Obstetric History

Introduction Date of birth Occupation - hours worked during pregnancy Gravida - total no. of pregnancies Twins count as two only when parous Parity - number of live births at any gestation or stillbirths >24 weeks Twins count as two Superscript after parity number indicates the number of pregnancies that did not result in parity Gestational age at presentation if known Previous Obstetric History List pregnancies chronologically and identify outcomes Gestation and birthweight of babies Abortions, miscarriages, curettage and any associated symptoms (sepsis, haemorrhage) Miscarriages - gestational age, reason, procedures Terminations - reason, gestational age, method, complications, current attitude Delivery method - NVD, C-section, forceps, ventouse Particularly previous C-section, difcult vaginal delivery, PPH, signicant perineal trauma Length of labour Puerperal problems - PPH, pyrexia, breast infections, feeding difculties, mental disorders Breast or bottle feeding Complications associated with each pregnancy: Recurrent miscarriages - increased risk of miscarriage, fetal growth restriction Preterm delivery increased risk Hypertension or pre-eclampsia - increased risk of pre-eclampsia, FGR Abruption risk of recurrence Congenital abnormality - recurrence risk dependent on type of abnormality Macrosomic baby and gestational diabetes FGR UTI Bleeding Unexplained stillbirth - increased risk of gestational diabetes

Antenatal History Dating the Pregnancy: Dated from the last menstrual period (LMP) - median duration of pregnancy is 40 weeks or 280 days Estimated delivery date is LMP + 9 months 7 days +/- difference in cycle from 28 days Term delivery = 37-42 weeks Ultrasound scan dates and ndings - may be used to date pregnancy if performed before 20 weeks Crown-rump length up to 13 weeks for dates Head circumference from 14-20 weeks for dates Normal cycle Planned/unplanned Recent contraceptive use Pregnancy symptoms: Insomnia, fatigue, headache Reux Nausea/vomiting Constipation Bleeding/spotting ~4 weeks after implantation there may be a small amount of bleeding due to implantation of the blastocyst Lower abdominal or back pain Urinary frequency or dysuria Fetal movements Investigations already performed and results Hypertension: Visual disturbances Headaches Oedema Past history - pregnant, not pregnant Abdominal pain Fetal wellbeing - movement and growth Vaginal bleeding: How much? When? Bright red? Clots? Precipitating cause Contractions or pain Blood group? Ruptured membranes: When? Precipitating event? Pain? How much uid? Colour? Fetal wellbeing - movement and gestation Contractions - before/after rupture, timing and character Fever/unwell Past history

Past Gynaecological History Regularity of periods - women with very long cycles may have PCOS (increased insulin resistance and risk of gestational diabetes) Contraception methods - conception with IUD in situ carries an increased risk of miscarriage Previous episodes of PID - increased risk of ectopic pregnancies Date of last cervical smear Previous treatment for cervical changes Knife core biopsy associated with an increased risk for both cervical incompetence and stenosis leading to preterm delivery and dystocia in labour Large loop excision of transitional zone predisposes to preterm birth Previous ectopic pregnancy Recurrent miscarriage: ?antiphospholipid syndrome - increased risk of miscarriage, FGR and preeclampsia Balanced translocations may lead to congenital abnormality Cervical incompetence Multiple previous rst trimester terminations of pregnancy increase the risk of preterm delivery Previous gynaecological surgery Presence of pelvic masses - ovarian cysts, broids Previous history of sub-fertility - donor egg/sperm use is associated with an increased risk of pre-eclampsia and the rate of preterm delivery is higher in assisted conception pregnancies Medical & Surgical History Pre-existing medical diseases impacting pregnancy: DM - macrosomia, FGR, congenital abnormality, pre-eclampsia, stillbirth, neonatal hypoglycaemia Hypertension - pre-eclampsia Epilepsy - increased t frequency, congenital abnormality Renal disease - worsening renal disease, pre-eclampsia, FGR, preterm delivery VTE - increased risk during pregnancy, pre-eclampsia, FGR HIV - vertical transmission CT diseases - SLE may cause pre-eclampsia, FGR Myasthenia gravis/myotonic dystrophy - fetal neurological effects and increased maternal muscular fatigue in labour Previous surgery - adhesional obstruction may present in pregnancy Psychiatric history - severity, care, clinical presentation Have you ever suffered with your nerves? Previous postnatal blues/depression

Drug History Family History First-degree relative of mother with: Diabetes Thromboembolic disease Pre-eclampsia Serious psychiatric disorder - increased risk of puerperal psychosis History of congenital anomalies or genetic problems (eg. haemoglobinopathies) Allergies Social History Smoking, ETOH, illicit drugs Smoking causes a reduction in birthweight in a dose-dependent fashion and increases the risk of miscarriage, stillbirth and neonatal death Binge drinking may lead to fetal alcohol syndrome Marital status, home support, partners employment status Household income Housing

Template for Antenatal History

Demographic Details History of Presenting Complaint/Reason for Attending Current Pregnancy Gestation - LMP or EDD Single or multiple - chorionicity Details of the presenting problem (if any) or reason for attending What actions have been taken thus far? Is there a plan for the rest of the pregnancy? What are the patients main concerns? Any other problems in pregnancy? Any bleeding, contractions or loss of vaginal uid? Ultrasound What scans have been performed and why Any problems identied? Past Obstetric History List previous pregnancies and outcomes in order Gynaecological History Periods - regularity Contraceptive history Previous infections and treatment Last cervical smear - normal/abnormal Previous gynaecological surgery Past Medical & Surgical History Psychiatric History Family History Social History Allergies

Obstetric Examination
Maternal Weight & Height Women with BMI <20 are at higher risk of FGR and increased perinatal mortality, especially if weight gain in pregnancy is poor Women with BMI >30 have increased risk of gestational diabetes and hypertension, increased birthweight and a higher perinatal mortality rate No need to repeat weight measurement throughout pregnancy if normal Short women are more likely to have problems in labour - generally unpredictable during pregnancy Blood Pressure Evaluation Hypertension diagnosed for the rst time during pregnancy (two measurements >140/90 at least 4 hours apart) requires investigation for underlying cause (including fundoscopy) - renal, endocrine, collagen-vascular disease 90% of cases due to essential hypertension Perform BP measurement at every antenatal visit Measure BP with women seated or semi-recumbent Midstream Urine Asymptomatic bacteriuria - risk of ascending UTI greater in pregnancy Acute pyelonephritis increases the risk of pregnancy loss/premature labour and is associated with considerable maternal morbidity Persistent proteinuria or haematuria may be an indicator of underlying renal disease Proteinuria may indicate pre-eclampsia - investigate even trace amounts Abdominal Examination Semi-recumbent position on bed - women in late pregnancy or with multiple pregnancies may not be able to lie at A pillow under one buttock to move the weight of the fetus to the left or right may help Inspection: Assess shape of the uterus and note any asymmetry Look for fetal movements Scars Striae gravidarum or linea nigra (faint brown line running from umbilicus to the symphisis pubis) Palpation: Symphysis-fundal height measurement: Uterus is rst palpable at 12 weeks gestation and reaches the umbilicus at 20 weeks

 Screen for potential problems - poly-/oligohydramnios, multiple pregnancy or FGR Feel for the top of the fundus (rarely midline) and then the upper border of the symphysis pubis Measure the distance and plot on an SFH chart In the late third trimester, the fundal height is ~2cm less than the number of weeks Fetal lie, presentation and engagement: Palpate to count the number of fetal poles (head or bottom) to assesses number of pregnancies Assess the lie if labour is likely - ie. 34-36 weeks gestation If there is a pole over the pelvis the lie is longitudinal regardless of whether the pole is lying more to the left or right If longitudinal, assess the presentation with two hands: Cephalic - head down - if you can feel the whole head and it is easily movable it is likely to be free (5/5 palpable) Breech - bottom/feet down When the head is no longer movable it is engaged and only 1/5 or 2/5 palpable Oblique lie is when the leading pole does not lie over the pelvis Transverse lie is where the fetus lies directly across the abdomen Auscultation - not necessary if fetus has been active during examination and previously according to mother Listen over the area of the fetal shoulder - determined by identifying the position of the back and limbs Normal fetal HR is 110-160bpm Pelvic Examination Indications for examination: Excessive or offensive discharge Vaginal bleeding - in the known absence of a placenta praevia Cervical smear Conrm potential rupture of membranes Cusco speculum Digital examination to assess cervix if required