APPROACH TO OBSTETRIC PATIENTHISTORY TAKING

Always introduce yourself Respect, confidentiality and privacy during history taking Need a chaperon if you are a maleIt is vital that the history taker is sensitive to each individual situation and does not simply follow a formula to get all the facts right 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 (35 y/o)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:Primigravida Pre-eclampsia, dusfunctional labour and instrumental deliveries

Multipara 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: G3P2 currently in the 3rd pregnancy and has delivered 2 babies > 24 weeks 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: Irregular menstrual cycle (Shortened / Lengthened) Unreliable as they long forgotten their LMP date 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 2012EDD : 14th December 2012

b) Period of amenorrhea (POA) Example: LMP : 7th March 2012Period of clerking: 12nd July 2012POA : 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, etcHistory 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)PrimigravidaUsually first felt fetal movement between 18 to 20 weeks

Multipara 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 21st November 2011. Antenatal booking was done MCHC at Sungai Buloh on the 16th 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 mellitusMacrosomia, Fetal growth retardation, Pre-eclampsia, Congenital abnormality, Stillbirth, Neonatal hypoglycemia

HypertensionPre-eclampsia

Renal diseaseWorsening renal, Pre-eclampsia, FGR, Preterm delivery

EpilepsyIncreased fit frequency, Congenital abnormality

Venous thromboembolic diseaseIf associated thrombophilia, theres increase risk of thromboembolism, pre-eclampsia, FGR

HIVRisk of mother-to-child transfer if untreated

CT disordersPre-eclampsia, FGR

Myasthenia gravis / Myotonic dystrophyFetal neurological effects, Increased maternal 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 ( 30kg/m2Increased risk of Diabetes and Hypertension

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 Results from hormone-induced Na retentionOccurs 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 CauseSuggestive findingsDiagnostic approach

Pre-eclampsia Hypertension, proteinuria +/- significant non-dependent edema If severe, possibly theres symptoms of headache, pain in right upper quadrant, epigasric region or visual disturbance BP measurement CBC Urine protein measurement Electrolytes, BUN Glucose, Creatinine Liver function tests

DVT Tender, Erythema, Warmth Unilateral swelling of leg/calf Lower extremity duplex ultrasonography

Cellulitis Tender unilateral swelling in leg/calf, erythema, warmth, sometimes fever Manifestation often more circumsribed than in DVT U/s to rule out DVT unless swelling is clearly localized Examine source of 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 1st 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 !!

Involve both abdominal and pelvic examinationFirst, position patient to supine positionAsk for consent to expose the patients abdomen from xiphisternum to pubic symphysisAlways ensure patients comfort OBSTETRIC EXAMINATION PROPER

ABDOMEN EXAMINATIONInspection 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 Mechanical distension and rapidly developing areas during pregnancy as in abdomen, breasts and thighs are most commonly associated These off-color blemishes are caused by tearing of the dermis resulting in atrophy and loss of rete ridges Striae gravidarum (recent) Reddish purple streaks on abdomenStriae 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 symphysis16 weeks3 finger widths above symphysis

20 weeks3 finger widths below umbilicus

24 weeksAt umbilicus

28 weeks3 finger widths above umbilicus

32 weeksBetween umbilicus & xiphoid process

36 weeksAt xisphisternum

40 weeks1-2 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 descentb) 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 maneuversStep 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 uterusLongitudinal Cephalic or BreechTransverse 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 longitudinalIf theres no presenting part, one must suspect either an oblique or transverse lie Differences between cephalic and breech CephalicBreech

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 uterusPalpate either side of uterus, moving down to determine where the fetal back lies Steady the right side while left hand explores the right side of uterusThen, repeat using the opposite side and 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

Refers to presenting part of fetus that presents over the pelvic brim and in relation to cervixCephalicBreechWhen head occupies the lower segment of the uterusWhen buttock occupies the lower segment of the uterusPresentation

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 partsHead is said to be engaged If 2/5 or less of the head is palpable above the brim Limited mobility is appreciated

Head is said to be not engaged If 3/5 or more of the head is palpable above the brim Mobility is not limited

d) Liquor volume 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 alongitudinallie, 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 membranesPOSTNATAL 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

HistoryInfant 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: Involution of the uterus and the Presence/absence of tenderness and bowel sounds. Palpable bladder The perineum should be examined: Nature of lochia Tears / Episiotomy / Sutures If there is fever or tachycardia, consider: Phlebitis Breast abscess DVT 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.