1. This document provides guidelines for taking an obstetrics and gynecology history and physical exam. It outlines components to include in the patient's history of present illness, past medical history, family/social history, and physical exam.
2. Key items in the history include biodata, obstetric history, last menstrual period, estimated due date calculations, antenatal care profile, past pregnancies and deliveries, gynecological history, and medical/surgical history.
3. The physical exam section focuses on examining patients in the postpartum period and includes assessing pain, bleeding, lochia, feeding, urination, bowel movements, and neonate status.
2. OBS Hx
1. BIODATA
• Name
• Age
• Parity- Total number of viable pregnancies
-Viability: Weight>500g, Week>20(WHO),28(
Kenya, MLKH), 24?
-e.g Primigravida
-Para1+1( 1viable, +1 is unviable)
-2 viable, 2 miscarriages and 1 ectopic= Para2+3
-Para 5+1 with 2 living children
-Twins;?
3. • Gravidity: No. of pg including current one
• LNMP- Last normal menstrual period( day 1)
• EDD- Expected due date
Expected date confinement
• GBD- Gestation by date
• Duration of admission: 1/7, 1/52, 1/12
NOTE
-Add Residence and occupation if significant
- Malaria endemic zones, Radiologist, Chemical
industries( embryotoxic)
4. EDD CALCULATIONS
• Naegele’s Rule
-Add 1 year and 7 days to the LMP and subtract
3 months
-Add 9 to January, February and March
( 01,02,03) since it’s impossible to subtract 3
months from them.
6. Calculations: EDD
1. LNMP 5/12/20
Add 7 to date( 5+7)=12
Subtract 3 from months (12-3)=9
EDD 12/9/21
2. 25/4/20
+7/-3/
32/1/21 January= 31 days, add extra days to
-31 next month
1/2/21 EDD= 1/2/21
7. calculations
• If Jan, Feb, March: Add 9
LNMP 25/1/21
EDD +7/+9/21
32/10/21 October= 31 days
-31/
1/11/21
• Calculate EDD for following
25/7/20 16/9/20 14/2/21 15/3/21 16/5/21
8. GBD Calculations
• Obs wheel
• Online calculators
• Manually ( forward/ backward calculation
based on the closest date to edd)
Eg Today is 16/5/21
LNMP 16/9/20 EDD 23/6/21
Forward calculation: Days remaining in may( 31-
16)= 15 days , June ( 23 days) , Total (15+23)=38
9. Cont..
• Convert 38 days to gestation weeks
38/7= 5 weeks 3days
• Full gestation ( 39 weeks 7 days- 6 weeks 4
days)
397/7 – 53/7 = 34 weeks 4days
GBD: 34weeks 4 days
• Calculate for the other EDD examples in
previous slides
10. Hx cont..
• Chief complaints
Eg Drainage of fluid for 1/7
Lower abdominal pains( lap) for 3/7
Epigastric pain
Per vaginal bleeding
Unilateral lower limb swelling
Vomiting
11. Hx cont..
• History of presenting illness
Patient was well until a day prior to admission
when she presented with :
Laps- SOCRATES
Eg Gradual onset, sharp in character, increasing
in frequency and intensity, radiating to the back,
no aggrevating or relieving factors.>>> ‘Labor’
Scale1/10
12. Cont..Intro of HPI in some cases
• Patient referral?
• Patient with known comorbids eg DM,HIV,HTN
The patient is known to have DM for 4 years
now , on treatment with Metformin500mg BD,
compliant and on follow up at MLKH.
HIV-HAART Regimen, last Viral load, CD4 count
13. Cont..HPI
• Describe symptoms as per hutchisons
• Drainage of fluid/ bleeding: Onset, volume( pads
number), duration, consistency( fluidy, clots),
blood stained, mucoid, color( fresh bright red
blood or dark red), smell, draining to what level(
amount) eg to feet, staining under garments, bed
sheets
• Discharge: Color, watery, odour, cyclic( relation to
menses), recurrent, respose to tx, itching,
burning, pain
16. Hx of current pregnancy
• Availability of ANC booklet
• No. of visits, 1st visit ?
Schedule, atleast 4 visits:
1st; before 16th week of pg
2nd visit: 16-28 wk
3rd visit: 28-32wk
4th visit: 32-40th week
• IFAS( ADD on eg ranferon, bld txn, reactions?)
• Tetanus toxoid( no.)
• Deworming
• Malaria prophylaxis and LLITN
Endemic zones, dose, drug( sp), other options, exclusion( hiv+ve with
cotrimoxazole)
17. ANC..
Profile:
• Hb( normal/ high/ low)
Read anaemia in pg, classification
• Blood group
• Rhesus: +ve, -ve
What to be done in rh neg
• VDRL( syphyllis test) +ve –ve
If +ve, confirmatory test with TYPHA
• HIV/ Serostatus , Reactive/ Non reactive
• Urinalysis
18. Anc..
• TB screening
• Hep B screening
• Any other complications, treatment , outcome
• BP ranges
19. Past obs Hx
• Gives potential complications
• Establish, parity eg para 5+0
• The 11 things must be included for each pg:
- Year, length of pregnancy(term),duration of labor,
type of delivery*(svd, emergency cs, elective cs)and
indication for cs), outcome(LMI) live male/female
infant),sex of neonate, BWT, apgar( cried
immediately),antepartum, intrapartum or
postpartum complications, current status of baby.
20. Gyn hx
• Menstrual hx
Menarche, cycle length, duration, amount,
dysmenorrhoea
143-4
28
• Contraceptive hx; duration, side effect
• Sexual hx: debut, dyspareunia, post coital bleeding, STDs tx,
no of partners
• Screening breast, cervix ca( read guidelines for which age ,
who is eligible?, methods)
21. Past medical, medication and surgical
hx
• 1st admission?,
• No. of previous admissions and outcomes,
when , where, what..
• Known food/ drug allergies
• Bld txn, reactions
• Hiv status
• Other chronic illnesses…( may have already
mentioned in hpi)..dm, htn
23. Family social hx
• Marital status
• Occupation and level of education
• Husband occupation
• Care of other siblings while she’s is admitted
• Insurance
• Smoking/ alcohol
• Familial illnesses, DM,SCD,VTE
• Twinning( maternal side)
24. Summary
• Name, age, para, gravida,lnmp, edd, gbd, day
of admission, cc.
• Any other relevant info eg comorbid…
Impression….( for some lecturers) at gbd
PHYSICAL EXAM
25. Post natal hx( cs, svd?)
Introduction***Use right tense
Name, age, NOW para, last lnmp, edd, gbd
would have been/was doing* days post op due
to ( emergency /elective cs, indication( sec to),
outcome, BWT, apgar..
HPI
What patient presented with….
As of today..:
26. HPI..
• Pain at incision site, socrates
• Lochia; amount(pads), smell, color
• Bleeding( anaemia)/ delayed pph
• Feeding: NPO, oral sips(6h post cs then
light(soft)feeds then normal feeds at 24h)
• Catheter in situ or removed, urine output(
volume, color, frequency)
• Bowel movements, flatus?
• Calf pain and swelling and Pulmonary embolism
fx
27. Cont…
• Ambulates
• Neonate status: breastfeeding and frequency,
breasts active, milk letdown, meconium, cord
care, nbu admission?, immunization
Read attachment techniques, motilium, drugs to
stop milk let down bromocryptine( if infant
dead)
Remember family planning post op
28. P/E
• Head to toe cns, resp, cvs, p/a
Vitals, J ACLOD
p/a
Fundal height- involution and tenderness
Dressing…clean,soiled,midline,
