normal- no murmurs
Gastrointestinal examination

1. Liver/ spleen palpable/could not be felt because of enlarged uterus.

Diagnosis

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Obstetrics Case Proforma Swapneel Shah
Mrs ____, age _____, GPLAD, comes with _____months of amenorrhea with _____ weeks size uterus with
a single live fetus in longitudinal lie, flexed attitude, cephalic presentation, ______ as the presenting
part, which is floating/ engaged with medical/obstetric diagnosis e.g.________
Investigations

1. Hemoglobin
2. Blood grouping- give anti-D if required
3. HIV-ELISA
4. VDRL
5. Malformation scan- 18 to 20 weeks
6. FBS/PLBS
7. TT neonatal tetanus
8. Urine- sugar and protein
9. HBsAg
10. TSH- if increased, do free T3, T4.

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