Obstetrics history taking and physical examination

Obstetrics history taking and physical examinationCreated OnApril 19, 2020Last Updated OnApril 19, 2020byadmin You are here: Main Clinical Examination Obstetrics history taking and physical examination < All Topics Table of Contents HISTORY TAKING PATIENT DETAILS Name, age Gravida and parity (G&P) Gravida – total number of pregnancies regardless of its outcome, including present one Parity – Number of live births and stillbirths delivered after stage of viability (22 weeks) In cases of miscarriage – it should be stated with a “+ no of miscarriage”, for example: G3P1+1 à patient is having her 3rd pregnancy, whereby she has 1 living child and 1 miscarriage In cases of multiple gestation – gravida is still taken as 1, but after the delivery she will have para 2 if twins or accordingly Last menstrual period (LMP) Reliable LMP – fulfil Naegele’s rule Sure of date Regular cycle of 28-30 days Not breastfeeding within 2 months Not on hormonal therapy within 3 months Estimated date of delivery (EDD) Calculated following Naegele’s rule as explained above If LMP not reliable, Estimate from early ultrasound (<20 wks.) – revised EDD (REDD) IF REDD & LMP differ <1wks – take LMP IF REDD & LMP differ >1wks – take REDD Period of amenorrhoea (POA)/ Period of gestation (POG) POA – duration of pregnancy based on LMP if her menstrual period is regular POG – duration-based REDD, whereby in cases where the LMP is not known of the periods are irregular Occupation of patient and husband CHIEF COMPLAINT The presenting symptoms/signs of patient + duration Contraction pain? Duration? Regular/ Irregular? With or without show (blood‐stained mucous from vagina) Leaking liquor? Time? Amount? Colour? Antenatal pyrexia? FM (fetal movement) – good/less/not moving? – ‘Fetal kick chart’ Anaemia Sign and Symptoms of respiratory tract infections or urinary tract infections? HISTORY OF PRESENTING ILLNESS (HOPI) The further description of symptom/signs which can include or exclude differentials HISTORY OF PRESENT PREGNANCY 1st trimester Planned or unplanned pregnancy Physical examination: height, weight, blood pressure First ultrasound to confirm the gestational age of fetus Confirm the last menstrual period Booking antenatal check-up- blood test- Hb, blood grouping and rhesus typing Urine: look for pus cells if more than 5, proceed with urine C&S Prescribe hematinic 2nd trimester Quickening- how long does it take to complete the kicks, need to complete fetal kick chart – the mother needs to start to calculate the no of kicks from 9 am and note down the time, when completed 10 kicks Physical examination- weight, height, blood pressure, uterus corresponds to the date Detailed scan when indicated- anomaly scan Tetanus toxoid injection -first vaccination is given in the first trimester soon after your pregnancy tests are confirmed. 2nd injection is at 4 weeks before EDD Modified glucose tolerance test – done at 18 weeks and if negative, can be repeated at 24 weeks if has risk factors Review any significant complains. 3rd trimester Fetal movements Fetal growth, weight Signs and symptoms of labour Monitor blood pressure, uterine size Optimize the mother’s condition for delivery PAST OBSTETRICAL HISTORY Marriage – age, age of 1st pregnancy A detailed history of each and every pregnancy starting from Antenatal Natal – term of pregnancy, location of delivery, duration of labour, any complications, mode of delivery – if c-section: emergency/elective, child born alive/stillbirth Post-natal – any complications, neonatal diseases, birth weight, breast feeding, PAST GYNAECOLOGICAL HISTORY Has 4 components to it Gynaecological problems – any previous history of gynae problems or gynaecological surgery Menstrual history – start from...

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