APPROACH TO OBSTETRIC PATIENT

HISTORY TAKING
Always introduce yourself
Respect, confidentiality and privacy during history
taking
Need a chaperon if you are a male
It

is vital that the history taker is sensitive to each

individual situation and does not simply follow a

The elements that need to be considered are those factors that would be
relevant to or have an impact in (1) coming to a diagnosis and (2)
management of patient
Patients particulars
Name, Age, Race, Marital Status, Occupation, Gravidity and Parity
Age (particularly concerned about very young & the elderly)
Very
young
(<18 y/o)
Elderly
(>35
y/o)

Higher perinatal morbidity and mortality as it associated

with late antenatal booking, complacency on mothers part
& inability of mother to cope with pregnancy due to
immaturity
Especially if she is primigravida, pregnancy is associated
with higher risk of miscarriages, higher incidence of fetal
malformations or medical disorders & more likely to have
dysfucntional labour

Parity status
- Primigravida and grandmultipara associated with certain problems:
Primigravi

Pre-eclampsia, dusfunctional labour and instrumental

da
Multipara

deliveries
Anemia, placenta previa, malpresentation, postpartum
hemorrhage

Gravidity

(G)

no.

of

conception

include

current

pregnancy

(regardless of outcome)
Parity (P) no. of viable pregnancy (reaches beyond 24 weeks
gestation)
Abortion (A) no. of pregnancy terminated before 24 weeks gestation

Example:
o G3P2 currently in the 3rd pregnancy and has delivered 2 babies >
24 weeks
o G3P1A1 (G3P1+1) currently in the 3rd pregnancy and has

delivered 1 babies >

24 weeks and 1 miscarriage
Last menstrual period (LMP) to calculate
a) Expected date of delivery (EDD)
- Computed from 1st day of last menstrual period (LMP) as stated by
-

Naegeles rule
Counting forward by nine months and adding 7 days
If the menstrual cycle is longer than 28 days, add the dfference
between cycle length and 28 to compensate
Naegeles rule cannot be applied in the following condition:
o Irregular menstrual cycle (Shortened / Lengthened)
o Unreliable as they long forgotten their LMP date
o Has been on oral contraceptive prior to missing her periods (as
few cycles after stopping oral contraception may be anovulatory)
Patient must be informed that she may go into labour either before
or after her EDD as term is actually defined as 37-42 weeks
hence, EDD shoud ideally be defined as a range of date between 37-

42 weeks rather than a fixed date

Example:
LMP : 7th March 2012
EDD : 14th December 2012

b) Period of amenorrhea (POA)

- Example:
LMP : 7th March 2012
Period of clerking: 12nd July 2012
POA : 18 weeks
Date of admission and clerking
Presenting complaint
Ask the patient to tell you more about how things are going
Identify and state the problem concisely and adequately
- Diagnosed to have twin pregnancy by ultrasound examination done at
14 weeks
- History of antepartum hemorrhage at 34 weeks of gestation
Example:
Current complaint:- Fresh vaginal bleeding for 2 days
Relevant:- How does it occur, How much, Is the bleeding progressively
becoming more, Any associated pain, Investigation or treatment received

(details and response), Does the bleeding affect the well-being of baby,
etc
History of current pregnancy
When was pregnancy suspected? Any pregnancy symptoms (i.e. nausea
or vomiting)
Is it planned or unplanned?
- If unplanned, how did she react? Did she consider termination?
- How did her partner/ family react?
- Has it caused any problems with them, has these been resolved?
When was the pregnancy confirm and how?
Details of 1st, 2nd and 3rd trimester progress
- 1st Excessive vomiting, Bleeding (Miscarriage), Pain (Ectopic
pregnancy)
- 2nd Rupture of amniotic fluid, Bleeding, Pain (Preterm labour)
Laboratory test & ultrasound scanning
Antenatal booking (BMI & BP), visit? How often & its progress?
Fetal movement (quickening)
Primigravid

Usually first felt fetal movement between 18 to 20

a
Multipara

weeks
Commonly the first movement felt between 16 to 18
weeks

Armed with this information, date of quickening can be used to cross-

check the date of last menstrual period to see if they coincide

Any medication taken during this pregnancy
- Specific name, Amount being taken, Route & Frequency

of

administration; How well and How long it has been / is being taken
when needed
Example:
- Puan Mariam realized she was pregnant when she missed three
months of her menstrual period associated with pregnancy symptoms
such as nausea and vomiting which mainly occurs in the morning. The
-

pregnancy was confirmed by urine pregnancy test and ultrasound.

This is a planned pregnancy and she is very sure of the date of her last
menstrual period and this makes her EDD on the 21 st November 2011.
Antenatal booking was done MCHC at Sungai Buloh on the 16 th April
2011 at 12 weeks of pregnancy.

Routine urine and blood test was

done and reported as normal. An ultrasound confirm singleton

pregnancy which correspond to dates.

She was given 3 types of medication (name) and took them regularly.
She attended her antenatal check-up regularly. There was no
complication during the first, second and early third trimester when
she complained of passing out fresh blood from the vagina.

Past obstretric history

Important for establishing risk in current pregnancy
List the pregnancies in date order
Details of each pregnancy
- Date/year, Place of birth, Gestation week, Mode of delivery
- Antenatal period Normal or Complicated
- Sex, Weight, Curent health of the baby, Duration of breastfeeding
- Problems during labour & Postnatal complications
- Miscarriages & Terminations
- Example:
2012 Full term uncomplicated pregnancy ended in a spontaneous
vaginal delivery at 39 weeks, normal progress of labour, delivered live
baby boy weighing 3.5 kg. Postpartum period was uneventful.

The

baby was breastfed for 6 months, alive and healthy.

Features that likely to have impact on further pregnancies:
- Preterm delivery
- Early onset pre-eclampsia
- Abruption
- Congenital abnormality
- Macrosomic baby
- Recurrent miscarriage Increase risk of miscarriage, Fetal growth
-

restriction (FGR)
Unexplained stillbirth increased risk of GDM (perform OGTT to exlude
diabetes)

Menstrual history
Age of menarche
Regularity or irregularity of her menstrual periods over the last few
months
- Regular relevant to date pregnancy accurately
- Irregular best to redate the pregnancy from an early ultrasound
examination
Menstural blood flow for how many days?
Volume (Normal, Moderate, Heavy)
- Normal, Menorrhagia, Oligomenorrhea
- Polymenorrhea, Metorrhagia (breakthrough bleeding)
Any clots (correlate to cents sized) or flooding

 Any associated dysmenorrhea or intermenstrual (IMB) or postcoital

bleeding
Gynaecology history
Contraceptive history
- What method? When started and stop? Why stop? Any side effects?
- Relevant if conception has occurred soon after combined oral
contraceptive pill (OCP) or depot progesterone preparations have
-

stopped
OCP taken during early pregnancy have been associated with birth

defects
Retained intrauterine devices (IUDs) cause early pregnancy loss
(miscarriages), infection and premature delivery

Cervical / pap smear

- When, where does the last smear been done? How was the results?
- Awareness and compliance on follow up
- Gently taking a smear in first trimester does not cause miscarriages
Previous episodes
a) Pelvic inflammatory disease
- Increase risk of ectopic pregnancy
- To establish any infections that have been adequately treated
b) Ectopic pregnancy
- Required to know site of ectopic and how it was managed
- Implication of straightforward salpingectomy for ampullary ectopic
-

much less than those after complex operation for a cornual ectopic
Offered an early ultrasound scan to establish site of any future
pregnancies

c) Knife cone biopsy

- Associated with increased risk for both cervical incompetence and
stenosis

leading to preterm delivery and dystocia in labour

respectively
d) Recurrent miscarriages
- Antiphospholipid syndrome
Increases risk of further pregnancy loss, FGR and pre-eclampsia
- Balanced translocation lead to congenital abnormality
- Cervical incompetence predispose to late 2nd and early 3rd
trimester delivery
Previous gynaecological surgery
- Important as this can have potential sequelae for delivery

Presence of pelvic massess (ovarian cysts and fibroids) impact on

delivery

Previous sub-fertility history

- Ovarian hyperstimulation syndrome following IVF
- Donor egg or sperm use increased risk of pre-eclampsia
- Preterm delivery higher in assisted conception pregnancies
Medical and surgical history
All pre-existing medical disease should be carefully noted
Major pre-existing disease that impact on pregnancy and their
potential effects
Diabetes mellitus

Macrosomia, Fetal growth retardation, Preeclampsia, Congenital abnormality, Stillbirth,

Hypertension
Renal disease

Neonatal hypoglycemia
Pre-eclampsia
Worsening renal, Pre-eclampsia, FGR, Preterm

Epilepsy
Venous

delivery
Increased fit frequency, Congenital abnormality
If associated thrombophilia, theres increase risk

thromboembolic

of thromboembolism, pre-eclampsia, FGR

disease
HIV
CT disorders
Myasthenia gravis /

Risk of mother-to-child transfer if untreated

Pre-eclampsia, FGR
Fetal neurological effects, Increased maternal

Myotonic dystrophy

muscular fatigue in labour

Surgical procedure
- Should be recorded chronologically, include date, hospital, surgeon &
-

complication
Trauma (i.e. A fractured pelvis may result in diminished pelvic capacity)
Blood transfusion

Psychiatric illness
- Enquiries include severity of illness, care received and clinical
-

presentation
Leading question: Have you ever suffered with your nerves?
If women have had child before, any problem with depression/the blues
after births

Women with any significant psychiatric problems should be cared for

by multidisciplinary team including midwife, GP, consultant &
psychiatric team

Drug and allergy history

Vital to establish what drugs women have been taking and duration
Pregnancy medication (i.e. Folates, Anti-emetics, etc)
OTC drugs & Homeopathic / Herbal remedies
Recreational drugs
Allergy (note the type and timing of reaction) Rashes / Anaphylactic
shock

Family history
Impact on mothers health during/after pregnancy & having implications
for fetus
Maternal history of 1st degree relative (sibling or parents) with
- Diabetes, Thromboembolic disease, Pre-eclampsia
- Serious psychiatric disorder (As theres increased risk of puerperal
psychosis)
Family history of babies with congenital abnormality (Down syndrome),
Potential genetic problems (i.e. Hemoglobinopathies)
Any twins or triplet in the family
Any known allergies How it was diagnosed? What sort of problems it
cause?
Social history
Marital status (Single/Married/Widowed/Separated/Divorced)
Occupation (both wife and husband)
- Exposure to solvents (CaCl4) / insulators (polychlorobromine
compounds)
leads to teratogenesis or hepatic toxocity
What sort of housing the patient occupies (i.e. A flat wit lots of stairs and
no lift)
Smoking / Alcohol consumption / Illicit drug intake
- Smoking causes reduction in birth weight in dose-dependent way,
-

increases risk of miscarriages, stillbirth and neonatal death

Binge drinking leads to fetal alcohol syndrome (constellation of

features in baby)
Domestic violence (emotional threat from partners or relatives)
Nutritional status
Financial problem & Childcare arrangement followed delivery

Summary (example)
Puan ABC, a 32-year-old teacher who is currently in her third pregnancy
at 32 weeks presented with a two day history of antepartum
haemorrhage. Her baby has been actively moving and she has no
abdominal pain and not in labour.

GENERAL EXAMINATION
Its purpose is to detect certain clinical features that may have an impact
or bearing on management of patient
Always start with observing the general disposition of patient
In any clinical setting, wristwatches or rings with stone should be
removed
Ensure alcohol gel being used when moving from one clinical area to
another and always wash hands before and after patient contact
Height give an idea as to capacity of bony pelvis
Short stature (<148cm) Indicate smaller pelvic capacity
Obesity index [ Weight(kg)/Height(m2) ]
BMI <

High risk of FGR & Increase perinatal

20kg/m2
BMI >

mortality
Increased

30kg/m2

Hypertension

risk

of

Diabetes

and

Position
Lying down comfortably and no need to sit upright
Placed in a semiprone position (left lateral tilt) to prevent aortocaval
compression
A need to sit upright Indicate sign of cardiac disease / grossly enlarged
uterus causing a splint in the diaphragm
Vital signs
Temperature
Blood pressure tends to decrease in 2nd trimester
- Measure bp with woman seated or in semi-recumbent position
- Do NOT lie her in left lateral position lead to under-reading of bp
- BP > 140/90mmHg HT diagnosed for 1st time in early pregnancy
should prompt for underlying cause, i.e. Renal, Endocrine & Collagen
vascular disease
Pulse rate (Regularity, Volulme, Radio-femoral delay) Increase

 Respiratory rate
Head and neck

Face: Pregnant chloasma (brown patches on forehead and cheeks)

Eyes: Conjunctiva pallor (anemia), Sclera jaundice
Oral cavity: Hydration, Hygience
Neck : Symmetrical enlargement of thyroid gland normal in pregnancy.
Lymph nodes?

Lower limb
Physiologic edema
a) Results from hormone-induced Na retention
b) Occurs when enlarged uterus intermittently
compresses the inferior vena cava during
recumbency, obstructing outflow from both
femoral veins
Edema is done over medial maleolus / over lower tibia for 20
seconds
It can be very painful if theres excessive edema !!!!
If its significant, it may indicate either compression of pelvic veins and
inferior vena cava by gravid uterus or pre-eclampsia
Causes of edema in late pregnancy
Cause

Suggestive findings
Hypertension, proteinuria +/-

Preeclampsi
a

significant non-dependent
edema
If severe, possibly theres
symptoms of headache, pain
in right upper quadrant,

Diagnostic approach
BP measurement
CBC
Urine protein
measurement
Electrolytes, BUN
Glucose, Creatinine
Liver function tests

epigasric region or visual

disturbance
DVT

Tender, Erythema, Warmth

Unilateral swelling of leg/calf

Lower extremity
duplex
ultrasonography

Tender unilateral swelling in

Cellulitis

leg/calf, erythema, warmth,

sometimes fever
Manifestation often more

U/s to rule out DVT

unless swelling is
clearly localized
Examine source of

circumsribed than in DVT

infection

SYSTEMIC EXAMINATION
Cardiovascular examination
Inspect pericardium
Felt the apex beat whether it is displaced or remain at midclavicular line
Routine auscultation for maternal heart sound in asymptomatic women is
unnecessary
Note that collapsing pulse and functional / flow murmur heard over
left sternal edge may be normal in pegnancy (at the end of 1 st trimester
in 80% of women)
Women coming from areas where rheumatic heart disease is prevalent &
those with significant symptoms or known history of murmur / heart
disease should undergo examination during pregnancy
Respiratory examination

Evaluate respiratory rate and evidence of respiratory distress

Whether chest wall move symmetrically on respiration
Trachea centrally placed?
Air entry heard normal and equal in both lung fields
Any added sound?

Breast examination
Must examine for any lumps when lumps are detected, urgent surgical
referral is a must as risk of being cancer under 40s is about 5%
If inverted nipples are present, patient are to encourage to evert them
- Otherwise breastfeeding may be compromised
- May predispose to infection or breast abscess
Urinary examination
Screening of midstream urine for asymptomatic bacteriuria in pregnancy
Risk of ascending UTI is much higher in pregnancy

 Acute pyelonephritis increases the risk of pregnancy loss, premature

labour, associated with considerable maternal morbidity
Persistent proteinuria or hematuria indicator of underlying renal
disease
Neurological examination
When pre-eclampsia is suspected, reflexes should be assessed
Presence of > 3 beats of clonus is pathological !!

OBSTETRIC EXAMINATION PROPER

Involve

both

abdominal

and

pelvic

examination
First, position patient to supine position
Ask for consent to expose the patients
abdomen from xiphisternum to pubic

ABDOMEN EXAMINATION
Inspection
Assess shape, size of uterus and note any asymmetry
- Over distension indicate Polyhydramnios or Multiple pregnancy
- Irregular appearance indicate Malpresentation or Presence of fibroids
Look for fetal movement and surgical scars (especially previous lower
segment transverse / longitudinal c-section or laparoscopic marks around
umbilicus)
Cutaneous signs (skin changes)
- Linea nigra Dark vertical line due to increased melanocyte
stimulating hormone produced by placenta (also causes melasma and
darkened nipples)
-

Striae / stretch marks

o Mechanical distension

and

rapidly

developing

areas

during

pregnancy as in abdomen, breasts and thighs are most commonly

associated
o These off-color blemishes are caused by tearing of the dermis
resulting in atrophy and loss of rete ridges
o Striae gravidarum (recent) Reddish purple streaks on abdomen
Striae albicans (old) Silver/white indicate previous pregnancy
-

Superficial veins Altered path of venous drainage due to IVC

pressure by uterus

Excoriations Mainly due to obstetric cholestasis

Umbilicus Centrally placed? Flat / Everted?

Palpation

a) Symphysis-fundal height (SFH)

Gives an idea of how far advanced the pregnancy is
Usually measured in cm or in term of finger breaths above pubis
symphysis
16 weeks 3 finger widths above symphysis
20 weeks 3 finger widths below umbilicus
24 weeks At umbilicus
28
3 finger widths above umbilicus
weeks
32 weeks Between umbilicus & xiphoid process
36 weeks At xisphisternum
40 weeks 1-2
finger
widths
below
xisphisternum

 Measurement
- Palpate using ulnar border of left hand moving from sternum
-

downwards
Locate the fundus of uterus which gives a firm feeling
Measure the distance between the fundus and upper border of
pubis symphysis

The distance usually corresponds to gestational age to determine

whether the fundal height consistent with the estimation of maturity
[ 20-36 weeks (+/-2cm); 36-40 weeks (+/-3cm) ]
Example:
- 32cm = 32 weeks (correlate with dates)
- Date 32 weeks but SFH measures 28 cm (smaller than dates)
-

May be due to reduction in amniotic fluid or descent of fetal head

Date 32 weeks but SFH measures 36 cm (bigger than dates)

May be due to increase fetal size, increase amniotic fluid or no

fetal descent
b) Number of fetus
Singleton pregnancy demonstrated by presence of 2 poles
If multiple fetal parts are felt, multiple pregnancy are suspected
The palpation of > 2 poles, though confirmatory of a multiple
pregnancy can sometimes be difficult to establish
In polyhydramnios, fetal parts are difficult to feel & parts especially the
head is best balloted rather than palpated
c) Leopolds maneuvers
Step 1: Fundal grip to determine the nature of upper pole and lie of
fetus
Lie Relationship of longitudinal axis of
fetal spine to longitudinal axis of uterus
-

Longitudinal Cephalic or Breech

Transverse Longitudinal axis is

across the horizontal axis of uterus

Oblique Head/Breech at one of

iliac fossa
If a pole is present, then the lie has to be longitudinal
If theres no presenting part, one must suspect either an oblique or
transverse lie
Differences between cephalic and breech
Cephalic

Breech

Hard, Smooth, Round

Ballotable

Firm, Irregular, Wider

Non-ballotable

Step 2: Lateral (umbilical) grip to determine lie of fetus and fetal back
Apply gentle pressure on each side
uterus
Palpate either side of uterus, moving
down to determine where the fetal back
lies
Steady the right side while left hand
The fetals back will feel firm and smooth
The fetals extremities may give small irregularities and protrusion to
confirm
Step 3: Lower (pelvic) grip to determine presentation and for
engagement
Presentation
Refers to presenting part of fetus that
presents over the pelvic brim and in
relation to cervix
Cephalic
When head

Breech
When buttock

occupies the

occupies the lower

lower segment

segment of the

Engagement
To see if the presenting part is engaged which relevant only in late
pregnancy
Fetal head must be viewed as sphere and divided into 5 parts
Head is said to be -

If 2/5 or less of the head is palpable above the

engaged

brim
Limited mobility is appreciated
If 3/5 or more of the head is palpable above

Head is said to be not engaged

d) Liquor volume

the brim
Mobility is not limited

 Estimate the amount of liquor whether Adequate, Reduce (suspect

IUGR) or Excessive (suspect fetal abnormality)

Auscultation
Normal fetal heart = 110-160bpm
You may hear the fetal heart by using
- Pinard fetoscope position it over area of fetal anterior shoulder
- Hand-held Doppler device as in early pregnancy, fetal heart may
not be audible with a fetoscope
With twins, you must be confident that both have been heard
Feel the mothers pulse at the same time

At the end of examination

Recovered the patient
Let the patient to dress herself in private
Help her to sit up and thank her

Summary of findings

Puan Mariam looks well. There is no pallor or jaundice. She is afebrile.

Her blood pressure is 150/100. Cardiovascular and respiratory system
are normal.

On inspection, the abdomen is distended by a gravid uterus. Striae

gravidarum and linea nigra was noted on the abdominal skin. There was
no obvious surgical scar noted and no dilated veins. The umbilicus was
flat and centrally placed.

On superficial palpation, the abdomen was soft, non tender and no

contraction felt.

Symphyseal Fundal height is 36cm which is in keeping with the current

gestation. There is a singleton fetus in a longitudinal lie, with cephalic
presentation and the head is not engaged.

The fetal back is on the

mother right side. The liquor is clinically adequate. The fetal heart was
heard at the regular rate of 142 beats per minutes.

Pedal edema is present up to mid-tibia and urinalysis is 2+ for protein.

Vaginal examination was not done.

PELVIC EXAMINATION

Serves 2 main purposes:

- To determine any pathology present in pelvic organs
- To assess pelvic capacity, primarily to exclude a contracted pelvis
Routine pelvic examination is not necessary
Given that many women think that it may cause miscarriage and find it
an unplesant experience for them
Consent MUST be sought and a female chaperon present
However in certain circumstances, vaginal examination is needed
- Excessive or offensive discharge
- Vaginal bleeding (in known absence of placenta previa)
- To perform a cervical smear
- To confirm potential rupture of membranes

POSTNATAL EXAMINATION
Delivery progress
- No. of days since delivery
- Mode of delivery, Indications if assisted delivery
- Mode of onset of labor (spontaneous/induced)
- Length of labor
- Amount of blood loss
History
Infant
-

Sex, Weight, Apgar score, Cord pH?

Well-being? Breastfeed?

Vitamin K / BCG / Hepatitis B given?

Puerperium
-

Lochia, Fever, bowels, bladder, breast engorgement, pain and

analgesia
Consider contraception
Quick history of previous pregnancies, personal social history.

Examination
- Consider mood and appearance (anemia), Temperature, BP

CVS/RSP, Breasts examination

Abdominal examination:
o Involution of the uterus and the
o Presence/absence of tenderness and bowel sounds.
o Palpable bladder

The perineum should be examined:

o Nature of lochia
o Tears / Episiotomy / Sutures

If there is fever or tachycardia, consider:

o Phlebitis
o Breast abscess
o DVT
o Wound infection

Summary of findings
Puan Norsiah is a 32 year old Malay lady, she had an emergency LSCS
following a failed induction for post dated pregnancy 3 days ago. The
surgery was uncomplicated and she delivered a baby girl weighing 3.2
kg and an Apgar score of 9.

The post-operative period has been uneventful and both mother and
baby

are

planned

for

discharge

tomorrow.

She

is

presently

breastfeeding. The baby has had her BCG and Hepatitis B vaccinations.
Vitamin K has also been given.

On examination Puan Norsiah is afebrile, there is mild pallor, PR is

90/minute and BP is 130/80. On abdominal examination there is a
surgical plaster over her lower abdomen. The uterus is about 18 weeks
size and feels firm. The abdomen is soft and non tender and bowel
sounds are present.

Lochia loss is normal. Other systems are normal.