Comprehensive revision notes covering all areas of obstetrics required for medical school final exams and postgraduate exams such as the MSRA. 100+ pages of concise, user-friendly and structured notes with a lot of images to aid your learning and help you efficiently revise. Also features a section...
Obstetric History Summary:
• Presenting complaint
• History of presenting complaint
• History of current pregnancy
• Past medical history
• Past obstetric history
• Past medical history
• Past surgical history
• Drug history
• Allergies
• Family history
• Social history
• Summary sentence
Presenting complaint: start off with an open questions: “Tell me why you’re here today”? “Tell me why your GP has sent
you to the hospital”.
Common PC:
• Abdominal pain
• Itching
• Reduced fetal movements
• Bleeding
• Routine antenatal appointment
• BP check
• Shortness of breath
• Chest pain
History of presenting complaint:
• Expand on presenting complaint, try not to interrupt
• Move towards closed questions after initial account
• Is this pregnancy specific or not?
Expansion:
• Abdominal pain
o Usual pain questions
o Distinguish between contractions, tightening’s, Braxton Hicks and non-pregnancy specific causes of pain
• Itching
o Distribution
o Medical history
o Associated features
o E.g. palms and soles of feet in cholestasis
• Bleeding
o Think of the cause
o Associated pain
o Heaviness, colour, exacerbating factors
History of current pregnancy:
Divide into trimesters:
T1: Up to 12 weeks
• LMP- 1st day
• Cycle- regular/irregular
• Estimated due date
• Planned/unplanned?
• Contraception (if just came off the OCP may make cycles vary)
• How/when found out about pregnancy
• When went to GP and booked care
• Booking appointment with midwife
• Dating scan
• Booking bloods
,• Screening result (combined test/nuchal translucency)
• Any early pregnancy ultrasounds/GER/admissions?
• Hyperemesis gravidarum?
• Booked under midwifery-led care or consultant-led care?
T2: Up to 12-28/40
• Anomaly scan: anatomy, placental site
• Any admissions/illnesses?
• Any extra scans?
• Fetal movements (quickening = around 18/40)
T3: 28-42/40
• 28/40 bloods – anaemia, GTT
• Any admissions/illnesses?
• Any extra scans?
• Fetal movements?
Past obstetric history:
• Gravidity: the number of times a woman has been pregnancy regardless of outcome
• Parity: any live or still births after 24 weeks
• E.g. 19 weeks pregnant, 2 miscarriages (6/40, 23/40), 1 previous emergency C-section = G4P1
• E.g. 32/40, 1 TOP for Down’s syndrome at 13/40 = G2P0
In chronological order
• Date/year
• Antenatal course – any complications e.g. preeclampsia/placenta praevia etc
• Place of birth – which hospital/country/home
• Gestation at delivery
• Onset of labour – spontaneous or induced
• Analgesia – water/entonox/epidural
• Mode of delivery – spontaneous/ventouse or forceps/emergency or elective caesarean. Why?
• Baby – weight, gender, name, current health
• Postnatal – any complications – PPH (post-partum haemorrhage)? Retained products of conception?
**Always ask next questions sensitively in appropriate setting. Be aware of patient cues**
• Past termination: how many weeks? Method (medical or surgical)? Complications?
• Past miscarriages: how many weeks? How diagnosed? Method (conservative, medical or surgical)? Complications? If
>3, any investigations/causal factors?
Past gynaecological history:
• Cycle
o Relevance for dating
o Hx PCOS
o Fibroids
• Last smear test
o Any abnormal smears, when is next smear due?
o Any cervical treatment – large loop excision of transformation zone (LLETZ)
• Previous contraception, plans for contraception
• Previous gynaecological investigations/surgery?
o Infertility
o PID (STIs), ectopic pregnancies
Past medical history:
• Conditions that can have an effect on baby
o Diabetes (endo)
o Thyroid disease
• Conditions that can have an effect on mum – can worsen when pregnant
o Chronic hypertension (cardio)
o VTE
o Epilepsy (neuro)
o Asthma (resp)
o Sickle cell disease
, o IBD (gastro)
• Hospital admissions
• Multidisciplinary team
Past surgical history:
• Previous abdominal operations – adhesions
• Previous uterine surgery e.g. myomectomy – implications on mode of delivery
• Appendicectomy
• LLETZ
• History of general or local anaesthetics
Drug history:
• Pregnancy medication
o Folic acid 400mcg or 5mg (if obese, or anti-epileptic drug use give 5mg)
o Vitamin D 10mcg
o Pregnacare
• Antiemetics, antacids
• Teratogenic drugs
o ACE inhibitors/retinoids/sodium valproate/methotrexate
• OTC/herbal remedies
• Allergies – nature of allergy
Family history:
• Medical Conditions
o Diabetes, hypertension, VTE
• Inherited conditions
o Cystic fibrosis
• Preeclampsia
o Mother or sister à 4-8 fold increase risk in this pregnancy
• Recurrent miscarriages
Social history:
• Living situation
o “Who is at home with you”? “Who lives with you”?
o What type of accommodation? How many people are there? Stairs?
• Support
o “Who will help you at home after the birth”?
• Occupation
o Maternity leave/changing duties
• Relationship
o Father of baby – job/involved/single
• Smoking:
o Nicotine – how many for how long? Help to stop/cut down
o Cannabis/crack
• Alcohol
o Be specific
o Quantities/how frequent/type of alcohol
• Recreational drug use
o IV drug use
o Cocaine – increased risk of placental abruption
o How is habit funded?
Summary Sentence: don’t just repeat the history/say it all a bit quicker – pull out the salient points. For example:
“In summary, this is a 28 year old nulliparous lady who has presented with a 1 week history of headaches and visual
disturbances at 32 weeks gestation”. “I would like to firstly exclude pre-eclampsia and after examining the patient my
initial investigations would be blood pressure and urinalysis for proteinuria and then blood tests…”
, The basics
Normal pregnancy:
• Women typically do a pregnancy test at home, then go to their GP. The GP will then advise them to make a booking
appointment.
• From the booking appointment onwards, the woman’s urine will be checked at every appointment for pre-eclampsia (protein)
and diabetes (glucose), her blood pressure will be taken and her abdomen examined.
• ~9 weeks = antenatal booking appointment
• 8-12 weeks = viability scan:
o Presence of foetal heart (is it a viable pregnancy?)
§ Foetal heart activity can be seen from around 7 weeks gestation
§ Once a foetal heartbeat is seen, there is a 90% chance of the pregnancy continuing, so the patient can be
reassured
o Is the foetus in the right position?
o Is it a multiple pregnancy?
o Measure crown-rump length to determine the estimated date of delivery (the earlier you are in pregnancy, the less
variation there is in foetal size, therefore by measuring the crown-rump length at this early stage you get a very
accurate idea of the gestational age and therefore of the EDD).
o Can also look at the nuchal thickness at this stage to assess the risk of the foetus having Down’s syndrome
§ Combined test is valid between 11-14 weeks
• 16 weeks = midwife appointment to go over all the information from the booking appointment. This is usually when the
mother first gets to hear the baby’s heartbeat – use either pinard stethoscope or foetal Doppler.
• Up to 18 weeks gestation, any issues the woman has with the pregnancy would fall under gynaecology, but after 18 weeks it
starts switching over to obstetrics.
• 20 weeks = anomaly scan:
o The foetus is now big enough to pick up all the different details e.g. eyes, ears, heart, brain, liver, kidneys, fingers,
femur length, feet.
o If there are known cardiac problems in the family, this scan tends to be done slightly later (around 24 weeks) so that
these can be picked up.
• 28 weeks = antenatal care starts (as the real problems of pregnancy only start presenting from 28 weeks onwards). Women
are seen in the antenatal clinic every 4 weeks from 28 weeks until the last couple of weeks of pregnancy, where they are seen
weekly. Most women therefore have 6-7 antenatal appointments.
• Routine antenatal clinic appointment:
o Mental state (ask how she is feeling)
o Blood pressure (normal = <140/90)
o Urine dip (test for protein and glucose. Some will also look for leukocytes and nitrites)
o Symphysiofundal height (normal = number of weeks pregnant +/- 2)
o Lie and position of foetus
o How much of foetal head is palpable
o Foetal heartbeat
• 28 weeks = routine bloods taken:
o FBC – for anaemia and gestational thrombocytopenia
o Group and save – looking for abnormal antibodies, because the baby and placenta are foreign bodies (as they are
50% paternal) so we want to make sure that the body is not rejecting them by developing antibodies against them.
o Random blood glucose – if it is above 7.8, then do a full glucose screen – patients are starved, then have a sample
taken for a baseline (if high, would suspect underlying T2DM). Then give them a glucose load and see what their
body’s response to it is.
• Term = from 37 completed weeks of pregnancy to 41 completed weeks of pregnancy.
• Weight of babies at term varies massively – average is 3.5kg, but can be anywhere from 1.8-5.8kg.
Home births:
• Low risk pregnancies can have a home birth with no issues, and even high risk pregnancies can opt for a home birth if they
want one, although they should be advised that they may have to be brought into hospital if there are any complications.
• For home births, the midwife brings equipment for infant resuscitation, cannulation and delivery of IV fluids.
• If there is any deviation from normal in a home birth, the woman should be encouraged to transfer to hospital.
Risk assessment:
• Women can change from high risk to low risk and vice versa throughout pregnancy. For example, a woman may have
hyperemesis gravidarum at the start of pregnancy and be high risk, but may then recover from this and be low risk for the
remainder of her pregnancy. Alternatively, a woman may be low risk right the way through her pregnancy, and then develop
pre-eclampsia at 38 weeks.
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