HISTORY AND EXAMINATION IN

OBSTETRICS AND GYNAECOLOGY

OBSTETRICS

History
- Detailed history and Examination for
the
assessment of mother and fetus,
identify risk factors in them and plan
management
1. Demographic details
- Name - Husband’s name
- Age - Age
- Education - Education
- Residence - Occupation
- Occupation - Consanguinity
- Date and Time
2. Main complaints
3. Obstetric History
4. Gynaecological History
5. History of present pregnancy
7. Past medical and surgical History
8. Family History
9. Social History
10. Drug History.
 1. Demographic details
 Age: Old associated with
 chromosomal abnormalities e.g. trisomy 21
Down's syndrome
 Medical disorders e.g diabetes and
hypertension
 Elderly primigravida (35 years) medical and
obstetric problem
 Multiple pregnancy (multipara) dizygotic twins
 Hydatidiform mole
 Young Age associated with
- per-eclampsia-eclampsia
- Consanguinity:
 Single gene inheritance Autosomal

recessive
 e.g sickle cell anaemia sex- linked e.g.

haemophilia
 2. Main Complaints
(3-4 complaints and duration)
2.1. Reason for admission or ante-natal visit
e.g. hypertension, Breech, repeated
caesaren section
2.2. Obstetric complaints Pain, Bleeding,
leakage liquor, absent foetal movement,
swelling
2.3. Medical or surgical Fever, vomiting,
cough
3. Obstetric History
3.1. Duration of marriage; infertility,
Assisted
3.2. Gravida Para Stillbirth Abortion
Gravida :
Total number of pregnancies irrespective of

outcome.
Used only if woman is currently pregnant.
 Para: Total number of all deliveries (alive
or stillbirth) that have reached 28 weeks
(24 weeks).
3.3. Detailed description of all previous
deliveries (28 weeks or more)
- Gestational age
- Ante-natal complications (hypertension-
anaemia - bleeding)
- Spontanous or induced (indication)

- Mode of delivery Spontanous vaginal,

caesarean section (indication), forceps
(indication) ventous (indication), Breech
extraction, Destructive operation
- Complications of delivery Bleeding,
Retained placenta
Baby
Alive, SB
 Weight
 Apparent malformation
 Apgar
 Condition now and age
- Purperium
 Normal
 Bleeding, fever, urinary, DVT,
anaemia, breast feeding.
3.4. Stillbirth
- Macerated: Intra- uterine foetal
death – 24 hours
- Fresh: Intra-partum asphyxia
- Gestational age
- Ante-natal complications
- spontaneous or induced
- mode of delivery
- congenital malformation
- weight
- Puerperium.
3.5. Abortion
- Gestational age
- Spontanous
- Blood transfusion
- Complications
(Bleeding – infection- perforation )
 Example:
- Married for 10 years
- Gravida VI Para III One SB One Abortion
- First pregnancy:
Term, no ante-natal complications,
spontaneous vaginal delivery without
complications, weight 3 kg, now alive and
well 8 years old, normal puerperium.
- second pregnancy: fresh still birth term,
Breech, assisted breech delivery, weight 3.5
kg , no congenital malformation. Normal
puerperium
- 6th pregnancy: Abortion
12 weeks, spontaneous, Evacuation done, had
two pints of blood.
4. Gynaecological History
4.1. Menarche: Age when first menstruation
4.2. Katamina – cycle length and beeding duration
4/28
4.3. LMP: Last Menstrual Period
4.4. EDD: Expected Date of Delivery
4.5. Regular or irregular: 4/28
4.6. Gestational age in weeks: EDD= 40 weeks
4.7. Use of contraceptive pills: 3 months prior
pregnancy
4.8. Dysmenorrhoea
4.9. Vaginal discharge (colour-amount- odour-
Blood-
itchy)
4.10. sexually transmitted Diseases
4.11. Most deliveries 37-42 weeks
- Factors making the calculation of pregnancy form LMP
unreliable:
- Uncertain dates
- Irregular periods (anything other than 28 days
regular eycle)
- Pills within 3 months before pregnancy
- Breast feeding within 2 months.
- Calculation of LMP in In Vitro fertilization (IVF)

Embryo Transfer = day 14

 Neagle's formula

 Gestational age from the LMP = 280 days-40

weeks
 365-90 = 275 +7 =282
Example:
- Menarche = 13 years
- Kata = 4/28
- LMP = 4.5.2008
- EDD = 11.2.2009
- Gestational age = 36/52
- No contraceptive pills in last 3
months prior preg
- white vaginal discharge itchy
5. History of present complains
 Example: Bleeding

 Duration, amount, pain, recurrent, causes.

6. History of Present Pregnancy

6.1. First trimester
Bleeding- hyperemesis- constipation – anaemia-
urinary problems- X-ray- drugs, U/S
6.2. Second trimester
Foetal movement from 20 weeks Bleeding,
liguor, U/S
6.3.Third Trim ester
Foetal movement
Bleeding – liquor
6.4. Any other complications or procedures (malaria,
immunization- screening)
7. Past Medical or Surgical History
7.1. Any PH of Medical – surgical
7.2. Diabetes, Hypertension, Renal, Heart,
Asthma, epilepsy, thyroid
7.3. Hospital admission- blood transfusion-
surgical operation.
 8. Family History

- Diabetes, hypertension
- Twins
- Malformed babies
9. Social History
 Residence, occupation, habits
10. Drug History
10.1. Allergy
10.2. Drugs used for long duration
steroids,
hypotensive, diabetic, epilepsy,
immunosuppersive druge, Asthma,
Psychiatric illnesses
10.3. Drugs using now.
Summary
Includes the followings
1. Name
2. Age
3. Gestational age
4. Obstetric history Gr Para Abortions
5. All abnormal deliveries
6. Main complaints
7. Significant PH, FH, SH, Drug
8. plan of management (if know)
9. condition now.
 Examination
 1. General Examination
 1.1. Postion comfortably in supine
position
 1.2. Right side of patient
 1.3. verbal consent
 1.4. General
Looks well or in pain, comfortable, not dayspneoe
short or tall, canula, catteter etc
1.5. Eyes: conjectiva, pallor. Sclera- jaundice
1.6. Mouth: Dental caries, artificial teeth, anaemia
1.7. Neck: Thyroid, jugular venous presuure,
lymph
nodes
1.8. Hand: nails for anaemia- palmer Ereythema
1.9. Pulse: rate, volume, regularity, collapsing,
vessel
wall, synchronus, femoral, Peripheral pulses
1.10. Blood Pressure Sitting or lying on left-side
1.11. Breasts: Scars, veins - Nipple
(protruding, fissures, cracks, infection)
- masses
 - Discharge (colostrums , milk, pus,

blood)
1.12. Heart
1.13. Respiratory
1.14 . Body Mass Index BMI=

Weight in Kg = 80 = 20
(Hight in meters) 2 2 × 2 = 4
2. Obstetric Examination
2.1. Inspection:
Distended – symmetrical- moves with
respiration – umbilicus – surgical scars-
striae gravidarum, linea nigra- ( feotal
movment if seen) Hernial orifices:
mainly anterior abdominal wall.

2.2. Superficial Palpation

- soft, firm, guarding
- Tender, not tender
- Mass
 Differential diagnosis of tender abdomen:
Labour, abruption, acute hydramios,
chorioamnionitis, red degeneration
fibroid,
twisted ovarian cyst, acute appendicitis,
renal stone, UTI, gall bladder stone or
infection, liver, peptic ulcer, acute
pancreatits, peritonitis, intestinal
obstruction, parasitic.
2.3 Deep palpation
Liver spleen kkidney
Difficult in advanced pregnancy

2.4. Obstetric Examination

- Fundal grip: which part occupies fundus

- Lateral grip: feel back (lie, position, FH)
- First pelvic grip: presentation
- Second pelvic grip: engagement
- Fetal Heart sounds
- Estimation of fetal weight and liquor
- Lower limbs (oedema- Voricose veins)

Vaginal examination is not a routine Done only if

there is an indication.
 Example:
- Looks well, not dayspnoeic, comfortable, tall
- not anaemicor jaundiced
- no dental caris or artificial teeth

- thyroid not enlarged

- Pulse 90 /min BP=110/70

- Breasts: nipple protruding, no fissure or cracks
no lump. Colostrums nipple discharge.
- Inspection:
Abdomen symmetrically distended, moves with
respiration, umbilicus flat, suprapubic
transverse incision scar, grid iron scar, no
hernia
- Superficial palpation: soft- not tender- no
masses
- Obstetric examination.
Fundal hight 34 weeks
Longitudinal lie- cephalic
Left occipito lateral
Head not engaged
Foetal heart heared
Average wt foetus, average amount of
liquor
- lower limbs: no oedema or varicose veins.
 GYNAECOLOGY
- History and Examination similar to
obstetrics with few differences and
modifications.
1. Age:
- Childhood: vulvovaginitis, Prercocious
Puberty
- Adolescence: Menstrual problems
- Fibroid 30 years+
- Ovarian cancer: menopause
- Cervical cancer: menopauce
- Endometrial cancer: menopauce
- Prolapse and incontince: menopauce
2. Main Compaints
 Abnormal uterine bleeding, dysmenorrhoe,
dysparunia, pelvic pain, mass, infertility,
urinary, vaginal discharge, Backache.
3. Abdominal mass
 Site, size, consistency, mobility, tender
smooth or irregular, ascites, pelviabdominal.
4. Vaginal examination:
- Indication, privacy , empty blader, good hight
third person
- inspection: vulva
- speculum: cervix
Digital; vaginal, cervix, fornices
- Bimanual; size of uterus, mobile, tender
consistency, adenerae.