1.

02 OBSTETRICS - I
HISTORY & PHYSICAL EXAM
Dr. Wendy R. Nicanor November 20, 2019
• Recommended Frequency of Prenatal Check-up (DOH)
o at least 4 prenatal check-ups
I. History Taking
A. General Data
▪ 1 visit during the first 3 months
B. Chief Complaint ▪ 1 visit during the 4th to 6th months
C. History of Present Pregnancy (OB) ▪ 2 visits during 7th to 9th months
D. History of Present Illness (GYN)
E. Past History
F. Family History • Name
G. Personal & Social History • Age Example:
H. Gynecological History This is a case of JC, 28 year old,
I. Menstrual History
• Sex G4P2 (1-1-1-2), married,
J. OB History • OB Score residing in Las Pinas City
K. Review of Systems • Marital status admitted for the first time on
II. Physical Examination • Address November 20, 2019.
A. General Physical Exam • Admission
B. Abdominal Exam (first, second, etc.)
C. Pelvic Exam
D. Rectal Exam • Date of consultation
III. Appendix

• one or more symptoms

or concerns causing Example:
the patient to seek care nausea, vomiting, vaginal
History Clinical Plans of
& PE Impression management • The patient should be bleeding, labor pains,
able to present the hypogastric mass, delayed
problem as she sees it, menses, abdominal pain
in her own words.
Diagnostics Therapeutics • Make every attempt to quote the patient’s own words
(ex. Labs, UTZ, (ex. Surgery,
MRI, CT) Medical)

Figure 1. Steps in the diagnosis and management of patients

• In relation to the chief complaint (includes antenatal
history)
• History taking is an art; most basic skill that every • Includes the history of the patient before the baby is born
clinician must acquire, learn, & master or delivered
• Building patient rapport is vital; first contact of physician o 1st trimester - 0-14 weeks of gestation
has with the patient is critical o 2nd trimester -15-28 weeks of gestation
• It allows an initial bond of trust to be developed on which o 3rd trimester - 29-42 weeks of gestation
the future relationship may be built • Organized and orderly sequenced
• It is very important that the patient feels that the clinician • Labor pains:
sees her as a whole person (Individual Human Person) o Onset of uterine contractions
and not just a history that has to be accomplished o Time of onset
• Clinical presentation of the patient’s pregnancy or disease o Point of reference
following a prescribed written format ▪ How many hours prior to consultation?
• An Obstetric patient should be Pregnant, if you are not ▪ How many hours prior to admission?
pregnant you are nonobstetric • Other symptoms:
• Gyne patients are patients who are not pregnant but with o Bloody show - a normal sign in pregnancy (near term
gynecologic problems like vaginal bleeding, pelvic mass, of when in labor) where the blood vessels in the
etc. cervix tear or rupture due to dilation and effacement
(shortening and thinning)
HISTORY TAKING OUTLINE IN OB-GYN o Vaginal bleeding
1. General Data o Watery vaginal discharge
2. Chief Complaint o Abdominal / back pain
3. History of Present Pregnancy (OB) • Written in paragraph form
History of Present Illness (Gyne) • Tabulated form - course of pregnancy is uneventful
4. Past History NOTES
5. Family History • Here is where you will write your AOG; when did the pregnancy
6. Personal & Social History started? Usually with a positive pregnancy test. At what age or
7. Gynecological history how many months amenorrhoeic?
8. Menstrual History • Also ask the patient’s past consultations before you. Is the patient
9. OB History taking any prenatal meds? Who prescribed that? Also determine
10. Review of systems if she needs to continue taking these medications or not.
• Ask for previous lab results. Example: Ultrasound results. See if
you need to ask more lab tests to run for your patient

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• In relation to chief complaint
• If pelvic mass:
o Duration (onset)
o Associated symptoms: Pain, Urinary symptoms,
Bowel changes, Weight loss
• If abnormal vaginal bleeding:
o Duration (onset)
o Prolonged menses
o Increased amount
o Intermenstrual bleeding
o Associated symptoms: Weight loss, Constipation,
Urinary problems
• Medical History
o Chronic diseases and treatment
o Pulmonary diseases
o Cardiovascular diseases
o Diabetes and thyroid disorders
o Gastrointestinal and renal abnormalities
Example:
The patient is a known asthmatic since childhood. She is
admitted in the hospital twice a year. Her medications are
Budenoside, Combivent and Ventolin. She had her last
asthma attack in July 2016.
• Surgical History
o Surgical procedures: Appendectomy,
Cholecystectomy, when and where was the
procedure performed
o Except OB procedures (Caesarean Section,
Hysterectomy)
Example:
The patient had appendectomy in 2012 at PGH and
cholecystectomy in 2015 at PGH
• Hospitalization
• Past and current medication
• Drug and food allergies
• Should be written in Chronological Order
• Health status of the first order relatives
• History of similar illness or symptoms
• History of hereditary diseases
• Diabetes, HPN, heart disease, cancer
Example:
Both parents are hypertensive. Her brother is asthmatic.
No history of hereditary familial diseases reported.
• Summary of the patient’s lifestyle which may be relevant
to the present condition/illness
• Educational attainment
• Occupation (patient and husband)
• Habits:
o Smoker: pack years
o The patient is a college graduate, employed as a
bank teller
o She is a non-smoker and occasional alcoholic
beverage drinker
o Her first coitus is at age 22
o She has 1 non-promiscuous---30
o Alcoholic beverage drinker: quantity, frequency
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History & Physical Exam in OB-GYN 1.02
o Sexual practices: age at first coitus, # of past and
current partners
Example:
The patient is a college graduate, employed as a bank
teller. She is a non-smoker and occasional alcoholic
beverage drinker. Her first coitus was at age 22. She has
1 non- promiscuous sexual partner.
• Disease of women - female reproductive system
o vaginitis, venereal warts or genital warts
• Diagnostic procedures:
o Pap smear - screening test for cervical cancer
o Biopsy
o D&C
o Laparoscopy
o Hysteroscopy
• Surgical procedures:
o Enucleation of ovarian cyst – removal of the ovarian
cyst (not the whole ovarian tissue)
o Tubal surgery
o Hysterectomy
o Vulvar & vaginal surgeries
• Except OB procedures
Example:
• The patient underwent myomectomy or specifically
uterine procedures. Implication: This means the
patient cannot go into full-term. High probability of
preterm birth. Affects the patient’s mode of delivery.
In myomectomy, uterus is scarred. You cannot allow
the patient to go into labor
• Patient diagnosed a year before of her pregnancy of
myoma. Implication: You will advise the patient on
what symptoms to expect; Mode of delivery,
remember that myoma can either increase or
decrease in size or stay the same during pregnancy.
If it decreased in size, pwede sya maging tumor
previa. If increasing in size naman, di na pwede mag
normal labor si patient
• Age of menarche
• Subsequent menses
o Interval
o Duration
o Amount (# of pads per day, fully-soaked, streaks etc.)
• Symptoms (ask what day of the cycle they had it)
o Dysmenorrhea
o Sweating
o Headache
o Diarrhea
• Last Menstrual Period (LMP)
o patient would always say about the last day of her
menses.
o You should always emphasize the first day of her last
menstruation.
o Very critical why? Because this will be the basis of
your computation for the baby’s age of gestation
o Previous Menstrual Period (PMP) - another way of
checking if menstruation is regular or not
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 History & Physical Exam in OB-GYN 1.02

Example: AGE OF GESTATION (AOG)

Patient had her menarche at age 11. Subsequent menses • common term used during pregnancy to describe how far
at regular 28-30 days cycle, 4 days duration consuming 3- along the pregnancy is
4 pads/day associated with dysmenorrhea. • measured in weeks, from the first day of the woman's last
LMP: February 21, 2018 menstrual cycle to the current date
PMP: January 6, 2018
• Computation:
o LMP: October 1, 2019
o Date today: November 20, 2019
( Fly - Philippine - Air - Lines ) 1. Subtract “1” from no. of days of October “31” = 30
days
• Gravidity - number of times the mother has been 2. Add the answer to the subsequent number of
pregnant, regardless of whether these pregnancies were days in the next months, until today (30 + 20 = 50
carried to term. Current pregnancy, is included in this days)
count 3. Divide by 7 to convert to weeks (50 / 7 = 7.14
• Parity - number of pregnancies that has reached at least 4. 7 x 7 = 49. Then, 50 – 49 = 1 day
20 weeks (including live births and stillbirths) o AOG: 7 weeks, 1 day
o Full Term – number of term deliveries (37 weeks)
o Premature – number of premature deliveries Example:
(>20 to <37 weeks or >141 to <259 days) • LMP: September 15, 2019
o Abortion – total number of spontaneous or induced • Date today: November 20, 2019
abortions and miscarriages, including ectopic Days in September 30
(-) date today -15
pregnancies, prior to 20 weeks
15
o Live Birth – number of living children (+) days in October +31
46
G3P0 (0-0-2-0) (+) days in November +20
• A patient went into your clinic with a positive Until today 66
pregnancy. She had an ectopic pregnancy before, (÷) no. days in a week ÷ 7
and she underwent dilatation and Tip: 7 x 9 = 63. Then, 66 – 63 = 3 days 9.42
curettage/completion curettage. • AOG: 9 weeks, 3 days
Explanation: G3 because positive pregnancy test +
ectopic pregnancy + completion curettage which • Fundic Height:
means she already had 3 pregnancies. P0 because o Estimate gestational age
no past pregnancies have reached 20 weeks, 2 o Numerically equals AOG
score for the third number because of her ectopic
pregnancy and completion curettage. No full terms, • Ultrasound:
no pre-terms and no live births o If irregular cycle, ultrasound imaging have made fetal
G1P1 (1-0-0-2) age and growth assessment possible with reasonable
• patient had a twin pregnancy that reflects on the degree of accuracy
number of live births o Doppler ultrasound is often used to easily detect
fetal heart action at 10 to 12 weeks with such
instruments
• Mean duration of pregnancy calculated from the first day
of the LMP is very close to 280 days or 40 weeks
• Year of delivery
TIMING FROM NAEGELE’S RULE • Manner of delivery
• estimate the expected delivery date by adding 7 days to o If cesarean section, ask the indication why
the date of the first day of the last normal menstrual period o Implication: there are certain indications of CS that
and counting back 3 months can allow your patient to go through trial of labor or
• estimates expected date of delivery (EDD), estimated date vaginal birth after cesarean section. However, there
of birth (EDB) or estimated date of confinement (EDC) are indications that will warrant you another repeat
• The cycle should be regular CS. So kapag mga outright na C/S ‘to sa pangalawa,
mag-CPD or cephalopelvic disproportion. This means
Example: maliit yung sipit-sipitan
FOR APRIL – DECEMBER • Mode of delivery
LMP: September 10, 2019 09 / 10 / 19 o if it is term, preterm.
EDD: June 17, 2020 -3 +7 +1 o Implication: there are certain causes of preterm that
06 / 17 / 20
can be repeated with the present pregnancy.
FOR JANUARY – MARCH
LMP: January 5, 2019 01 / 05 / 19 Pwedeng ang cause ay cervical insufficiency or that
EDD: October 12, 2019 +9 +7 +0 the cervix is fully opened.
10 / 12 / 19 o That can be avoided. Tatahiin mo yung cervix para
hindi bumuka.
TIMING FROM OVULATION: If the woman’s date of the last • Associated Conditions/Congenital Anomalies
ovulation is known, just add 267 days to estimate EDD • Birthweight

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 History & Physical Exam in OB-GYN 1.02

• Place of Birth and Authority that Managed the Delivery 5. Chest

o House, lying-in, attended by midwife, or traditional o Lungs
birth attendant. o Heart
o Implications: complications can be traced based o Breast – Look for masses
from the person who delivered the baby; Repair - Malignant – firm and fixed
surgically - Benign – Movable and doughy
Example: G4P2 (1-1-1-2)
▪ Observe for any nipple discharge
• G1 - 2002, delivered to a live term baby boy by C/S, Color Possible causes
UPHDMC, BW- 7lbs, with no complications White, Cloudy, an infection of the breast or
• G2 - 2004, delivered by NSD to a live pre-term baby Yellow, Or Filled With nipple
girl, UPHDMC, BW - 4lbs, with no complications Pus
• G3 - 2007, incomplete abortion at 12 weeks Green cysts
gestation completed by curettage, UPHDMC Brown Or Cheese- mammary duct ectasia (blocked
• G4 - present pregnancy (always include if patient is Like milk duct)
gravid or pregnant) breast cancer, especially if it’s
Clear
only coming from one breast
Bloody papilloma or breast cancer

• HEENT
• 18-20 weeks AOG
• Cardiovascular/respiratory
• ≥ 20 weeks AOG
• Gastrointestinal
• Examinations:
• Genitourinary
1. Inspection
• Endocrine 2. Fundic height (cm)
• Neurologic/neuromuscular 3. Leopold’s maneuver
• Vascular (thrombophlebitis, etc.) 4. Lie, presentation
• Psychiatric 5. Estimated Fetal Weight (EFW) in grams
6. Auscultation of Fetal Heart Tones (FHT) – as early as
10 weeks

• The physician should perform a thorough physical exam
from the first visit and each annual checkup.
• It is the time to gather information about the patient and to
teach her what she should know about her body and her
health
• The patient should wear a gown that will ensure warmth
and modesty
• Presence of an assistant (third party)
o Offers warmth, compassion and support to the patient
during uncomfortable and potentially embarrassing
portions of the exam.
o Assists the physician during procedures
o Protects the physician from having his/her intentions
misunderstood by the patient
1. General Survey
o Level of consciousness (Alert, Awake)
2. Weight, Height, and Body Mass Index (BMI)
o The BMI of an OB patient should be determine
before the pregnancy to monitor if there is wait gain
during the course of pregnanc7
o Implications: px might have GDM; advise px to add
or lessen caloric intake to minimize complications
3. Vital signs
o Blood pressure (BP)
o Respiratory rate (RR)
o Pulse rate (PR)
o Temperature
4. HEENT (Head, Eyes, Ears, Nose, Throat)
Positioning
• Only expose the area being examined
• Examine patient in the supine position
• In later trimesters, the patient should adopt the semi-sitting
position with the knees bent
o This position is more comfortable and reduces the weight of
the gravid uterus on the descending aorta and inferior
vena cava
o Compression interferes with venous return from the lower
extremities and pelvic vessels, causing the patient to feel
dizzy and faint, the supine hypotensive syndrome
INSPECTION
• Inspect for striae gravidarum, scars, size, shape, and
contour; Purplish striae and a linea nigra are normal in
pregnancy
o Due to hormonal changes
FUNDIC HEIGHT
• locate the pubic symphysis and place the “zero” end in
centimeters of the tape measure where you can firmly feel
the bone
o The bladder must be emptied and follow the contour
of the uterus and not the abdomen to avoid
inaccuracies
o Obesity and leiomyomas can cause inaccuracies. In
such cases, UTZ may be used
• monitors fetal growth and amniotic fluid volume
• If the AOG is 30 weeks, the fundic height should be 30
cm

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 History & Physical Exam in OB-GYN 1.02

AOG equals Fundic Height (Fetal growth estimation) LEOPOLD MANEUVER – III (Pawlick’s Grip)
• height recorded in cm = approximate AOG in weeks • Answers the question “what fetal part lies above the
o 12 weeks after LMP - Above pubic symphysis pelvic inlet?”
o 16 weeks - Halfway between pubic symphysis and • Determines if the fetal presenting part is engaged or not,
umbilicus as well as the station
o 20 weeks - at the level of umbilicus
o 36 weeks - fundus is just below ensiform cartilage o If engaged - the fetal part is unmovable
• Implications: o If not engaged - the fetal part is movable
o If >4 cm - consider multiple gestation, a large fetus, extra • If the most distal part of the lower fetal pole cannot be
amniotic fluid, or uterine leiomyoma. palpated, it is usually engaged in the pelvis.
o If <4 cm - consider low-level amniotic fluid, missed abortion, • The examiner is facing the maternal head
intrauterine growth retardation, or fetal anomaly • Using one hand, grasp the lower portion of the abdomen
just above the symphysis pubis (Figure 5)
LEOPOLD MANEUVER – IV (Pelvic Grip)
• Answers the question “on which side is the cephalic
prominence?”
• Determines the engagement of the fetal presenting part
Figure 2. o Fetal part is engaged - examiner’s hands diverge
Growth patterns of from each other
the uterine fundus by o Fetal part is not engaged - examiner’s hands
weeks of pregnancy
converge
• Determines the fetal attitude (the relation of fetal parts to
one another)
o Flexion - the cephalic prominence is on the same
LEOPOLD MANEUVERS side as the fetal small parts
• used to determine the fetal position in the maternal o Extension - the cephalic prominence is on the same
abdomen beginning in the 2nd trimester side as the fetal back (w/ resistance)
• Determine readiness for vaginal delivery by • The examiner is facing the patient’s feet
assessing: • There is palpation of the bilateral lower quadrants, above
o Upper and lower fetal pole, namely, the proximal and the symphysis pubis
distal fetal parts o If ever the baby’s head has descended into the pelvis,
o Maternal side where the fetal back is located the examiner may differentiate the anterior shoulder
o Descent of the presenting part into the maternal using the third maneuver (Figure 6)
pelvis
o Extent of flexion of the fetal head
• Performing the maneuvers may be difficult or
impossible due to the following:
o The patient is obese
o Amniotic fluid is excessive
o Placenta is anteriorly planted
• Technique:
o First 3 maneuvers – examiner stands on the right side
of the bed, facing the mother
o 4th maneuver – face the feet of the mother
LEOPOLD MANEUVER – I (Fundal Grip)
• Answers the question “what fetal pole/part occupies the Figure 3 Figure 4
fundus?”
o Cephalic - fetal head; round, hard, and ballotable
o Breech - nodular; soft, harder to grasp
• The examiner is facing the maternal head
• Occasionally, neither part is easily palpated at the fundus,
• as when the fetus is in a transverse lie.
• The uterine fundus is palpated with both hands
(Figure 3)
LEOPOLD MANEUVER – II (Umbilical Grip)
• Answers the question “on which maternal side is the fetal
back?”
o Fetal back - feels flat and firm
o Fetal small parts - nodular
• The examiner is facing the maternal head
• There is palpation of paraumbilical areas or the sides of Figure 5 Figure 6
the abdomen (Figure 4)

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 History & Physical Exam in OB-GYN 1.02

LIE/PRESENTATION
• Incidence of various presentations at or near term: • Hair pattern on the mons pubis and labia majora
o Vertex 98% • Skin (excoriation, discoloration, ulcers, etc.)
o Breech 3.5% • Episiotomy scar
o Face 1.3% • Clitoris, Labia majora & minora, Introitus (hymen),
o Shoulder 0.4% Perineum, Anus, Urethra, Bartholin’s glands
• Lie • Mink for pus/mucus
o Longitudinal • Pelvic organ prolapse
o Transverse • Cystocele, Cystourethrocele, Rectocele
o Oblique • Note: If there’s a patient who complains of vaginal mass,
• Presentation so painful that the patient unable to walk anymore.
o Cephalic o On palpation, around the lateral portion of the
o Breech vulvovaginal structure
o most probably chances are it’s a bartholin’s gland
ESTIMATION OF FETAL WEIGHT (EFW)
abscess because that’s the area where the
• Consider Intrauterine Growth Restriction (IUGR) if fundal bartholin’s glands are.
height (FH) is 2-3 cm less than what is expected for AOG.
• Johnson’s Rule:
o Weight (g) = K (x – n) • Used to help examine the cervix and vaginal walls
▪ K = 155 • Technique:
▪ x = FH in cm o Relaxation may minimize, but not eliminate,
▪ n = 12 (if engaged) discomfort from the speculum
11 (if unengaged) o Always explain the procedure and always ask the
• Weight (g) (FH + station) x 100 patient for permission
o Lubricate the speculum with warm water
FETAL HEART TONE (FHT) o Using the non-dominant hand, part the labia
• Doppler: 10-12 weeks o Insert closed speculum sideways for ease of access,
o Heard earliest at 10 weeks then rotate downwards 90° before opening speculum.
• Stethoscope: 18-20 weeks • Inspect the vagina & cervix:
o Identify the fetal back o Bluish discoloration of vagina (Chadwick’s sign)
o Auscultate the fetal back o Presumptive sign of pregnancy
o Check the maternal pulse while listening to the FHT o Nabothian cyst (firm bumps in the cervix’s surface)
▪ To make sure that the pulse you are listening to o Lesions
is the baby’s pulse, not the mother’s pulse o Endocervical discharge
o Maternal pulse is slower than the fetal pulse o Cervical dilatation
• Normal FHT: 120-160 bpm • Perform a Pap smear if indicated, and collect other
vaginal specimens such as STI cultures, wet mount
samples, or group B strep swabs as appropriate
1. Inspection
o Flat/globular/distended
o Irregular contour
o Skin discoloration/striae
o Scars
2. Palpation
o Organomegaly
o Firm/nodular, soft mass
o Movable/fixable mass
3. Percussion
o Tympanic
o Dull
4. Auscultation
o Bowel sounds

• Patient in supine and lithotomy position (legs in stirrup)

• Drape legs with a sheet; give patient time to relax and be Figure 7. Bimanual Examination
comfortable
1. Inspection • Technique:
2. Speculum Examination o Insert two lubricated fingers into the introitus, palmar
3. Bimanual Examination side down, with slight pressure downward on the
4. Internal Examination perineum.
5. Rectal Examination o Maintaining downward pressure on the perineum,
gently turn the fingers palmar side up.
• In order: to prevent contamination

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 History & Physical Exam in OB-GYN 1.02

• Gynecological Patient • No history of sexual intercourse

o Length of cervix
o Dilation is opening of the cervical canal.
o Effacement is shortening/ thinning of the cervical
canal. If cervix is fully effaced, it is paper thin.
o Fornix (shallow, full, bulging)
o Uterus
▪ Position (anteflexed, retroverted, midline)
▪ Size (may be compared with AOG in weeks)
▪ Shape
▪ Consistency
▪ Mobility tenderness
• Adnexae (Fallopian Tubes and Ovaries)
o Position - anterior, lateral, or posterior to uterus
o Size - normal: 3x2 cm
o Consistency, Mobility, Tenderness
o Ovaries are not palpable in post-menopausal
patients. If palpable, it is a pathologic sign
o Rectal exam instead of internal exam
o Use the index finger
o Evaluate the uterus and adnexae
o Palpate the rectum in all dimensions with the rectal
examining finger
o Note the anal sphincter tone
o Check for haemorrhoids, fissures, masses
• Evaluation of the adnexae
o Move fingers into the right vaginal fornix
o Follow with the abdominal hand
o Bring the two hands close together by sweeping the
abdominal hand downwards, allowing the right
adnexae to be palpated between the two hands
o Repeat the same on the left side

• Uterus shape - anteverted

o This is not done on a minor, unless necessary and
with consent from parent or guardian
• Not done on a patient who has not yet had sexual
intercourse; unless necessary and with her consent
• Instead, a rectal examination is done REFERENCES
• Evaluation of the Uterus 1. Batch 2021 Trans
o Insert the middle and index into the vagina so that 2. Sumpaico’s Textbook of Obstetrics 2nd Ed.
they rest beneath the cervix in the posterior fornix 3. William’s Obstetrics 24th Ed.
o Place hand on the abdomen above the symphysis 4. Bates’ Guide to Physical Examination & History
pubis Taking 12th Ed.
o Elevate the uterus by placing up on the cervix and 5. Lecture Notes
“delivering” the uterus to the abdominal hand so that
the uterus is palpated between two hands

• Rectovaginal Exam
o The middle finger is inserted into the rectum
o Palpate the rectovaginal septum for any thickness or
mass
o Identify uterosacral ligaments for thickening

Figure 8.
Rectovaginal
Examination

After the rectovaginal exam:

o Palpate the rectum in all dimensions with the rectal
examining finger
o Note the anal sphincter tone
o Check for hemorrhoids, fissures, masses
o Obtain a stool sample and check for occult blood in
women >35 years of age

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