SECTION (I)OBSTETRIC CASE TAKINGThe science ofThe science ofThe science ofThe science of obstetricsobstetricsobstetricsobstetrics is that branchis that branchis that branchis that branchof medicine that dealsof medicine that dealsof medicine that dealsof medicine that deals with more than awith more than awith more than awith more than a9 May 2013 Osama M. Warda, MDof medicine that dealsof medicine that dealsof medicine that dealsof medicine that deals with more than awith more than awith more than awith more than ahuman being at a timehuman being at a timehuman being at a timehuman being at a time; namely the; namely the; namely the; namely thepregnantpregnantpregnantpregnant----parturient woman and herparturient woman and herparturient woman and herparturient woman and herfetus(s). This character is unique forfetus(s). This character is unique forfetus(s). This character is unique forfetus(s). This character is unique forthat branch of medicine.that branch of medicine.that branch of medicine.that branch of medicine.
The obstetric diagnosis:Includes the following items in sequence:gravidity1, parity2, duration ofpregnancy (weeks)3, fetal lie4,presentation5, position6,9 May 2013 Osama M. Warda, MDpresentation5, position6,engagement7 , disease in currentpregnancy (pregnancy induced,pregnancy associating)8 , previousdisease that may affect themanagement (medical/surgical) 9.
Definitions…..1.Gravidity = the number of pregnancies-includingthe current one- regardless the outcome; whetherdelivery or abortion).Abnormal pregnancies e.g. molar & ectopicpregnancies are included.9 May 2013 Osama M. Warda, MDAbnormal pregnancies e.g. molar & ectopicpregnancies are included.2.Parity (= the number of deliveries); that’s to saythose pregnancies that had been terminated bywhatever means beyond 20 gestational weeks ,regardless the fetal outcome whether living ordead, single or more).
Definitions…..3. Duration of the current pregnancy:it is calculated in weeks using differentmethods:Naegele’s formula: used when the 1st day ofthe last normal menstrual period (LNMP) is9 May 2013 Osama M. Warda, MDthe last normal menstrual period (LNMP) iscertainly known. The expected date ofdelivery (assuming that human pregnancyis 40 weeks) is calculated by adding 7 daysto the days & 9 months to the month.Other clinical methods : (e.g. fundal level,symphysis-fundal length, date ofquickening).
Definitions4. Lie: the fetal lie means the relationship betweenthe longitudinal axis of the fetus to that of itsmother. Thus we have longitudinal lie if both are in linewith each other, transverse lie if they are perpendicular toeach other, and oblique lie if the lie was not longitudinal nortransverse.9 May 2013 Osama M. Warda, MDtransverse.Oblique lieTransverse lieLongitudinal lie
Definitions5.Presentation: it means which part ofthe fetus is in relation to (presents) thepelvic inlet & first felt during vaginalexamination.9 May 2013 Osama M. Warda, MDexamination.The fetus may presents with its head ( i.e.cephalic presentation), or by its buttockswith or without the feet (i.e. breechpresentation), finally, if the lie istransverse, the fetus will present with itsshoulder (i.e. shoulder presentation).
Cephalic presentationPRESENTATIONS9 May 2013 Osama M. Warda, MD
Definitions……6.Position: fetal position means theposition of the fetal back in relation tothe anterior abdominal wall of themother whether anterior or posterior,9 May 2013 Osama M. Warda, MDmother whether anterior or posterior,to the right or to the left. The 4standard fetal positions are: LeftAnterior, Right Anterior, RightPosterior, and Left Posterior- in thatorder.
POSITIONSInC3rd4th9 May 2013 Osama M. Warda, MDCEPHALIC1st2nd
Stations of fetal headEngagement * : is the passage of thewidest transverse diameter of thepresenting part below the plane of pelvicbrimbrim9 May 2013 Osama M. Warda, MD
Definitions7. Complications of the currentpregnancy: for example; pre-eclampsia,ante-partum hemorrhage, prematurerupture of fetal membranes, fetalmalformation, fetal death, Rh- iso-immunization,…………etc9 May 2013 Osama M. Warda, MDimmunization,…………etc8. Previous diseases or surgicalprocedures that can affect themanagement of the currentpregnancy: for example, maternal cardiacdisease, diabetes mellitus, uterineanomalies or fibroids, previous uterinescar,…………..etc
The requirement for proper obstetrical diagnosisinclude the following items (items of obstetric casetaking):1- HISTORY TAKING2- CLINICAL PHYSICAL EXAMINATION3- URINE EXAMINATION FOR PROTIEN & SUGAR.9 May 2013 Osama M. Warda, MD3- URINE EXAMINATION FOR PROTIEN & SUGAR.
1- HISTORY TAKING1-Personal history.2. Complaint.3. Menstrual history.9 May 2013 Osama M. Warda, MD4.Obstetric history.5. Past history.6. Family history.7. Present history.
1- HISTORY TAKINGPersonal Hx. is started with gravidity and parityfollowed by usual items.Complaint is started by cessation of mens. Sincethe last normal menstrual period….9 May 2013 Osama M. Warda, MDMenstrual Hx. is mentioned in details if preg.is less than 7ms., but can be substituted withLNMP & EDD after 7ms.Obstetrical Hx. Must be mentioned even if –veFTNP-FTND-PTL-SB-Difficult L- CS- Last D-Abortions- puerperia.
1- HISTORY TAKINGFamily Hx. Twining (couples)+ usual itemsPast Hx. Of pregnancy related complication+usual itemsPresent Hx;1. The condition started…..9 May 2013 Osama M. Warda, MD1. The condition started…..2. Early pregnancy sympt.3. Confirmation of preg (pt, us)4. Date of quickening5. Analysis of the presenting complaint(s)6. Symptoms of high risk preg. (PE, APHge, PROM)7. Symptoms of approaching labor.8. Associated GIT& Urinary symptoms
2- CLINICAL PHYSICAL EXAMINATION1- General examination.2- Abdominal examination.9 May 2013 Osama M. Warda, MD3- Obstetric maneuvers4- Vaginal examination in an obstetric case.5- Bedside urine analysis for protein & sugar.
General examination.Gait : limp, polio, wadlingConstitution: feminine /masculineBuilt : BMI; < 19-24 Kg/M2 >9 May 2013 Osama M. Warda, MD<Vital signs (BP-Pulse-temp-RR)General examination of the patient fromthe head to the heel: head, neck, breasts,chest & heart, limbs & back [only report the +vefindings]
General examination.+9 May 2013 Osama M. Warda, MDBREAST Edema footEdema hands+++THYROIDTanner staging breast
Abdominal ExaminationTHE 9 ABDOMINAL AREAS9 May 2013 Osama M. Warda, MD
Abdominal ExaminationInspection• contour, movement with respiration, s.c. angle, umbilicus, skin.• hernial orifices, pubic hairPalpation• Suprficial palpation; tenderness, rigidity, superficial masses• Deep palpation; liver, spleen, renal angles, abd.mass9 May 2013 Osama M. Warda, MDtionPERCUSSION• Dullness over the uterus• Shifting dullness for ascitesAUSCULTATION• Intestinal sounds, venous hum, umbilical/placental souffle, FHS
Abdominal ExaminationLIVERRT KIDNEYSPLEEN9 May 2013 Osama M. Warda, MDPinard ST
OBSTETRIC MANEUVERSThe AimThe maneuverUterine size in gestational weeksFundal levelDetermine which fetal part occupy the fundusuteriFundal gripDetermine the direction (position) of fetal back.Umbilical grip Determine the direction (position) of fetal back.Umbilical gripDetermine which fetal part occupy the loweruterine segment as well as engagement.First pelvic gripDetermine the fetal head attitude, hencedetermines the dominator in cephalicpresentations.Second pelvicgripA quick method to determine the fetal lie,presentation, and fetal tone.Combined grip9 May 2013 Osama M. Warda, MD
Fundal LevelPalpate e- left handWhere is your right hand?9 May 2013 Osama M. Warda, MD
Fundal Grip9 May 2013 Osama M. Warda, MDHead or breech??Head or breech??Head or breech??Head or breech??
Umbilical Grip9 May 2013 Osama M. Warda, MD1stposition 2ndposition 3rdposition 4thpositionThe Back Left-anterior Right -anteriorRight-posterior Left-posteriorVertex LOA ROA ROP LOPBrow RFP LFP LFA RFAFace RMP LMP LMA RMABreech LSA RSA RSP LSPShoulder LscA RScA RScP LSc P
First pelvic grip9 May 2013 Osama M. Warda, MDHead or breech?Engaged or not?
Second pelvic gripWhat is the headAttitude?Sinciput vs occiput9 May 2013 Osama M. Warda, MDSinciput vs occiput
Vaginal Examination in obstetric case1. Diagnosis of early pregnancy:2. Diagnosis of the clinical type of abortion:**3. Cases of antepartum hemorrhage:4. Cases of suspected PROM:5. Transvaginal diagnostic procedures:9 May 2013 Osama M. Warda, MD5. Transvaginal diagnostic procedures:6. Assessment of pelvic capacity:7. Diagnosis of labor & follow-up of its progress:8. Confirmation of fetal presentation & position:
CLINICAL TYPES OF ABORTIONSClinical Typeof abortionBleeding Discharge Uterine size Internalcervical osFever Septicemia1.Threatened + - = amenorrhea closed - -2.Inevitable +++ - < amenorrhea open - -3.Incomplete ++ - < amenorrhea open - -9 May 2013 Osama M. Warda, MD3.Incomplete ++ - < amenorrhea open - -4.Complete + + < amenorrhea closed - -5.Missed + + brown < amenorrhea closed - -6.Infected Any Pus Any Any + -7. Septic any Pus Any Any ++ +
BEDSIDE URINE ANALYSISThe obstetric case taking is notcomplete except after urine analysisto detect glucose, and protein.GLU = strips9 May 2013 Osama M. Warda, MDGLU = stripsPROT.=strips or boiling