Fourth year Obstetrics

MEDICAL SCHOOL OBSTETRICS




KNOWLEDGE FOR FINALS



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, Obstetrics



Before 18 weeks’ gestation most obstetric conditions are unlikely i.e. pre-
eclampsia, GDM etc. so questions should concentrate more on abdominal pain
and bleeding.

1. Key pregnancy details initially.
 What is the gestational age?
 When was her LMP?
 What is her due date?
 How many pregnancies has the woman had?
 How many live pregnancies has the woman had?

2. Presenting complaint, back to routine history taking
 Acute or gradual
 Duration
 Severity
 Symptoms may depend on gestational age
 Intermittent or continuous
 Precipitating or relieving factors?
 Associated symptoms?
 Previous episodes?

3. Screening questions for symptoms
 Pain (THINK: UTI, abruption, pelvic girdle pain, constipation)
 Nausea and vomiting
 Reduced fetal movements
 Vaginal bleeding (THINK: Antepartum haemorrhage, placenta
praevia, cervical causes i.e. ectropion)
 Vaginal loss (discharge of SROM)
 Headache/visual disturbance/epigastric pain/swelling (THINK: pre-
eclampsia)
 Pruritus (THINK: obstetric cholestasis)
 Urinary symptoms and bowel symptoms

NB: Nausea and vomiting should peak and finish by the 20th week of pregnancy.
Hyperemesis gravidum is more common in pregnancies with higher levels of
beta HCG such as in molar pregnancies and multiple pregnancies.


4. Important pregnancy questions


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,  Ultrasound results including position of the placenta, growth of the
fetus, anomalies. Did she accept the screening for Down’s Patau’s
and Edward’s?
 Rhesus status of the mother and father?
 Has mum been taking folic acid pre-conception and throughout?
 Planned mode of delivery
 Lead on from here to talk about other children and their mode of
delivery. Discuss the pregnancies of previous children, as well as the
post-natal period and early ears.


5. Previous medical history and previous pregnancies
 Significant medical problems
 Surgical history
 Mental illness
 Gynaecological history
 Smear history
 Birth weights of children, mode of delivery, complications in the
antenatal period and post-natal period

6. Drug history
 Medications
 Allergies
 Contraceptive history
 Pregnancy medication (folic acid, oral iron, Antiemetics, aspirin)

7. Social history
 Smoking
 Alcohol
 Drugs
 Occupation


Examination

 Empty bladder before examination – NB: This will be impressive to
ACC examiners if you ask the patient this before examining.
 Inspection of abdomen for linea nigra, Striae Gravidarum and Striae
albicans
 Palpation of 9 area noting if any pain, guarding or rebound tenderness
is present.




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,  Identify the borders of the uterus and the height of the fundus (12
weeks = pubic symphysis, 20 weeks = umbilicus, 36 weeks = xiphoid
process of sternum)
 SFH (symphysis-fundal height) measurement with measuring tape
facing down in order to remove bias. The height should correspond
with the week’s gestation +/- 2cm.
 NB: Find the fundus using the ulnar side of the hand.

 Fetal lie (i.e. longitudinal or transverse)

 Presentation (i.e. cephalic or breech)

 Assessment of engagement (using pelvic palpation of 5th of the fetal
head palpable)

 Auscultation with stethoscope or sonicaid (sonicaid from 12 weeks
and stethoscope from 24 weeks) listen over the anterior shoulder
of the fetus

 Blood pressure
 Urinanalysis
 Speculum




Figure 1: example of pelvic palpation of 5th's palpable. The head is fully engaged once 2/5 palpable abdominally.




Antenatal care (before and during a pregnancy)


1. Educate women on normal physiological changes in pregnancy


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