History Taking – Obstetrics (Abdominal Examination)

History Taking - Obstetrics

History Taking – Obstetrics

History Taking – Obstetrics History taking in obstetrics different in some aspect as we have to note the points regarding the growing baby so we can take care of both the mother ans the fetus.

Personal Data

Name: Mrs. __________________ W/O: Mr. ____________________       Age: __________

Married for: _______ Education: ______ Occupation: _________   Resident of: __________

Gravida: _________   Para: _______ Abortions: ________ Last Child Born: ______________

LMP: _____________             DOP: _________________                 EDD: ________________

Mode of Admittance: ____________                         Date of Admittance: _______________

Presenting Complaint

  • Gestational amenorrhea
  • She is admitted for control of blood pressure (PIH)
  • She is admitted for control of diabetes (GDM)
  • She is admitted for evaluation and correction of anemia (Anemia in pregnancy)

History of Presenting Illness (HOPI)

Mrs. __________ was alright _________ weeks/months back when she missed her periods and started having signs and symptoms of pregnancy. She is a known/not known case of ________ and her pregnancy is planned/spontaneous. She confirmed her pregnancy by urine pregnancy test (UPT)/ultrasound after _______ weeks of missing periods. She was/wasn’t having normal menstrual cycle when she conceived pregnancy.

1st Trimester

  • Booking at antenatal care clinic: _________
  • H/O nausea, vomiting _________________
  • H/O fever, rash ______ if yes then medications taken or not
  • H/O breathlessness
  • H/O urinary complaints
  • H/O abdominal/back pain
  • H/O vaginal discharge
  • H/O PV bleeding
  • Folic acid supplements
  • Dating scan
  • H/O of HTN, DM, Thyroid disease, asthma or TB before pregnancy

2nd Trimester

  • H/O vaginal discharge
  • H/O PV bleeding
  • H/O increased BP
  1. Headache
  2. Epigastric pain
  3. Blurred vision
  • H/O anemia
  • H/O fits
  • Quickening or fetal movements at ________ weeks
  • Anomaly scan
  • Regular use of Ca++ and Iron supplements
  • H/O breathlessness
  • H/O of DM
  1. Polyuria
  2. Polydipsia
  3. Polyphagia

3rd Trimester

  • Tetanus vaccination
  • H/O increased BP
  1. Headache
  2. Epigastric pain
  3. Blurred vision
  • H/O abdominal/back pain
  • H/O PV leakage
  • H/O PV bleeding
  • Growth scan
  • H/O labour pain
  • H/O GDM symptoms
  1. Polyphagia
  2. Polydipsia
  3. Polyuria
  • H/O hand/foot swellings
  • H/O chest pain, palpitations, breathlessness
  • H/O burning micturition, dysuria
  • H/O change in bowel habits

Obstetrical History

Gravida: ______ Para: ______ Abortions: _______ Alive: _______ M: ______ F: ______

Sr. No. Date of Deliver DOP, Term, pre or post-term Place of Delivery Sex Birth Weight Status Complications

(APH, PIH, PPH)

Breast feed or not Vaccinated according to EPI schedule or not

Gynecological History

  • Age of menarche
  • M/C previous (regular or irregular)
  • M/C present
  • Duration of menses
  • Soaked pads per day
  • Bleeding: Scanty, moderate or severe
  • H/O Dysmenorrhea
  • H/O Dyspareunia
  • H/O intermenstrual bleeding
  • Pap smear
  • Contraceptive method used
  • Its side effects if used

Past Medical & Surgical History

  • Diabetes
  • Hypertension
  • Ischemic Heart Disease
  • Tuberculosis
  • Asthma
  • Hepatitis
  • H/O previous surgery

Family History

  • 1st cousin marriage
  • Joint family system or not
  • Family H/O
  • Diabetes
  • Hypertension (HTN)
  • Ischemic Heart Disease (IHD)
  • Breast cancer
  • Ovarian cancer
  • Endometrial cancer
  • Abnormal children

Socioeconomic History

Her husband is a ____________ and she belongs to a lower/middle/upper class of socioeconomic status. They live in joint family system/separately and her diet does/does not contain/s fresh fruits and meat.

Personal History

  • Appetite
  • Sleep
  • Bowel
  • Burning micturition
  • Smoking
  • Weight gain/loss
  • Allergy to drugs

General Physical Examination

A young/old/middle aged lady lying comfortably on bed with a branula on her R/L hand, Foley catheter passed or not (oxygen mask or any kind of medical device attached), is well oriented in time, space and person having vitals of;

  • Blood pressure: ____ mmHg
  • Pulse: ________ Beats/minute
  • Temperature: ___0F
  • Respiratory rate / per minute
  • Pallor (anemia)
  • Yellow discoloration (jaundice)
  • Orodental hygiene
  • Thyroid
  • Lymph nodes
  • Breast
  • Edema
  • JVP raised or not

Others;

Systemic Examination

  • CVS
  • Respiratory
  • GIT
  • CNS

Abdominal Examination

Inspection

  • Size
  • Shape
  • Pigmentation
  • Striae gravidarum
  • Scar (Pfennansteil incision)
  • Fetal movements
  • Prominent veins
  • Any mass prominent
  • Shape of umbilicus
  • Cutaneous signs of pregnancy (Linea nigra)

Palpation

  • Tenderness
  • Fundal Height (SFH)
  • Number of fetuses
  • Lie of the fetus (longitudinal axis pf the fetus in relation to the longitudinal axis of uterus)
  • Presentation of the fetus (the part of fetus that overlies the pelvic brim)
  • Check for grip
  1. Fundal Grip
  2. Lateral/umbilical grip (place one hand on the one side of the uterus and stabilize it while palpating the other side)
  3. Pelvic grip
  4. Pawlik grip

Auscultation

Fetal heart rate (FHR) is calculated with Pinard stethoscope.

Investigations

  1. Baseline investigations
  • CBC
  • Blood grouping & Rh factor
  • Blood sugar
  • Hepatitis B & C screening
  • Urine complete
  • USG
  1. Specific investigations
  • Coagulation profile
  • Obstetrical ultrasound

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History Taking – Obstetrics

History Taking – Obstetrics