HISTORY TAKING AND EXAMINATION OF THE OBSTETRIC PATIENT��

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BY

Professor AS Anzaku

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OUTLINE

• Introduction
• Definitions of key obstetric terms
• Pattern/steps for History taking
• Physical examination
• Examination of the gravid uterus
• Pelvic examination
• Key points
• Conclusion

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Introduction

• History & examination in obstetrics is quite different from other clinical disciplines
• Must appear decently - Your appearance have influence on patients
• Type of questions change with GA as well as the aim of examination
• Handles two individuals at the same time
• Client concept in obstetrics – most have no complaints/symptoms

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Introduction cont;

• You must be gender sensitive
• Some areas of the history involve private aspects of the woman’s life e.g previous STOP
• Need a chaperone especially for Physical examination
• Make sure patient is comfortable – seated or sitting on the bed
• Establish a good rapport with the patient
• History should be comprehensive especially at booking visit

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Meaning of Obstetric terms

• Lie
• Relationship of the long axis of the fetus to the long axis of the uterus or maternal spine; At term, longitudinal (99%) which is normal, transverse, oblique
• Presentation
• The part of the fetus occupying the lower pole of the uterus ; At term, cephalic (96%), breech (3-4%), shoulder etc
• Presenting part – detectable on VE
• Part of the presentation which overlies the internal os; e.g vertex, brow, face, complete breech, extended breech, footling breech

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Types of Lie

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• Attitude
• Relation of the different parts of the fetus to one another. Towards term, the head, trunk and limbs of the fetus maintain attitude of flexion on all joints, forming an ovoid mass
• Denominator
• Arbitrarily fixed bony point on the presenting part in relation to the various quadrants of the maternal pelvis
• Vertex - Occiput
• Face - Mentum (chin)
• Breech - Sacrum
• Shoulder - Acromion

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Attitudes – Neck Flexion/extension

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Fetal positions

• Position
• Relation of the denominator to the different quadrants of the maternal pelvis; e.g ROA, ROP, LOA, LOP

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Descent & Engagement

• Descent refers to proportion of fetal head palpable per abdomen - assessed in fifths
• Engagement - When the greatest horizontal plane (biparietal) has passed pelvic brim, the head is said to be engaged
• Fetal head either 1/5th or 2/5th palpable

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• Station
• Refers to relationship between fetal presenting part and maternal ischial spines
• Assessed on VE during labour

* using finger breadth/width - (British i.e -3 to +3)

* Centimeters (Americans i.e -5 to +5)

• The level of ischial spines is the halfway between the pelvic inlet and outlet

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• This level is known as station zero (0)
• Station is stated in minus figures, if it is above the spines (–1, –2, –3, –4 and –5 cm)

* OR (–1, –2, –3)

• In plus figures if it is below the spines (+1, +2, +3 , +4 and +5 cm)

* OR (+1, +2, +3)

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Stations

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Steps in History taking

• Biodata
• Menstrual history/dating the pregnancy
• Presenting complaint(s)
• History of presenting complaint(s) & systemic review
• History of current pregnancy (± systemic review)
• Past obstetric history
• Gynaecological history
• Past medical & surgical history
• Family & social history
• Drug history
• Summary of the history

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BIODATA

• Include; Name, age, ethnic group, address, religion, occupation, marital status
• Clinical relevance:

* Age - teenage pregnancy & pregnancy in elderly women (>35 years) is associated with risk of adverse outcomes

* Marital status – pregnant single women are associated with social problems

* Address - for contact by social workers

* Ethnic groups – some conditions are common in certain tribes e.g twinning among the Yorubas

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Menstrual history/dating pregnancy

• Parameters usually written at the right top corner of the clerking sheet(not compulsory)
• Involves ascertaining the Gravidity, parity, LMP (1^st day), EDD, EGA ± LCB

NOTE;

• Gravidity refers to the total number of times a woman has been pregnant
• Parity refers to the number of pregnancies that end as a birth/delivery at or beyond 28 weeks GA irrespective of the outcome

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• Dating pregnancy is in weeks usually by using;

* LMP

* Ultrasound

• EDD is arrived at using Naegele’s rule or USS
• EDD from LMP using Naegele’s rule is based on the assumption that;

*Average GA is 280 from the LMP, cycle length is 28 days, ovulation occurs on day 14

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• EDD = add 7 days to the date & then 9 months to the month or subtract 3 months from the month

*E.g LMP of 20/4/2022, the EDD will be 27/1/2023

*Short hand: G6P3+2 – This means sixth pregnancy, delivered 3 times and had 2 miscarriages/ectopic pregnancies

NOTE; If date of ovulation is known, as in (ART), the EDD can be calculated by adding 266 days

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Presenting Complaint, HPC & Systemic review�

• Presenting Complaint(PC), HPC & systemic review as in other clinical specialties
• PC Refers to the symptom(s) the woman is complaining of with the duration(s) – as much as possible state in patient’s words
• HPC involves exploring the symptoms in PC with the aim of making a diagnosis

*Narrate the symptomatology in sequence.

*Include facts, dates and essential details

• Systemic review – to assess symptoms in other systems other than the one involved (noted under PC)

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History of Current pregnancy

• How did she know she was pregnant? – amenorrhoea & early pregnancy symptoms
• Was the pregnancy confirmed? – PT or USS
• Any problem(s) so far in this pregnancy? – excessive nausea & vomiting, dysuria, abdominal pain, abnormal vaginal discharge, PV bleeding
• When did she book for ANC (GA), what tests were done & the results, which routine drugs has she been taking?; How many visits so far?
• Any prophylaxis – malaria, tetanus toxoid
• Ask about fetal quickening

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Past Obstetric History

• History of all previous pregnancies in chronological order
• This is to ascertain whether a past adverse obstetric event may re-occur during pregnancy, labour, or postpartum
• Each pregnancy; the following are sought for:

*How long ago was the pregnancy?; booking status; problem(s) encountered during the pregnancy eg DM, HT/PE, IUFD; preterm or term delivery; spontaneous or induced labour; duration of labour; mode of delivery;

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Past obstetric history cont

*Did the baby cried immediately after delivery?;sex & weight of the baby; congenital abnormality; any problem(s) experienced during labour, delivery & puerperium;

*Baby was breastfed?, exclusive or mixed feeding, duration of breastfeeding

*Was the baby fully immunized?

*What is the current status of the baby (alive or death); if alive, is he/she doing well?; if death, possible cause of death

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Gynaecological history

• Includes - Age at menarche, menstrual regularity, cycle length, menstrual volume, duration of menstruation; menopausal status & duration
• Ascertain history of dysmenorrhoea, dyspareunia, past STI/PID
• Contraceptive history – type(s) & duration of usage
• Date of previous papanicolaou (pap) smear
• History of previous abortion(s) can also be ascertained here

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Past Medical & Surgical history

• History of co-existing or previous medical conditions should be documented e.g DM, HT/PE, renal disease, SCD, HIV, TB, cardiac diseases, psychiatric illness, epilepsy etc
• History of previous surgeries – myomectomy, metroplasty, VVF repair, laparotomy/indication
• Previous blood transfusion, hospital admission(s)/indications

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Family & Social History

• Family history of some medical conditions especially in first degree relatives can adversely impact on the health of the mother during pregnancy & beyond and on the fetus
• Ascertain family history of HT/PE, DM, psychotic disorders, SCD, TB, HIV(especially husband),
• Family history of twinning
• Social history include – smoking, alcohol intake, substance abuse, marital status, domestic violence

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Drug History/Summary

• Establish any drug(s) she is taking & the indication(s) including herbal medications
• May have to discontinue or modify some drugs in pregnancy
• What routine drugs is she taking?
• Any drug allergy?

Summary of History

• Usually include age, parity, GA, presenting complain and any other important finding(s) from the history
• Usually in 1 or 2 sentences

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Clinical Examination of an obstetric Patient

• This should be meticulously carried out
• Must seek consent from the patient & may need a chaperone
• Position the patient in supine position with the hands at the sides
• Adequate appropriate exposure
• General physical and systemic exams are generally the same as in other clinical disciplines
• General examination– appearance, height, weight, ?BMI, pallor, jaundice, cyanosis, oral lesions(HIV), temperature, pedal oedema, and breast examination

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Breast examination

• Not a routine examination - may be relevant in primigravidae to assess the nipples
• Inspect and palpate for:
• size, symmetry, nipple inversion, masses, nipple discharge, or skin changes

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Examination cont

• Systemic examination – includes
• Respiratory system – RR, chest symmetry & movement, tactile & vocal fremitus, auscultation for rhonchi, crepitations & other abnormal chest signs
• Cardiovascular system – Pulse & its characteristics, BP, JVP, activity of the precordium, apex beat, heart sounds & murmurs

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Examination cont

• Abdominal examination (IPPA) – symmetry, hernias, surgical scars, tenderness, palpate for masses, organomegaly & auscultate e.g for bowel sounds

Obstetric examination;

*Examination of the gravid uterus

*Pelvic examination

• Central nervous system & musculoskeletal system (SCD)

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Examination of the gravid uterus

• Extend of examination depends on the GA - IPPA
• Position the patient in semi-recumbent position in a bed or examination couch & expose patient from the xiphisternum to the pubic hair line
• Two methods widely use – Leopold maneuver or conventional method
• Inspects for symmetry of abdomen, surgical scars, linea nigra, striae gravidarum, fetal movements

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Examination - gravid uterus cont;

• Ask the patient about any painful area in the abdomen
• Palpate for area of tenderness
• Steps in Leopold manoeuvre (modified)

*(1) Measure symphysiofundal height – Helps in GA estimation - applicable from 20-22 weeks gestation upward

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SFH measurement

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*Using a non elastic, flexible tape, measurement is from the upper border of the uterus to the superior border of the symphysis pubis

*It corresponds to the GA with an error margin of ±2 weeks

*Large SFH with respect to the GA raises possibility of wrong date(LMP), multiple pregnancy, polyhydramnios, uterine fibroid in pregnancy, fetal macrosomia, pelvic tumours etc

*Smaller SFH may suggest wrong date, IUGR, oligohydramnios etc

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**Below 20-22 weeks, anatomical landmarks are used to assess uterine size/GA�

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Examination - gravid uterus cont

*(2) Palpate for fetal part (pole) occupying the upper uterine segment (head or breech)

* (3) Palpate for the fetal position (lateral palpation) – assess for the back of the fetus

* (4) Palpate for the fetal part/pole occupying the lower uterine segment (head or breech)

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* (5) Demonstrate the lie of the fetus – longitudinal, transverse or oblique)

* (6) Assess the descent – in fifths

* (7) Auscultate for the FHT using pinard stethoscope or doppler(sonicaid) – compare with maternal pulse

*(8) Cover the patient, ask her to turn to her side and thank her for allowing you to examine her

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Assessment of descent

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Pelvic examination

• Consent must be sought and a chaperone present especially for the overtly fearful or potentially seductive patient
• Routine pelvic examination is not recommended
• Patient place in dorsal position
• Need angle lamp & a tray containing items needed for the examination – swabs, antiseptics, gloves, speculum (Graves, Cusco, Sims) and other appropriate instruments

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Dorsal Position for PE/VE

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Pelvic examination cont

• Inspect the vulva – for rashes, redness, swellings, warts, ulcers, discharge, pigmentation & blood
• Swab the labia with antiseptic – Use minimum of 3 swabs (usually 5)
• Gently part the labia
• Introduce speculum with the blades vertical into the vagina & rotate it to lie in the horizontal plane
• Slowly open the blades to inspect the cervix & take sample(s) if needed e.g cytology, ECS

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Pelvic examination cont

• Close the blades & gently remove the speculum

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Pelvic examination cont

• Digital examination - usually bimanual – Two fingers of gloved right hand introduce into the vagina
• Advance them towards the cervix while the left hand is position on the suprapubic region
• Aims of pelvic examination;

* Uterine size, mobility and position can be assessed

* Adnexal mass or tenderness, cervical motion tenderness and the POD

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Bimanual Examination

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Key points

• Good & relevant history comes with repeated practice backed by sound knowledge
• Be courteous and gentle
• Ensure patient is comfortable
• Hx & examination should be appropriate for the information you need & the GA
• Must be able to present your findings in a clear & concise manner
• Should be able to have differential diagnoses at end of Hx & examination

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Conclusion

• History taking and clinical examination is an important aspect of any clinical discipline as most diagnosis can be made at this stage
• Investigative procedures are never substitute for clinical assessment

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• THANK YOU

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