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History taking & Examination of an obstetrics case
EXAMINATION OF AN OBSTETRICS CASE
DR. A.V.RAJESHWAR RAO,
H.O.D & ASSISTANT PROFESSOR OF
DEPARTMENT OF GYNAECOLOGY AND OBSTETRICS.
DR. VAMSHIKRISHNA DUSSA,
P.G XVIII BATCH, MD-PART 1
DEPARTMENT OF HOMOEOPATHIC PHARMACY.
• History taking
• Examination Part:
1. Keywords Before Examination
2. General examination
3. Abdominal examination
4. Vaginal examination
Aims & Objective:
• To screen the high risk cases.
• To treat the complications detected early by
• To educate mother by demonstrating the labour.
• To ensure continued medical surveillance and
• To remove the fear about the delivery and to gain
confidence before labour.
• To ensure normal pregnancy with delivery of healthy
• To motive the couple about to need of family planning
• To give appropriate advice to couple seeking MTP.
Date of first examination:
Age: A woman having her first pregnancy at the age
of 30 or above is called elderly primigravida.
Gravida: Gravida denotes a pregnant state both
present and past, irrespective of the period of
Parity: Denotes a state of previous pregnancy
beyond the period of viability.
Gravida X, Para (A-B-C-D)
X = Total number of pregnancies including this one
A = Number of TERM PREGNANCIES ( >37 weeks)
B = Number of PRETERM PREGNANCIES ( 28 weeks to
C = Number of ABORTIONS (< 24 weeks)
D = Number of BABIES ALIVE at present.
Duration of marriage:
- This is relevant when dealing with pregnancy
- Helps in noting fertility or fecundity of a woman.
- Pregnancy early after marriage- high fecundity
- Pregnancy lately after marriage – low fecundity
Occupation : helps dealing occupational hazards.
Occupation of husband :
- Gives fair idea about the socio-economic status of
- By this we can know likely complications with her
status like anemia, prematurity, preeclampsia.
H/O Present Pregnancy:
- Important complications in different trimesters of
present pregnancy are to be noted carefully
- These are hyperemesis and threatened abortion
in first trimester; features of pyelitis in second
trimester and anemia, preeclampsia and ante
partum hemorrhage in the last trimester.
- Number of previous antenatal visits.
- Immunisation status has to be noted.
- Any medication or radiation exposure in early
pregnancy or medical surgical events during
pregnancy should be enquired.
- Related to Multigravida
- Previous obstetrics events are to be recorded
chronologically as per the proforma.
- Proforma in next slide
- To be relevant, enquiry is to be made whether
she had antenatal and intranatal care before.
Puerperium Baby Weight,
• Obstetrics H/o can be summed up as:
1. No. of living children
4. Health status of the baby:
6. Last issue:
• Menstrual history:
- Cycle, duration, amount of blood flow and first
day of the last normal menstrual period (
L.N.M.P) are to be noted
- From the L.N.M.P., the expected date of the
delivery (E.D.D) has to be calculated
- Calculation of the expected date of delivery
- THIS IS DONE BY NAEGELE’S FORMULA
• NAEGELE’S FORMULA:
- Calculation of the expected date of delivery
(EDD): this is done accordingly
- Adding 9 months and 7 days to the first day
of the last normal (28 day cycle) period.
- Alternatively one can count back 3 calendar
months from the first day of the last period
and then add 7 days to get the expected date
of the delivery.
- Former method is more commonly employed.
• Ex: The patient had her first day of last
menstrual period on 1ST jan. By adding 9
Calendar months it comes to 1st October and
then add 7 days i.e. 8th October which
becomes the E.D.D
• For IVF pregnancy, date of L.M.P IS 14 DAYS
PRIOR TO THE DATE OF EMBRYO TRANSFER
( 266 DAYS)
Past Medical/ 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
• Thyroid disease
• B asthma
• Any previous surgery.
• 7- Drug history and allergy.
• 8- Social History → Cigarette smoking, illegal drug
use, domestic violence, psychiatric illness specially in
• 9- Family History
- Hereditary illness → DM., HTN., thalassemia, sickle
cell disease, hemophilia
- Congenital defects eg. neural tube defects, Down
Keywords Before Examination
• Before examination, explain to the patient the
need and the nature of the proposed
• Obtain a verbal consent.
• The examiner (either male or female) should be
accompanied by another female.
• Respect her privacy and examine in a private
• Expose only relevant parts of her anatomy for
• Ensure the patient is comfortable and warm.
Keywords Before Examination
• Ask patient to empty the bladder .
• Patient should lie in the dorsal position with
thighs slightly flexed.
• She is slightly rolled to the left side to prevent
compression of the inferior vena cava by the
enlarged uterus (inferior venacaval syndrome
or supine hypotensive syndrome).
• Ask for any tender area before palpating the
• Stand right to her.
• VITAL DATA
• NUTRITIONAL STATUS
• FACIAL FEATURE/EXPRESSION
• VITAL DATA:
1. Blood pressure :
• Record while she is in sitting and Semi-Recumbent
( 45 degrees) posture.
• Record in every visit.
• Usually unaffected or Slightly lower than
normal due to SVR ( SYSTEMIC VASCULAR
If BP > 140/90 mm Hg on 2 separate
occasions 6 Hrs apart:
• Chronic Hypertension: if recorded before 20
weeks of pregnancy or may be persisted
before pregnancy. With + family history.
• Gestational Hypertension : if recorded after
20 weeks of pregnancy.
2. Pulse rate: slightly increased
3. Heart rate : Increased. Murmurs heard-
normal- continuous hissing murmur- systolic
type-also called mammary murmur- over
tricuspid area at left 2nd and 3rd intercostal
4. Respiratory rate: usually unaffected. feels
shortness of breath with slight exertion due
to elevated diaphragm.
5- Temperature: may rise by 0.4 ºF
• i.e..98.6 ºF to 99 ºF
• Due to increased metabolic rate
• NUTRITIONAL STATUS:
• Nails- white spots in zinc deficiency, brittle
nails in magnesium deficiency.
• Tongue- May be Large in iodine or niacin
deficiency. May be pallor in Fe++ deficiency.
Cyanotic in CHD. Brown in CKD. site- dorsum
• Weight- The abnormal nutritional status can
be described as obesity and emaciation.
• Check weight in every visit.
• Parameter- Body mass index (BMI)
• Weight gain for a woman with normal BMI
( 20-26) is 11-16 kgs.
• Weight gain for a obese woman ( BMI > 29 )
should be less than 7kgs.
• Weight gain for a under weight woman ( BMI
< 19 ) is 18 kgs.
• Parameters helps in early intervention of
preeclampsia ( in obese ) and IUGR of fetus
( in under weight ).
• Short stature women are mostly to suffer with
• May cause IUGR OF FETUS.
• FACIAL FEATURE/EXPRESSION
• Some facial appearances are pathognomonic
• Here the patient may be having thyrotoxicosis.
• The appearance of the patient’s face may also
provide information regarding psychological
makeup: is the person happy, sad, angry or
• SKIN : Extreme pigmentation around neck,
face, forehead. Common in pregnancy
• Palmar erythema – due to high estrogen
• Hirsutism – mild common, if more – Cushing
• ICTERUS- Bulbar Conjunctiva, under surface of
Tongue, Hard Palate- to rule out any LIVER
• LEGS-EDEMA – common- physiological
• other causes- preeclampsia, anemia, cardiac
failure, nephrotic syndrome
• NECK- Neck veins, thyroid gland ( diffuse
enlargement common in pregnancy-50 % of
cases), lymph gland enlargement ( any H/o of
Kochs/ other pathologies of lymph nodes).
• BREAST- Examination of breast is mandatory not
only to note presence of pregnancy changes ,but
also to note the nipples/skin around areola.
**Purpose is to correct the
abnormalities(cracks/fissures) early so that to
make easy breast feeding more safely too infant
Normal in pregnancy
Abnormal in pregnancy
• Can be examined in three parts
• 1- INSPECTION
• 2- PALPATION
• 3- AUSCULTATION
• Size of the uterus:
• If the length & breadth are both increased multiple
• If the length is increased only large baby
• Shape of the uterus:
• Length should be larger than broad this indicates
longitudinal lie. But if the uterus is low and broad
indicates transverse fetus lie.
• Look for fetal movements.
- Look for scars.
- CUTANEOUS SIGNS - Linea nigra, Striae gravidarum, Striae
albicans, Umbilicus flat or everted, Superficial veins.
- SKIN CONDITIONS- Ringworm/Scabies
Aim to assess the:
• Height of the uterus ( symphysis-fundal
• Gestational age
• Foetal poles
• Foetal lie
• Presentation part- cephalic(head), breech,etc
• Level of engagement of presenting part
• Estimate fetal weight
• Amniotic fluid
Of the above parameters
• To assess FETAL POLE, FETAL LIE, FETAL
PRESENTING PART, ATTITUDE AND
ENGAGEMENT OF FETAL HEAD- LEOPOLD’S
MANOUEVRE IS FOLLOWED
Following techniques employed during palpation to
assess the above parameters
1) Height of the uterus (Symphysis-Fundal Height):
• The distance from the symphysis pubis to the uterine fundus
(top of the uterus)- size of the uterus directly related to the
size of the fetus.
• Place ulnar border of the left hand on the highest part of the
• Mark this point with a pen after obtaining her permission.
• The distance between the upper border of the symphysis
pubis upto the marked point is measured by tape.
• This corresponds to gestational age
2) Gestational age :
• The distance from the symphysis pubis to the uterine
fundus (top of the uterus) corresponds to the
gestational age/ duration of pregnancy.
• After 24 weeks of pregnancy, the distance measured
in cm normally corresponds to the period of
gestation in weeks.
3) Fetal Pole, Lie , Presenting Part , Engagement And
Attitude Of Fetal Head are assessed by LEOPOLD’S
LEOPOLD’S MANOUEVRE : Done by four
• 1- Fundal grip - To assess fetal pole
• 2- Lateral grip - To assess fetal lie
• 3- Pawliks grip - To assess presenting part
• 4- Deep pelvic grip – To assess engagement
and attitude of fetal head.
1) Fundal grip:
• Both hands placed over the fundus and the contents of the
• A hard smooth, round pole indicates a fetal head.
• Broad, soft and irregular mass suggestive of breech.
• In transverse lie no parts are palpated.
2) Lateral Grip or umbilical grip:
• Move both hands in a downward direction from the fundus
along the sides of the uterus to determine the "lie" of the
• "Lie" is the relationship btw the longitudinal axis of the fetus
and the longitudinal axis of the mother.
• The "lie" is usually longitudinal, hence baby is lying length-
wise in the same direction as mother's longitudinal axis.
• Other "lies" are transverse lie (fetus lies across the long. axis
of mother) and oblique lie (fetus lies at an oblique angle to
the mother's long. axis).
• Can also determine which side the foetal back is situated by
feeling the firm regular surface of the foetal back on one side
and the irregular, lumpy surface as the foetal limbs on the
3) Pawliks grip: (second pelvic grip )
• The thumb and four fingers of the right hand are placed over
the lower pole of uterus keeping the ulnar border of palm on
the upper border of the suprapubic area to determine the
• Presenting part of fetus is the lowest most part of the fetus at
the inlet of the pelvis.
• In transverse lie, pawliks grip is empty.
• If not engaged the presenting part can be grasped and moved
side to side.
Presenting Part- breech
presenting part of fetus occupying the lower
pole of uterus i.e. cephalic(vertex), breech,
face, brow or shoulder.
4) Deep pelvic grip: ( first pelvic grip )
• Determines two points about the fetus
1) The attitude of the fetal head
2) Engagement of the fetal head
1) The attitude of the fetal head :
The examiner turns around to face patients feet.
• Each hand placed on either side of the fetal trunk lower down.
• The hands moved downwards towards the fetal head.
• Note made as to which hand first touches the fetal head (This
point called cephalic prominence- may be sinsipital or
• Cephalic prominence helps determine the attitude (i.e.
flexion, deflexed or extended) of fetal head.
• If cephalic prominence is on the opposite side
of fetal back, fetal head is well flexed (normal
position). (here cephalic prominence is
• If cephalic prominence on the same side as
fetal back, fetal head is extended (abnormal
position). (here cephalic prominence is
• If examiners hands reach the fetal head
equally on both sides ( both sincipital &
occipital poles), fetal head is deflexed
('Military position, indicating mal-position)
2)Engagement of the fetal head:
- Engagement of the fetal head defined as having
occurred once the widest transverse diameter of
the fetal head (bi-parietal diameter) has passed
through the pelvic inlet into the true pelvis.
- Procedure: Continue moving both hands down
around the fetal head, determine how far around the
head you can get.
- Examiner should be able to palpate part of fetal head
still in the lower abdomen (also called the 'false'
pelvis but cannot palpate the part of fetal head in the
Abdominal palpation to determine engagement of the head
A- Divergence of fingers- engaged head
B- Convergence of fingers- not engaged
- If you divide the fetal head into five-fifths, you
estimate how many fifths of the fetal head can be
- If 5,4 or 3 fifths can still be palpated, most of the
head is still up, hence the widest part of the head has
not engaged into the pelvis.
- If only 2,1 or 0 fifths of fetal head felt, the widest
part of the head has engaged into the pelvis.
• Diagrammatic representation showing the
difference between an engaged and a fixed
head by use of egg cups and eggs.
• Amniotic fluid :
- Useful in assessing the well being and
maturity of fetus
- Excess or less volume of liquor amnii is
assessed by AMNIOTIC FLUID INDEX (AFI)
- AFI: Maternal abdomen is divided into 4
quadrants taking the umbilicus, symphysis
pubis and the fundus as the reference points.
- With ultrasound, the largest vertical pocket in
each quadrant is measured.
- The sum of the four measurements(cm) is AFI.
• AFI helps to diagnose the clinical conditions
called oligohydramnios and polyhydramnios.
• Normal level of amniotic fluid at term-40
weeks is 600-800 ml.
• Other values: at 12 weeks: 50 ml, at 20 weeks:
400 ml, at 36-38 weeks: 1 liter.
• There is gradual decrease in levels after 38
Estimate foetal weight:
• Difficult and requires practice.
• Approximate prediction of the fetal weight is more
important than the mere estimation of the uterine
• This is more important prior to induction of labour
or elective caesarian section.
• Following methods are useful :
1- Fetal Growth Velocity :
2- Johnsons Formula:
1- Fetal Growth Velocity :
• Normal growth-26.9 gm/ day
• More during 32-36 weeks
• Declines by 24 gm/day after 36 weeks
• ** individual fetal growth varies.
2- Johnson's formula:
• Applicable only in vertex presentation
• Fundal height (cm) noted above the pubic
• Fundal height ( cm)- 12 (if Vertex above Ischial
Spine ) × 155 = weight
• Fundal height ( cm)- 11 (if vertex below Ischial
Spine) × 155 = weight
This will be fetal weight in grams.
• • e.g., 32 (Fundal height)-12(constant) x155(
constant) => 20 x 155=3100gms.
• Importance: for monitoring FETAL HEART SOUNDS
• Helps in diagnosis of live baby but its location
of maximum intensity can resolve doubt about
the presentation of the fetus.
• FHS are best audible through back in vertex
and breech presentation where the convex
portion of back the back is in contact with the
• How ever in face presentation, FHS are heard
through fetal chest.
• FHS is maximum below the umbilicus in cephalic
• FHS is maximum around the umbilicus in breech.
• Location of FHS depends on the position of the
head and degree of decent of the head even in
• In Occipito anterior position, FHS is heard in
middle of the spino-umbilical line.
• In occipito-posterior –> towards the mother flank
on same side
• In occipito-lateral -> towards laterally .
• In left occipito-posterior position –> FHS is most
difficult to locate.
Types of monitoring:
Pinnard stethoscope :The heartbeat of the baby may
be checked by a simple instrument which looks like a
short trumpet that is held against the pregnant
tummy. This is called a Pinnard stethoscope (or
fetoscope) and can be used by a midwife or doctor to
listen to the heartbeat periodically.
• A fetoscope can detect and transmit fetal heart
sounds at 18 to 20 weeks and beyond.
Regular stethoscope : useful in monitoring heart beat
after 18 to 20 weeks( same as pinnards fetoscope)
• Toward the end of the first trimester, usually around
the 10th or 11th week of gestation, it is possible to
hear fetal heart tones. It is possible only by
Doppler: Doptone machine
• Doppler machines may be very simple and report
only the rate and rhythm of the beat, but more
sophisticated models will provide additional
information about blood flow in the umbilical artery.
• A vaginal examination (speculum or digital
examination) is not part of a routine obstetric
examination but may be indicated to diagnose
rupture of membranes or onset of labour.
• Can be done bimanually by hands and by