Obstetric History and Examination

A thorough obstetric history and examination are crucial for providing comprehensive antenatal care and ensuring positive maternal and fetal outcomes. This section outlines the key components to elicit from the patient.

Personal Details

• Name, Age, Address, Occupation: Standard demographic information.
• Duration of Marriage: Important for understanding the context of conception, especially in cases of subfertility.
• Parity (Gravida/Para): Number of pregnancies and their outcomes (e.g., G3P2L2A1 – Gravida 3, Para 2, Live 2, Abortion 1).
• Brief Note about Previous Pregnancies:
  • Mode of deliveries (NVD/LSCS – indication for C-section).
  • Number of living children, their health status.
  • History of abortions or stillbirths.
• Blood Group: Crucial for Rh incompatibility and potential need for anti-D immunoglobulin.

Example Presentation: “Mrs. Silva, a 28-year-old primigravida, married for 3 years in a non-consanguineous marriage. She was on oral contraceptives for 18 months after marriage before planning this pregnancy. Her blood group is O positive.”

Presenting Complaint

The main reason the patient is seeking medical attention. Limit to a maximum of two components.

• Admitted for confinement.
• Abdominal pain (in labour or not?).
• Vaginal bleeding (fresh/altered, massive/spots, clots/no clots).
• Reduced fetal movements.
• For management of Hypertension (HPT) or Diabetes Mellitus (DM).
• For planned Elective Lower Segment Cesarean Section (EL/LSCS) – indication?
• Other symptoms: dribbling, oedema, fever, cough, cold.

History of Presenting Complaint (HOPC)

Describe each component separately in chronological order.

• Bleeding: Fresh/altered, massive/spots, clots/no, associated abdominal/back pain.
• Fever: Pattern, chills, rigor, sweating, associated features.
• Pain: Use SOCRATES (Site, Onset, Character, Radiation, Associated features, Timing, Exacerbating/Relieving factors, Severity).

Example Presentation: “The patient presents with complaints of reduced fetal movements since yesterday morning. She usually feels around 10 movements in 12 hours, but has only felt 3 in the last 24 hours. There is no associated pain or bleeding.”

While less critical in ongoing pregnancy, it’s vital for dating and understanding fertility context.

• Age of Menarche: (Only for subfertility assessment).
• Regularity, Volume, Duration of Cycles: (e.g., “Regular cycles, 28-30 days, normal volume, 3-7 days duration”).
• Dysmenorrhoea: History of painful periods.
• Last Menstrual Period (LRMP): Documented by recall.
• Calculated Estimated Due Date (EDD): Using Naegele’s rule (LRMP + 9 months + 7 days).
  • If 30-day cycles: $EDD = LRMP + 9 \text{ months} + 7 \text{ days} + 2 \text{ days}$.
• USS Scan Confirmation: Whether a dating scan was done to confirm EDD/POG (Period of Gestation) or POA (Period of Amenorrhoea).

Example Presentation: “Her last menstrual period was on January 1st, 2025. She has regular 28-day cycles with normal flow. A dating scan at 10 weeks confirmed her EDD as October 8th, 2025.”

For a primigravida, start from the day she got married. For multigravida, start from the last delivery.

Pre-conception Period

• Contraceptive History: Type and duration of contraception used.
• Folic Acid Supplementation: When started and duration.
• Decision to have a baby: Any pre-conception counseling or clinic visits.

Example Presentation: “After her last delivery, she was on Depo-Provera for 18 months. She stopped Depo-Provera and started taking folic acid 3 months prior to conception, as advised during her pre-conception clinic visit.”

Conception & Early Pregnancy (First Trimester: up to 12 weeks)

• Confirmation of Pregnancy: Missed periods, urine strip test positive.
• Booking Visit: Date, registration with PHM (Public Health Midwife), referral to specialized unit (e.g., THK) around 12th week.
• Booking Visit Assessments: Height, weight, BMI, BP, pallor, oedema, initial blood and urine investigations (FBC, PPBS, Blood group, VDRL, HIV, Hep B, UFR, Urine sugar, Urine protein).
• Dating Scan: To confirm EDD, viability, number of fetuses, Nuchal Translucency (NT) scan for gross defects.
• Routine Supplements: Folic acid, Thriposha (if applicable).
• Vaccination: Rubella, Tetanus Toxoid (TT).
• Early Pregnancy Complications: Nausea, vomiting, loss of appetite, PV bleeding, hyperemesis gravidarum.

Example Presentation: “She missed her periods in April 2025, and a urine strip test at home was positive. She registered with the PHM and had her booking visit at 10 weeks, where initial blood tests were done and a dating scan confirmed a viable singleton pregnancy with an EDD of January 2026. She experienced mild nausea and vomiting in the first trimester, which resolved spontaneously.”

Mid-Pregnancy (Second Trimester: 13-28 weeks)

• Supplements: Calcium, Iron, Vitamin C.
• Complications: Gestational Diabetes Mellitus (GDM), Pregnancy-Induced Hypertension (PIH), vaginal bleeding, anaemia, Urinary Tract Infections (UTI).
• Anomaly Scan (18-22 Weeks): Findings.
• Quickening: Around 20 weeks.
• Hospital Admissions: Any admissions and their management (if any).

Example Presentation: “During the second trimester, she continued her iron and calcium supplements. An anomaly scan at 20 weeks was reported as normal. She experienced quickening around 18 weeks. There were no significant complications or hospital admissions during this period.”

Late Pregnancy (Third Trimester: 29-40 weeks)

• USS Scan (growth scan): For Intrauterine Growth Restriction (IUGR), malpresentation, placenta location.
• Antenatal Care: Satisfaction with care, advices given (dietary, rest, kick count chart).
• Reason for Current Hospital Admission: If applicable.

Example Presentation: “In the third trimester, a growth scan at 32 weeks showed appropriate fetal growth and an anterior placenta. She was advised on kick counts and felt satisfactory fetal movements daily. She is currently admitted for routine confinement at 39 weeks of gestation.”

Past Medical History (PMHx)

Elicit history of chronic medical conditions, especially those relevant to pregnancy.

• Hypertension (HPT)
• Diabetes Mellitus (DM)
• Renal disease
• Heart disease (e.g., NYHA classification)
• Thyroid enlargement/disorders
• Bronchial Asthma (BA)
• Psychiatric disorders
• Epilepsy

Example Presentation: “She has a known history of gestational diabetes in her previous pregnancy, managed with diet control. She denies any history of hypertension or thyroid disorders.”

Past Surgical History (PSHx)

• Any previous surgeries, describe in detail (type of incision, complications, management).

Example Presentation: “She underwent an appendectomy 5 years ago, which was an uncomplicated procedure with a Pfannenstiel incision.”

Drug History

• Long-term Medications: Any ongoing prescribed or over-the-counter medications.
• Modifications during Pregnancy: If any medications were changed or stopped due to pregnancy.
• Recreational Drug Use: Alcohol, smoking, illicit drugs.

Example Presentation: “She is currently taking iron and calcium supplements as prescribed during antenatal visits. She denies any other long-term medications, alcohol consumption, smoking, or illicit drug use.”

Allergic History

• Known Allergies: To medications, food, or environmental factors.
• Nature of Reaction: Describe the type of allergic reaction experienced.

Example Presentation: “She has a known allergy to penicillin, which causes a generalized rash. She denies any food or environmental allergies.”

Personal History

• Dietary History: “She is taking a normal diet with adequate calories and proteins, and micronutrients.”
• BMI Assessment: Well-nourished, high BMI, low BMI.

Social History

• Family History: GDM, PIH, IHD, stroke, ovarian CA, endometrial CA.
• Husband’s Details: Age, occupation, smoking/alcohol consumption.
• Family Support: Crucial for post-delivery care.
• Economy: Financial stability.
• Logistics: Nearest hospital, vehicle availability.
• Contraception: Plans for contraception after delivery.
• Knowledge/Education Level: Important for patient education.

Example: “She lives with her husband and in-laws, who provide good family support. Her husband is a daily wage earner. The nearest hospital is 15 minutes away by car. She plans to use injectables for family planning after delivery.”

The mother should be comfortably lying in a supine position, well-exposed from xiphisternum to pubic symphysis.

• General Appearance: Well-looking, afebrile, not dyspnoeic.
• Anthropometry: Height, Weight, BMI.
• Pallor & Icterus: Assess for anaemia and jaundice.
• Oral Hygiene: Dental caries, glossitis, angular stomatitis.
• Thyroid: Any enlargement.
• Lymphadenopathy: Check for any enlarged lymph nodes.
• Clubbing, Cyanosis, Oedema: Ankle/sacral oedema (up to mid-calf level), central cyanosis, clubbing.
• Varicose Veins: Presence and extent.

Systemic Examination

• Breast Examination: Suitability for breastfeeding (everted nipples), exclude masses (screening).
• Cardiovascular System (CVS):
  • PR (Pulse Rate): Rate, volume, rhythm.
  • BP (Blood Pressure): Seated or left lateral position (to avoid supine hypotensive syndrome).
  • Auscultation: S1, S2, murmurs (if present, perform full CVS exam).
• Respiratory System (Respi):
  • RR (Respiratory Rate).
  • Trachea: Not deviated.
  • Auscultation: Vesicular breathing, no added sounds.

Procedure: Informed consent, proper exposure (xiphisternum to PS), patient orientation, examination, thank the patient.

Inspection

• Abdomen: Enlarged due to gravid uterus, symmetrical/asymmetrical, uniformly enlarged.

  Example Comment: “Abdomen is symmetrically enlarged due to a gravid uterus.”

• Skin Changes: Linea nigra, striae gravidarum, linea alba (normal signs of pregnancy).

  Example Comment: “Linea nigra and striae gravidarum are present.”

• Umbilicus: Flat/everted.

  Example Comment: “Umbilicus is flat.”

• Scars: Surgical scars (describe specifically, mention in PSHx), keloids.

  Example Comment: “No surgical scars visible.”

• Veins: No dilated veins.

  Example Comment: “No dilated veins noted.”

• Fetal Movements: Visible fetal movements.

  Example Comment: “Visible fetal movements are observed.”

Palpation

• Symphysio-Fundal Height (SFH):
  • Palpate fundus with ulnar/radial border of hand.
  • Palpate pubic symphysis over cloth.
  • Measure SFH in cm along the midline.
  • Interpretation: Within 20-36 weeks, SFH (in cm) $\approx$ POG (in weeks) $\pm$ 2 cm.
  • <20 weeks: Fundus below umbilical level.
  • >36 weeks: SFH may reduce if head is engaged.

    Example Comment: “SFH is 30 cm, compatible with 30 weeks POG.”

• Fetal Head: Hard/rounded/smooth surface, ballotable (not engaged) or not movable (engaged).

  Example Comment: “Fetal head is hard, rounded, smooth, and ballotable (not engaged).”

• Fundus: Irregular/firm mass (breech).

  Example Comment: “An irregular, firm mass (breech) is palpable at the fundus.”

• Sides: Feel for resistance (back of fetus).

  Example Comment: “Fetal back is palpable on the left side, offering resistance.”

• Fetal Heart Sound (FHS): Use Pinnard stethoscope, stabilize abdomen, measure FHR.

  Example Comment: “FHS heard in the left lower quadrant, rate is 140 bpm, regular.”

• Estimated Fetal Weight (EFW): Clinical estimation.

  Example Comment: “Estimated fetal weight is approximately 2.5 kg.”

• Lie: Longitudinal, transverse, oblique.

  Example Comment: “Fetus is in longitudinal lie.”

• Presentation: Cephalic, breech.

  Example Comment: “Presentation is cephalic.”

• Liquor Amount: Polyhydramnios (globular fundus, can’t feel fetal parts, floating head), Oligohydramnios (can see fetal body shape, feel fetal movements easily).

  Example Comment: “Liquor amount appears average.”

Example Summary: “SFH is 38 cm, compatible with POG of 39 weeks. There is a single fetus in longitudinal lie, cephalic presentation, head not engaged. Breech at fundus, back on right side (likely Right Occipito Anterior). FHS heard in right iliac fossa, regular. Liquor amount is average.”

Twin Examination Considerations

• Inspection: Abdomen symmetrically distended, evidence of pregnancy (striae, linea nigra), visible FM, no visible veins.

  Example Comment: “Abdomen is symmetrically distended, larger than expected for dates, with prominent striae.”

• Palpation: SFH larger than POA (e.g., 48cm). Palpate multiple fetal poles (3 fetal poles needed to confirm twins clinically).

  Example Comment: “SFH is 48 cm. Three distinct fetal poles are palpable, confirming twin pregnancy.”

• Auscultation: Not mandatory, but two people can hear FHS at same time, or use CTG.

  Example Comment: “Two distinct fetal heart sounds heard simultaneously by two examiners, differing by >10 bpm.”

Auscultation

• Fetal Heart Sound (FHS): Auscultate using a Pinard stethoscope or Doppler.

  Example Comment: “Fetal heart rate is 145 bpm, regular, heard clearly in the left lower quadrant.”

• Bowel Sounds: Presence of bowel sounds.

  Example Comment: “Normal active bowel sounds present.”