Professional Documents
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Day.10 ANC
Day.10 ANC
• Vital statistics.
• Complaints.
• History of present illness.
• History of Current/Present pregnancy.
• Obstetric history.
• Past gynecological history.
• Past medical and surgical history.
• Drug history and allergies.
• Social history.
• Personal history.
• Family history.
VITAL STATISTICS:
▪ Name:
▪ Date of first examination:
▪ Address:
▪ Age: A woman having her first pregnancy at
the age of 30 or above (FIGO-35 YEARS) is
called Elderly primigravida.
- Extremes of age (Teenage and Elderly) are
obstetrics risk factors.
▪ Gravida & Parity :
- Gravida: Denotes a pregnant state both
present and past, irrespective of the period of
gestation.
- Parity: Denotes a state of previous pregnancy
beyond the period of viability.(>28weeks,
foetus weight -1000g)
- Gravida and Para refer to pregnancies and not
to babies.
- As such, a women who delivers twins in first
pregnancy is still a Gravida one and Para one.
• A pregnant woman with a history of two
abortions and one term delivery can be
referred as fourth Gravida but first primipara.
• It is customary in clinical practice to
summarize the past obstetric history by two
digits affixing the letter P (doesn’t denote
parity here).
• Eg: P(2+1)= 2 denotes two viable births, 1 is
one abortion.
BUT IN SOME CENTERS IT IS EXPRESSED BY 4
DIGITS. EXAMPLE: P(A-B-C-D)
A = Number of TERM PREGNANCIES(37-42 Wks)
B = Number of PRETERM PREGNANCIES
(28 weeks to < 37 weeks)
C = Number of MISCARRIAGES (< 28 weeks)
D = Number of BABIES ALIVE at present.
▪ Duration of marriage:
- This is relevant when dealing with pregnancy
- Helps in noting fertility or fecundity of a
woman.
- Pregnancy early after marriage - High
fecundity.
- Pregnancy lately after marriage - Low
fecundity.
▪ Religion:
▪ Occupation: Helps in dealing occupational
hazards.
▪ Occupation of husband :
- Gives fair idea about the socio-economic
status of the patient.
- By this we can know likely complications with
her status like anemia, prematurity,
preeclampsia.
▪ Period of Gestation:
- The duration of pregnancy is to expressed in
terms of completed weeks.
- A fraction of a week of more than 3 days is to
be considered as completed week.
- In calculation the weeks of gestation in early
part of pregnancy, counting is to be done from
the first day of Last Normal Menstrual Period (
L.N.M.P) and later months of pregnancy,
counting is to be done from expected date of
delivery (E.D.D)
• Most reliable clinical parameter of gestational
age assessment is an Accurate LMP.
• In case of persons who had used oral
contraceptives(OC) LMP may be inaccurate.
• In case of OC use, ovulation may not have
occurred 2 weeks after the LMP.
• In such situation the estimation of gestational
age is more accurate with ultrasonography in
the first trimester.
COMPLAINTS:
- Categorically, the genesis of complaints are to
be noted.
- Even if there is no complaint, enquiry is to be
made about the sleep, appetite, bowel habit
and urination.
HISTORY OF PRESENT ILLNESS:
- Elaboration of the chief complaints as regard
their onset, duration, severity, use of
medication and progress is to be made.
HISTORY OF CURRENT PREGNANCY:
• First Trimester
• Second Trimester
• Third Trimester
HISTORY OF IST TRIMESTER: ( First 12 weeks)
• Amenorrhea during the reproductive period in
an otherwise healthy individual having
previous normal periods, is likely due to
pregnancy unless proved otherwise.
• If H/o Amenorrhea (6-8 weeks), Bleeding p/v
(dark, continuous) is associated with lower
abdominal pain (acute, colicky) (on sides
initially and later whole abdomen) chances of
Ectopic pregnancy.
• Placental sign- Cyclic bleeding till 12 weeks of
pregnancy.
(This happens until Decidual space is obliterated
by the fusion of D. vera with D. capsularis)
• Tiredness, Malaise
Other normal physiological symptoms:
• Nausea/Vomiting- if severe- Hyper-emesis
Gravidarum.
• Heart-burn, Constipation, Insomnia.
• Increased frequency in urination- noted
between 8-11th weeks of gestation.
• Cannot be seen after 12th week due to
straightening of uterus (again seen in 3rd
trimester when uterus pressure increases due
to engagement of fetal head)
HISTORY OF SECOND & THIRD TRIMESTER:
• History of fetal movements- Quickening- 18th
week (2 weeks early in Multigravidae)- more
in 3rd trimester.
• Symptoms of Anemia, Miscarriage, Hyper
emesis gravidarum.
• If H/o Amenorrhea, Bleeding p/v (slight, bright
red), painless (dull lower back pain), and if
bleeding first and pain later- suggestive of
Abortion.
• If H/o Amenorrhea, bleeding p/v ( recurrent,
sudden), painless- Placenta previae.
• If Symptoms of heavy bleeding, partial
expulsion of products of conception which
resemble grapes with nausea and vomiting,
cramping lower abdominal pain, history of
ovarian cysts- Molar pregnancy.
• Ask for vaccination H/o ( Tetanus and Rh.
Immunization)
Results of all Antenatal blood tests-
• Routine and Specific.
• Results of Anomaly and other scans (Details of
results can be cross checked with the notes).
Note:
• Remember that the pain may be unrelated to
the pregnancy so keep an open mind!
Causes of abdominal pain in pregnancy include:
• Obstetric: Preterm/Term Labour, Placental
Abruption, Ligament Pain, Symphysis Pubis
Dysfunction, Pre-eclampsia/HELLP Syndrome,
Acute Fatty Liver Of Pregnancy.
• Gynaecological: Ovarian cyst rupture, Torsion,
Uterine fibroid degeneration.
• Gastrointestinal: Constipation, Appendicitis,
Gallstones, Cholecystitis, Pancreatitis, Peptic
Ulceration.
• Genitourinary: Cystitis, Pyelonephritis, Renal
stone pain & Ureteric Colic.
OBSTETRICS HISTORY:
- Related to multigravida
- Previous obstetrics events are to be recorded
chronologically as per the proforma.
- Proforma in next slide
- To be relevent, enquiry is to be made whether
she had antenatal and intranatal care before.
No. Year Pregnancy Labour Methods Puerperium Baby Weight,
And Events Events Of Delivery Sex Condition At
Date Birth, Duration
Of Breast
• Feeding
Immunization
3
For each pregnancy, note:
• Age of the mother when pregnant.
• Antenatal complications.
• Duration of pregnancy.
• Details of induction of labour.
• Duration of labour.
• Presentation and method of delivery.
• Birth weight and sex of infant.
• Also enquire about any complications of the
puerperal period.
Possible complications include:
• Postpartum hemorrhage.
• Infections of the genital and urinary tracts.
• Deep vein thrombosis.
• Perineal complications such as breakdown of
the perineal wounds.
• Psychological complications (e.g. postnatal
depression).
Obstetrics H/o can be summed up as:
• Status of Gravida, Parity, Number of deliveries
(Term, Preterm), Miscarriage, Pregnancy,
Termination (MTP) and Living issue.
E.g.: Mrs. R.L, (P 2+0+1+2), G4, P2, Miscarriage
1, Living 2 at 36 weeks of present pregnancy.
2 = Number of TERM PREGNANCIES .
0 = Number of PRETERM PREGNANCIES.
1 = Number of MISCARRIAGES.
2 = Number of BABIES ALIVE at present.
PAST GYNAECOLOGICAL HISTORY
•
PAST MEDICAL/ SURGICAL HISTORY
• Some medical conditions may have impact on the
course of the pregnancy or the pregnancy may
have an impact on the medical condition
examples:
• Heart disease.
• Hypertension.
• Diabetes.
• Epilepsy.
• Thyroid diseases.
• Asthma.
• Any previous surgery.
• Kidney disease.
• UTI.
• Autoimmune disease.
• Psychiatric disorders.
• Hepatitis.
• Venereal diseases.
• Blood transfusion.
DRUG HISTORY AND ALLERGY
• Current medications.
• Medications taken at any time during the
pregnancy.
• If currently pregnant, ensure the patient is
taking 400mcg of folic acid daily until 12
weeks gestation to reduce the incidence of
Spina Bifida.
• Any allergies and their severity (Anaphylaxis or
a rash?)
FAMILY HISTORY:
• Any history of hereditary illnesses or
congenital defects is important and is required
to ensure adequate counseling and screening
is offered.
• Familial disorders such as thrombophilias.
• Previously affected pregnancies with any
chromosomal or genetic disorders in maternal
side.
• Multiple gestations.
• Consanguinity.
PERSONAL HISTORY:
• Contraceptive history prior to pregnancy:
- LMP may be a withdrawal bleed following pill
usage. The first ovulation may be delayed by 4-6
weeks
• Smoking and Alcohol habits: They have got some
relation with their low birth weight of the baby
• Previous history of blood transfusion,
corticosteroid therapy, immunization against
tetanus, prophylactic administration of anti-D
immunoglobulin are to be enquired.
SOCIAL HISTORY:
ASK
ABOUT:
• Her partner age, occupation, health.
• How stable the relationship is.
• Any domestic violence.
• If she is not in a relationship, who will give her
support during and after the pregnancy?
• Ask if the pregnancy was planned or not.
• If she works, enquire about her job and if she
has any plans to return to work.
EXAMINATION PART
KEYWORDS BEFORE EXAMINATION
• Before examination, explain to the patient the
need and the nature of the proposed
examination.
• Obtain a verbal consent.
• The examiner (either male or female) should
be accompanied by another female.
• Respect her privacy and examine in a private
room.
• Expose only
KEYWORDS BEFORE EXAMINATION
relevant parts of her anatomy for
examination .
• Ensure the patient is comfortable and warm.
• Ask patient to empty the bladder .
• Patient should lie in the dorsal position with
thighs slightly flexed.
• Stand right to her.
KEYWORDS BEFORErolled
• She is slightly EXAMINATION
to the left side to prevent
compression of the inferior vena cava by the
enlarged uterus (inferior venacaval syndrome
or supine hypotensive syndrome).
• Ask for any tender area before palpating the
abdomen.
Dorsal
position/Supine
position with
thighs slightly
flexed
GENERAL
EXAMINATION
• VITAL DATA
• NUTRITIONAL STATUS
• HEIGHT
• FACIAL FEATURE/EXPRESSION
• SKIN
• ICTERUS
• LEGS
• NECK
• BREAST
GENERAL
EXAMINATION
• VITAL DATA:
1. Blood pressure :
• Record while she is in sitting and Semi-Recumbent (
45 degrees) posture.
• Record in every visit.
• Usually unaffected or Slightly lower than
normal due to SVR ( SYSTEMIC VASCULAR
RESISTANCE).
If BP > 140/90 mm Hg on 2 separate occasions 6
Hrs apart:
• Chronic Hypertension: if recorded before 20
weeks of pregnancy or may be persisted
before pregnancy. With + family history.
• Gestational Hypertension : if recorded after
20 weeks of pregnancy. It can cause placental
abruption, still birth.
2. Pulse rate: Slightly increased(Cradiac output
increased)
3. Heart rate : Increased
4. Respiratory rate: usually unaffected. feels
shortness of breath with slight exertion due
to elevated diaphragm.
5- Temperature: may rise by 0.4 ºF
• i.e..98.6 ºF to 99 ºF
• Due to increased metabolic rate
• NUTRITIONAL STATUS:
• Nails- white spots in zinc deficiency, brittle
nails in magnesium deficiency.
oedema of feet
• NECK- Neck veins, Thyroid gland ( diffuse
enlargement common in pregnancy-50 % of
cases), Lymph gland enlargement ( any H/o of
Kochs/ other pathologies of lymph nodes).
• BREAST- Examination of breast is mandatory
not only to note presence of pregnancy
changes ,but also to note the nipples/skin
around areola.
• The breast changes are evident between 6-8
weeks.
• The nipple and the areola become more
pigmented specially in dark women.
• Montgomery’s tubercles are prominent.
• Thick yellowish secretion (colostrum) can be
expressed as early as 12th week.
• Breasts are enlarged with vascular
engorgement evidenced by the delicate veins
visible under the skin.
• Breast changes are valuable only in
primigravidae, as in multigravidae the breasts
are enlarged and often contain milk for years.
• **Purpose is to correct the abnormalities
(cracks/fissures) early so that to make easy
breast feeding more safely too infant after
delivery.
NEC
K
- Diffuse swelling
- common- 50 % Abnormal swelling
cases of pregnancy
BREAST
Normal in pregnancy
Abnormal in pregnancy
GENERAL SYSTEMIC REVIEW
• CNS
• GIT
• GENITALIA
• URINARY SYSTEM
• LOCOMOTORY SYSTEM
• CNS: following finding are checked
- sleeplessness, mental irritability due to some
psychological background
- Any depression/psychosis
- Anaesthesia of the thighs – due to
compression of Lateral Cutaneous Nerve.
- Carpel tunnel syndrome- median nerve
compression in later months of pregnancy.
• GIT:
- Gums –usually congested and spongy
- Esophageal reflux- due to relaxed sphincter-
by progesterone.
- Constipation- due to atony
- Other signs of any disturbances should noted
clearly.
- Chances of gall stones- due to raised
cholesterol- advise USG if pain in Rt
hypochondria.
ABDOMINAL EXAMINATION
• Can be examined in three parts
• 1- INSPECTION
• 2- PALPATION
• 3- AUSCULTATION
INSPECTION
- SIZE OF THE
UTERUS:
• If the length & breadth are both increased →
multiple pregnancies, polyhydramnios
• If the length is increased only → large baby
- Shape of the uterus:
• Length should be larger than broad this
indicates longitudinal lie. But if the uterus is low
and broad indicates transverse fetus lie.
• Pendulous abdomen-
In primigravidae is sign of inlet contraction.
INSPECTION
• If there is lateral implantation of the placenta
then the uterus enlargement will be
asymmetrical- piskacek’s sign.
- Look for fetal movements.
(More prominently seen in 3rd trimester / Less
in oligohydramnios)
- Look for scars.
- Herniations.
INSPECTION
- CUTANEOUS SIGNS - LINEA NIGRA,
STRIAE
gravidarum, Striae albicans, Umbilicus flat or
everted, Superficial veins.
- SKIN CONDITIONS- Ringworm/Scabies
LINEA NIGRA
EVERTED UMBILICUS
FETAL PARTS
STRIAE ALBICANS
PALPATION
Aim :
• Palpation of fetal parts
• Active fetal movements
• Height of the uterus (symphysis-fundal height)
• Gestational age
• Foetal poles
• Foetal lie
• Presentation part- cephalic(head), breech,etc
• Attitude
• Level of engagement of presenting part.
• Uterine contractions.
• Estimate fetal weight.
• Amniotic fluid.
•Any cephalo-pelvic disproportion
Of the above parameters
• To assess FETAL POLE, FETAL LIE, FETAL
PRESENTING PART, ATTITUDE AND
ENGAGEMENT OF FETAL HEAD- LEOPOLD’S
MANOUEVRE IS FOLLOWED
1) Palpation of fetal parts
- Distinctly felt after 20th week
- Usually done to estimate the fetal
pole/presenting part.
2) Active fetal movements
- Gives positive evidence of pregnancy.
- Felt at intervals by placing the hand over the
uterus as early as 20th week. Indicates live
fetus.
- Intensity more in last trimester.
3) Height of the uterus (Symphysis-Fundal Height):
• The distance from the symphysis pubis to the
uterine fundus (top of the uterus)- size of the
uterus directly related to the size of the fetus.
Technique:
• Place ulnar border of the left hand on the highest
part of the uterus (fundus).
• Mark this point with a pen after obtaining her
permission.
• The distance between the upper border of the
symphysis pubis upto the marked point is measured
by tape.
• This corresponds to gestational age
FUNDAL REGION
TAPE
SYMPHYSEAL REGION
4) Gestational age :
• The distance from the symphysis pubis to the
uterine fundus (top of the uterus) corresponds
to the gestational age/duration of pregnancy.
• After 24 weeks of pregnancy, the distance
measured in cm normally corresponds to the
period of gestation in weeks.
5) FETAL POLE, LIE , PRESENTING PART , ENGAGEMENT
AND ATTITUDE OF FETAL HEAD ARE ASSESSED BY
LEOPOLD’S MANOUEVRE.