OB HISTORY and PE

HISTORY
- Preterm: 2 days PTA, + uterine contraction
1. Introduce yourself relieved by bed rest
2. Date and time of interview Few hours PTA, + uterine contraction,
3. Date of admission + vaginal bleeding
4. General Data
a. Name - Abortion: 2 days PTA, + uterine contraction/
b. Age hypogastric pain,
c. Gender Few hours PTA, + profuse bleeding,
d. Religion + bloody meat
e. Civil status
f. Birthday - Ectopic Pregnancy:
g. Marital status + abdominal pain/ hypogastric pain with spotting
h. Address +prolonged bleeding, brownish discharge
i. Race/ethnicity/ citizenship There can be fainting spells
j. Number of admission
 Reason of admission 7. Past Medical History
 date  Childhood illness –measles, mumps, rubella,
k. % reliability poliomyelitis, varicella, pertussis, rheumatic fever,
 Adults – not so important scarlet fever, others.
 Minors – IMPORTANT!!!  Medical – HTN, DM, Asthma, blood dyscrasias,
congenital anomalies, goiter, cancer, hepatitis, STI,
5. Chief complaint allergies, injuries/accidents, hospitalization (date,
 Medical term na dapat  place, treatment), medications (name of drug,
 Reasons for consultation dosage)
o + uterine contraction  Surgical – date, place, indication, type of
o + hypogastric pain operation
o + labor pain  Psychiatric – illness, time frame, diagnosis,
o + spotting hospitalization, treatments
o + vaginal bleeding
o Decrease fetal movement (3rd trimester) 8. Family History
o Postpartum care (nanganak sa tricycle  Outline or diagram
tapos dinala sa hospital)  Age, health, cause of death of each immediate
o Epigastric pain in preterm – relative – parents, grandparents, sibling, children
preeclampsia due to stretching of the and grandchildren
glisson’s capsule in the liver  Heredofamilial diseases, DM, HTN, cardiac
 LMP – last menstrual period diseases, asthma, cancer, etc.
 PMP – previous menstrual period (date of
menstruation prior to the LMP) 9. Personal and Social History
 AOG = # of days since LMP up to present day/7 - House type, number of rooms, CR-type, number of
family members living together in the house
EDC - Husband’s background – age, birthday,
(Jan- march) (April – Dec) educational attainment, occupation, drinker,
LMP LMP smoker, drug user?
+9 months + 7days -3 months + 7days + 1 year - Occupation
- Educational attainment
6. History of Present Illness - Lifestyle (alcoholic, smoker, drug user)
 State in chronological order, from the start of the - Source of income
illness
 Elaborate OPQRST (Onset, Precipitating factors, 10. Environmental History
Quality, Relieving/aggravating factors, Severity, - Water source for drinking and washing
Timing- duration, frequency, location)
- garbage disposal
 Associated signs and symptoms + its OPQRST
- sewage disposal
- nearby factories
- TERM: Few hours PTA, the patient noted uterine
contractions occurring every 10-15 minutes,
associated with vaginal bleeding, watery
discharge and good fetal movement. Denies
nausea, vomiting, and headache. Due to the
persistence of the increasing severity and
frequency of uterine contraction, the patient seeks
consultation, hence, admitted.
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 OB HISTORY and PE
11. Gyne History
a. Menstrual history
o MIDAS: Menarche, Interval, Duration, Tetanus toxoid
Amount, Signs and Symptoms - 5 doses (throughout pregnancy)
o Associated signs and symptoms like 1st preg - 2 shots 1-month interval
dysmenorrhea, breast tenderness, last shot -given prior to delivery
headache mood swings, PMS *safe to give at any month of pregnancy
o Characterize subsequent menses
o OCP use Age of pregnancy can be detected thru:
- LMP
b. Sexual history - Quickening
 Coitarche - Fundic Height
 Sexual habits - Ultrasound
 Number of partners
PHYSICAL EXAMINATION
12. OB History I. GENERAL SURVEY
- GP score!!!! GP (TPAL)
- Gravity – number of pregnancies regardless of VITAL SIGNS
outcome
- Parity – number of delivery reaching age of II. ABDOMEN
viability (beyond 20 weeks)
- TPAL (Term-post term included, Preterm, Abortion, INSPECTION
Living) Globular, flat, slightly globular
- 1st pregnancy – date, route of delivery, weight (+) striae, (+) linea nigra
- Note for hospitalization during the course of
pregnancy
PALPATION
 First trimester (14 weeks) A. FUNDIC HEIGHT: ask the patient to empty her bladder
o Cognizant of pregnancy –when, how - measure from symphisis pubis to the level of fundus
o Use of PT
o Prenatal check up  Intrauterine growth restriction or wrong dating
 TVS result - if <2cm from the fundic AOG
 Lab workup
 Macrosomia/ Multiple Fetuses
 Medications – folic acid (for fetal brain
development) - if >2cm from the fundic AOG
 Diet AOG FH
 Exposure to radiation, intake of
teratogenic and illicit drugs 12 wks Above the symphysis pubis
o UTZ – done at 1st trimester: 6-12 weeks
 To measure the crown-foot length of the 16 wks Midway of umbilicus and
fetus hypogastric area

 Second trimester (28 weeks) 20 wks Level of Umbilicus

o Quickening (primi- 18-20 weeks, multi – 16-18 28 wks 6 cm above the umbilicus
weeks) 34 wks Below intercostal ribs
o Any hospitalization – signs and symptoms, 36 wks 2 cm below xyphoid
indications, treatment 40 wks 4 cm below xyphoid
o Prenatal check up
 Low risk: every 4 weeks
 High risk: every 2 weeks ESTIMATED FETAL WEIGHT (JOHNSON’S RULE)
o Frequency of prenatal check up
 Every 4 weeks until 28 weeks Fetal weight in grams = (fundic ht in cm – n) x 155
 Then every 2 weeks until 36 weeks
 Weekly thereafter where n = 12 if station below ischial spine (engaged)
11 if above the ischial spine (unengaged)
 Third trimester (36 weeks)
o + vaginal bleeding
o Regular prenatal check up

13. ROS
- Signs and symptoms related to CC

MED IIIA 2016

 OB HISTORY and PE
B. LEOPOLD’S MANEUVER:

 stay at the right side of the patient

 rub and warm hands
 ask the patient to position into dorsal recumbent to relax iii. LM3 (PAWLIK’S GRIP): What fetal part lies above the
the abdomen pelvic inlet?

i. LM1 (FUNDAL GRIP): What fetal pole or part occupies the Head not engaged - round ballotable, easily displaced
fundus? Head engaged – felt as relatively fixed, knoblike part

Breech – irregular, nodular parts felt

Cephalic – round
ii. LM2 (UMBILICAL GRIP): Which side is the fetal back? iv. LM4 (PELVIC GRIP): Which side is the cephalic prominence?

Back - linear, convex, bony ridge  Face the patient’s feet and places one hand each on
Small Parts – numerous nodulation either side of the lower pole of the uterus
 Cephalic prominence – part of the fetus that prevents
the deep descent with one hand

Flexion – cephalic prominence same side as fetal parts

Extension – same side as fetal back

C. FETAL HEART TONE: When the back of the fetus is determined (@LM2), auscultate for the FHT using the bell of the stethoscope

 Count for full minute

 Normal: 120-160 bpm
 Describe which side of the abdomen FHT was heard: R/L UQ, R/L LQ

AOG DEVICE
6 wks UTZ
12 wks Doppler
16 – 19 wks Stethoscope

III. PELVIC EXAM

TYPES OF SPECULUM
Graves Speculum - wider blade and their sides are also curved.
- because vaginal canal may be wider in parous women,
Graves Speculum is used

Pederson Speculum - flat narrow design to accommodate a narrower vagina

- advantageous in younger, virginal, or nulliparous patients,
as well as in elderly women

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 OB HISTORY and PE
SPECULUM EXAM
Inspect the Cervix:
 Separate the labia Violaceous, smooth, (+) erosions, (+) polyps
 Insert speculum in transverse and downwards with minimal whitish discharge
 Rotate – open – lock the speculum moderate discharge, curds-like, yellowish in color

INTERNAL EXAM

 Separate the labia

 Insert index and middle finger
 Palpate for the cervix

Non pregnant Pregnant Preterm labor

Cervix smooth, firm, close internal os
Uterus small, movable, nontender
Adnexae no masses, no tenderness
R/L side if with mass: with presence of
movable mass or fixed
smooth, soft, close Soft, 1 cm dilated
enlarged to 3-4 month AOG, palpated Enlarged to 7 mo AOG
midway of symphysis pubis to umbilicus
no mass palpated If uterus big enough (7-9 mo)
Adnexae cannot be assed due to
enlarged abdomen

Degrees of laceration
First degree laceration is limited to the fourchette and superficial perineal skin or vaginal mucosa
*submucosa – subcutaneous
Second degree laceration extends beyond fourchette, perineal skin and vaginal mucosa to perineal muscles and fascia, but
not the anal sphincter
* submucosa - subcutaneous – fascia
Third degree fourchette, perineal skin, vaginal mucosa, muscles, and anal sphincter are torn;
3a: - partial tear of the external anal sphincter involving less than 50% thickness
3b: - greater than 50% tear of the external anal sphincter
3c: - internal sphincter is torn
* submucosa - subcutaneous - fascia – muscle
Fourth degree fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal mucosa are torn
** submucosa - subcutaneous - fascia – muscle – anus
Periurethral Tear at the top of the vagina, near the urethra
Laceration

* FISTULA – result of fourth degree laceration

Advantages and disadvantages of EPISIOTOMY

MEDIAN MEDIAN LATERAL
2 types of Episiotomy Anatomic < >
1. Median Blood loss < >
o Less painful, easier to repair, heals faster Faulty wound healing < >
but may extend to rectum if perineal body Pain < >
is short
Extension > <
2. Mediolateral
o more commonly used

INDICATION OF EPISIOTOMY

1. Fetal head is big enough/ vagina cannot accommodate the fetal head
Purpose: to widen the vaginal wall

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 OB HISTORY and PE
PLACENTA

MECHANISM OF PLACENTAL EXPULSION

SCHULTZE MECHANISM - Occurs initially at the central portion of the placenta
“ shiny” - placenta descends by dragging the membranes along thus forming some form of an inverted sac
DUNCAN MECHANISM - occurs first at the periphery
ðirty” - placenta descends to the vagina sideways

SIGNS of PLACENTAL SEPARATION

1. Calkin’s Sign - uterus becomes globular and firmer.

2. A sudden gush of blood
3. Uterus rises in the abdomen as the detached placenta drops to the lower uterine segment and vagina
4. Umbilical cord lengthens or protrudes out of the introitus.

FREQUENCY OF PRENATAL CHECK UP

AOG LOW RISK HIGH RISK
28 weeks 4 weeks 2 weeks
36 weeks 2 weeks 1 week
>36 weeks 1 week 3 days

JL, Tae ka ba?

Mukha ka kasing tae eh
HOHOHO!

-Ponce|Sawey-

MED IIIA 2016