OBSTETRIC CASE

Husband’s name :

Education :

Name Age DOA Residence Occupation Socio Economic status

(According to modified
Kuppuswami classification)
Education

Obstetric score : Gravida Para Live Abortion Death ML :

Chief complaints LMP

G3 P1 L1 A1 with 9 months of amenorrhea EDD

-Appreciating fetal movements well came with c/o SEDD(early scan)

- Pain abdomen POG :

-Decreased fetal movements Cycles : regular

-Leaking/ bleeding per vagina/ white discharge per vagina TT1,TT2 - taken

-Admitted in view of Hb/scan showing reduced liquor/ scan showin fetal growth restriction

- Loose stools/ vomiting / burning micturition

-Sugar/ BP monitoring

HISTORY OF PRESENT ILLNESS

Pain abdomen - onset , duration , type, nature, aggrevating/relieving factors

White discharge – duration, amount, nature, associated with itching , blood tinged

Anaemia –weakness,/lethargy, palpitation, breathlessness,edema, loss of appetite, worms in stools,

any chronic disease like TB

GHTN – edema,blurring of vision, epigastric pain, vomiting, nausea, decreased urine output.

DM – polyuria, polyphagia,polydipsia, sweating, palpitation

Acute GE – onset,duration, episodes/day, H/O outside food intake, blood tinged

OBSTETRIC HISTORY
Married life- Consanguinity-

1st pregnancy - Type of conception/ Antenatal complications like GDM/ GHTN/ Anaemia/Preterm/FTND

LSCS(Indication for LSCS)/ Vaccum assisted/ Forceps assisted indication for instrumental

Delivery)/ place of delivery/ Birth weight/ sex of the baby/NICU admission/ H/O blood

TRANSFUSION/ h/o Anti-D injection in Rh-ve/ H/O wound infection or resuturing/ 5 yrs

Back/Baby alive and healthy( immunized/not)

2nd pregnancy – Spontaneous/ MTP- missed abortion/ anomalous fetus/ 3 months of amenorrhea

3 years back/ D&C done/ check USG done

Ectopic/ molar pregnancy( detais to be taken)

Present pregnancy – Booked/ Unbooked case

T1 – Spontaneous conception

UPT done at 1 ½ months of amenorrhea

Dating scan done at 2 months – found to be normal

Folic acid tablets taken regularly

Baseline blood investigations done – found to be normal

No H/O radiation exposure/ drug allergy

No H/O spotting or bleeding PV / pain abdomen

NT/NB scan taken at 3 months- found to be normal

T2 – QUICKENING FELT AT 5 ½ MONTHS

Anomaly scan done at 5 manths of amenorrhea – found to be normalk

2nd dose of TT injection taken

Iron and calcium takenregularly

Oral glucose tolerance test done – found to be normal

 No H/O headache/blurring of vision/epigastric pain/ nausea/vomiting/pedal edema/increased BP

Reading.

T3 – Continued to perceive fetal movements

Growth scan done – found to be normal

Iron and calcium tablets taken regularly

No H/O bleeding/ leaking PV/ white discharge PV

No H/O pain abdomen

No H/O headache/blurring of vision/ epigastric pain/ nausea/ vomiting/pedal edema

MENSTRUAL HISTORY
Age of menarche-

Regular cycles 4-5 days of flow No clots

28-30 days changes 2-3 pads per day No dysmenorrhea

PAST HISTORY
Not a known case of Diabetes/ Hypertension/ Tuberculosis/ Bronchial asthma/ Thyroid disorder/
Epilepsy/ Cardiac diseases

H/o treated covid positive

Covid injection 2 doses taken

No past surgical history

No H/O Blood transfusion/ iron sucrose infusion

PERSONAL HISTORY
Mixed/ vegetarian diet

Regular bladder

Good appetite and adequate sleep

No drug addiction

FAMILY HISTORY
No H/o DM,HTN,bleeding disorders in the family

No H/o multiple pregnancy/ H/o birth of baby with congenital anomalies in the family

Nutrition h/o – anaemia,GDM, IUGR,PF

GENERAL PHYSICAL EXAMINATION

Built – Avarage / short stature/ tall stature

Nutrition – Avarage / good/ poor or malnourished/ obese

Conscious anda oriented to time/ place/ person

Height : cm Prepregnancy weight : kg

Weight : kg BMI : Wt (kg)/ Ht (m2) : Weight gain in pregnancy : (kg)

Pallor

No icterus/ cyanosis/clubbing/ lymphadenopathy

B/L Grade 1 edema + - grading of edema 1+ - below ankle

2+ - above ankle below knee

3+ - above knee

4+ - anasarca

Breast/spine/thyroid – Normal

Gait – normal/waddling

Skin , hair , nails – normal

Pulse-Rate /rhythm /volume / any delay

BP- / mmhg @right arm in sitting posture

Respiratory rate - /min ,spo2-97%@RA , Temp - 0 C/F

CNS - Higher mental function – Normal

CVS – s1,s2 + , No murmurs

RS – B/L AE +, No added sounds

P/A

Inspecton

Longitudinally distended

Umbilicus- Central and everted

Lnea nigra and striae gravidarum seen

No scars/ dilated veins

Palpation

Fundal height - wks

Symphysio fundal height- cm --- difference of 3 cm ? FGR

Abdominal girth

Liquour clinically increased / reduced

Fundal grip- Broad,soft, irregular, non- ballotable---s/o breech

Lateral grip- R – Irregular knob like structure – limb buds

L – Smooth,curved, uniform structure – spine

1st pelvic grip – Hard, globular, ballotable mass – Head

2nd pelvic grip – Head 4/5th palpable—not engaged

Clinically kg

Auscultation

FHS+ /min at Left spino umbilical line

P/S - No active leak/ Bleeding PV / candidiasis / or trichomoniasis

P/V – Cervix soft,posterior, os close,uneffaced, Vagina at – 3 station

Pelvis adequate, Bishop score -

DIAGNOSIS:
-