Oxford Handbook of Clinical Examination and Practical Skills (2 edn)
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History taking in obstetrics
Although there are parts particular to this history, most is the same as the basic outline described in 
Chapter 2 and we suggest that readers review that chapter before going on.
Demographic details
These terms can be confusing and, although it is worth knowing the definitions and how to use them, they should be supplemented with a detailed history and not relied on alone as you may miss subtleties which alter your outlook on the case.
The number of pregnancies (including the present one) to any stage
The number of live births (at any stage of gestation) and stillbirths after 24 weeks’ gestation
Pregnancies terminating before 24 weeks’ gestation can be written after this number with a plus sign.
A woman who is currently 20 weeks pregnant and has had two normal deliveries* = Gravida 3, Para 2
A woman who is not pregnant and has had a single live birth and one miscarriage at 17 weeks = Gravida 2, Para 1+1
A woman who is currently 25 weeks pregnant, has had 3 normal deliveries, one miscarriage at 9 weeks, and a termination at 7 weeks = Gravida 6, Para 3+2.
There is some controversy as to how to express twin pregnancies. Most people suggest that they should count as 1 for gravidity and 2 for parity—but you should check your local practice on this.
*The verb ‘to deliver’ is often misused by students of obstetrics as it is often misused by the population at large.
Babies are not delivered.
In fact, the mothers are ‘delivered of’ the child—as in being relieved of a burden.
Check your nearest dictionary!
Estimated date of delivery (EDD)
Subtract 3 months from the first day of the LMP
Add on 7 days and 1 year.
If the normal menstrual cycle is <28 days, or >28 days, then an appropriate number of days should be subtracted from or added to the EDD. For example, if the normal cycle is 35 days, 7 days should be added to the EDD.
It is important to also consider at this point any detail that may influence the validity of the EDD as calculated from the LMP; such as:
Was the last period normal?
What is the usual cycle length?
Are the patient’s periods usually regular or irregular?
Was the patient using the oral contraceptive pill in the three months prior to conception? If so, calculations based on her LMP are unreliable.
Current pregnancy
Ask about the patient’s general health and that of her fetus. If there is a presenting complaint, the details should be documented in full. Also ask about:
Fetal movements:
Not usually noticed until 20 weeks’ gestation in the first pregnancy and 18 weeks’ in the second or subsequent pregnancies.
Any important laboratory tests or ultrasound scans.
Include dates and details of all the scans, especially the first scan (dating or nuchal translucency scan).
Past obstetric history
Ask about all of the patient’s previous pregnancies including miscarriages, terminations, and ectopic pregnancies.
For each pregnancy, note:
Age of the mother when pregnant.
Antenatal complications.
Duration of pregnancy.
Details of induction of labour.
Duration of labour.
Presentation and method of delivery.
Birth weight and sex of infant.
Also enquire about any complications of the puerperal period. The puerperium is the period from the end of the 3rd stage of labour until involution of the uterus is complete (about 6 weeks).
Possible complications include:
Postpartum haemorrhage.
Infections of the genital and urinary tracts.
Deep vein thrombosis.
Perineal complications such as breakdown of the perineal wounds.
Psychological complications (e.g. postnatal depression).
Past gynaecological history
Record all previous gynaecological problems with full details of how the diagnosis was made, treatments received, and the success or otherwise of that treatment.
Record the date of the last cervical smear and any previous abnormal results.
Take a full contraceptive history.
Past medical history
Note especially those conditions which may have an impact on the pregnancy including:
Diabetes.
Endocrine disorders such as thyroid disorders or Addison’s disease.
Asthma.
Epilepsy.
Hypertension and heart disease.
Renal disease.
Infectious diseases such as TB, HIV, syphilis, and hepatitis.
Identification of such conditions will allow the obstetrician to consider early referral to a specialist for shared care.
All previous operative procedures.
Blood transfusions and receipt of other blood products.
Psychiatric history—may extend beyond ‘simple’ postnatal depression.
Drug history
Take a full drug history which should include all prescribed medication, over-the-counter medicines, and illicit drugs.
Record any drug allergies and their nature.
If currently pregnant, ensure the patient is taking 400 micrograms of folic acid daily until 12 weeks’ gestation to reduce the incidence of spina bifida.
Family history
Ask about any pregnancy-related conditions such as congenital abnormalities, problems following delivery, etc.
Ask also about a FHx of diabetes.
Ask especially if there are any known hereditary illnesses. Appropriate counselling and investigations such as chorionic villus sampling or amniocentesis may need to be offered.
Social history
As well as the full standard social history, ask about:
Her partner—age, occupation, health.
How stable the relationship is.
If she is not in a relationship, who will give her support during and after the pregnancy?
Ask if the pregnancy was planned or not.
If she works, enquire about her job and if she has any plans to return to work.
Bleeding
During pregnancy
We suggest the reader turns to the Oxford Handbook of Obstetrics and Gynaecology1 for more detail.
Symptoms: light bleeding, abdominal pain, fainting if pain and blood loss is severe
Signs: closed cervix, uterus slightly larger and softer than normal, tender adnexal mass, cervical motion tenderness.
Symptoms: light bleeding. Sometimes: cramping, lower abdominal pain
Signs: closed cervix, uterus corresponds to dates. Sometimes, uterus is softer than normal.
Symptoms: light bleeding. Sometimes: light cramping, lower abdominal pain and a history of expulsion of products of conception
Signs: uterus smaller than dates and softer than normal. Closed cervix.
Symptoms: heavy bleeding. Sometimes: cramping, lower abdominal pain, partial expulsion of products of conception
Signs: uterus smaller than dates and cervix dilated.
Symptoms: heavy bleeding, partial expulsion of products of conception which resemble grapes. Sometimes: nausea and vomiting, cramping, lower abdominal pain, history of ovarian cysts
Signs: dilated cervix, uterus larger than dates and softer than normal.
This is known as ‘antepartum haemorrhage’ (APH). See the Oxford Handbook of Obstetrics and Gynaecology 1 for more detail.
The placenta is positioned over the lower pole of the uterus, obscuring the cervix. Bleeding is usually after 28 weeks and often precipitated by intercourse. Findings may include a relaxed uterus, fetal presentation not in pelvis, and normal fetal condition.
This is detachment of a normally located placenta from the uterus before the fetus is delivered. Bleeding can occur at any stage of the pregnancy. Possible findings include a tense, tender uterus, reduced or absent fetal movements, fetal distress, or absent fetal heart sounds.
After establishing an exact time-line and other details about the symptom, ask about:
Exact nature of the bleeding (fresh/old).
Amount of blood lost.
Number of sanitary pads used daily.
Presence of clots (and, if present, size of those clots).
Presence of pieces of tissue in the blood.
Presence of mucoid discharge.
Fetal movement.
Associated symptoms such as abdominal pain (associated with placental abruption; placenta praevia is painless).
Possible trigger factors—recent intercourse, injuries.
Any history of cervical abnormalities—and the result of the last smear.
After pregnancy
Primary PPH: >500ml of blood loss within 24 hours following delivery.
Secondary PPH: any excess bleeding between 24 hours and 6 weeks post delivery. (No amount of blood is specified in the definition.)
Nulliparity, multiparity, polyhydramnios, prolonged labour, multiple gestation, previous PPH or APH, pre-eclampsia, coagulation abnormalities, genital tract lacerations, Asian or Hispanic ethnicity.
Uterine atony (most frequent cause), genital tract trauma, coagulation disorders, retained placenta, uterine inversion, uterine rupture.
Retained products of conception, endometritis, infection.
Take a full history as for bleeding during pregnancy. Ask also about symptoms of infection—an important cause of secondary PPH.
Abdominal pain
A full pain history should be taken as in Chapter 2 including site, radiation, character, severity, mode and rate of onset, duration, frequency, exacerbating factors, relieving factors, and associated symptoms.
History taking
Take a full obstetric history and systems enquiry. Ask especially about a past history of pre-eclampsia, pre-term labour, peptic ulcer disease, gallstones, appendicectomy, and cholecystectomy.
Causes
Remember that the pain may be unrelated to the pregnancy so keep an open mind. Causes of abdominal pain in pregnancy include:
Obstetric
Preterm/term labour.
Placental abruption.
Ligament pain.
Symphysis pubis dysfunction.
Pre-eclampsia/HELLP syndrome.
Acute fatty liver of pregnancy.
Gynaecological
Ovarian cyst rupture, torsion, haemorrhage.
Uterine fibroid degeneration.
Gastrointestinal
Constipation.
Appendicitis.
Gallstones.
Cholecystitis.
Pancreatitis.
Peptic ulceration.
Genitourinary
Cystitis.
Pyelonephritis.
Renal stones.
Renal colic.
Labour pain
This is usually intermittent, regular in frequency, and associated with tightening of the abdominal wall.
Hypertension
Hypertension is a common and important problem in pregnancy and you should be alert to the possible symptoms which can result from it such as headache, blurred vision, vomiting and epigastric pain after 24 weeks, convulsions or loss of consciousness.
Pregnancy-induced hypertension
Two readings of diastolic blood pressure 90–110, 4 hours apart after 20 weeks’ gestation.
No proteinuria.
Mild proteinuric pregnancy-induced hypertension
Two readings of diastolic blood pressure 90–110, 4 hours apart after 20 weeks’ gestation.
Proteinuria 2+.
Severe proteinuric pregnancy-induced hypertension
Diastolic blood pressure 110 or greater after 20 weeks’ gestation.
Proteinuria 3+.
Other symptoms may include:
Hyper-reflexia
Headache
Clouding of vision
Oligura
Abdominal pain
Pulmonary oedema.
Eclampsia
Convulsions associated with raised blood pressure and/or proteinuria beyond 20 weeks’ gestation.
May be unconscious.
Minor symptoms of pregnancy
These so-called ‘minor’ symptoms of pregnancy are often experienced by a number of woman as normal changes occur. This is not to say that they should be ignored as they may point to pathology.
Nausea and vomiting
The severity varies greatly and is more common in multiple pregnancies and molar pregnancies.
Persistence of vomiting may suggest pathology such as:
Infections
Gastritis
Biliary tract disease
Hepatitis.
Heartburn/gastro-oesophageal reflux
Heartburn is a frequent complaint during pregnancy due partially to compression of the stomach by the gravid uterus.
Constipation
Often secondary to ? progesterone.
Improves with gestation.
Shortness of breath
Due to dilatation of the bronchial tree secondary to ? progesterone.
Peaks at 20–24 weeks
The growing uterus also has an impact.
Other possible causes (such as pulmonary embolus) need to be considered.
Fatigue
Very common in early pregnancy.
Peaking at the end of the first trimester.
Fatigue in late pregnancy may be due to anaemia.
Insomnia
Due to anxiety, hormonal changes, and physical discomfort.
Pruritus
Generalized itching in the third trimester may resolve after delivery.
Biliary problems should be excluded.
Haemorrhoids
May resolve after delivery.
Varicose veins
Especially at the feet and ankles.
Vaginal discharge
Exclude infection and spontaneous rupture of the membranes.
Pelvic pain
Stretching of pelvic structures can cause ligament pain which resolves in the second half of the pregnancy.
Symphysis pubis dysfunction causes pain on abduction and rotation at the hips and on mobilization.
Backache
Often first develops during the 5–7th months of pregnancy.
Peripheral paraesthesiae
Fluid retention can lead to compression of peripheral nerves such as carpal tunnel syndrome.
Other nerves can be affected, e.g. lateral cutaneous nerve of the thigh.
Outline obstetric examination
Explain to the patient that you would like to examine their womb and baby and reassure them that the procedure will be quick and gentle.
You should have a chaperone present, particularly if you are male.
As always, ensure that the room is warm and well lit, preferably with a moveable light source and that you will not be disturbed.
As for the gynaecological examination, you should follow an orderly routine. The authors’ suggestion is shown on p. 475. It is standard practice to start with the cardiovascular and respiratory systems—this not only gives a measure of the general health of the patient but also establishes a ‘physical rapport’ before you examine more delicate or embarrassing areas (Box 14.8).
General inspection
Cardiorespiratory examination
Abdominal inspection
Abdominal palpation
Uterine size
Fetal lie
Fetal presentation
Engagement
Amniotic fluid estimation.
Auscultation of the fetal heart
Vaginal examination
Perform bedside urinalysis (particularly protein) if able.
General inspection
Always begin with a general examination of the patient (as in Chapter 3) including:
Temperature.
Hydration.
Coloration.
Nutritional status.
Lymph nodes.
Blood pressure.
Note especially:
Any brownish pigmentation over the forehead and cheeks known as chloasma.
Distribution of facial and body hair, as hirsutism may be a presenting symptom of various endocrine disorders.
Height, weight, and calculate BMI.
Blood pressure should be measured in the left lateral position at 45° to avoid compression of the inferior vena cava by the gravid uterus.
Anaemia is a common complication of pregnancy so examine the mucosal surfaces and conjunctivae carefully.
Examining other systems
A routine breast examination is not normally indicated unless a female patient complains of breast symptoms, in which case you must carefully look for any pathology such as cysts or solid nodules.
Abdominal inspection
Look for the abdominal distension caused by the gravid uterus rising from the pelvis. Look also for:
Asymmetry.
Fetal movements.
Surgical scars.
Pubic hairline (transverse suprapubic Pfannenstiel incision)
Paraumbilical region (laparoscopic scars).
Cutaneous signs of pregnancy including:
Linea nigra (black line) which stretches from the pubic symphysis upwards in the midline
Red stretch marks of current pregnancy (striae gravidarum)
White stretch marks (striae albicans) from a previous pregnancy
Other areas that can undergo pigmentation in pregnancy include the nipples, vulva, umbilicus, and recent abdominal scars.
Umbilical changes:
Flattening as pregnancy advances
Eversion secondary to increased intra-abdominal pressure (e.g. caused by multiple pregnancies or polyhydraminios).
Palpation
Before palpating the abdomen, always enquire about any areas of tenderness and visit those areas last.
Palpation should start as for any standard abdominal examination ( Chapter 7) before proceeding to more specific manoeuvres in an obstetric examination.
Uterine size
The symphysial–fundal height (cm) = weeks of gestation.
The uterus first becomes palpable at 12 weeks’ gestation
20 weeks’ gestation = at the level of the umbilicus
36 weeks’ gestation = at the level of the xiphisternum.
A guide to the surface landmarks for uterine size.
Between 16–36 weeks, there is a margin of error of ±2cm, ±3cm at 36–40 weeks, and ±4cm at 40 weeks onwards.
Technique
You need a tape measure for this—don’t start without it!
Use the ulnar border of the left hand to press firmly into the abdomen just below the sternum.
Move the hand down the abdomen in small steps until you can feel the fundus of the uterus.
Locate the upper border of the bony pubic symphysis by palpating downward in the midline starting from a few centimetres above the pubic hair margin.
Measure the distance between the two points that you have found in centimetres using a flexible tape measure.
Fetal lie
This describes the relationship between the long axis of the fetus and the long axis of the uterus and, in general, can be:
Longitudinal: the long axis of the fetus matches the long axis of the uterus. Either the head or the breech will be palpable over the pelvic inlet.
Transverse: the fetus lies at right angles to the uterus and the fetal poles are palpable in the flanks.
Oblique: the long axis of the fetus lies at an angle of 45° to the long axis of the uterus, the presenting part will be palpable in one of the iliac fossae.
Examination technique
The best position is to stand at the mother’s right side, facing her feet.
Put your left hand along the left side of the uterus.
Put your right hand on the right side of the uterus.
Palpate towards the midline with one and then the other hand.
Use ‘dipping’ movements with flexion of the MCP joints to feel the fetus within the amniotic fluid.
You should feel the fetal back as firm resistance or the irregular shape of the limbs.
You should now palpate more widely using the 2-handed technique above to stabilize the uterus and attempt to locate the head and the breech.
The head can be felt as a smooth, round object that is ballotable—that is, it can be ‘bounced’ (gently) between your hands
The breech is softer, less discrete, and is not ballotable.
Fetal presentation
This is the part of the fetus that presents to the mother’s pelvis. Possible presenting parts include:
Head: cephalic presentation. One option in a longitudinal lie.
Breech: podalic presentation. The other option in a longitudinal lie.
Shoulder: seen in a transverse lie.
Examination technique
Stand at the mother’s right side, facing her feet.
Place both hands on either side of the lower part of the uterus.
Bring the hands together firmly but gently.
You should be able to feel either the head, breech, or other part as described above under ‘fetal lie’.
Paulik’s grip
It is also possible to use a one-handed technique (Paulik’s grip) to feel for the presenting part—this is best left to obstetricians. In this, you use a cupped right hand to hold the lower pole of the uterus. This is possible in ~95% of pregnancies at about 40 weeks.
Engagement
When the widest part of the fetal skull is within the pelvic inlet, the fetal head is said to be ‘engaged’.
In a cephalic presentation, palpation of the head is assessed and expressed as the number of fifths of the skull palpable above the pelvic brim. A fifth is roughly equal to a finger breath on an adult hand.
The head is engaged when 3 or more fifths are within the pelvic inlet—that is when 2 or fewer fifths are palpable.
When 3 or more fifths are palpable, the head is not engaged.
Number of fetuses
The number of fetuses present can be calculated by assessing the number of fetal poles (head or breech) present.
If there is one fetus present, 2 poles should be palpable (unless the presenting part is deeply engaged).
In a multiple pregnancy, you should be able to feel all the poles except one—as one is usually tucked away out of reach.
Amniotic fluid/liquor volume estimation
The ease with which fetal parts are palpable can give an indication as to the possibility of reduced or increased amniotic fluid volume.
Increased volume will give a large-for-dates uterus that is smooth and rounded. The fetal parts may be almost impossible to palpate.
Reduced volume may give a small-for-dates uterus. The fetus will be easily palpable giving an irregular, firm outline to the uterus.
Percussion
This is usually unhelpful unless you suspect polyhydramnios in which case, you may wish to attempt to elicit a fluid thrill.
Auscultation
Auscultation is used to listen to the fetal heart rate (FHR). This is usually performed using an electronic hand-held Doppler fetal heart rate monitor and can be used as early as 14 weeks.
Using Pinard’s fetal stethoscope
A Pinard’s fetal stethoscope is not useful until 28 weeks’ gestation. It is a simple-looking device rather like an old-fashioned ear-trumpet.
Place the bell of the instrument over the anterior fetal shoulder.
Press your left ear against the stethoscope so as to hold it between your head and the mother’s abdomen in a ‘hands-free’ position or hold the instrument lightly with one hand.
Press against the opposite side of the mother’s abdomen with your other hand so as to stabilize the uterus.
It should sound like a distant ticking noise. The rate varies between 110 and 150/minute at term and should be regular.
Vaginal examination
Vaginal examination allows you to assess cervical status before induction of labour. You should attempt this only under adequate supervision if you are unsure of the procedure.
This examination allows you to assess the degree of cervical dilatation (in centimetres) using the examining fingers.
Examination of the vagina and cervix should be performed under aseptic conditions in the presence of ruptured membranes or in cases with abnormal vaginal discharge.
Technique
The examination should be performed as described in Chapter 13. The findings take experience to recognize. The student should not shy away from this examination due to its intimate nature.
Findings
Assess:
Degree of dilation.
Full dilation of the cervix is equivalent to 10cm
Most obstetric departments will have plastic models of cervices in various stages of dilatation which you can practise feeling.
The length of the cervix.
Normal ~3cm but shortens as the cervix effaces secondary to uterine contraction.
The consistency of the cervix which can be described as:
Firm
Mid-consistency
Soft (this consistency facilitates effacement and dilatation).
Position.
As the cervix undergoes effacement and dilatation it tends to be pulled from a posterior to an anterior position.
Station of the presenting part.
The level of the head above or below the ischial spines which may be estimated in centimetres.
