Guidelines for Medical Students Gynaecological & obstetric history taking and physical examination Department of Obstetrics & Gynaecology
University of Malta Medical School
Malta
2011
Published by
Department of Obstetrics & Gynaecology
University of Malta Medical School, Malta
© Department of Obstetrics & Gynaecology, UMMS, 2011
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CONTENTS INTRODUCTION ...........................................................................................................................................4 HISTORY TAKING..........................................................................................................................................4 Introduce yourself and obtain consent to take history ..........................................................................5 Personal history ......................................................................................................................................6 Presenting complaint ..............................................................................................................................6 Associated Symptoms – Systemic enquiry..............................................................................................8 Menstrual history....................................................................................................................................8 Sexual history..........................................................................................................................................8 Obstetric history .....................................................................................................................................9 Past medical & surgical history ...............................................................................................................9 Drug history ............................................................................................................................................9 Family history........................................................................................................................................10 Social history.........................................................................................................................................10 CLINICAL EXAMINATION ............................................................................................................................11 Obtaining consent to examine patient .................................................................................................11 Systemic Examination ...........................................................................................................................12 Abdominal Examination........................................................................................................................13 Obstetric Examination ..........................................................................................................................17 Gynaecological Examination .................................................................................................................19 EXAMPLE – PRESENTATION OF AN ANTENATAL HISTORY & EXAMINATION.............................................23 Presentation of the History...................................................................................................................23 Presentation of the Examination ..........................................................................................................26 EXAMPLE –ANTENATAL CASE WRITE‐UP ...................................................................................................28 3
INTRODUCTION Female reproductive health is an important component of medical education. Regardless of the speciality that the medical students will ultimately choose to pursue, as medical practitioners they need to have a basic knowledge and skills pertinent to the care of the female patient. They need to not only need to know how to perform the clinical assessment, but how to do this in a sensitive, competent, and ethical manner. The principles of history taking and physical examination in obstetric and gynaecological patients are similar to those in other branches of medicine, but there are aspects that are specific to the speciality. In general, history taking and physical examination should be carried out in a logical sequence. The medical student should understand the purpose of each posed question and each observational aspect of the examination. While there is marked overlap between the clinical assessment of the obstetric and the gynaecological patient, it will be appreciated that the emphasis differs in the two clinical situations. HISTORY TAKING The scope of taking a clinical history in any situation is to identify the clinical problem and obtain sufficient detail to allow for the formulation of a provisional diagnosis so that the subsequent clinical examination and investigations are targeted to narrow down the diagnostic possibilities further. The eventual presentation of the clinical history, whether this is presented verbally or in the written format, should follow a logical and chronological sequence preferably in paragraph format [as in a story] – see example. 4
During history taking, the medical student should at all times show the patient the respect that is due to her; while full confidentiality must be maintained at all times bearing in mind that the relationship between the professional and his client is based on mutual trust and respect. The medical profession has long identified the need for confidentiality with the classical Hippocratic Oath stating: “All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.” The concept of professional secrecy relating to the medical profession was so strongly felt that it was incorporated within the Criminal Code of Malta [Ch.9:257]. The law reads as follows: “If any physician, surgeon, obstetrician or apothecary or, in general, any other person who, by reason of his calling or profession, becomes the depository of any secret confided to him1, shall, except when compelled by law to give information to the public authority, disclose such secret, he shall, on conviction be liable to a fine.” Furthermore, any conviction under this heading may also involve disciplinary action on the part of the Medical Council. History taking should follow a logical and chronological sequence. Each clinician has his particular preference. A general useful scheme for a gynaecological history is outlined below. Introduce yourself ƒ “Hello. I am Mr/Ms ****, a medical student. Do you mind if I ask you some and obtain consent questions about your medical condition?” to take history 1
This includes the medical student and any other paramedical professional. 5
Personal history Presenting complaint ƒ Name, age, address [if relevant], marital status, occupation. ƒ “What is the problem that brought you to the hospital/clinic?” ƒ Best to record this in the patient’s own words. ƒ “Were you referred by your doctor or did you self‐refer yourself to the hospital/clinic?” ƒ Patient may not furnish sufficient details, in which case it will be necessary to amplify with specific directed questions. E.g. SOCRATES relating to pain:‐ o Site: where, local/diffuse o Onset: rapid/gradual, pattern, worse/better since onset o Character: sharp/dull/stabbing, burning/cramp/crushing o Radiation: “Does the pain affect you anywhere else?” [to thigh/loin/elsewhere] o Alleviating factors: “What do you do to make yourself comfortable?” “Is the pain better after menstruation?” o Time course: “When did the pain start?”; if pain is chronic “What made you seek attention now?” “Is the pain worse at any particular time of the cycle?” o Exacerbating factors: “Is there anything that brings on the pain or makes it worse?” o Severity & Impact on life: “On a scale of 1 to 10, at what level would you classify the pain?” "Does it interrupt your life?" 6
In the obstetric patient, its may be best to consider the “presenting complaint” in two parts: A. The history of present illness or complaint [see above]; and B. The history of the current pregnancy. The history of the current pregnancy is best considered in different trimesters to date. 1. First trimester: After taking the menstrual history [see below], one proceeds to ask about any problems that may have occurred during the first three months of pregnancy, particularly specific associated symptomatology of nausea/vomiting, vaginal bleeding, and urinary symptoms. Establish when patient confirmed her pregnancy [“When did the pregnancy test show up as positive?”]; and establish when she actually first visited her doctor. “Was the pregnancy planned?” In which case did she start preconceptional folic acid. If not when did she start these and other haematologicals [if at all]. “Was an ultrasound scan done at any time during the first three months?” If so, “What comments did the doctor make about the findings?” 2. Second trimester: ƒ Where there any particular problems during the second three months of pregnancy? ƒ Any bleeding? Any urinary problems? Any other problem/s? ƒ When did she visit the doctor? Were any blood tests performed and what was she told about the results, anaemia, blood group, etc.? ƒ Was an ultrasound scan done during this period and what were the doctor’s comments about this? Was the placenta in the correct position? Was the foetus growing adequately? ƒ Were any abnormalities noted during examination? Was the blood pressure normal? Any glycosuria or albuminuria noted? 3. Third trimester to date: Where there any particular problems after the sixth month of pregnancy? Any bleeding? Any urinary problems? Any other problem/s? 7
Associated Symptoms – Systemic enquiry Menstrual history Sexual history ƒ “Is there anything else that you have noticed relating to the pain?” – vaginal discharge [colour, consistency, amount, smell] or bleeding [amount, colour]; weight changes; fever, bowel problems [constipation, diarrhoea, etc]; urinary problems [dysuria, frequency, hesitancy, nocturia, colour change, incontinence, feeling of incomplete emptying, etc.]; etc. ƒ Length and regularity of cycles ƒ Severity of menses ‐ length of menses, heavy, flooding, presence of clots, number of tampons/pads used ƒ Pain during menses – timing of pain in relation to menses [beginning, end]; character of pain [dull persistent, coliky] ƒ Last menstrual period [first day] ƒ Presence of spells of no periods in absence of pregnancy; bleeding between periods; after intercourse. ƒ Time of menarche and menopause. If menopausal: assess for associated symptoms [hot flushes, night sweats]; history of postmenopausal bleeding. ƒ Sexually active; number of partners [be discreet!]. ƒ Contraception being used currently and any used previously. ƒ Physical or other difficulties during intercourse – if pain check whether deep/superficial, always/ sometimes. ƒ Pap smear: date & result of last smear. 8
Obstetric history Past medical & surgical history Drug history ƒ Any difficulty in conceiving; “What treatment was used to assist the infertility?” ƒ Possibility of current pregnancy. ƒ Number of previous children ‐ gender, antenatal problems, birth weights, mode of delivery, postpartum complications [bleeding, thrombosis, infection]. ƒ Number of miscarriages, terminations and/or ectopics – what month they occurred, pattern of miscarriage [spontaneous, induced], surgery performed. ƒ “Do you currently suffer from any illnesses – hypertension, diabetes, epilepsy, asthma, bleeding disorders, etc?”; “Have you ever been seriously ill before – cardiovascular episodes, jaundice, STD – PID, etc.?” ƒ “Have you undergone any surgery – appendicitis, gynaecological surgery – abdominal or vaginal [inclusive D&C]?”; “Did you have any problems with anaesthesia?”; “Did you require blood transfusion?” ƒ “Have you ever seen a gynaecologist before – for what reason?” ƒ “Have you received all the childhood vaccinations – rubella, HPV, TB?” ƒ “Are you on any medications at present – list?” ƒ “Are you allergic to any medications‐ what happened when you took the medication?” [ensure allergy since patients often associate development of vaginal thrush as an adverse reaction to antibiotic use]. 9
Family history Social history ƒ “Are your parents still alive?” “Do they suffer from any illness?” – if dead – “What was the cause of death?” ƒ “Do you have any brothers or sisters?” – if yes – “What is their state of health?” ƒ “Is there any family related disease in your family that you are aware of?” – diabetes, hypertension, malignancy, twins ƒ “What is the state of health of your spouse? Your children?” ƒ Race & migration if relevant ƒ Present and past occupations ƒ Diet, physical activity ƒ Smoking, alcohol, entertainment drugs ƒ “Who lives with you at home?” – support of other household members; “Any pets?” ƒ “Have you travelled overseas recently? – Where?” At this point one should be in a position to identify the PRESENTING COMPLAINT and to formulate a working provisional diagnosis. 10
CLINICAL EXAMINATION The scope of the clinical examination is to gather further clues to supplement the information gathered from the clinical history to help identify the clinical problem and narrow down the differential diagnosis. With this aim in mind, the examination should be a comprehensive but targeted one. Always obtain the patient consent to allow you to perform the examination and explain at all times to the patient what you plan to do. ¾ REMEMBER TO ALWAYS PUT THE PATIENT AT EASE AND ENSURE COMFORT. ¾ BE SENSITIVE TO THE PATIENT’S FEELINGS AND DECENCY. Obtaining consent to ƒ “Do you mind if I examine you? You can ask me to stop at any time you feel examine patient uncomfortable?” 11
Systemic Examination A systemic examination is always useful since it can identify conditions that may predispose or aggravate the presenting complaint. General appearance ƒ Weight: anorexic, cachectic, or obese. ƒ Hydration level, Hyperventilation, Hiccupping, Twitching, spasms Hands & Arms ƒ Examine nails: koilonychias, leuconychia [white transverse bands], Muehrcke's nails [white paired lines near fingernail tip]; finger clubbing; nicotine stains ƒ Check palms for palmar crease, anaemia or erythemia ƒ Wrists: check pulse re rate, regularity, and character. ƒ Check for scratch marks, injection marks, spider naevi, bruising. ƒ Check blood pressure Face, neck, chest ƒ Check eyes: jaundice, anaemia, consider fundoscopy when indicated. ƒ Mouth: fetor. ulcers, infections, hypertrophic gums/gingivitis. ƒ Face: cloasma, rash. ƒ Check heart sounds: rate, rhythm, extra sounds/murmurs ƒ Check lungs: wheezing, bronchial sounds, crepitations [basal], etc. Legs ƒ Check for oedema [pitting – till what level: ankle/shin]; ƒ Presence of varicosities +/‐ thrombosis [superficial/deep – unilateral swelling, tenderness] ƒ Check peripheral vasculature: pulses ƒ Check toes & foot: signs of discolouration, gangrene, tophi. 12
Abdominal Examination An abdominal examination is an essential part of the gynaecological examination and should preferably precede the genital examination. The adage of INSPECTION – PALPATION – PERCUSSION – AUSCULTATION should always be adhered to. During the examination, ensure that the abdomen is sufficiently exposed to allow a clear overall view from the symphysis pubis to the costal margin. As part of the abdominal examination, remember to always include the supraclavicular region [check for Virchov lymph nodes]; and the inguinal region [check for lymph nodes/hernia]. o REMEMBER TO AGAIN OBTAIN CONSENT TO EXAMINE THE PATIENT’S ABDOMEN. o REMEMBER TO INFORM AND EXPLAIN TO THE PATIENT WHAT YOU INTEND TO DO AT ALL TIMES. o WARN PATIENT TO INFORM YOU IF THE EXAMINATION BECOMES UNCOMFORTABLE AT ANY TIME. o ALWAYS LOOK AT THE PATIENT’S FACE DURING THE EXAMINATION TO IDENTIFY ANY SIGNS OF PAIN OR DISCOMFORT ELICITED DURING THE EXAMINATION. o MAKE SURE THAT THE PATIENT HAS RECENTLY EMPTIED HER BLADDER. 13
Inspection Palpation – ensure warm clean hands; ensure relaxation of abdominal muscles. ƒ
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Assess the general appearance of the abdomen – distended [fat, foetus, faeces, flatus, fluid, full‐sized tumours], umbilicus [flattened, possible presence of hernae, Sister Joseph nodule, Cullen’s discolouration], superficial vein prominence, telangectasia/caput medusae, discolouration, pigmentation, scars [one may need to roll the patient to the side], striae, presence of stoma, any obviously visible masses/peristalsis/movements/pulsations. Start with light palpation first and go systematically through all the six divisions of the abdomen – RIF, right Hypochondrium, epigastrium, left hypochondrium, LIF, hypogastrium. [Start from non‐tender location first] o Look for any masses, tenderness with/out guarding Proceed with deeper palpation, warning the patient that this may be uncomfortable – in which case is to tell you and you will stop the examination. Keep a visual lookout for and facial grimace that reflect discomfort. Go through the six divisions of the abdomen. o Look for any masses, tenderness with/out guarding o If any tenderness – check for the presence of rebound tenderness warning the patient first. Also, assess for any referred pain during palpation. o If a mass is palpable, assess size [measure diameter in centimetre or gestational age equivalence], form [regular/irregular], consistency [hard, soft, cystic], mobility, tenderness, relationship to abdominal wall [superficial, intra‐
abdominal], etc. 14
Percussion ƒ
Proceed to examine specifically for an enlarged or tender liver [check Murphy’s sign], spleen and kidneys. Remember to also check the back for tenderness over base of spine or over loin [“kidney punch”], sacral oedema. ƒ
Percuss for the top border of liver down Right midclavicular line [normally at 5th rib] and continue down to abdominal edge calculating span [generally 12.5 cm]. Percussion of liver border for loss of dullness in presence of air in abdomen. Percuss spleen to assess size when splenomegaly suspect. Percuss for kidney size estimation when enlarged; to assess an enlarged bladder or extent of abdominal mass. Check for the presence of ascites o Shifting dullness – the doctor’s percussing finger is placed vertically so that finger tip is pointing towards the patient’s legs; start percussing at midline and continue left laterally until dullness noted. Level marked and patient rolled over to right for a few minutes, then repercuss. Ascites present if the dullness moves medially and previous point of dullness is now resonant. o Fluid thrill – doctor places hands on each of the patient’s flanks, while the patient is asked to place her left lateral edge of the hand vertically on the midline at the umbilicus; doctor flicks hand on right flank, a corresponding thrill is felt by the contralateral hand. ƒ
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Auscultation ƒ
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Below umbilicus to assess bowel sounds for: o Rushing sound called "borborygmi"; o No sound for 3 minutes; o "Tinkling" sound. Above umbilicus for: AAA bruit; Venus hum. Right and Left above umbilicus for renal artery stenosis. Over liver for: Friction rub [grating during breathing]; Bruit. Over spleen for splenic rub. 16
Obstetric Examination The obstetric examination can be considered a specialised addition to the examination of the abdomen, its scope being to assess the pregnancy characteristics. Examination of the abdomen is accomplished with the patient supine. Late in pregnancy, care must be taken to have the patient lie slightly to one blood flow, leading to syncope. side, lest the pregnant uterus impede vena cava Inspection ƒ Assess the general appearance of the abdomen o Distended consistent with pregnancy; flattening or eversion of umbilicus; presence of striae gravidarum; presence of linea nigra; presence of scars [note gynaecological/obstetric surgery scars, laparoscopy, etc]. o Observe regularity of uterine shape [may be partially rotated to one side or the other]; look for presence of foetal movements. Palpation – ensure ƒ Assess fundal height starting from the xiphisterum and working one’s way warm clean hands; downwards until fundus is palpated. Measure symphysis‐fundal height in ensure relaxation of cm – equivalent to gestational age in weeks. abdominal muscles. ƒ By lateral palpation using both hand on either side of the abdomen, assess the lie of the foetus [longitudinal/transverse/oblique], the locality of the back [right/left] and the presentation [cephalic/breech]. ƒ If longitudinal, assess the degree of the descent of the presenting part through the pelvic brim – assessed in the number of fingers one can place over foetal head suprapubically [in fifths – 2/5th is considered engaged; 3/5th unengaged]. Auscultation ƒ Listen over the foetal heart where the scapula is located. Assess heart rate to maternal pulse 17
Assessing engagement of head 18
Gynaecological Examination The pelvic examination is an integral component of any gynaecological consultation and fundamental to planning any gynaecological intervention. In all settings, the patient’s consent must always be obtained before a pelvic examination is undertaken. ¾ BLADDER MUST BE EMPTIED PRIOR TO EXAMINATION ¾ PERFORMED IN LITHOTOMY POSITION [on back, legs apart, knees bent], OR LEFT LATERAL POSITION ¾ INFORM THE PATIENT OF WHAT YOU PLAN TO DO AND INFORM HER OF YOUR OBSERVATIONS. Inspection ƒ Examine the external genitalia noting and rashes, swellings, ulcerations, lesions. Separate labia with forefinger and thumb and examine clitoris. Look for any discharge and note characteristics [purulent/clear/blood stained] ƒ Tell patient to bear down and cough – look for any vaginal wall or introital bulges [prolapsed vaginal walls or uterine descent] or passage of urine [stress incontinence – ideally here bladder would be full] 19
Speculum inspection. ƒ
Insert Cusco’s [bivalve] speculum – lubricate, insert in upwards direction with blades closed using one hand while labia are separated with other hand; open blades gently to visualise cervix and vaginal walls. Close blades slowing during withdrawal. o Look for any cervical lesions [ectopy, polyps, cysts, tears, etc], vaginal discharge [purulent/clear/blood stained]; cervical inflammation; etc. o Perform a Cervical smear using spatula and/or brush rotaing both through 360o and smearing samples lightly on a smear. o May perform high vaginal swab, cervical swabs, wet slides for infection. 20
Bimanual palpation. ƒ
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Palpate Bartholin's glands [posterior of labia major]. Lubricate index and middle finger if necessary. While the left index finger and thumb separate labia, the right index and middle finger are Insert into vagina. The cervix is located [assess: size, shape, position, tenderness, mobility]. Then perform a bimanual examination: keeping the “vaginal” finders pushing upwards and backwards, push the left hand down back onto the symphysis pubis. o Palpate the uterus [assess position – anteverted or retroverted; size; consistency; mobility; tenderness, cervical excitation. o Palpate the fornices while using the left hand to push down from the iliac fossae to the suprapubic region [assess ovarian size; adnexial masses, tenderness]. 21
In the obstetric patient, a pelvic examination can help assess progress of labour by assess certain specific criteria related to the state of the cervix. All these parameters are included in Bishop Score to give an overall numerical score of the state of the cervix. Score 0 1 2 3 Dilatation 0 1‐2 3‐4 >5 Effacement <40% 40‐60% 60‐80% >80% Consistency Firm Moderate Soft Position Posterior Middle Anterior Station ‐3 ‐3 ‐1,0 +1,+2 Bishop Score Criteria Effacement Descent of head [station] in pelvis 22
EXAMPLE – PRESENTATION OF AN ANTENATAL HISTORY & EXAMINATION See http://www.clinicalexam.com/pda/o_obs_antenatal_history_exam.htm Presentation of the History Introduction This is <Mrs.XXXX>, a <?? year old> <occupation>, from <locality> who is <?? weeks pregnant> with her <No.??> baby. The reason she is in hospital is <a routine check‐up || breech presentation || preeclampsia || diabetes || PROM || APH || etc...>. Current Pregnancy Focusing our attention on this pregnancy, the first day of <Mrs. XXXX's> last menstrual period was the <date ??>. She is <certain || uncertain> of the date, because she <wrote it in her diary || remembers the day of conception>. She has a <regular/irregular> cycle with menses occurring every <?? day>. <She had stopped the combined oral contraceptive pill><? months before becoming pregnant>. [If contraception like OCP failed, you may wish to ask her why it did not work]. By Nageles's rule, her estimated date of delivery should be the <date ??>. The current pregnancy was <planned || unexpected> and <Mrs. XXXX> <was || was not> taking periconceptual folic acid. She had a positive pregnancy test at <…?> weeks. She visited her doctor at <? weeks> when <all parameters were normal // she was found to have ????>. During the first trimester of pregnancy, she <was well // had only minor symptomatology of nausea with occasional vomiting // required admission for severe vomiting and/or vaginal bleeding [in which case amplify]>. She booked into hospital at 23
<? weeks> and a subsequent ultrasound scan <confirmed // corrected> her menstrual dates. All other ultrasound parameters were reported <normal // abnormal [in which case amplify]>. She felt quickening at <?. weeks>. During her booking visit, <all her clinical parameters were normal // she was found to have ??? [in which case amplify]>. Routine screening investigations have shown her to be <Rhesus positive || Rhesus negative> and she is <rubella immune || not rubella immune || uncertain of her rubella status>. She <breastfed || bottlefed> her previous children and intends <breastfeeding || bottlefeeding> this baby. She opted for antenatal care with <her general practitioner || private specialist // the hospital>.Her antenatal course was subsequently <normal until she was admitted to hospital on this occasion || normal except for a ... at ... weeks gestation>. <Mrs. XXXX> was admitted to hospital <>>>? days> ago. She complained of <……...>. Since coming into hospital, the investigations she have had are <……....> which showed <……....>. <Mrs.XXXX> tells me that she is being kept in the hospital <for observation>. Obstetrical history Turning our attention to <Mrs. XXXX's> previous obstetrical history, she has <…? girls or otherwise>, aged <..? and ..? years>. They are <both well // one suffers from ……..l>. [If an abnormal pregnancy, give full details, e.g.: In her first pregnancy, she <was induced> at <39 weeks>, and after <2 hours || 6 hours [depending on if making start of labour as when enter labour ward]>, <under went a Caesarean section> because of <foetal distress>. The Caesarean section was performed <under epidural>. The baby weighed <2.5kg> at birth and <was not admitted || was admitted for ... days> to the neonatal unit. She had <no post‐operative complications || post‐operative complications of ...>.][If a normal pregnancy, brief outline, e.g.: In her second pregnancy, she <went into spontaneous labour> at 24
<40> weeks and had <a normal vaginal delivery>. The baby weighed <3.0kg>.] [If a miscarriage, also be brief, e.g.: <Mrs. XXXX> also had a <…?> miscarriage <…?> months ago at <…? weeks> and <underwent //did not undergo an ERPC>.] Past gynaecological history With regards to <Mrs.XXXX's> past gynaecological history. Her last smear test was in <…….?>, it was <normal // abnormal>, and all of her previous smear tests have <been normal // occasional showed abnormality>. <She has not undergone and gynaecological surgical procedures // She require a …….. in ……..? for …..?>. Past medical & surgical history <Mrs. XXXX has not relevant past medical or surgical history // On briefly reviewing Mrs. XXXX's past medical and surgical history, she gave a history of ......> Family history Her family history <has no illness of note // has a history of …... in the ………>. In particular, there is <no family history> of diabetes, and <no> twins in the family. Social history With regard to social history, <Mrs. XXXX> works as a <???>. <She also works at home looking after her children>. She is due to go on a <…?3 month> maternity leave starting in <…?> weeks time. She is residing in <a 2 bedroom apartment>. Her husband works as a <????>. Her children are being looked after by <the children's grandmother>. <Mrs. XXXX> <does not smoke || smokes ... cigarettes a day> Prior to the pregnancy, she <did not smoke || smoked ... cigarettes a day>. She has <not taken any 25
alcohol || has restricted herself to ... units of alcohol per week> since finding out she was pregnant. She <is> taking iron and folic acid supplements. Summary of history In summary, therefore, this is <Mrs.XXXX>, a <?? year old> <?occupation>, from <locality>, who is <…? weeks pregnant> with her <No. ?> baby. The reason she is in hospital is <a routine check‐up || breech presentation || preeclampsia || diabetes || PROM || APH || ...>. <Mrs.XXXX> is being kept in the hospital <for observation>. Presentation of the Examination General <Mrs. XXXX> looks <clinically well // unwell>. Her temperature is <….? Celsius>. Her pulse is <80 bpm, regular rhythm, and normal character and volume>. Her blood pressure is <???/??>. Her respiratory rate is <..?>. Her urine sample is <normal || shows elevated <protein || glucose || ...>. [If she is in hospital for a disease, describe the relevant findings. For example, if preeclampsia: She has <pedal oedema || no evidence of pedal oedema> and her lower deep tendon reflexes <are || are not> elevated.] Abdominal On inspection of the abdomen, there is an <ovoid || globular> swelling, consistent with <the pregnant state || a ... trimester pregnancy>. There <are || are no> cutaneous signs of pregnancy, such as striae gravidarum and linea nigra. There <are no visible scars || are visible scars consistent with a prior...>. There <are || are no> visible foetal movements. 26
On palpation, I measured the symphysio‐fundal height on the inches side to reduce observer error, and found it to be <…? centimetres>, which <is || is not> compatible with gestation. The foetal parts that I feel in the fundus appear to be the <breech> as they are <soft, irregular, and non‐ballotable>. The lie is <longitudinal || transverse || oblique> and the back would appear to be on the <right || left> as it offers more resistance to palpation and I feel small parts on the opposite side. The presentation appears to be <cephalic || breech || shoulder>. The head <is || is not> engaged. The foetus appears clinically <normal || small || large> in size. The liquor volume appears clinically <normal || reduced || increased>. The foetal heart is best heard over the <back> and <below the level> of the umbilicus, and is <normal>. Summary of Examination This is a <singleton || multiple> pregnancy, <longitudinal || transverse || oblique> lie, <cephalic || breech> presentation, the head <is || is not engaged>, the foetus is clinically <normal || large || small> in size, the liquor volume is clinically <normal || reduced || increased>, and the foetal heart is <normal>. 27
EXAMPLE –ANTENATAL CASE WRITE‐UP Case Summary Ms. X is a 28‐year old secondagravida Rhesus negative woman who presented to the emergency department with painless moderate vaginal bleeding at 34 weeks of gestation. History of Present Pregnancy Mrs. X had her last menstrual period on the 14th January 2008, computing her expected date of delivery to the 21st October 2008; her cycles having been previously normal and regular every 28‐30 days. She did not give a history of any menstrual problems. Mrs. X had no problems during the first trimester other than slight nausea and occasional vomiting. This she accepted as normal, since it did not particularly distress her. The pregnancy was planned and she had started folic acid two months previous to conception. She continued to take folic acid throughout the first trimester. She did not give any history of vaginal bleeding during the first three months of pregnancy. She attended her family doctor at eight weeks of pregnancy, when a clinical examination was reported as normal. She attended the antenatal clinic and booked her confinement at Mater Dei Hospital during the second trimester at 14 weeks of gestation. All routine investigations taken [complete blood count; TORCH‐
Syphilis‐Hepatitis C‐HIV screen; blood glucose] at that visit were normal. Her blood group was A Rhesus negative; antibody titre for anti‐D was negative. A general clinical examination was normal. Uterine size corresponded to dates; foetal heart was audible using a doptone stethoscope. She had her first ultrasound scan at 18 weeks of gestation. She was told that while the foetus was normal, the placenta was low‐lying and that she will need a further scan in the third trimester to correctly assess the 28
significance of this. She had no problems during the second trimester and gave no history of any episodes of vaginal bleeding. She was started on haematinics at 14 weeks of gestation. Mrs. X had no problems during the early part of the third trimester until 32 weeks of pregnancy. All routine antenatal visits were reportedly normal with adequate foetal growth and blood pressure. She was given a prophylactic anti‐D injection [500 IU] at 28 weeks of pregnancy. Ultrasound scan done at 32 weeks of gestation confirmed the persistence of a low placentation; foetal growth and well being was normal; foetal presentation was transverse. In retrospect she mentioned that at about 31 weeks, she had an episode of mild vaginal spotting the morning after having had sexual intercourse. The bleeding was slight lasting only one morning and she did not particularly alarm herself. She was advised to refrain from having sexual intercourse. History of presenting complaint She presented at 34 weeks of gestation with painless vaginal bleeding of sudden onset. The present episode of bleeding was sudden in onset and severe enough for the blood to trickle down her thighs. There were no associated features such as pain or any discomfort. On admission, the bleeding had settled to only a slight vaginal loss. The foetus was easily palpable; presentation was cephalic oblique with the back to the left. Foetal heart was audible and of normal rate. Symphyseal‐fundal height was about 34 cm corresponding to the gestational age. There was no tenderness over the uterus. There were no signs of maternal cardiovascular shock; the patient’s pulse was 80 beats per minute, blood pressure 110/70 mmHg. An ultrasound scan confirmed the clinical findings; the placenta was praevia, apparently marginal and posterior (Type 2 placenta praevia). Foetal growth corresponded to gestation. 29
An intravenous infusion was set up, while blood was taken for haemoglobin estimation and cross‐match. An anti‐D injection was administered. Regular monitoring of vaginal blood loss, pulse and blood pressure were carried out; while foetal heart rate monitoring was also carried out intermittently. The mother also received two doses of dexamethasone [12 mg every 12 hours] to assist foetal lung maturity. The patient was reviewed after 24 hours. The vaginal bleeding had stopped completely, there being only a slight browning staining on the vaginal pad. All parameters had remained normal. The intravenous infusion was stopped. She was transferred to the Antenatal Ward and told that she needed to remain in hospital throughout the remaining antenatal period. She had a repeat episode of slight bleeding at 35 weeks of gestation, which was managed conservatively. Foetal monitoring with cardiotocography and ultrasound showed no abnormality. An anti‐D immunoglobulin dose [500 IU] was repeated. Past Obstetric History The patient had had a previous pregnancy four years earlier. The antenatal period had run a normal course. Onset of labour was induced since the patients’ pregnancy had run to over a week past her estimated dates. Labour had progressed effectively, but foetal distress was diagnosed at about 5 cm cervical dilatation. An Emergency Caesarean section was thus performed. A live born male infant, weighing 3400 gm was delivered. She gave no history of miscarriages. Past Medical & Surgical History The patient gave no history of any significant medical events. She had had an appendectomy performed at the age of 15 years. 30
Past Gynaecological History The patient had no relevant gynaecological events. Her menarche occurred around the age of 10 years; her cycles stabilising within about a year. She had had regular smear tests after she became sexually active; these having been always normal. Her last smear test was performed about six months before embarking on this current pregnancy. During the inter‐pregnancy period she used the oral contraceptive pill [Yasmine] for contraception. Drug History The patient was on no long‐term medication, except for the haematinics received during her pregnancy. She did not report any drug allergies. She did not smoke cigarettes and did not abuse alcohol at any time during her pregnancy. Social History The patient was in a stable relationship. She married at the age of 20 years; and lived with her husband and child. She worked as a clerk in an industrial manufacturing setting. She intended to apply for parental leave to care for her children. Examination at 36 weeks of pregnancy The patient was examined at 36 weeks of pregnancy. At this point in time, she was an inpatient in the hospital. There were no acute symptoms. On examination the patient was in good general health. She did not appear anaemic and was not distressed in any way. Cardiovascular system was normal; her blood pressure and pulse being 110/60 mmHg and 70 beats/min respectively. There was no lower limb oedema. Abdominal examination conformed to a 36 weeks of pregnancy. On visual examination there was a distended abdomen with a 31
faint linea nigra and some striae gravidarum. On palpation, the symphysis‐fundal height measured 37 cm; the foetal lie appeared to be oblique with a cephalic presentation and the back to the left side. The foetal heart was audible on the left lower quadrant. Follow up of this pregnancy At 37 weeks of pregnancy, the patient suffered a sudden onset of severe vaginal bleeding while having a shower. She was transferred to the Central Delivery Suite. Assessment at this stage, showed a persisting unstable lie of the foetus. In view of the severity of bleeding and the maturity of the infant, a decision was made to undertake delivery by urgent Caesarean section. This was carried out under spinal anaesthesia. At surgery, the placenta was confirmed to be a posterior Type 2 placenta praevia. A female infant, weighing 3540 gm, was born with an Apgar score of 8 at 1 minute. The infant required no resuscitation. The Caesarean section proceeded without any complications. The patient was treated with a syntocinon infusion (40 units in 500 mls infusion) during the first 24‐
hours post‐operatively. She also received intra‐operative prophylactic antibiotics ‐ three eight‐hourly doses of intravenous Augmentin (amoxycillin 250 mg and clavulanic acid 125 mg) on induction has been compared with three 8 hourly doses in 900 patients. The foetus blood group was reported as Group O Rhesus negative; Coombs test was negative. No anti‐D prophylaxis was thus administered to the mother. She was discharged with her child four days after surgery with a post‐operative haemoglobin level of 10.5 g/dl; she was advised to continue her haematinics for a further six weeks. Case Discussion This case involved a pregnancy in a secondagravida woman complicated by Type 2 Placenta praevia. The situation was further complicated by a Rhesus negative blood group. 32
The patient was noted to have a possible abnormal placentation at her first ultrasound scan at 18 weeks of gestation when the placenta was noted to be low‐lying. While this observation is suggestive of an eventual placenta praevia at term, not all cases of low‐lying placentae discovered in the second trimester remain so in the third trimester when the lower segment actually develops. The patient, by virtue of her previous caesarean section, was at high risk of abnormal placentation. The clinical course was typical of the condition with warning bleeding occurring at 32 weeks of gestation [after sexual intercourse], followed by more severe bleeding at 34 weeks and subsequently. The initial management followed in this case included an expectant regimen awaiting foetal maturity. In anticipation of the possible need for a premature birth, foetal lung maturity was augmented by the administration of dexamethasone. Blood was cross‐matched and kept in reserve to enable timely transfusion should the need arise. At 37 weeks of gestation, the bleeding increased significantly, and in view of the degree of foetal maturity, a decision to terminate the pregnancy was taken. Because of the persisting unstable lie, a Caesarean section was decided upon. The case was further complicated by a maternal Rhesus negative blood group. To obviate the possibility of subsequent immunization, a prophylactic dose of anti‐D immunoglobulin was administered at 28 weeks is line with current guidelines. In anticipation of possible feto‐maternal transfusion, a further dose was given whenever the patient experienced episodes of bleeding. These prophylactic measures proved needless since the foetus was eventually found to have been Rhesus negative. 33