History Taking and Physical

Examination in Obstetrics
(For year C1 Students)

Zelalem A, MD.
History Taking
Basic Concepts in History Taking
• Respect, confidentiality and privacy during history
taking are crucial issues during history taking
• Information should flow in logical and chronological
sequence
• History taking should not be simply translating the
patients words into medical English language, but
should get the clinician to form a provisional
diagnosis that he/she would plan the examination and
investigation accordingly.
Components
1. Identification
2. Chief complaint
3. History of the present pregnancy/ illness
4. Past obstetrics history
5. Gynecologic history
6. Past medical and surgical history
7. Personal , Family and Social History
8. Review of systems
Obstetrics
1. Identification
– Name
– Age
– Address
– Marital Status
– Religion
– Date and time(of admission/ evaluation)
– Ward, bed no.
– Occupation
– ( Historian)
Obstetrics Cont…
• Name-
• Age
– <18yrs,>35yrs-high risk
– Many gynecologic illnesses are age dependent
• Address-
– home location, telephone, e mail, personal physician’s address,
– To contact the patient or her physician when needed
• Marital Status
– Married, single, divorced, widowed.
– Relation ship- monogamous, polygamous
• Religion
– Religious specific attitudes
• Date and time(of admission/ evaluation)
• Ward, bed no.
• Occupation
– To assess socioeconomic status
• ( Historian)
Obstetrics Cont…
2. Chief complaint
• The most important problem which pushed the patient or
client to seek medical attention
• Patient might have come for routine ANC follow up or with
specific complaint. Nausea and vomiting, vaginal bleeding,
head ache, etc.
• To elicit the chief complaint ask broad questions;-
– What brought you today?
– Tell me what has been going on.
– What is your problem?
– What are your complaints?
Obstetrics Cont…
3. History of the present pregnancy(illness)
Includes:
– Reproductive history
• Gravidity(i.e. number of pregnancies including the current
one) -all previous pregnancies-term live births, stillbirths,
abortions, ectopic pregnancies or molar pregnancy
• Parity-the number of pregnancy that have extended beyond
fetal viability (>_28weeks Ethiopia, >_20weeks WHO)
whether the fetus is delivered alive or dead.
– Prim parity, Multiparity, grand Multiparity
• Abortions- pregnancies terminated before viability
Obstetrics Cont…
• Reproductive history (Gravidity and parity) is explained by the
terminology Gravida X, Para Y, Abortion Z: where
– X is the total number of pregnancies (including this one).
– Y is the number of births beyond 28 weeks gestation.
– Z is the number of miscarriages or termination of pregnancies before 28 weeks
gestation.
• Example - a woman who is pregnant for the 4th time with 1
normal delivery at term, 1 termination at 9 weeks and 1
miscarriage at 16 weeks would be gravida 4, para 1, abortion 2.
Obstetrics Cont…
– Calculated Gestational Age and EDD-
• LNMP(-first day of last normal menstrual period.)
• GA is calculated starting from LNMP and reported in completed weeks
and days
• To calculate EDD or EDC we use Naegeles rule(if we are using
European Calendar 9 months+7days, for Ethiopian Calendar
LNMP+9months+10 days or
+5days if pagume is 5 or +4 if pagume is 6 and
is passed)
• Calculate gestational age in completed weeks and days
• Example
– LNMP to be considered reliable it should have been regular, no OCP for at least 3
months or 3 regular cycles,6 months after last Depo-Provera injection, 3 regular
cycles if lactating.
Obstetrics Cont…
• Calculate the EDD which is 40 weeks or 280 days after
LNMP
– Term pregnancy 37-42 completed weeks
– Preterm pregnancy<37 weeks
– Post term pregnancy>_42weeks.
*only 5% of women deliver on the expected day
• If LNMP is unknown, or unreliable, first trimester
ultrasound can be used and calculated from it.
Obstetrics Cont…
– (History of 1st trimester)
• Method of confirmation of pregnancy, general health (tiredness,
malaise, and other non-specific symptoms) bleeding ,pain.( Ectopic
pregnancy, misscariage) vaginal discharge, hyperemesis, urinary
problems investigations( ultrasound, blood and urine test ), drug history
(treatment), vaccination
– (History of second & third trimester)
• History of fetal movements symptoms(Quickening-maternal feeling of
fetal movement for the first time). It is used for dating pregnancy if
LNMP is unknown. Quickening for primigravida occurs at 16-18weeks.
• History of anemia, miscarriage, ectopic pregnancy, vaginal discharge,
UTI, hyper emesis gravidarum symptoms of APH, PIH, Diabetes,
preterm labor, ask for vaccination.
Obstetrics Cont…
– ANC status should be documented and if not followed the
reason should be sought.
• Regular use of folic acid, iron and calcium supplements
• Results of all antenatal blood tests- routine and specific. Results of
anomaly and other scans (details of results can be cross checked
with the notes).
– Elaborate the chief complaint
• Any complaint during the present pregnancy- eventful or
uneventful
• Onset, course, severity, duration
• What increases/ decreases the symptom
• Any associated symptom.
• Any investigation done, result, treatment taken and response.
Obstetrics Cont…
– Ask for danger signs
• vaginal bleeding
• leakage of liquor
• abdominal pain etc.
• fetal movements are asked to assess fetal wellbeing
– Other positive and negative statements are based
according to the patients complaints e.g. head
ache, blurring of vision, epigastric pain or
convulsion in hypertensive disorders of pregnancy
etc.
Obstetrics Cont…
– Post-natal History:
• Ask labor and delivery history and the postnatal period.
• Are you breast feeding the baby?
• Have you passed feces and urine?
• Ask about lochia /bleeding ?
• How is the baby doing?
• How is the mother doing?
Obstetrics Cont…
4. Past obstetrics history
• Document all information on each previous pregnancy in
chronological order
• Date of delivery - Complications
• Length of PG Pregnancy
• Weight and sex of infant Labor
• Length of labor Postpartum
• fetal presentation or with the Infant
• Type of delivery
– Spontaneous vaginal
– Induced vaginal
– Cesarean
– Spontaneous or elective abortion
– Most obstetric and Gynecologic problems are recurrent e.g. APH, PPH,
PROM, DM, C/S, ectopic pregnancy& abortion.
Obstetrics Cont…
5. Gynecologic history
– Contraception- use or need for any, type and duration
– Sexual history- including history of STD.
- Risk assessment of HIV/AIDS
– History of gynecologic operation- including history of circumcision,
prior uterine surgery like hysterectomy, metroplasty, D&C, E&C, MVA.
– Menstrual history;- age of menarche, interval between periods,
duration of flow amount and character of flow degree of discomfort.
*Normal menstrual cycle:1-8days of flow, 21-35days in
length, 10-80ml in amount, dark non clotting.
*Clotting of menstrual blood, increased no of pads used,
causing anemia indicate pathology.
Obstetrics Cont…
6. Past medical and surgical history
– Some medical conditions may have impact on the course of
the pregnancy or the pregnancy may have an impact on the
medical condition examples:
- Heart disease - Hypertension
- Dm - Epilepsy
- Thyroid disease - B asthma
- Any previous surgery - Kidney disease
- UTI - Autoimmune disease
- Psychiatric disorders - Hepatitis
- Venereal diseases - Blood transfusion
Obstetrics Cont…
– Pregnancy may aggravate medical illnesses the medical
disorders e.g. DM, hypertension, thyrotoxicosis of
hyperthyroidism.
– Previous blood transfusion may relate to hemolytic disease
of the new born.
– History of maternal infection during pregnancy e.g. STD,
rubella etc.
– Medications taken at any time during the pregnancy.
– Any allergies and their severity (anaphylaxis or a rash?).
Obstetrics Cont…
7. Personal , Family and Social History
– Early child hood history, number of siblings, whether
parents and siblings are alive or not. If dead reason for
death should be mentioned to cover familial reasons.
– Educational level, Economic status(income)
– Habits-smoking, alcohol and drug use may have a
deleterious effect on pregnancy e.g. fetal alcohol syndrome
Obstetrics Cont…
– Complication e.g. pre eclampsia, preterm labor, PROM,
etc.
– Family history-DM, hypertension, tuberculosis, twinning,
hereditary disease(DM., Hpt., thalassemia, sickle cell disease,
hemophilia) and chromosomal anomalies and
pregnancy induced hypertension, allergies, mental
disorders run in family.
– Congenital defects eg. neural tube defects, Down syndrome
Obstetrics Cont…
– Additional information includes
• Feelings towards the PG
• Whether the PG was planned, wanted
• Preference for sex of child
• Social supports available
• Experiences with mothering
• History of abuse in relationships
Obstetrics Cont…
8. Review of systems
– Review all the systems
– Effects of PG are seen in all systems.
• Special attention is given to:
– Reproductive system
– Cardiovascular system
• Endocrine system
– Diabetes
• Urinary tract
– Infection
– Kidney function
• Respiratory function
– May be compromised…
» later PG
» tocolytic therapy for preterm labor
Physical Examination
 General Recommendations
• Conducted in the environment that is aesthetically
pleasing to the patient
• The clinician should request permission (consent)before
starting a pelvic examination. Written consent is not
required, with the exception of examination under
anesthesia(EUA).
• Female assistant(chaperone) should be present
• Adequate gowning and draping to avoid embarrassment.
• Warm instruments, reassurance and adequate lighting
should be conducted thoroughly.
• General appearance
• Vital signs
– BP-measured in the sitting position or 30degree
left lateral tilt to avoid supine hypotension
syndrome due to vena caval compression.
– RR-1-4 breaths increase during pregnancy
– Height in cms-100(20% above or below this is the
normal range), weight gain>1kg/week is abnormal
• Height<150cms is risk for contracted pelvis(CPD)
• HEENT:-Emphasize on conjunctiva, sclera, and
teeth
• LGS:-thyroid, breast-detailed examination
• Nipple retraction-should be treated during pregnancy
so that it will not interfere with breast feeding
• Chest:-same as non pregnant
• CVS:-same –PMI may be deviated to the left.
• S3 gallop may be heard normally
• Functional systolic murmur<3/4 grade may be heard
• Abdomen:
– Inspection
• Distention-symmetrical/asymmetrical-tilted to the left, site of distention,
uniformity, shape and movement.
• linea nigra-mid line hyper pigmentation due to increased MSH during
pregnancy.
• Stria gravidarum-purplish marks on the abdomen due to the distention-
New strea gravidarum or old strea gravidarum (strea albicantes)
• umbilicus-flat, inverted or everted
• scars: non surgical or surgical- sub umbilical mid line or pfennestiel-
suprapubic transverse scar
• Distended veins
• Flanks –full or not
• visible fetal movement
• pulsatile mass
– Palpation
• Superficial palpation
– Look for any rigidity, tenderness, superficial mass, characterize
the mass, abdominal wall defect. Look for mass, and
organomegally. Characterize mass
Obstetric palpation(Leopold maneuver)
1st- Fundal palpation- has two purposes
– 1)Determination of fundal height
– 2)to know what occupies the fundus
1) Fundal height measurement:- after correcting for
dextrorotation .
There are two methods of measuring the fundal height.
a) Finger method:-
Below the umbilicus;- 1 finger=1 week
Above the umbilicus;- 1 finger=2 weeks
Uterus at symphasis =12 weeks
At the umbilicus-20 weeks
At xyphisternum-38 weeks
Midway b/n symphasis and umbilicus-16weeks
Midway b/n umbilicus and xiphisternum-28weeks
 b)Tape measurement:- symphasis fundal
height measurement in centimeters with
tape meter 2 weeks of actual gestational age
– Rule: SFH times 2 divided by 7= gestational age in lunar
months
– Johnson`s formula
weight=SFH(in centimeters)-12(11)times150gms
2) what occupies the fundus
• Soft, irregular, bulky mass= the breech
• Hard, round, ballot able mass=Head
2nd - lateral palpation:- has two purposes
To know the
1. lie
2. side of the back
a) Lie Definition-the longitudinal axis of the fetus in
relation to the longitudinal axis of the mother Longitudinal lie,
Transverse lie, Oblique lie
b)side of the back- to auscultate the FHR on that
side FHR can be auscultated at 20 weeks by using the Dee
Lee/Pinnard stethoscope
3rd - Pelvic palpation:-it has three purposes.
1) to know the presentation
2)descent of the presenting part
3)attitude of the fetal head
A)Presentation :-part of the fetus that occupies the lower uterine pole E.g.
cephalic presentation, Breech presentation, Shoulder
presentation
B)Descent:-is measured after identifying the anterior shoulder using rule
of 5th-5/5th
–floating, 4/5th –fixed, 2/5th engaged
C)Attitude:-relationship of the fetal parts to eachother(especially the fetal
head to the trunk):
-cephalic prominence on the side of the back=extended attitude
-cephalic prominence opposite to the side of the back=flexed attitude =normal
-the other is military attitude
4th - Pawlik’s grip:-It has two purposes
1) to know the presentation
2) descent of fetal head floating or fixed
• Purcussion:-Shifting and flank dullness and fluid trill-
ascitis, polyhydramnious
• Auscultation:-FHB first heard at the 20th week on the
side of the back
- Below the umbilicus in cephalic presentation
- Above umbilicus in breech presentation
- Flanks in OP position
Pelvic assesment
– Speculum examination and digital examination-refer to Gynecologic
session
– Done at twice during pregnancy unless otherwise indicated and in
labor.
1.Early during the first trimester
Purpose
-to diagnose pregnancy
-to date pregnancy accurately by measuring the uterin size
-to diagnose pelvic problems like ovarian cyst and uterin
anomalies& vaginal congenital anomalies like septa early.
2.Late in pregnancy(>37weeks)
Purpose:-
-pelvic assessment for the purpose of diagnosing contracted pelvis
-soft tissue assessment
-bony pelvis assessment:-assess pelvic inlet, mid cavity and outlet.
1. Pelvic evaluation
Inlet:-Diaginal conjugate-1.5cms=True conjugate(AP diameter) or is the sacral
promontory reachable?
Head fitting test(Muller-hillin’s maneuver)-to assess if the head can negotiate the pelvic
inlet
Mid cavity:-assess prominence of schial spines, sacrospinous ligament should
accommodate 2 fingers , concavity of sacrum, pelvic side walls straight, convergent or
divergent.
Outlet:-sub pubic arch should accommodate 2 fingers,the intertuberous diameter
should accommodate the four knuckles of the clenched fist and the coccryx should be
mobile.
 2.to assess the bishop score:- assess the status of cervcal
ripening for Induction. 5 factors assessed –cervical
effacement, dilatation, softening, position and station of
the presenting part.
3. In labour:-
– exaluate cervical dilatation, effacement, station of the presenting part
ascertain position, molding ,caput formation and evaluate the pelvis.
• GUS-CVAT or supra pubic tendernes
• Extrimities:-look for edema-pretibial and pedal(dependent
edema)-80%of normal gravidas can have it.
– Other areas to look of pathological(non dependent-edema)
• Facial edema sacral edema
• Tightening of ring (finger) abdominal wall edema

• CNS:-Reflex
-Consciousness
-Gross neurological deficit