Dedication

To our Islamic nation with souls we protect and serve you To our friends at Tanta Medical School you can be the best in the world

General obstetric sheet

(I) History:

A) Personal history
1- Name: Patient named Mrs ---------------------------- .. * Female patient named -------------------------- .. * Significance : 1. To get familiar "* " ( : ) 2. Indicates religion of husband Circumcised " Muslims, Christians, Jewish" Non Circumcised cancer cervix 3. Indicates social standard & culture ( ) "contraceptive methods" 2- Age: 20-26 yrs best age of pregnancy d.t: o Lowest maternal mortality rate o Lowest prenatal mortality rate 3- Marital status: o Married since 1999 o Married for 10yrs. o Repeated marriage should be mentioned o Divorce or husband death timing should be mentioned. " =9 " ...*

 Significance : 1. May indicate long period of infertility. 2. Pregnancy after long period of infertility precious baby 4- Parity -------- boys / girls. -------- males/ females. How many of them living? How old is the youngest one? 5- Residence Significance : 1- Recall for any emergency * Anti D 1- .2- 6- Occupation * Jobs of stress: should be avoided as Academic teaching " D.V.T & V.V" Radio therapy teratogenicity. Health care givers dealing with infections diseases 7- Special habits 1- Smoking 2- Alcohol * Complications: 1) Abortion 2) Accidental Hge. 3) IUGR "" "" ()

4) Congenital 5) Preterm labour 3- Drugs 4- Domestic animals * Cats, dogs & goats Toxoplasmosis Recurrent abortion" 5- Coffee & tea anemia 6- Vaginal douches: High Vaginal douches: 8- Husband : 1- Name 2- Age 3- Occupation 4- Special habits 5- Socioeconomic Varicocele : * transmit infection Complicate pregnancy "infertility"

B) Complaint:
" Patient own words" chronological manner 1- Complaints of pregnancy complications a) preterm labour " lower abd. Pain" b) PROM passage of watery vaginal fluid" c) Placenta previa " recent vaginal bleeding d) Fetal distress " fetal movement". Complaints of associated diseases: ..... She is referred from outpatient clinic while they accidentally discovered . during antenatal care. Hypertension Elevated blood pressure. 1- 2- 3- 4

 D.M Elevated blood sugar Placenta previa " Lower inserted placenta Ployhydramnios Excessive abd. enlargement" 3- Control of condition " Antenatal care" ..... She is referred from.. for antenatal care to control her condition.

C) History of present illness

1- Pregnancy symptoms 2- Pregnancy test 3- Seek for medical advice 4- 1st trimester events 3 3 5- 2nd trimester events 6- 3rd trimester events 7- Other systems review 8- Medications 9- Investigations 3 3

1- Symptoms of pregnancy:

The story started when she missed a period & suffered from nausea, vomiting, breast heaviness ..etc 2- Pregnancy test:
Pregnancy test was done in blood & urine & it was positive.

3- Seek for medical advice : "Ante natal care"

4-1st trimester events:

threatened abortion Infection Hyperemesis gravidarum Pyelonephritis

1-
(lower colicky pain, bleeding) (Vaginal discharge) ( excessive vomiting ) (fever, dysuria, loin pain)

If Ve :

* The 1st trimester was smooth as no symptoms suggestive of

If +Ve : At the 1st trimester the patient suffered from

The patient has noticed

Gradual enlargement of her abdomen & She felt the fetal movements Quickening"
& still felt up till now. ()

5- 2nd trimester events .

1- Pre-eclampsia " Headache, blurred vision" 2- Pyelonephritis " fever, loin pain, dysuria" 3- Polyhydramnios " fetal movement, Abd size . 4- Placenta previa " bleeding" 5- Pump failure (heart failure) " Palpitation , dyspnea, L.Ledema" 6- Blood sugar (D.M) " Polyphagia, Polyuria, polydepsia parasethia ..........

If Ve :
The 2nd

trimester was smooth as no symptoms

suggestive of

If +Ve :
At the 2nd trimester the patient suffered from

6- 3rd trimester events:

As 2nd trimester

D) Menstrual history
1- Menarche Normally 9-14 yr

2- Duration average 2-7 days 3- Length of cycle average 21- 35 days

4- 1st day of last menstrual period to use this period for calculation of EDD the period should fulfill these criteria 1- Regular menstruation " at least last 3 months" 2- No use of OCP 3- No abortion or AUB " in last 3 months " ..... The last menstrual period . was & the patient is sure of that date & she had 1 2 3

5- E.D.D
1- last menstrual period 2- Examination 3- Ultrasound 4- History " by fundal level" " at 10 the week"

1- 7

N.B

(3 2- 9 ) 1 2 3 9 4-21

6- Expected Gestational age:

Last Menstrual period

E.D.D

( -4 ) 3 31 1st day of last menstrual period E.D.D: Today is: 10/4/2007 = 40 WK 10/3/2007 EDD 3/7/2006 = 0 WK

So Expected gestational age is 35 week & 5 days 2 week" ***** 1st day of last M.P 3/7/2006 E.D.D: Today is: 10/4/2007 = 10/3/2007 04 LMP

So Expected gestational age is 14 weeks 2 week" E) Contraceptive History: - Methods - Results:

F) Obstetric History: - Date - Duration - Medical disorders - Out come - Place of delivery - Puerperium

- Feeding

*****

Obstetric examination

1- General examination
A Stand on the right side A General data: Height, weight & gait. Vital signs: Pulse, BP, temperature & respiratory rate. The eye for, jaundice & edema of the lids. Pallor, cyanosis, hirsutism, pigmentations & septic foci. The neck for goiter enlarged LN & congested neck veins. Chest &heart examination. Breast examination for signs of pregnancy & any abnormalities. Limb examination for edema, varicose veins & deformities. Back examination, for any deformity. General debilitating disease: thyroid, DM, .cardiac.

2- Abdominal examination
a. Inspection:
The size of abdomen & pendulous abdomen is detected in the standing position. In case of transverse lie the abdomen is transverse from side to side. A transverse groove e.g. in occipito-posterior and mentoposterior. Fetal limb movements.

 Scars as a cesarean section scar, Striae gravidarum & pigmentations as linea nigra. Masses as hernia.

b. Palpation:
Superficial palpation, for tenderness & rigidity. Deep palpation to examine the abdominal organs. Obstetric palpation includes; a- Fundal level By the ulnar border of the left hand starting at the xiphisternum after centralizing the uterus to correct the dextro-rotation. After engagement. The fundal level descends to the level of 32 weeks. The differences between 32 weeks and term i.e." 38-42 "Weeks: a. The period of amenorrhea suggests the gestational age. b. lightening &pelvic pressure symptoms suggests a full term fetus c. Engagement of the head suggests a full term fetus. d. The size of the fetus & the fundus of the uterus helps.

causes of oversized uterus

Mis-calculation Polydramnios Twins Vesicular mole Macrosomia or hydrocephalus Associated fibroid

causes of undersized uterus

Mis-calculation Oligohydramnios Transverse lie Missed abortion and IUFD Anencephaly Small size of the uterus

4- Causes of non engagement of head in PG

Fetal
Large head hydrocephalus Malposition malpresentation Multiple pregnancy Short cord Polyhydramnios b- Obstetric palpation : The fundal grip 1. The fundus of the uterus is palpated by both hands to detect the part of the fetus occupying the fundus i.e the head in 3.5% or the breech in 96%. Lateral umbilical grip 2. The uterus is fixed with by 1 hand at the level of the umbilicus while then both hands are alternated: for the back, which is felt smooth firm & convex. The limbs which are felt as mobile knobs. While in transverse lie the head is felt on one side & the breech on the other. 1st pelvic grip "Pawlick grip": 3. The hand is placed on the symphysis pubis with the thumb parallel to one inguinal ligament & the 4 fingers parallel to the other. It is done for: 1. Detection of the parts of the fetus occupying the lower part of the uterus. 2. Detection of engagement if less than if less than 2/5 of the head is felt

Maternal
Contracted pelvis Tumor in pelvis Placenta previa Full bladder or rectum No cause may be found

2nd pelvic grip 4. Facing the patient's feet both hands are pushed towards the pelvis: 1. To detect the degree of flexion of the head. 2. To detect the engaged head of an unsuspected twin. c- Auscultation of the fetal heart sound (FHS): 5. FHS is heard by the Pinard stethoscope (20 weeks gestation) or the Sonicaid (10th week gestation). 6. Normally the fetal heart rate is between 110-160 b/m, regular, tic tac rhythm. 7. The point of maximum intensity of the FHS is heard through the anterior scapula & is determined by the fetal position e.g. In occipito- anterior, FHS is heard below the umbilicus. Near the midline at the anterior superior iliac spine In occipito posterior (OP), FHS are heard below the umbilicus in the flank i.e. lateral to the site of occipitoanterior. In breech presentation, FHS are heard above the umbilicus In transverse lie, On one side of the umbilicus towards the head Values of auscultations of FHS: 1) It is a sure sign of pregnancy. 2) It gives an idea of the fetal position & presentation. 3) Diagnosis of intrauterine fetal death. 4) Diagnosis of fetal distress e.g. bradycardia. 5) Diagnosis of twins.

Differential diagnosis of the FHS: 1. Uterine souffl: - It is a soft blowing sound coinciding with the maternal pulse. - It is due to increased blood flow in the dilated maternal uterine vessels. 2. Umbilical (funic) souffl: - It is a soft bowling rapid sound coinciding with the fetal pulse It is due to blood flow in the umbilical vessels.

3. Sounds of fetal movements. 4. Aortic pulsations. 5. Intestinal sounds.

5- Vaginal examination
Indications of vaginal examination 1. Any complications during pregnancy e.g. bleeding or discharge. 2. At the 36 weeks to do cephalo-pelvic disproportion tests if the head is no engaged in a primigravida. 3. During labor: see management of normal labor.

6-Diagnosis
Should be written as in the following method: - Age - Obstetric formula Gravidity-Parity-Abortion-Living-Dead e.g. G2 P1 A0 L2 - Gestational age - Single or Multiple - Living viable - Lie -Presentation if G2 and L2 not preferred to say D0

Complications with pregnancy

N.B: Dont Say: * Female patient .

* G1 P0 A0 L0 in case of primigravida * Gestational age in odd numbers (37wks wrong) But say it in even numbers (36wks plus or minus 2 wks)

Remember That Dont forget that taking a sheet is an Art and actually it is a matter of difference about the way of taking it. Indeed , A doctor is not considered to be a doctor unless he gives his own comment on the sheet , finally what ever you do you couldnt satisfy all points of view.

And at the end

This is another masterpiece by :

Dr.M.Basiony

Other works : Summary to A.Gafar Clinical Obstetrics

You can find all my works at : MedFlux.com

Special Thanks
Thanks to Dr.Islam El-Sawahly for his generous time and help during the preparation of this work Cover designed passionately by : Asim Phoenix