How to Take a Good Obstetrical History & Performing a Thorough Clinical Examination

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HISTORY:

Demographical Details/Personal Profile:

1. Name

2. Age

3. Education

4. Occupation

5. Marital Status (if married, for how long? )

6. Residence

7. Date, time & mode of Admission

8. Which pregnancy?

Presenting Complaints:

1. Gestational amenorrhoea and its duration (in weeks)

2. Any other complaint

a. Labor pains

b. PROM

i. PROM at term

ii. PPROM

c. Vaginal bleeding (APH, PPH etc.)

d. Abdominal pain (other than labor pains)

e. Decreased/absent fetal movements

f. Seizures

g. HTN or Pre-eclampsia or Eclampsia (Symptoms)

h. DM or GDM (Symptoms)

i. Anemia (Symptoms)

j. Hyper/hypothyroidism (Symptoms)

k. Ischemic Heart Disease (Symptoms)

l. Valvular Heart Disease (Symptoms)

History of Present Pregnancy:

1. Planned/ Unplanned

2. Wanted/ Unwanted

3. Reaction to pregnancy

4. LMP (first day of last menstrual period)

5. Use of Contraception

6. Any spotting or bleeding

7. Specific things to ask in First Trimester

a. Confirmation of pregnancy, how and when?

b. Any symptoms of pregnancy (Nausea, vomiting etc.)

c. Urine/Serum Pregnancy test

d. Ultrasonography

e. Any antenal visit?

8. Specific things to ask in Second Trimester

a. When did patient start to feel fetal movements?

b. Any anomaly scan?

c. Any prenatal diagnosis? If yes, then what?

9. Specific things to ask in Third Trimester

a. Any CTG, USG or BPP done

b. Results of the above

c. Any findings on antenatal visits

d. Any hospital admission? If yes, then for what problems?

e. Fetal movements

f. Vaginal discharge (PROM)

g. Vaginal bleeding

Depending upon the other presenting complaint, following questions may be relevant to ask

1. Onset

2. Duration

3. Intensity/Severity

4. Aggravation and relieving factors 5. Associated features

Past Obstetrical History:

1. Number of children

2. Ages of all children

3. Mode of deliveries of all children

4. Gestational age of all children at the time of delivery (Term/Preterm etc.), present state of health (Alive/Died Later/Handicapped/Retarded)

5. Number of miscarriages and duration of gestation at those

6. Termination of pregnancy/pregnancies, At what gestation? For what reason?

Menstrual History:

1. Age of menarche

2. Cycle Regular or Irregular

3. Duration of Cycle

4. Quantity of Blood loss

5. Dysmenorrhoea

6. Intermenstrual Bleeding

7. Post coital Bleeding

8. Dyspareunia

9. LMP

10. Cervical Smear

Past Gynecological History:

1. Any previous gynecological problems

2. Any treatment for the same

3. Cervical Swab

Sexual History:

1. Age at first intercouse

2. Coital freuency

3. Any coital difficulty

4. Number of sexual partners

5. Number of sexual partners of the patient’s partner/husband

Past Medical History:

(Please refer to clinical methods of Internal Medicine for details.)

Past Surgical History:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Inquiry:

From CVS, CNS, RS, GIT, GUT & MSK

(Please refer to clinical methods of Internal Medicine for details.)

Family History:

About Infectious diseases, IHD, HTN, DM, Multiple Pregnancy, Gynecological and other malignancies

(Please refer to clinical methods of Internal Medicine for details.)

Social/ Socioeconomic/ Biosocial History:

1. Place of living

2. Type of family

3. Monthly Income

Personal History:

(Please refer to clinical methods of Internal Medicine for details.)

Drug History:

(Please refer to clinical methods of Internal Medicine for details.)

Treatment History:

(Please refer to clinical methods of Internal Medicine for details.)

Examination:

General Physical Examination:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Examination:

CNS (Please refer to clinical methods of Internal Medicine for details.)

CVS (Please refer to clinical methods of Internal Medicine for details.)

RS (Please refer to clinical methods of Internal Medicine for details.)

Abdominal Examination:

1. Inspection

2. Palpation

a. Assessment of fundal height

i. Palpatory method

ii. Measurement method

b. Assessment of fetus

i. First manoeeuvre (Fundal palpation)

ii. Second manoeuvre (Lateral palpation)

iii. Third manoeuvre (Pawlik’s grip; palpation of presenting part)

iv. Fourth manoeuvre (For attitude of fetal head & engagement of head in fifths; 5/5, 4/5, 3/5, 2/5, 1/5)

3. Ausculation (with pinard stethoscope for fetal heart sounds)

Pelvic Examination: (Generally not required, specially contraindicated in vaginal bleeding (APH) or vaginal discharge)

(Ensure Adequate Privacy)

1. Inspection

a. Hair Distribution

b. Labial Appearance

c. Episiotomy Scar etc.

d. Stress incontinence

e. Vaginal Discharge

2. Palpation

3. Speculum Examination (for vaginal discharge, to confirm/exclude PROM)

4. Vaginal Examination (Not indicated if woman not in labor)

Only done in two conditions;

i. Before labor (Bishop scoring)

ii. During labor (to assess progress of labor; Dilatation of cervix & length of cervix)

Provisional/Working Diagnosis + Risk Scoring (High/Low Risk):

Differential Diagnosis (es):

Investigations:

a. Routine

b. Specific

Definite Diagnosis:

Plan of Management:

SUMMARY: