Obstetrics Case History

- S.P.Kamthankar

History

Vitals
A …… Years old …..(religion) patient………. (name) , ………. By occupation,
Resident of ………. Married since ……..yrs to ………….(name of husband)
who is ………( occupation of husband ) by occupation and
class…..(socioeconomic status ) Patient came with ……..months
amenorrhoea and came to the hospital on.……(date) for regular ANC
check ups following the first examination on ……..(date) / with chief
complaint of
Swelling over left leg since 8 days

H/O Present Illness –

Patient came with H/O ……months of amenorrhoea
Patient was apparently all right …… Days back when she started
developing Swelling over left leg localised up to mid thighs since 8 days
Which was Insidious in onset gradually progressive in nature, appear in
early morning & does not relived after rest

Negative history

No H/o
No H/o
No H/o
No H/o
No H/o
 H/O Present pregnancy

Diagnosis of pregnancy
Number of ANC visits
Date of first visit
Registered or not
Iron , calcium , Folic acid supplements
Radiation exposure
Immunisation – 2 TT injections 1st dose
2nd dose
USG – number of foetuses
Live or not
Biometry – Bi parietal diameter , Abdominal girth & Femoral
length (For gestational age estimation )
Position of placenta
Amount of amniotic fluid
Expected date of delivery
Any other significance
Other investigations – HBsAg , HIV ,CBC ,Urine
Any complications associated – DM ,HTN etc.

Obstetrical History
No Type of Sex Birth Complications Complications Complications Age Present
Delivery Weight during during during health
Pregnancy / delivery / peurperium / status
uneventful uneventful uneventful
1 FTND M 2.5 kg - - - 4 Well
yrs. immunised
& Healthy
2
3
4

Points to highlighted during specific period of gestation –

1st trimester -
Diagnosis of pregnancy
 Nausea
Vomiting
Polyuria
Folic acid Tabs
PV bleed or Leak
2nd trimester –
TT toxoid inj.
Iron Tabs. & Ca. ++ tabs.
QUICKENING – mention in range of weeks ( primi – 20wks multi 16-
18wks)
USG (all parameters described above)

Menstrual history
Menarche at …… yrs.
Regularly menstruating women with 5 days of cycle and normal flow
LMP -
EDD = LMP + 9months & 7 days / LMP – 3 months + 7days
(if LMP not know judge by festival and calculate rough estimate for
month of delivery)
Present Gestational age- ……months )

Past history
No H/o similar complaints in past
No Any surgical history or Any Major medical illness
No H/o Heart diseases(Rheumatic) , Renal diseases , TB ,UTI , prior
hospitalization
Detailed h/o treatment received if any for the disease or present
pregnancy

Family history
No H/o preeclamptic or eclamptic toxaemia in close family (Autosomal
Recessive)
 No H/o TB, HTN ,Multiple pregnancy ,Recurrent pregnancy loss

Dietary history
Type of diet – vegetarian / mixed

Make table of calorie and proteins & write accordingly

The calorie intake of the chid is ……. Kcal against the daily requirements of ……. Kcal
& thus having the deficit / excess of ….. kcal of energy
The protein intakes of the child is ….. gm. against the daily requirements of …… gm &
thus having the deficit / excess of …. Gms of proteins

Personal history
Diet/appetite
sleep
bowel & bladder habits
Addictions – alcohol , smoking
Contraception used
Drug allergy

General Examination

Patient is conscious & well oriented in time , space and person

Built – average / poor
Nutrition – Good/Avg. / poor

Height-
Weight- (Single reading is not of much significance measure serially once / twice a
wk.)
Don’t take BMI

Temperature-
 Pulse - …….. regular rhythmic normal volume equal on both sides
BP - …….mmHg measured in Right arm supine position
(appearance of Muffling sound is considered as diastolic by auscultatory method )
Note - Roll Over Test – record BP in 15 degree left lateral position &
then measure in supine position immediately
Observe for the fall in diastolic BP
Positive test –diastolic BP increased due to
excess raised peripheral resistance in response to RAAS (Ang- II)
Respiratory Rate-

Pallor
Cyanosis
Icterus
Clubbing
Edema (physiologic is pedal below ankles B/L non dependent relieved
after 8-10 hrs. of rest )
Lymphadenopathy

Systemic Examination

Per Abdominal Examination

Inspection
Contour – uniformly enlarged after 2nd trimester
Apparent height of Uterus
Fullness of flanks on inspection
Umbilicus – everted / inverted.
Foetal movements – seen/not seen
Scar/incision marks – location transverse/vertical health(healthy
,unhealthy ,keloid) & dimension & name of surgery
Linea nigra
Stria gravidarum
Dilated veins

Palpation
 Symphysio-fundal height - …..cm
Fundal Height - …..WKs
Grips –
a. Pawlik/1st Pelvic – Hard globular ballotable structure s/o Head
b. Pelvic/2nd Pelvic - Convergence
c. Lateral – Right – Irregular knob like parts s/o Limb
Left – Hard Continuous resistant feel s/o Back
d. Fundal - Soft Irregular mass s/o Breech

Lie – Longitudinal /Transverse/Horizontal

Position – LOA /
Presentation – Cephalic / Breach / podalic
Engagement -
Attitude( only after PV Examination) – Flexion / Extension at neck
Presenting part ( only after PV Examination) – Vertex / Sacrum /
Acromian

(Note :- Head – hard ,globular & non ballot able structure.

Breech – soft ,knob like irregular structure.
Cord – hard continues structure )

Auscultation
Foetal heart sounds –
a. Present or not
b. Rate
c. Location – at junction of upper 1/4th and lower 3/4th of line joining
left ASIS & Umbilicus(Left Spino-umbalical line )

Vaginal Examination
Only if >37 wk.

Diagnosis
Gravida ……
Para ……
With …. Wks. of gestation is a case of
/ came for routine ANC checkup
Not in labour