- ■ History Taking and Clinical Examination
- ■ Obstetric Case Discussions
- ■ Single Best Answer and Multiple Choice Questions
- ■ Labor and Delivery
- ■ Active Management of Labor
- ■ Obsteric Short Questions
- ■ Operative Obstetrics
- ■ Practical Obstetrics
- ■ Maternal Health—Global Scenario and India
Chapter Objectives
- Good knowledge and understanding to demonstrate:
- ■ Clinical skills
- ■ Communication skills
- ■ Review of the physical signs based on physiology/pathology
- ■ Identification of risk factors
- ■ Ability to organize investigations
PATIENT PARTICULARS
Name: Mrs.………………….
Age: …………… years
Address: …………………………………………………………….
Occupation:
Educational status:
Duration of marriage:
Gravida:
Parity:
- Religion:
- Occupation of the husband:
- Socioeconomic status:
- Date of admission:
- Date of examination:
LMP……………. EDD ……………………………. Period of gestation in weeks……………
Chief complaints: Pain abdomen/headache/vaginal bleeding/urinary problems are to be recorded, in order of priority or by chronological onset of events. Some patients may not have any complaints but have been admitted due to some significant observation like raised blood pressure (BP), or for investigations and planning mode of delivery as in a case with Rh-isoimmunization or pregnancy with prior cesarean delivery.
History of present illness: Elaboration of the chief complaints as regard to their onset, duration, severity, use of medications, investigations, and progress, is to be made.
History of present pregnancy: Important complications of different trimesters of the present pregnancy (if any) are to be recorded carefully. Number of antenatal visits (booking status), immunization status, intake of iron and folic acid are to be recorded. Any medication or radiation exposure in early pregnancy or medical/surgical events during pregnancy should be enquired and recorded. Woman's perception of fetal movements may be mentioned.
Obstetric history: Previous obstetric events are to be recorded chronologically. This is relevant in a multigravida. The obstetric history is summed up as gravida………., para………., miscarriage………., MTP………. and living issue…….
Menstrual history: Menarche (age)…….years, cycle 28–30 days, duration 3–4 days; amount of flow: (average/scanty), dysmenorrhea (if any). LMP………….EDD…………. (Naegele's formula); period of gestation………… weeks.
Past surgical history: Previous surgery—general (appendicectomy) or gynecological (myomectomy).
Family history: Hypertension, diabetes, hemoglobinopathy, twinning or congenital malformation or consanguineous marriage is to be enquired and recorded.
Personal history: Contraceptive practice, smoking, chronic medications (corticosteroids), habit forming drugs are to be enquired. Sleep, appetite, bowel and bladder habits are to be mentioned.
EXAMINATION
■ General survey ➤ Build ➤ Nutrition ➤ Height (Fig. 1.1) ➤ Weight (Fig. 1.1) ➤ Pallor ➤ Jaundice ➤ Cyanosis ➤ Tongue, teeth, gum and tonsils ➤ Neck veins ➤ Neck glands ➤ Thyroid ➤ Breasts ➤ Pulse ➤ Blood pressure ➤ Temperature ➤ Respiratory rate ➤ Edema legs | ■ Mental status
■ Systemic examination ❖ Examination of cardiovascular and respiratory system
❖ Musculoskeletal system ❖ Examination of abdomen
Any tenderness, liver, spleen (any organomegaly) ❖ Obstetric examination:
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Different Gadgets Used in the Antenatal Clinic to Assess Maternal Health and Fetal Wellbeing
OBSTETRIC EXAMINATION
Preliminaries: (a) Verbal consent from the patient should be taken, (b) presence of a female attendant, (c) prior bladder evacuation, (d) proper exposure of abdomen, (e) woman in dorsal posture with thighs and knees slightly flexed (Fig. 1.7), (f) the candidate is to stand on the right side of the patient.
EXAMINATION PROPER
A. Inspection: Enlargement of the abdomen; uterine shape — ovoid (longitudinal/transverse); contour of uterus — smooth or any fundal notching.
Skin condition: Presence of linea nigra (Fig. 1.8), striae gravidarum, umbilicus (everted), presence of any scar mark, infection (scabies, if present) venous prominence, visible fetal movements, etc.
B. Palpation: Centralization of the uterus should be done (Fig. 1.9).
(a) Height of the uterus in terms of weeks (Fig. 1.9)
(b) Symphysiofundal height in cm (Fig. 1.10)
(c) Obstetric grips (Leopold's maneuvers):
- First Leopold (fundal grip)
- Second Leopold (lateral or umbilical grip)
- Third Leopold (Pawlik's grip)
- Fourth Leopold (pelvic grip).
For methods of examination, observation and inference, see Dutta obs 8/e, p 87.
C. Auscultation of fetal heart sound using a stethoscope or Doppler (along the spinoumbilical line in case of cephalic presentation).
Summary of the case: A case summary is to be made mentioning the age, parity, period of gestation, highlighting in brief the important and relevant information in the history, general physical examination and obstetric examination (obstetric palpation and auscultation). See case 1.
Provisional diagnosis: A provisional diagnosis is to be made and written in few lines mentioning the woman's age, parity, gravida, period of gestation and the complication (if any) in pregnancy.
Suggested investigations: (a) Routine antenatal investigations (Dutta obs 8/e, p 110). and (b) investigations relevant in the given case for diagnosis and/or management.
Differential diagnosis: Where applicable.
NORMAL PUERPERIUM
HISTORY TAKING AND CLINICAL EXAMINATION
The basic format is more or less same as in an antenatal case.
Points of difference are:
- Instead of recording the LMP—mention the date and time of childbirth.
- Instead of EDD and period of gestation—mention the number of days in puerperium.
- Chief complaints should be highlighted, the problems of puerperium (e.g. pain abdomen, pain perineum, breast problems, urinary problems, etc.) only.
- History of present illness: Elaboration of chief complaints (mentioned in ‘C’) as discussed in an antenatal case, e.g. pain abdomen starts since the time of delivery. The pain is mild in nature at times spasmodic. Pain located in the perineum, specially over the area of episiotomy. The lochial discharge is normal. It is bright red in color. She changed 3–4 pads in the last 12 hours. Pads are partly soaked. Her pain has improved as she has taken some medicine (analgesic—ibuprofen).
- Instead of “History of Present Pregnancy” mention in brief the history of preceeding pregnancy (e.g. Mrs. CR was admitted in the hospital last evening at about 7 pm with labor pain following a term pregnancy. She was a booked case in this hospital. Her course in pregnancy in all the trimesters were uneventful. She had a spontaneous vaginal delivery with right mediolateral episiotomy on …………….at…….am/pm. The total duration of labor was 5 hours. She had uneventful third stage of labor.
Rest of history (past, family, obstetric, etc.): Same as that of an antenatal case.
Examination:
- General survey: Record of temperature is important, besides the other (BP, etc.) parameters mentioned in an antenatal case (p. 3-4).
- Examination of chest: For cardiovascular system and respiratory system are same as in an antenatal case.
- Breast examination: To enquire about breast problems (pain and lactation difficulty) breast examination is needed (in the presence of a female attendant).
- Palpation (abdomen) for any tenderness and organomegaly (liver/spleen) is done.
- Obstetric palpation: Preliminaries are same as in an obstetric case.
- Measuring the height of the uterus (bladder should be empty and uterus must be centralized). It is expressed in relation to the level of umbilicus.
- Symphysiofundal height measurement (in cm).
- Palpation of the uterus to note tenderness, surface irregularity, mobility and palpation for any other abdominal mass (ovarian) is done (obstetric grips and auscultation are not applicable here).
HISTORY AND EXAMINATION OF THE BABY
A: (i) Birth — Date and time, (ii) Apgar score (cried at birth), (iii) weight, (iv) passage of urine and meconium and (v) breastfeeding.
B: Examination: (i) Skin color, (ii) respiration, (iii) jaundice, (iv) head, (v) chest, (vi) heart and lungs, (vii) abdomen, (viii) umbilicus (any discharge, infection), (ix) genitalia, (x) anus, (xi) any congenital malformation such as limbs, digits, etc. (xii) gestational age (term/preterm).
Summary of the case: (Case 3) p. 29.
Mrs. …………. 22 years, P1+0+0+1, delivered vaginally in this hospital following a term pregnancy. Live baby boy/girl was born on …………. at …………. Mrs. … has got mild pain in the abdomen and the perineum. On examination she is afebrile, uterine fundus is at the level of umbilicus (…………. cm above the symphysis pubis) and the episiotomy wound is healthy. Lochial discharge is normal. Bladder function is normal (she has passed urine).
Baby cried at birth. Baby on examination is found to be a term one, normal and is on breast milk.
Provisional diagnosis: Mrs.……………………, 22 years old, P1+0+0+1 with a term healthy baby girl, 2.7 kg, delivered on………………. date………………. She is on the second day of normal puerperium (Fig. 1.11).
Post-partum Exercises
