Identification

Name (use initials when reporting for wider

audience)

Age
Occupation, Marital Status*
Religion
Address

*Information on marital status and occupation help assess

the socioeconomic status of the pregnant woman. Low
socioeconomic status is associated with several poor
pregnanacy outcomes Eg preterm labor, PROM, low birth
weight, anemia, Pre-eclampasia, Eclampsia

** adolescents (< 18 ) and the elderly gravida (> 35)

are at particular risk for adverse pregnancy outcome

Chief Complaint

Most pregnant women come for

routine ANC
May have minor routine complaints eg
abdominal discomfort, morning sickness,
back pain, leg pain, urinary frequency and
urgency,
Some complaints may mark a serious
problem and warrant
Eg- vaginal bleeding, fetal movement, headache,
visual disturbance ,leakage of liquor, abdominal pain,

History of Present Pregnancy (HPP)

HPP is the most important part of obstetric history

and is composed of
1.Summary of reproductive performance

Gravidity-refers to all previous pregnancies i.e.

term, preterm, live birth, stillbirth, abortion,
ectopic pregnancy, molar pregnancy
Primigravidity (1st pregnancy) is associated with increased risk of
PIH, labor abnormalities, CPD and obstructed labor

Parity- all previous pregnancies that have

reached fetal viablity and delivered dead or
alive ( i.e. at or beyond 28 weeks of
gestational age for Ethiopia and UK , 28
weeks according to other western countries)

HPP
Parity- all previous pregnancies that
have reached fetal viablity and
delivered dead or alive ( i.e. at or
beyond 28 weeks of gestational age
for Ethiopia and UK , 28 weeks
according to other western countries)
Primipara- 01 previous delivery
Multipara- > 02 previous deliveries
Grand multipara - > 5 previous
deliveries

HPP
2. Last normal menstrual Period (LNMP), Expected
Date of Delivery (EDD) and Gestational age (GA)
LNMP- 1st day of last menses
For LNMP to be reliable,
It should be regular ( cycle length vary among
individuals ranging b/n 21 to 35 days)
It Should be similar to previous cycles in volume
and duration of flow
If the woman was on OCPs it should be
discontinued for at least 03 months ahead of LMP
Lactating women should have 03 regular cycles
before LMP

HPP
EDD calculation ( 280 days after LMP)and GA
Naegels Rule
Subtract 03 months from LNMP and add 07days
Eg If LNMP is February 12 then EDD will be on
November 19

Calculation according to the Ethiopian

calendar ( 12 months of 30days and pagume
5days/ 6 days with each leap year)
LMP+ 9mths + 10days- if EDD doesnt cross a year
LMP+ 9mths + 5 days- if EDD crosses a year and
pagume is 05 days
LMP + 09 mths + 04 days- if EDD crosses a year
and pagume is 6 days

HPP

Gestational age
GA is calculated in completed weeks
Preterm pregnanacy- GA below
37completed wks
Early Term pregnancy: 37 38 6/7 Week
Full Term Pregnancy: 39- 41 6/7
Post-term pregnancy: > 42 weeks

GA calculation is based on the

assumption a 28 day regular cycle
length- ovulation on the 14th day

HPP

In addition to LMP other methods are used to

estimate GA
Early US before 20 weeks
Ultrasonography may be considered to confirm
menstrual dates if there is a GA agreement
within 1 week by CRL obtained in the 1st trimester or
within 10 days by an average of multiple fetal biometric
measurements (eg,CRL, BPD, HC, AC,FL) obtained in the 2 nd
(up to 20 weeks GA) . ACOG-2008

Quackening date
around the 17th week for multipara ( experience from
previous pregnancies)
Around the 19th week for primipara

Fundal height at umbilicus~20 weeks

HPP

ANC
if no ANC or delayed start reason
Details of ANC
Prepregnancy weight /BMI and weight at
booking and on subsequent visits
Blood pressure recordings
Lab investigation results

Blood group, Rh, hemoglobin level

UA for bacteruria, infection and hCG
RVI,
RPR/ VDRL test
HBsAg

HPP

Health education about nutrition,

sanitation, labor, breast feeding and
contraception
Iron supplementation, malaria
prophylaxis, TT immunization,
Any drug use- prescription,
overthecounter or herbal
medications
Significant symptoms of illness early
in pregnancy like excessive nausea
and vomiting, Vaginal bleeding

HPP

Detailed discussion of the presenting

complaint
Always ask about the common danger
signs of pregnancy
Head ache (severe, persistent, not
responsive for analgesia)
Visual disturbance
Epigastric/ RUQ pain
Vaginal bleeding
Leakage of liquor per vagina
Fetal movement status

HPP

Positive and negative statements

directed at possible DDx to the
presenting complaint
NB: Relevant informations should be switched from
other sections ( past ob Hx, Medical and surgical
hx , family hx etc. ) to the HPP.

Nutritional Hx

Detailed enquiry whether the woman

takes adequate amount of
carbohydrates, fat, proteins ,
minerals and vitamins
Look for any food restrictions for
cultural reasons or taboos

Past obstetric History

Detailed chronological documentation of

all previous pregnancies i.e. year,
gestation length, labor duration,
presentation, fetal outcome ( weight,
alive/ dead), mode of delivery
Any antepartum, intrapartum or
postpartum complications
Eg APH, PPH, IUGR, PROM, Malpresentations,
macrosomia, congenital anomalies, molar
pregnancy, GDM, Hypertensive disorder
NB- most of these complications have a significant
recurrence risk

Gynecologic History

Menstrual history
Age at menarchae
Regular, irregular ,intermenstrual
bleeding/ spotting
Amount and duration of flow
Discomfort during menses
(Dysmenorrhoea)
Premenstrual symptoms (cyclic affective
and somatic symptoms in the luteal
phase)

Contraception use history

Past medical and surgical History

Episodes of acute/ chronic illnesses, duration,

treatment outcome , follow up , current status
Such chronic illnesses as DM, HTN, Thyroid
disease ( thyrotoxicosis and hypothyroidism),
cardiac and renal disease that affect pregnancy
outcome need to be integrated with the HPP
Hx of blood transfusion possibility of minor blood group incompatibility and Rh
isoimmunization

STI Hx and treatment

Hx of pelvic surgery
Eg myomectomy, hysterectomy, metroplasty- cause uterine
scarring and may dehisce during pregnancy and labor

Hx of surgery involving other organ systems

Personal and Family History

Place of birth and bringing up

Education, occupation, income
Habit of smoking, alcohol , caffein or illicit drug use
siblings Number of sisters and brothers
Alive
Dead cause of death

Parents
Age
Health status
If deceased- age when dying and cause of death

Family history of chronic illnesses ( eg DM,

Hypertension Epilepsy etc.) or any hereditary disease
Family history of twining

Review of System (Functional

enquiry)
Detailed orderly search for any
symptoms pertaining to each organ
system

Physical Examination
General Appearance
Comfortable, in CRD, acutely/
chronically sick looking,
body habitus ( obese, malnourished),
stature ( extremely short?), skeletal
deformities
Fascial features- chloasma of pregnancy,
puffy face
NB. some of the above descriptions can
be placed at the respective systemic
examinations

PE-Vital Signs
BP
Measured in the left lateral ( usually for
inpatients) or sitting positions
The right arm should be used consistently, in
a roughly horizontal position at heart level.
For DBP both phases ( IV-muffling and Vdisappearance of sound) should be recorded.

PR, RR, T0 are taken the same way as any

medical patientNB- physiologic changes caused by pregnancy
should be taken into account while interprating
results

PE
HEENT
look for chloasma, Conjunctival pallor, icteric sclera
Buccal mucosa- wet or dry ?
Gingival hypertrophy, gingivitis?
Oral thrush?

LGS Breast (engorgement, areolar pigmentation

,montgomery tubercles.), thyroid and all accessible LN
areas are examined

Chest
CVS
PMI displacement lateral to the MCL, S3 and systolic
murmurs < Grade III are usual non pathologic findings
Look for varicose veins in the lower extremities and
vulva

Physical Examination
Abdomen
Exposure
The patient should be supine with a
comfortable pillow, the arms lie by her sides
The abdomen should be exposed from just
below breasts to the symphisis pubis just
below the pubic hairline ( not to miss
pfannenstel scar)
NB- the woman is often asked to expose the
abdomen by herself

PE-Abdomen
Inspection
Grossly distended abdomen?
Protuberence- central or localized tone area
Movemnt of abdomen with respiration
Flank fullness
Uterine dextrorotation ( abomen tilted more to the right)
Black line (linea Nigra) more prominent in the midline b/n
umbilicus and and symphysis pubis.
Striae gravidarum- stretch marks due to disruption of collagen
fibers of dermis ( breasts and thighs can also be involved)
NEW- purplish, few
Old (straie albicantes)- whitish, multiple

Umbilicus-flat, iverted, everted?

Scar- location, size and thickness
distended veins and ascitis portal hypertension
Abdominal wall edema with peau-d-orange appa=earance
part of ana sarca

PE-Abdomen
Superficial palpation
In each quadrant
areas of rigidity, tenderness, abd wall masses
Location of appendix base in advanced
pregnancies at higher level than McBurneys
point ( pushed up by the gravid uterus)
Diffuse tenderness and rigidity / generalized
peritonitis chorioamnionitis abruptio
placentae, ruptured appendicitis, perforated
PUD

PE-Abdomen
Deep Palpation
Detection of hepatomegally and
splenomegally

PE- Abdomen
Obstetric Palpations (Leopolds
maneuvers)
Four sequential maneuvers Performed on
the gravid uterus i.e. the fundal, lateral,
pelvic palpations and the Pawliks grip.
NB before 28 weeks of gestation fundl
height determination is the only palpation
possible as the fetus is too small to
determine lie or presentation
Fetal heart beat can be ascultated from
20th week of gestation

PE- Abdomen
1- Fundal Palpation
Objectives:Determination of Height of
fundus ( Gestational Age) and what
occupies the fundus
Abdominal assymetry need to be
corrected first ( if dextro or levorotation is
there) and the bladder should be empty
before starting examination
A.Fundal Height determination- two
methods ie Tape measurement of
symphysis fundal height (SFH) in cms or
Finger method

PE- Abdomen
I.SFH tape measurement (tape
measurement)
In the midline along the linea nigra
traversing the umbilicus
The fundal height in cm accurately
matches to the gestational age b/n
18- 34 weeks
More reliable method than the finger
method

PE-Abdomen
II. Finger method
Fundus just palpable at Spubis 12 weeks
Midway b/ Spubis and umbilicus 16 weeks
At Umbilicus 20 weeks
Generally 1 finger above umbilicus
represents 2 weeks
At Xyphesternum 38 weeks/term
36 week by finger is comparable to 40
weeks of GA due to decrease in fundal
height after engagement

PE- Abdomen
NB
a fundal height to GA discripancy of upto 02 weeks is
acceptable. A positive or negative discripancy of more
than 02 week mandates further investigation to
identify the possible underlying cause.
The commonest cause of both +ve and ve
discrepancies (large for date and small for date
respectively) is wrong dating
Other possible causes
+ve Discrepancy multiple gestation,
polyhydramnios, macrosomia, GTD, leiomyoma,
ovarian tumor,
-ve discripancy IUGR, oligohydramnios, PROM,
transverse lie, IUFD, missed abortion

PE- Abdomen
B- determining what occupies the
fundus
Palpate and ballot the fundal area with
both hands
Head hard, round, ballotable
structure
Breech soft,bulky, irregular, non
ballotable

PE- Abdomen
2- Lateral Palpation
Objective- determination of fetal lie and identification
of the side of the back
A. Lie orientation of the fetal longtudinal axis with
respect to that of the mother ie longtudinal,
Transverse or Oblique
Lateral palpation is performed alternatively on both
sides using one hand to stabilize the uterus.
The back feels like hard, stright/ flat structure while
the extremities on the opposite side feel like
multiple nodular parts
Fetal heart beat can be easily auscultatted on the side
of the back

PE- Abdomen
3- pelvic palpation
Objectives- identification of fetal presentation and attitude ( if
cephalic) Cephalic prominence
The examiner faces the patient's feet and places a hand on either
side of the uterus, just above the pelvic inlet. When pressure is
exerted in the direction of the inlet, one hand can descend
farther than the other. The part of the fetus that prevents the
deep descent of one hand is called the cephalic prominence.
Presentation can be Cephalic , breech or shoulder
Attitude flexed-the cephalic prominence is on the same side as the small
parts.
Extended,-the cephalic prominence is on the same side as the
back.
military
Desscent- from 5/5 ( floating) to 0/5
Engagement- minimum of 2/5 descent

PE- Abdomen
4- Pawliks Grip
Objective- identification what fetal,part lies in the
lower segment ( presentation) and its mobility
A single examining hand is placed just above the
symphysis.
The fetal part that overrides the symphysis is
grasped between the thumb and third finger. If the
head is unengaged, it is readily recognized as a
round, hard object that frequently can be displaced
upward. After engagement, the back of the head or
a shoulder is felt as a relatively fixed, knoblike part.
In breech presentations, the irregular, nodular
breech is felt in direct continuity with the fetal back