Lectures in Obstetrics, Gynaecology and Women’s Health

5. The Obstetric History and Examination

Gab Kovacs¹ and Paula Briggs²

(1)

Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia

(2)

Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK

Obstetric History

The Obstetric Examination

Obstetric History

When taking an obstetric history, commence with the gynaecological history, as described in Chap. 4. Then expand on the details of pregnancies and confinements.

For each pregnancy document whether it:

· Ended in a live birth

· Gestation at delivery

· Duration of labour

· Any complications

· Normal delivery, assisted delivery (forceps or venteuse), or Caesarean Section (CS). If CS then what was the reason?

· Any post natal problems e.g. post partum haemorrhage, infection, thrombosis

· Breast fed and for how long

For this pregnancy:

· Last Normal Menstrual Period (LNMP)

· Whether the cycles prior to conception were regular

· Any complications e.g. bleeding, nausea and vomiting, infection etc.

The woman’s history should be organised in the following way:

Example of a simple history:

Example of a complicated history:

The Obstetric Examination

A “first visit” examination, should involve a general examination, including blood pressure, thyroid, heart, lungs, abdominal and a pelvic examination – as discussed above. The size of uterus should be confirmed.

The ankles and/or fingers should be examined for any oedema.

The patient should be weighed and her urine tested for glucose and protein.

Examination of the pregnant abdomen up to 28 weeks of gestation:

· Between 12 and 28 weeks of gestation, the uterus is palpable on abdominal examination, and its size should be correlated according to landmarks. It should be documented whether the uterus is growing as expected. Prior to 28 weeks, foetal parts cannot be felt sufficiently well to comment. It is normal practice to measure the height of the uterine fundus, in centimetres (cm) from the symphysis pubis.

Examination of the pregnant abdomen from 28 weeks onwards:

· Once the pregnancy has reached 28 weeks, the foetal parts should be palpable.

The following features of abdominal palpation should be determined and recorded:

· Fundal height – with reference to the landmarks (Table 5.1, Fig. 5.1) or as measured in cm from the symphysis pubis.

Table 5.1

Normal uterine growth during pregnancy (Fig. 5.1)

Fig. 5.1

The enlarging uterus during pregnancy

· Foetal lie – this is the relationship of the long axis of the foetus, with respect to the long axis of the uterus. If one is certain, then the side on which the foetal spine is located, can be stated and recorded, but this is not essential.

· Presenting part – this is the part of the foetus within the pelvic brim.

· Station of the presenting part – this is how far the presenting part has entered the pelvic cavity, with respect to the pelvic inlet (antenatally). During labour it is also assessed with respect to the ischial spines (See Chap. 19).

The station is important in assessing the degree of descent of the presenting part. This is explained in detail in Chap. 19. It is sufficient to say here that there are the three options listed in Table 5.2.

Table 5.2

Descriptors of foetal orientation

Engaged means that the widest diameter of the foetal head has passed through the pelvic inlet. This can be accurately diagnosed in a lateral X-ray with the woman standing, but of course this is rarely done. The clinical indication antenatally that the “head is engaged” is that less than three finger breadths of the foetal head are palpable above the pelvic brim (See Chap. 19).

After 28 weeks of gestation, the foetal heart should be audible using a foetal stethoscope, or Doppler.

As part of the antenatal examination the blood pressure should be checked, and fingers and ankles inspected for oedema. Finally, the urine should be tested for glucose and protein.

The antenatal findings should be summarized:

· Mrs Z is a 28 year old G3, P2 at 32 weeks of gestation.

· Her two previous pregnancies were uneventful, with normal vaginal deliveries at term.

· This pregnancy has been uneventful apart from some vaginal bleeding at 11 weeks.

· Her BP is 120/75.

· The fundal height is just above midway from the umbilicus to the xiphysternum (or 30 cm from the symphysis pubis).

· The foetal lie is longitudinal with a cephalic presentation.

· The head is mobile in the pelvic brim.

· The foetal heart is audible and is regular at 120 beats per minute.

· There is no peripheral oedema.

· Her urine is clear.

The obstetric aetiological shopping list.

· When considering the reason for an obstetric abnormality, it is good to have a system.

· Passengers/Passages/Powers: (an example of this framework is given in Chap. 23).

o Passangers

· Foetus

· Liquor

· Placenta

· Membranes

· Cord

o Passages

· Boney – the pelvic bones

· Soft tissues – cervix, vagina, perineum

o Powers

· Primary – the uterine muscles

· Secondary – the abdominal and intercostal muscles