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General obstetric sheet

(I) History:

A) Personal history 1- Name: االسم رباعى

• Patient named Mrs ---------------------------- تكتب على شكل.. *

• Female patient named -------------------------- ال تكتب على شكل.. *

• Significance :

1. To get familiar * تعطیك معلومات أكتر" عشان العیانة تأخذ علیك "

)تقلھا منمن مني مثال – عاشت األسامى –ھندردش معاكى –إزیك یا حاجة ( : مثال

2. Indicates religion of husband

• Circumcised → " Muslims, Christians, Jewish" فى مصر

• Non Circumcised → cancer cervix خارج مصر

3. Indicates social standard & culture

) ذكور(الصعایدة عاوزین رجالة

"contraceptive methods" ما تتزوج من أولسیتى مش عاوزة تخلف نجارد

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 شكلتكتب على... *

o Married for 10yrs.

o Repeated marriage should be mentioned

لو أكثر من زواج یجب ذكره

o Divorce or husband death timing should be mentioned.

علي اساس انھا حامل "شھور 9=خالل عمر الحمل " لو مطلقة أو أرملة یجب تحدید المدة

• Significance :

1. May indicate long period of infertility.

2. Pregnancy after long period of infertility → precious baby

4- Parity

• -------- boys / girls. تكتب على شكل

• -------- males/ females. وال تكتب على شكل

• How many of them living? كام عیل عایش

• How old is the youngest one? أصغر عیل عنده كام سنھ؟

5- Residence "تكتب بالتفصیل"

)رقم التلیفون –شقة –دور –عمارة –شارع –منطقة (

• Significance :

1- Recall for any emergency مثال *

Anti Dحقنة - 1

.لو حصل لخبطة فى العیال فى الحضانات - 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 "الموضوع محرج"

1- Smoking جوزك بیشرب سجایر؟

2- Alcohol جوزك بیشرب كحولیات؟

* 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: العیانھ تدخل الخرطوم نفسھ جوه *

High Vaginal douches: transmit infection

Complicate pregnancy

8- Husband : "infertility" فى حالة المفروض نذكر الزوج

1- Name

2- Age

3- Occupation Varicocele سواق :مثال ←

4- Special habits

5- Socioeconomic

B) Complaint: " Patient own words" chronological manner یھ؟ بتشتكى من إ

1- Complaints of pregnancy complications

a) preterm labour → " lower abd. Pain" 1- الطلق المبكر

b) PROM → “passage of watery vaginal fluid" 2- الكیس فرقع

c) Placenta previa → " recent vaginal bleeding 3- شیمة ساقطةمال

d) Fetal distress → "↓ fetal movement". 4 – حركة الطفل قلیلة

Complaints of associated diseases:

.....تكتب على شكل

• She is referred from outpatient clinic while they accidentally

discovered ………. → during antenatal care.

• Hypertension → Elevated blood pressure.

• D.M → Elevated blood sugar

• Placenta previa → " Lower inserted placenta

• Ployhydramnios→ Excessive abd. enlargement"

3- Control of condition " Antenatal care"

.....تكتب على شكل

• She is referred from…….. → for antenatal care to control her

condition.

C) History of present illness 1- Pregnancy symptoms زاي عرفت أنك حامل؟إ

2- Pregnancy test زاي تأكدتى أنك حامل ؟ إ

3- Seek for medical advice عملتى أیھ لما عرفتى

4- 1st trimester events شھور 3یھ إلى حصل فى أول إ

شھور 3عرفتى أنك عدیتى أول إزاي

5- 2nd trimester events شھور 3أیھ إلى حصل فى ثانى

6- 3rd trimester events شھور 3أیھ إلى حصل فى ثالث

7- Other systems review

8- Medications

9- Investigations

1- Symptoms of pregnancy: … تكتب على شكل

• The story started when she missed a period & suffered from

nausea, vomiting, breast heaviness …..etc

2- Pregnancy test: … تكتب على شكل

• Pregnancy test was done in blood & urine & it was positive.

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

4-1st trimester events: 1- األمراض التى تھمنى

• threatened abortion (lower colicky pain, bleeding)

• Infection (Vaginal discharge)

• Hyperemesis gravidarum ( excessive vomiting )

• Pyelonephritis (fever, dysuria, loin pain)

If –Ve : … تكتب على شكل * The 1st trimester was smooth as no symptoms suggestive of → وتقولھم

كلھم

If +Ve :

• At the 1st trimester the patient suffered from أو

• The patient has noticed إزاى عرفتى أنك عیتى

Gradual enlargement of her abdomen

& She felt the fetal movements “Quickening"

& still felt up till now. ( بیرفس –بیرقص –بینكش –بینبض الطفل )

5- 2nd trimester events . األمراض التى تھمنى 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

..........تكتب على شكل

If –Ve : … تكتب على شكل

• The 2nd trimester was smooth as no symptoms

suggestive of → وتقولھم كلھم

If +Ve :

• At the 2nd trimester the patient suffered from …… وتقول اللي بتشتكي

منھ او اشتكت منھ

6- 3rd trimester events: As 2nd trimester

D) Menstrual history 1- Menarche أول دورة جاتلك عند سن كام سنة؟

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 خر دورة كانت إمتى؟ أول یوم فى أ

• 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 "

.....تكتب على شكل

• 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 " by fundal level"

3- Ultrasound " at 10 the week" أحق سونار

4- History

شروط 3 صحیحة

على األیام 7نزود - 1

)3نطرح 12-4، 9نزود 3، 2، 1( على الشھور 9نزود - 2

6- Expected Gestational age: تطلعھا قدام أو ترجعھا لورا تحسب من خالل

E.D.D Last Menstrual period

على حسب مین أقرب

)أسابیع 13 –شھور 3( سابیع ویومین أ 4- ر الشھ •

مثال •

• 1st day of last menstrual period 3/7/2006 = 0 WK

E.D.D: 10/4/2007 = 40 WK

Today is: 10/3/2007 EDD أطرح شھر من أل بمعنى

So Expected gestational age is “35 week & 5 days ± 2 week"

*****

مثال آخر

1st day of last M.P 3/7/2006 صفر

E.D.D: 10/4/2007 = 40 أسبوع

Today is: 10/3/2007 LMP زود شھر على یعنى

So Expected gestational age is “14 weeks ± 2 week"

E) Contraceptive History:

- Methods

- Results :

یعني ھل بعد استخدامھا للوسائل دي حصل حمل ؟ وھل معاھا مضاعفات

N.B

F) Obstetric History:

- Date - Medical disorders - Place of delivery

- Duration - Out come - Feeding - Puerperium

*****

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

ü By the ulnar border of the left hand starting at the xiphisternum

after centralizing the uterus to correct the dextro-rotation.

ü After engagement. The fundal level descends to the level of 32

weeks.

ü 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 causes of undersized uterus

Mis-calculation Mis-calculation

Polydramnios Oligohydramnios

Twins Transverse lie

Vesicular mole Missed abortion and IUFD

Macrosomia or hydrocephalus Anencephaly

Associated fibroid Small size of the uterus

4- Causes of non engagement of head in PG

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

Fetal Maternal

Large head hydrocephalus Contracted pelvis

Malposition malpresentation Tumor in pelvis

Multiple pregnancy Placenta previa

Short cord Full bladder or rectum

Polyhydramnios 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.

ý In occipito- anterior, FHS is heard below the umbilicus.

Near the midline at the anterior superior iliac spine

ý In occipito posterior (OP), FHS are heard below the

umbilicus in the flank i.e. lateral to the site of occipito-

anterior.

ý In breech presentation, FHS are heard above the

umbilicus

ý 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 soufflé:

- 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) soufflé:

- 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 “ if G2 and L2 not preferred to say D0 ”

- Gestational age

- Single or Multiple

- Living viable - Lie -Presentation

- Complications with pregnancy

N.B: Don’t 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

Don’t 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 couldn’t 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”