GuidelinesforMedicalStudents

Gynaecological&obstetrichistorytaking
andphysicalexamination

Department of Obstetrics & Gynaecology

University of Malta Medical School
Malta
2011

Published by
Department of Obstetrics & Gynaecology
University of Malta Medical School, Malta

Department of Obstetrics & Gynaecology, UMMS, 2011

No part of this publication may be reproduced, stored in a retrieval system

or transmitted to any form by any means, electronic, mechanical,
photocopying, recording or otherwise, without the previous permission of
the publisher and author.

CONTENTS
INTRODUCTION ...........................................................................................................................................4
HISTORYTAKING..........................................................................................................................................4
Introduceyourselfandobtainconsenttotakehistory ..........................................................................5
Personalhistory ......................................................................................................................................6
Presentingcomplaint ..............................................................................................................................6
AssociatedSymptomsSystemicenquiry..............................................................................................8
Menstrualhistory....................................................................................................................................8
Sexualhistory..........................................................................................................................................8
Obstetrichistory .....................................................................................................................................9
Pastmedical&surgicalhistory ...............................................................................................................9
Drughistory ............................................................................................................................................9
Familyhistory........................................................................................................................................10
Socialhistory.........................................................................................................................................10
CLINICALEXAMINATION ............................................................................................................................11
Obtainingconsenttoexaminepatient .................................................................................................11
SystemicExamination ...........................................................................................................................12
AbdominalExamination........................................................................................................................13
ObstetricExamination ..........................................................................................................................17
GynaecologicalExamination .................................................................................................................19
EXAMPLEPRESENTATIONOFANANTENATALHISTORY&EXAMINATION.............................................23
PresentationoftheHistory...................................................................................................................23
PresentationoftheExamination ..........................................................................................................26
EXAMPLEANTENATALCASEWRITEUP ...................................................................................................28
3

INTRODUCTION
Female reproductive health is an important component of medical education. Regardless of the
specialitythatthemedicalstudentswillultimatelychoosetopursue,asmedicalpractitionerstheyneed
tohaveabasicknowledgeandskillspertinenttothecareofthefemalepatient.Theyneedtonotonly
needtoknowhowtoperformtheclinicalassessment,buthowtodothisinasensitive,competent,and
ethical manner. The principles of history taking and physical examination in obstetric and
gynaecologicalpatientsaresimilartothoseinotherbranchesofmedicine,butthereareaspectsthat
arespecifictothespeciality.

In general, history taking and physical examination should be carried out in a logical sequence. The
medicalstudentshouldunderstandthepurposeofeachposedquestionandeachobservationalaspect
oftheexamination.Whilethereismarkedoverlapbetweentheclinicalassessmentoftheobstetricand
thegynaecologicalpatient,itwillbeappreciatedthattheemphasisdiffersinthetwoclinicalsituations.

HISTORYTAKING
The scope of taking a clinical history in any situation is to identify the clinical problem and obtain
sufficientdetailtoallowfortheformulationofaprovisionaldiagnosissothatthesubsequentclinical
examination and investigations are targeted to narrow down the diagnostic possibilities further. The
eventualpresentationoftheclinicalhistory,whetherthisispresentedverballyorinthewrittenformat,
shouldfollowalogicalandchronologicalsequencepreferablyinparagraphformat[asinastory]see
example.

Duringhistorytaking,themedicalstudentshouldatalltimesshowthepatienttherespectthatisdueto
her; while full confidentiality must be maintained at all times bearing in mind that the relationship
betweentheprofessionalandhisclientisbasedonmutualtrustandrespect.Themedicalprofession
haslongidentifiedtheneedforconfidentialitywiththeclassicalHippocraticOathstating:Allthatmay
cometomyknowledgeintheexerciseofmyprofessionorindailycommercewithmen,whichoughtnot
to be spread abroad, I will keep secret and will never reveal. The concept of professional secrecy
relatingtothemedicalprofessionwassostronglyfeltthatitwasincorporatedwithintheCriminalCode
ofMalta[Ch.9:257].Thelawreadsasfollows:Ifanyphysician,surgeon,obstetricianorapothecaryor,
ingeneral,anyotherpersonwho,byreasonofhiscallingorprofession,becomesthedepositoryofany
secretconfidedtohim1,shall,exceptwhencompelledbylawtogiveinformationtothepublicauthority,
disclosesuchsecret,heshall,onconvictionbeliabletoafine.Furthermore,anyconvictionunderthis
headingmayalsoinvolvedisciplinaryactiononthepartoftheMedicalCouncil.

History taking should follow a logical and chronological sequence. Each clinician has his particular
preference.Ageneralusefulschemeforagynaecologicalhistoryisoutlinedbelow.

Introduceyourself
Hello.IamMr/Ms****,amedicalstudent.DoyoumindifIaskyousome
andobtainconsent
questionsaboutyourmedicalcondition?
totakehistory

Thisincludesthemedicalstudentandanyotherparamedicalprofessional.
5


Personalhistory
Presentingcomplaint

Name,age,address[ifrelevant],maritalstatus,occupation.
Whatistheproblemthatbroughtyoutothehospital/clinic?
Besttorecordthisinthepatientsownwords.
Were you referred by your doctor or did you selfrefer yourself to the
hospital/clinic?
Patientmaynotfurnishsufficientdetails,inwhichcaseitwillbenecessary
toamplifywithspecificdirectedquestions.E.g.SOCRATESrelatingtopain:
o Site:where,local/diffuse
o Onset:rapid/gradual,pattern,worse/bettersinceonset
o Character:sharp/dull/stabbing,burning/cramp/crushing
o Radiation:Doesthepainaffectyouanywhereelse?[to
thigh/loin/elsewhere]
o Alleviatingfactors:Whatdoyoudotomakeyourselfcomfortable?
Isthepainbetteraftermenstruation?
o Timecourse:Whendidthepainstart?;ifpainischronicWhat
madeyouseekattentionnow?Isthepainworseatanyparticular
timeofthecycle?
o Exacerbatingfactors:Isthereanythingthatbringsonthepainor
makesitworse?
o Severity&Impactonlife:Onascaleof1to10,atwhatlevelwould
youclassifythepain?"Doesitinterruptyourlife?"

Intheobstetricpatient,itsmaybebesttoconsiderthepresentingcomplaintintwoparts:
A. Thehistoryofpresentillnessorcomplaint[seeabove];and
B. Thehistoryofthecurrentpregnancy.

Thehistoryofthecurrentpregnancyisbestconsideredindifferenttrimesterstodate.
1. Firsttrimester:Aftertakingthemenstrualhistory[seebelow],oneproceedstoaskaboutany
problems that may have occurred during the first three months of pregnancy, particularly
specific associated symptomatology of nausea/vomiting, vaginal bleeding, and urinary
symptoms. Establish when patient confirmed her pregnancy [When did the pregnancy test
show up as positive?]; and establish when she actually first visited her doctor. Was the
pregnancyplanned?Inwhichcasedidshestartpreconceptionalfolicacid.Ifnotwhendidshe
start these and other haematologicals [if at all]. Was an ultrasound scan done at any time
during the first three months? If so, What comments did the doctor make about the
findings?
2. Secondtrimester:
Wherethereanyparticularproblemsduringthesecondthreemonthsofpregnancy?
Anybleeding?Anyurinaryproblems?Anyotherproblem/s?
When did she visit the doctor? Were any blood tests performed and what was she told
abouttheresults,anaemia,bloodgroup,etc.?
Was an ultrasound scan done during this period and what were the doctors comments
aboutthis?Wastheplacentainthecorrectposition?Wasthefoetusgrowingadequately?
Wereanyabnormalitiesnotedduringexamination?Wasthebloodpressurenormal?Any
glycosuriaoralbuminurianoted?
3. Third trimester to date: Where there any particular problems after the sixth month of
pregnancy?Anybleeding?Anyurinaryproblems?Anyotherproblem/s?
7


Associated
SymptomsSystemic
enquiry

Menstrualhistory

Sexualhistory

Isthereanythingelsethatyouhavenoticedrelatingtothepain?vaginal
discharge [colour, consistency, amount, smell] or bleeding [amount,
colour]; weight changes; fever, bowel problems [constipation, diarrhoea,
etc]; urinary problems [dysuria, frequency, hesitancy, nocturia, colour
change,incontinence,feelingofincompleteemptying,etc.];etc.
Lengthandregularityofcycles
Severityofmenseslengthofmenses,heavy,flooding,presenceofclots,
numberoftampons/padsused
Painduringmensestimingofpaininrelationtomenses[beginning,end];
characterofpain[dullpersistent,coliky]
Lastmenstrualperiod[firstday]
Presenceofspellsofnoperiodsinabsenceofpregnancy;bleedingbetween
periods;afterintercourse.
Timeofmenarcheandmenopause.Ifmenopausal:assessforassociated
symptoms[hotflushes,nightsweats];historyofpostmenopausalbleeding.
Sexuallyactive;numberofpartners[bediscreet!].
Contraceptionbeingusedcurrentlyandanyusedpreviously.
Physicalorotherdifficultiesduringintercourseifpaincheckwhether
deep/superficial,always/sometimes.
Papsmear:date&resultoflastsmear.


Obstetrichistory

Pastmedical&
surgicalhistory

Drughistory

Anydifficultyinconceiving;Whattreatmentwasusedtoassistthe
infertility?
Possibilityofcurrentpregnancy.
Numberofpreviouschildrengender,antenatalproblems,birthweights,
modeofdelivery,postpartumcomplications[bleeding,thrombosis,
infection].
Numberofmiscarriages,terminationsand/orectopicswhatmonththey
occurred,patternofmiscarriage[spontaneous,induced],surgery
performed.
Doyoucurrentlysufferfromanyillnesseshypertension,diabetes,
epilepsy,asthma,bleedingdisorders,etc?;Haveyoueverbeenseriouslyill
beforecardiovascularepisodes,jaundice,STDPID,etc.?
Haveyouundergoneanysurgeryappendicitis,gynaecologicalsurgery
abdominalorvaginal[inclusiveD&C]?;Didyouhaveanyproblemswith
anaesthesia?;Didyourequirebloodtransfusion?
Haveyoueverseenagynaecologistbeforeforwhatreason?
Haveyoureceivedallthechildhoodvaccinationsrubella,HPV,TB?
Areyouonanymedicationsatpresentlist?
Areyouallergictoanymedicationswhathappenedwhenyoutookthe
medication?[ensureallergysincepatientsoftenassociatedevelopmentof
vaginalthrushasanadversereactiontoantibioticuse].


Familyhistory

Socialhistory

Areyourparentsstillalive?Dotheysufferfromanyillness?ifdead
Whatwasthecauseofdeath?
Doyouhaveanybrothersorsisters?ifyesWhatistheirstateof
health?
Isthereanyfamilyrelateddiseaseinyourfamilythatyouareawareof?
diabetes,hypertension,malignancy,twins
Whatisthestateofhealthofyourspouse?Yourchildren?
Race&migrationifrelevant
Presentandpastoccupations
Diet,physicalactivity
Smoking,alcohol,entertainmentdrugs
Wholiveswithyouathome?supportofotherhouseholdmembers;
Anypets?
Haveyoutravelledoverseasrecently?Where?

AtthispointoneshouldbeinapositiontoidentifythePRESENTING COMPLAINTandtoformulatea
workingprovisionaldiagnosis.

10

CLINICALEXAMINATION
Thescopeoftheclinicalexaminationistogatherfurthercluestosupplementtheinformationgathered
fromtheclinicalhistorytohelpidentifytheclinicalproblemandnarrowdownthedifferentialdiagnosis.
Withthisaiminmind,theexaminationshouldbeacomprehensivebuttargetedone.Alwaysobtainthe
patientconsenttoallowyoutoperformtheexaminationandexplainatalltimestothepatientwhat
youplantodo.

REMEMBERTOALWAYSPUTTHEPATIENTATEASEANDENSURECOMFORT.
BESENSITIVETOTHEPATIENTSFEELINGSANDDECENCY.

Obtainingconsentto
DoyoumindifIexamineyou?Youcanaskmetostopatanytimeyoufeel
examinepatient
uncomfortable?

11

SystemicExamination
A systemic examination is always useful since it can identify conditions that may predispose or
aggravatethepresentingcomplaint.

Generalappearance
Weight:anorexic,cachectic,orobese.

Hydrationlevel,Hyperventilation,Hiccupping,Twitching,spasms
Hands&Arms
Examinenails:koilonychias,leuconychia[whitetransversebands],
Muehrcke'snails[whitepairedlinesnearfingernailtip];fingerclubbing;
nicotinestains
Checkpalmsforpalmarcrease,anaemiaorerythemia
Wrists:checkpulsererate,regularity,andcharacter.
Checkforscratchmarks,injectionmarks,spidernaevi,bruising.
Checkbloodpressure
Face,neck,chest
Checkeyes:jaundice,anaemia,considerfundoscopywhenindicated.
Mouth:fetor.ulcers,infections,hypertrophicgums/gingivitis.
Face:cloasma,rash.
Checkheartsounds:rate,rhythm,extrasounds/murmurs
Checklungs:wheezing,bronchialsounds,crepitations[basal],etc.
Legs
Checkforoedema[pittingtillwhatlevel:ankle/shin];

Presenceofvaricosities+/thrombosis[superficial/deepunilateral
swelling,tenderness]
Checkperipheralvasculature:pulses
Checktoes&foot:signsofdiscolouration,gangrene,tophi.
12

AbdominalExamination
Anabdominalexaminationisanessentialpartofthegynaecologicalexaminationandshouldpreferably
precede the genital examination. The adage of INSPECTION PALPATION PERCUSSION
AUSCULTATIONshouldalwaysbeadheredto.

Duringtheexamination,ensurethattheabdomenissufficientlyexposedtoallowaclearoverallview
from the symphysis pubis to the costal margin. As part of the abdominal examination, remember to
always include the supraclavicular region [check for Virchov lymph nodes]; and the inguinal region
[checkforlymphnodes/hernia].

o REMEMBERTOAGAINOBTAINCONSENTTOEXAMINETHEPATIENTSABDOMEN.
o REMEMBERTOINFORMANDEXPLAINTOTHEPATIENTWHATYOUINTENDTODOAT
ALLTIMES.
o WARNPATIENTTOINFORMYOUIFTHEEXAMINATIONBECOMESUNCOMFORTABLE
ATANYTIME.
o ALWAYSLOOKATTHEPATIENTSFACEDURINGTHEEXAMINATIONTOIDENTIFYANY
SIGNSOFPAINORDISCOMFORTELICITEDDURINGTHEEXAMINATION.
o MAKESURETHATTHEPATIENTHASRECENTLYEMPTIEDHERBLADDER.

13


Inspection

Palpationensure
warmcleanhands;
ensurerelaxationof
abdominalmuscles.

Assessthegeneralappearanceoftheabdomendistended[fat,foetus,
faeces,flatus,fluid,fullsizedtumours],umbilicus[flattened,possible
presenceofhernae,SisterJosephnodule,Cullensdiscolouration],
superficialveinprominence,telangectasia/caputmedusae,
discolouration,pigmentation,scars[onemayneedtorollthepatientto
theside],striae,presenceofstoma,anyobviouslyvisible
masses/peristalsis/movements/pulsations.
Startwithlightpalpationfirstandgosystematicallythroughallthesix
divisionsoftheabdomenRIF,rightHypochondrium,epigastrium,left
hypochondrium,LIF,hypogastrium.[Startfromnontenderlocationfirst]
o Lookforanymasses,tendernesswith/outguarding
Proceedwithdeeperpalpation,warningthepatientthatthismaybe
uncomfortableinwhichcaseistotellyouandyouwillstopthe
examination.Keepavisuallookoutforandfacialgrimacethatreflect
discomfort.Gothroughthesixdivisionsoftheabdomen.
o Lookforanymasses,tendernesswith/outguarding
o Ifanytendernesscheckforthepresenceofrebound
tendernesswarningthepatientfirst.Also,assessforany
referredpainduringpalpation.
o Ifamassispalpable,assesssize[measurediameterin
centimetreorgestationalageequivalence],form
[regular/irregular],consistency[hard,soft,cystic],mobility,
tenderness,relationshiptoabdominalwall[superficial,intra
abdominal],etc.
14

Percussion

Proceedtoexaminespecificallyforanenlargedortenderliver[check
Murphyssign],spleenandkidneys.Remembertoalsocheckthebackfor
tendernessoverbaseofspineoroverloin[kidneypunch],sacral
oedema.

PercussforthetopborderofliverdownRightmidclavicularline[normally
at5thrib]andcontinuedowntoabdominaledgecalculatingspan
[generally12.5cm].Percussionofliverborderforlossofdullnessin
presenceofairinabdomen.
Percussspleentoassesssizewhensplenomegalysuspect.
Percussforkidneysizeestimationwhenenlarged;toassessanenlarged
bladderorextentofabdominalmass.
Checkforthepresenceofascites
o Shiftingdullnessthedoctorspercussingfingerisplacedvertically
sothatfingertipispointingtowardsthepatientslegs;start
percussingatmidlineandcontinueleftlaterallyuntildullness
noted.Levelmarkedandpatientrolledovertorightforafew
minutes,thenrepercuss.Ascitespresentifthedullnessmoves
mediallyandpreviouspointofdullnessisnowresonant.
o Fluidthrilldoctorplaceshandsoneachofthepatientsflanks,
whilethepatientisaskedtoplaceherleftlateraledgeofthehand
verticallyonthemidlineattheumbilicus;doctorflickshandon
rightflank,acorrespondingthrillisfeltbythecontralateralhand.

15

Auscultation

Belowumbilicustoassessbowelsoundsfor:
o Rushingsoundcalled"borborygmi";
o Nosoundfor3minutes;
o "Tinkling"sound.
Aboveumbilicusfor:AAAbruit;Venushum.
RightandLeftaboveumbilicusforrenalarterystenosis.
Overliverfor:Frictionrub[gratingduringbreathing];Bruit.
Overspleenforsplenicrub.

16

ObstetricExamination
Theobstetricexaminationcanbeconsideredaspecialisedadditiontotheexaminationoftheabdomen,
itsscopebeingtoassessthepregnancycharacteristics.Examinationoftheabdomenisaccomplished
withthepatient supine.Lateinpregnancy,caremustbetakentohavethepatientlieslightlytoone
bloodflow,leadingtosyncope.
side,lestthepregnantuterusimpedevenacava

Inspection
Assessthegeneralappearanceoftheabdomen

o Distendedconsistentwithpregnancy;flatteningoreversionof
umbilicus;presenceofstriaegravidarum;presenceoflineanigra;
presenceofscars[notegynaecological/obstetricsurgeryscars,
laparoscopy,etc].
o Observeregularityofuterineshape[maybepartiallyrotatedtoone
sideortheother];lookforpresenceoffoetalmovements.
Palpationensure
Assessfundalheightstartingfromthexiphisterumandworkingonesway
warmcleanhands;
downwardsuntilfundusispalpated.Measuresymphysisfundalheightin
ensurerelaxationof
cmequivalenttogestationalageinweeks.
abdominalmuscles.
Bylateralpalpationusingbothhandoneithersideoftheabdomen,
assessthelieofthefoetus[longitudinal/transverse/oblique],thelocality
oftheback[right/left]andthepresentation[cephalic/breech].
Iflongitudinal,assessthedegreeofthedescentofthepresentingpart
throughthepelvicbrimassessedinthenumberoffingersonecanplace
overfoetalheadsuprapubically[infifths2/5thisconsideredengaged;
3/5thunengaged].
Auscultation
Listenoverthefoetalheartwherethescapulaislocated.Assessheart
ratetomaternalpulse
17

Assessingengagementofhead

18

GynaecologicalExamination
Thepelvicexaminationisanintegralcomponentofanygynaecologicalconsultationandfundamentalto
planninganygynaecologicalintervention.Inallsettings,thepatientsconsentmustalwaysbeobtained
beforeapelvicexaminationisundertaken.

BLADDERMUSTBEEMPTIEDPRIORTOEXAMINATION
PERFORMED IN LITHOTOMY POSITION [on back, legs apart, knees bent], OR LEFT LATERAL
POSITION
INFORMTHEPATIENTOFWHATYOUPLANTODOANDINFORMHEROFYOUROBSERVATIONS.

Inspection
Examinetheexternalgenitalianotingandrashes,swellings,ulcerations,

lesions.Separatelabiawithforefingerandthumbandexamineclitoris.
Lookforanydischargeandnotecharacteristics[purulent/clear/blood
stained]
Tellpatienttobeardownandcoughlookforanyvaginalwallor
introitalbulges[prolapsedvaginalwallsoruterinedescent]orpassage
ofurine[stressincontinenceideallyherebladderwouldbefull]

19


Speculuminspection.

InsertCuscos[bivalve]speculumlubricate,insertinupwards
directionwithbladesclosedusingonehandwhilelabiaareseparated
withotherhand;openbladesgentlytovisualisecervixandvaginal
walls.Closebladesslowingduringwithdrawal.
o Lookforanycervicallesions[ectopy,polyps,cysts,tears,etc],
vaginaldischarge[purulent/clear/bloodstained];cervical
inflammation;etc.
o PerformaCervicalsmearusingspatulaand/orbrushrotaingboth
through360oandsmearingsampleslightlyonasmear.
o Mayperformhighvaginalswab,cervicalswabs,wetslidesfor
infection.

20


Bimanualpalpation.

PalpateBartholin'sglands[posterioroflabiamajor].
Lubricateindexandmiddlefingerifnecessary.Whiletheleftindex
fingerandthumbseparatelabia,therightindexandmiddlefinger
areInsertintovagina.Thecervixislocated[assess:size,shape,
position,tenderness,mobility].
Thenperformabimanualexamination:keepingthevaginal
finderspushingupwardsandbackwards,pushthelefthanddown
backontothesymphysispubis.
o Palpatetheuterus[assesspositionantevertedorretroverted;
size;consistency;mobility;tenderness,cervicalexcitation.
o Palpatetheforniceswhileusingthelefthandtopushdownfrom
theiliacfossaetothesuprapubicregion[assessovariansize;
adnexialmasses,tenderness].

21

In the obstetric patient, a pelvic examination can help assess progress of labour by assess certain
specificcriteriarelatedtothestateofthecervix.AlltheseparametersareincludedinBishopScoreto
giveanoverallnumericalscoreofthestateofthecervix.

Score
0
1
2
3
Dilatation
0
12
34
>5
Effacement
<40%
4060%
6080%
>80%
Consistency
Firm
Moderate
Soft

Position
Posterior Middle Anterior

Station
3
3
1,0
+1,+2
BishopScoreCriteria

Effacement

Descentofhead[station]inpelvis

22

EXAMPLEPRESENTATIONOFANANTENATALHISTORY&EXAMINATION
Seehttp://www.clinicalexam.com/pda/o_obs_antenatal_history_exam.htm

PresentationoftheHistory
Introduction
This is <Mrs.XXXX>, a <?? year old> <occupation>, from <locality> who is <?? weeks pregnant>
withher<No.??>baby.Thereasonsheisinhospitalis<aroutinecheckup||breechpresentation||
preeclampsia||diabetes||PROM||APH||etc...>.

CurrentPregnancy
Focusingourattentiononthispregnancy,thefirstdayof<Mrs.XXXX's>lastmenstrualperiodwasthe
<date??>.Sheis<certain||uncertain>ofthedate,becauseshe<wroteitinherdiary||remembers
thedayofconception>.Shehasa<regular/irregular>cyclewithmensesoccurringevery<??day>.<She
had stopped the combined oral contraceptive pill><? months before becoming pregnant>. [If
contraception like OCP failed, you may wish to ask her why it did not work]. By Nageles's rule, her
estimated date of delivery should be the <date ??>. The current pregnancy was <planned ||
unexpected>and<Mrs.XXXX><was||wasnot>takingpericonceptualfolicacid.

She had a positive pregnancy test at <?> weeks. She visited her doctor at <? weeks> when <all
parameterswerenormal//shewasfoundtohave????>.Duringthefirsttrimesterofpregnancy,she
<waswell//hadonlyminorsymptomatologyofnauseawithoccasionalvomiting//requiredadmission
for severe vomiting and/or vaginal bleeding [in which case amplify]>. She booked into hospital at
23

<?weeks>andasubsequentultrasoundscan<confirmed//corrected>hermenstrualdates.Allother
ultrasound parameters were reported <normal // abnormal [in which case amplify]>. She felt
quickeningat<?.weeks>.Duringherbookingvisit,<allherclinicalparameterswerenormal//shewas
foundtohave???[inwhichcaseamplify]>.

Routinescreeninginvestigationshaveshownhertobe<Rhesuspositive||Rhesusnegative>andsheis
<rubella immune || not rubella immune || uncertain of her rubella status>. She <breastfed ||
bottlefed>herpreviouschildrenandintends<breastfeeding||bottlefeeding>thisbaby.Sheoptedfor
antenatalcarewith<hergeneralpractitioner||privatespecialist//thehospital>.Herantenatalcourse
wassubsequently<normaluntilshewasadmittedtohospitalonthisoccasion||normalexceptfora...
at...weeksgestation>.

<Mrs.XXXX>wasadmittedtohospital<>>>?days>ago.Shecomplainedof<...>.Sincecominginto
hospital,theinvestigationsshehavehadare<....>whichshowed<....>.<Mrs.XXXX>tellsmethat
sheisbeingkeptinthehospital<forobservation>.

Obstetricalhistory
Turning our attention to <Mrs. XXXX's> previous obstetrical history, she has <? girls or otherwise>,
aged<..?and..?years>.Theyare<bothwell//onesuffersfrom..l>.[Ifanabnormalpregnancy,give
fulldetails,e.g.:Inherfirstpregnancy,she<wasinduced>at<39weeks>,andafter<2hours||6hours
[dependingonifmakingstartoflabouraswhenenterlabourward]>,<underwentaCaesareansection>
because of <foetal distress>. The Caesarean section was performed <under epidural>. The baby
weighed<2.5kg>atbirthand<wasnotadmitted||wasadmittedfor...days>totheneonatalunit.She
had <no postoperative complications || postoperative complications of ...>.][If a normal pregnancy,
brief outline, e.g.: In her second pregnancy, she <went into spontaneous labour> at
24

<40> weeks and had <a normal vaginal delivery>. The baby weighed
<3.0kg>.][Ifamiscarriage,alsobebrief,e.g.: <Mrs.XXXX>alsohada<?>miscarriage<?>months
agoat<?weeks>and<underwent//didnotundergoanERPC>.]

Pastgynaecologicalhistory
With regards to <Mrs.XXXX's> past gynaecological history. Her last smear test was in <.?>, it was
<normal // abnormal>, and all of her previous smear tests have <been normal // occasional showed
abnormality>.<Shehasnotundergoneandgynaecologicalsurgicalprocedures//Sherequirea..in
..?for..?>.

Pastmedical&surgicalhistory
<Mrs. XXXX has not relevant past medical or surgical history // On briefly reviewing Mrs. XXXX's past
medicalandsurgicalhistory,shegaveahistoryof......>

Familyhistory
Her family history <has no illness of note // has a history of ... in the >. In particular, there is
<nofamilyhistory>ofdiabetes,and<no>twinsinthefamily.

Socialhistory
Withregardtosocialhistory,<Mrs.XXXX>worksasa<???>.<Shealsoworksathomelookingafterher
children>. She is due to go on a <?3 month> maternity leave starting in <?> weeks time. She is
residingin<a2bedroomapartment>.Herhusbandworksasa<????>.Herchildrenarebeinglooked
after by <the children's grandmother>. <Mrs. XXXX> <does not smoke || smokes ... cigarettes a day>
Prior to the pregnancy, she <did not smoke || smoked ... cigarettes a day>. She has <not taken any
25

alcohol||hasrestrictedherselfto...unitsofalcoholperweek>sincefindingoutshewaspregnant.She
<is>takingironandfolicacidsupplements.

Summaryofhistory
In summary, therefore, this is <Mrs.XXXX>, a <?? year old> <?occupation>, from <locality>, who is
<? weeks pregnant> withher <No. ?>baby. The reason she is in hospital is <a routine checkup ||
breechpresentation||preeclampsia||diabetes||PROM||APH||...>.<Mrs.XXXX>isbeingkeptin
thehospital<forobservation>.

PresentationoftheExamination
General
<Mrs. XXXX> looks <clinically well // unwell>. Her temperature is <.? Celsius>. Her pulse is
<80 bpm, regular rhythm, and normal character and volume>. Her blood pressure is <???/??>.
Herrespiratoryrateis<..?>.Herurinesampleis<normal||showselevated<protein||glucose||...>.
[Ifsheisinhospitalforadisease,describetherelevantfindings.Forexample,ifpreeclampsia:Shehas
<pedaloedema||noevidenceofpedaloedema>andherlowerdeeptendonreflexes<are||arenot>
elevated.]

Abdominal
Oninspectionoftheabdomen,thereisan<ovoid||globular>swelling,consistentwith<thepregnant
state||a...trimesterpregnancy>.There<are||areno>cutaneoussignsofpregnancy,suchasstriae
gravidarumandlineanigra.There<arenovisiblescars||arevisiblescarsconsistentwithaprior...>.
There<are||areno>visiblefoetalmovements.

26

Onpalpation,Imeasuredthesymphysiofundalheightontheinchessidetoreduceobservererror,and
foundittobe<?centimetres>,which<is||isnot>compatiblewithgestation.ThefoetalpartsthatI
feelinthefundusappeartobethe<breech>astheyare<soft,irregular,andnonballotable>.Thelieis
<longitudinal || transverse || oblique> and the back would appear to be on the <right || left> as it
offers more resistance to palpation and I feel small parts on the opposite side. The presentation
appearstobe<cephalic||breech||shoulder>.Thehead<is||isnot>engaged.Thefoetusappears
clinically<normal||small||large>insize.Theliquorvolumeappearsclinically<normal||reduced||
increased>.Thefoetalheartisbestheardoverthe<back>and<belowthelevel>oftheumbilicus,andis
<normal>.

SummaryofExamination
This is a <singleton || multiple> pregnancy, <longitudinal || transverse || oblique> lie, <cephalic ||
breech>presentation,thehead<is||isnotengaged>,thefoetusisclinically<normal||large||small>
insize,theliquorvolumeisclinically<normal||reduced||increased>,andthefoetalheartis<normal>.

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EXAMPLEANTENATALCASEWRITEUP
CaseSummary
Ms. X is a 28year old secondagravida Rhesus negative woman who presented to the emergency
departmentwithpainlessmoderatevaginalbleedingat34weeksofgestation.

HistoryofPresentPregnancy
Mrs.Xhadherlastmenstrualperiodonthe14thJanuary2008,computingherexpecteddateofdelivery
tothe21stOctober2008;hercycleshavingbeenpreviouslynormalandregularevery2830days.She
didnotgiveahistoryofanymenstrualproblems.

Mrs.Xhadnoproblemsduringthefirsttrimesterotherthanslightnauseaandoccasionalvomiting.This
sheacceptedasnormal,sinceitdidnotparticularlydistressher.Thepregnancywasplannedandshe
hadstartedfolicacidtwomonthsprevioustoconception.Shecontinuedtotakefolicacidthroughout
the first trimester. She did not give any history of vaginal bleeding during the first three months of
pregnancy. She attended her family doctor at eight weeks of pregnancy, when a clinical examination
wasreportedasnormal.

SheattendedtheantenatalclinicandbookedherconfinementatMaterDeiHospitalduringthesecond
trimester at 14 weeks of gestation. All routine investigations taken [complete blood count; TORCH
SyphilisHepatitisCHIVscreen;bloodglucose]atthatvisitwerenormal.HerbloodgroupwasARhesus
negative;antibodytitreforantiDwasnegative.Ageneralclinicalexaminationwasnormal.Uterinesize
corresponded to dates; foetal heart was audible using a doptone stethoscope. She had her first
ultrasoundscanat18weeksofgestation.Shewastoldthatwhilethefoetuswasnormal,theplacenta
was lowlying and that she will need a further scan in the third trimester to correctly assess the
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significance of this. She had no problems during the second trimester and gave no history of any
episodesofvaginalbleeding.Shewasstartedonhaematinicsat14weeksofgestation.

Mrs. X had no problems during the early part of the third trimester until 32 weeks of pregnancy. All
routineantenatalvisitswerereportedlynormalwithadequatefoetalgrowthandbloodpressure.She
wasgivenaprophylacticantiDinjection[500IU]at28weeksofpregnancy.Ultrasoundscandoneat32
weeksofgestationconfirmedthepersistenceofalowplacentation;foetalgrowthandwellbeingwas
normal;foetalpresentationwastransverse.Inretrospectshementionedthatatabout31weeks,she
hadanepisodeofmildvaginalspottingthemorningafterhavinghadsexualintercourse.Thebleeding
was slight lasting only one morning and she did not particularly alarm herself. She was advised to
refrainfromhavingsexualintercourse.

Historyofpresentingcomplaint
She presented at 34 weeks of gestation with painless vaginal bleeding of sudden onset. The present
episodeofbleedingwassuddeninonsetandsevereenoughforthebloodtotrickledownherthighs.
Therewerenoassociatedfeaturessuchaspainoranydiscomfort.

On admission, the bleeding had settled to only a slight vaginal loss. The foetus was easily palpable;
presentationwascephalicobliquewiththebacktotheleft.Foetalheartwasaudibleandofnormalrate.
Symphysealfundal height was about 34 cm corresponding to the gestational age. There was no
tendernessovertheuterus.Therewerenosignsofmaternalcardiovascularshock;thepatientspulse
was 80 beats per minute, blood pressure 110/70 mmHg. An ultrasound scan confirmed the clinical
findings;theplacentawaspraevia,apparentlymarginalandposterior(Type2placentapraevia).Foetal
growthcorrespondedtogestation.

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Anintravenousinfusionwassetup,whilebloodwastakenforhaemoglobinestimationandcrossmatch.
An antiD injection was administered. Regular monitoring of vaginal blood loss, pulse and blood
pressurewerecarriedout;whilefoetalheartratemonitoringwasalsocarriedoutintermittently.The
motheralsoreceivedtwodosesofdexamethasone[12mgevery12hours]toassistfoetallungmaturity.

The patient was reviewed after 24 hours. The vaginal bleeding had stopped completely, there being
only a slight browning staining on the vaginal pad. All parameters had remained normal. The
intravenousinfusionwasstopped.ShewastransferredtotheAntenatalWardandtoldthatsheneeded
to remain in hospital throughout the remaining antenatal period. She had a repeat episode of slight
bleeding at 35 weeks of gestation, which was managed conservatively. Foetal monitoring with
cardiotocographyandultrasoundshowednoabnormality.AnantiDimmunoglobulindose[500IU]was
repeated.

PastObstetricHistory
The patient had had a previous pregnancy four years earlier. The antenatal period had run a normal
course. Onset of labour was induced since the patients pregnancy had run to over a week past her
estimated dates. Labour had progressed effectively, but foetal distress was diagnosed at about 5 cm
cervical dilatation. An Emergency Caesarean section was thus performed. A live born male infant,
weighing3400gmwasdelivered.Shegavenohistoryofmiscarriages.

PastMedical&SurgicalHistory
Thepatientgavenohistoryofanysignificantmedicalevents.Shehadhadanappendectomyperformed
attheageof15years.

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PastGynaecologicalHistory
Thepatienthadnorelevantgynaecologicalevents.Hermenarcheoccurredaroundtheageof10years;
her cycles stabilising withinabouta year. She hadhad regular smear tests after shebecame sexually
active;thesehavingbeenalwaysnormal.Herlastsmeartestwasperformedaboutsixmonthsbefore
embarking on this current pregnancy. During the interpregnancy period she used the oral
contraceptivepill[Yasmine]forcontraception.

DrugHistory
Thepatientwasonnolongtermmedication,exceptforthehaematinicsreceivedduringherpregnancy.
She did not report any drug allergies. She did not smoke cigarettes and did not abuse alcohol at any
timeduringherpregnancy.

SocialHistory
Thepatientwasinastablerelationship.Shemarriedattheageof20years;andlivedwithherhusband
and child. She worked as a clerk in an industrial manufacturing setting. She intended to apply for
parentalleavetocareforherchildren.

Examinationat36weeksofpregnancy
Thepatientwasexaminedat36weeksofpregnancy.Atthispointintime,shewasaninpatientinthe
hospital.Therewerenoacutesymptoms.

On examination the patient was in good general health. She did not appear anaemic and was not
distressedinanyway.Cardiovascularsystemwasnormal;herbloodpressureandpulsebeing110/60
mmHg and 70 beats/min respectively. There was no lower limb oedema. Abdominal examination
conformedtoa36weeksofpregnancy.Onvisualexaminationtherewasadistendedabdomenwitha
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faintlineanigraandsomestriaegravidarum.Onpalpation,thesymphysisfundalheightmeasured37
cm;thefoetallieappearedtobeobliquewithacephalicpresentationandthebacktotheleftside.The
foetalheartwasaudibleontheleftlowerquadrant.

Followupofthispregnancy
At37weeksofpregnancy,thepatientsufferedasuddenonsetofseverevaginalbleedingwhilehaving
a shower. She was transferred to the Central Delivery Suite. Assessment at this stage, showed a
persistingunstablelieofthefoetus.Inviewoftheseverityofbleedingandthematurityoftheinfant,a
decisionwasmadetoundertakedeliverybyurgentCaesareansection.Thiswascarriedoutunderspinal
anaesthesia.Atsurgery,theplacentawasconfirmedtobeaposteriorType2placentapraevia.Afemale
infant, weighing 3540 gm, was born with an Apgar score of 8 at 1 minute. The infant required no
resuscitation.TheCaesareansectionproceededwithoutanycomplications.

The patient was treated with a syntocinon infusion (40 units in 500 mls infusion) during the first 24
hours postoperatively. She also received intraoperative prophylactic antibiotics three eighthourly
dosesofintravenousAugmentin(amoxycillin250mgandclavulanicacid125mg)oninductionhasbeen
comparedwiththree8hourlydosesin900patients.ThefoetusbloodgroupwasreportedasGroupO
Rhesus negative; Coombs test was negative. No antiD prophylaxis was thus administered to the
mother.Shewasdischargedwithherchildfourdaysaftersurgerywithapostoperativehaemoglobin
levelof10.5g/dl;shewasadvisedtocontinueherhaematinicsforafurthersixweeks.

CaseDiscussion
This case involved a pregnancy in a secondagravida woman complicated by Type 2 Placenta praevia.
ThesituationwasfurthercomplicatedbyaRhesusnegativebloodgroup.

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The patient was noted to have a possible abnormal placentation at her first ultrasound scan at 18
weeksofgestationwhentheplacentawasnotedtobelowlying.Whilethisobservationissuggestiveof
an eventual placenta praevia at term, not all cases of lowlying placentae discovered in the second
trimesterremainsointhethirdtrimesterwhenthelowersegmentactuallydevelops.Thepatient,by
virtueofherpreviouscaesareansection,wasathighriskofabnormalplacentation.

The clinical course was typical of the condition with warning bleeding occurring at 32 weeks of
gestation[aftersexualintercourse],followedbymoreseverebleedingat34weeksandsubsequently.
Theinitialmanagementfollowedinthiscaseincludedanexpectantregimenawaitingfoetalmaturity.In
anticipation of the possible need for a premature birth, foetal lung maturity was augmented by the
administration of dexamethasone. Blood was crossmatched and kept in reserve to enable timely
transfusionshouldtheneedarise.At37weeksofgestation,thebleedingincreasedsignificantly,andin
viewofthedegreeoffoetalmaturity,adecisiontoterminatethepregnancywastaken.Becauseofthe
persistingunstablelie,aCaesareansectionwasdecidedupon.

ThecasewasfurthercomplicatedbyamaternalRhesusnegativebloodgroup.Toobviatethepossibility
of subsequent immunization, a prophylactic dose of antiD immunoglobulin was administered at 28
weeks is line with current guidelines. In anticipation of possible fetomaternal transfusion, a further
dosewasgivenwheneverthepatientexperiencedepisodesofbleeding.Theseprophylacticmeasures
provedneedlesssincethefoetuswaseventuallyfoundtohavebeenRhesusnegative.

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