1.

ANTENATAL HISTORY:

BIODATA:

• Name. (Complete name w/o)

• Age (chromosomal disorders/anomalies and miscarriage, either early (13) age or late age (40) )
• Married for: Females married for 3 years and have not conceived (precious pregnancy) 35%
chances of conceiving after one month of marriage, 85% after an year, and 92% after two years.
• Cousin/ outsider: thalassemia and other genetic disorders.
• Gravida: The times female got pregnant (including miscarriages and abortions)
• Para: Delivery before 34 weeks / 6 months are considered an abortion. (It is written as a
superscript)
• After six months: IUD (stillbirth) or alive. (It is written as a subscript)
• LNMP (last normal menstrual period) to estimate gestational age and EDD( expected date of
delivery). Mostly females don’t remember their LNMP, in such cases, it is done through a dating
scan (1st ultrasound)
Nagler's rule for estimation of EDD: Day+7, Month+9 i.e if LNMP is 3rd May 2022, EDD will be
10th Feb 2023. Normal pregnancy is of 280 days or 40 weeks.
• Education of patient: for dealing with patients according to their understanding.
• Religion: Megaloblastic anemia is common in Hindus due to less usage of meat (low B12 in diet)
• Resident: to know if patients belong to an area of an epidemic outbreak. Eg: Kalazar disease in
Balochistan.
• Admitted through: OPD/ER.
• Presenting Complain: Eg, Presented with the history of 9 months of gestational amenorrhea
with per vaginal bleeding.

HISTORY OF PRESENTING COMPLAINTS:

FIRST TRIMESTER:

Starting from when she was pregnant.

Questions to be asked:

• Were you okay 9 months before?

• How did you know that you were pregnant? Eg: Confirmation through the P.T test.
• Did you go to any doctor for medicine? Have you got your dating scan? Did the doctor advise
other supplements (Calcium, Iron)?
• Folic acid dose during first 3 weeks?
Normal dose of folic acid: 400 micrograms.
Prophylactically for Diabetes Mellitus/ Neural tube defect/high-risk pregnancy: 5 milligrams) (
Caudal Regression Syndrome and Cardiac anomalies common in DM)
• Was the pregnancy planned or spontaneous?
• Check for the following symptoms,

Fever, flu, and rash for rubella.

Polyuria, polydipsia, and polyphagia for diabetes Mellitus.

Palpitations and excessive sweating for hyperthyroidism.

Nausea and vomiting. Excessive vomiting and nausea is called Hyperemesis gravidatis which is a
characteristic of molar pregnancy as Beta HCG is increased. It gives the appearance of a bunch of
grapes. If it is subsided by medicine then we'll rule out molar pregnancy.

Shortness of breath, headache, dull vision, blurring, Vaginal discharge, PV bleeding, burning
micturition.

(Write down positive symptoms first then write down negative ones)

For example: (According to the patient she was in her usual state of health 9 months back then she
missed her periods and 25 days were overdue. She confirmed pregnancy through pt strip, went to
the nearby doctor who advised her ultrasound. It was her planned/spontaneous pregnancy. Doctor
advised her some medicine (folic acid, calcium supplements). She had nausea and vomiting for the
first 3 months of pregnancy)

SECOND TRIMESTER: (14 weeks/4 months onwards)

• When did you notice the first movement of the fetus? (Quickening)
• Anomaly Scan (in which they check ears, eyes, and nose of the fetus) (18 to 20 weeks/ 5th
month)
• Tetanus immunization (7th or 8th month) Mostly starts at the 6th month but patients come
late.
• Pregnancy-induced hypertension (after 20 weeks) 4 hours apart, or on 2 separate occasions,
it exceeds 140/90 (Before 20 weeks it's chronic hypertension)
• Iron deficiency anemia is most common in the 2nd trimester characterized by fatigue. Ask
for headache, blurring of vision, blackouts, and shortness of breath.
• Diet: egg, meat, fish, fruit vegetable. Iron and calcium supplements.
• UTI, DM symptoms.
• If OGTT is normal on the 16th week then we do it again around the 24-28th week.

THIRD TRIMESTER (7 months/28 weeks onwards)

• Fetal growth: IUGR in hypertension, anemia.

• Systemic Review once again
• Antepartum hemorrhage Painless vaginal bleeding: Placenta Previa (low lying placenta)->
Dangerous for mother.
Painful PV bleeding due to premature separation of the placenta: Placental Abruption->
mother and baby in danger
Spontaneous rupture of membrane leading to drop in fetal heart rate, rupture of water bag,
small membranes rupture during the labor: Vasa Previa -> dangerous for the baby.
• History of PV bleeding: We'll start it as “Yesterday the patient got admitted to the ward for
fetal-maternal surveillance with complaints of PV bleeding for up to 7 days”
Then we'll ask
Onset?
 Quantity?
Presented with pain? (Intensity: mild, moderate, severe)
Associated with lower abdominal pain (onset, duration, intensity, associated factors i.e
fever, pyelonephritis, aggravating and relieving factor i.e cranberry in UTI, burning
micturition)

PAST OBSTETRIC HISTORY:

28 days death- NND- neonatal death

1 year-infantile death

5-year-childhood death.

Comment on each baby.

• Alive or death?
• Normal delivery or C-section?
• Complications during delivery? (Ex: Eclamptic fits)
• Postpartum hemorrhage? (PPH)
• Blood transfusion history?
• Miscarriages, why, and when(on which month of pregnancy)?

PAST GYNECOLOGICAL HISTORY:

• History of Anemia?
• menstrual cycle (days menstruation/days of the menstrual cycle) for ex: (5/28)
• flow (how many pads are soaked) (more than 10 pads account for heavy bleeding)
• clots (heavy bleeding)
• intermenstrual bleeding
• post-coital bleeding
• dysmenorrhea (painful menstruation)
• dyspareunia (painful intercourse) (dysmenorrhea and dyspareunia are classical features of
endometriosis)
• vaginal discharge
• pap’s smear (cervical cancer)

PAST MEDICAL/PAST SURGICAL HISTORY:

Any operation or surgery.

TRANSFUSION HISTORY:

DRUG HISTORY:

FAMILY HISTORY:
Hypertension, DM, TB, Hepatitis, Thalassemia, Cancer.

PERSONAL HISTORY:

SOCIOECONOMIC HISTORY:

2. ANTENATAL CARE:

ANTENATAL CARD:

When patient comes for booking, the card is made including her bio data.

• Name
• Age (chromosomal abnormalities)
• Occupation ( if she's a radiologist then she might have exposure to radiations, if patient has
low lying placenta, bedrest is advised to ensure less mobility, so we need to check the
working hours)
• Resident: Either it is remote or health care services are available, In case of last hour
complications accessibility to tertiary health care should be made possible)
• Married for: Precious pregnancy in primary gravida, more vigilant to prevent complications.
• Gravid and Para:

G: gravid uterus, times of pregnancy, including miscarriages

P: Para, less than 24 weeks-> superscript

greater than 24 weeks: still born, alive, miscarriages -> subscript
• Last pregnancy: hypertension, preeclampsia, eclampsia, diabetes, time interval.
• LNMP: 1st date of last period.
Date: date+7, Month: month+9
• Past medical and past Surgical History: Thalassemia, TB, DM, hypertension.
Removal of fibroids from uterus (Myomectomy) There are chances of uterine rupture due to
previous surgical history if patient is expecting a normal delivery. Repeated miscarriages.
• Family history: Hepatitis, blood disorder, DM, Hypertension.

EXAMINATION:
• BASELINES: CBC, URINE DR
CBC: Hb (IUGR is the complication of anemia) platelets (thrombocytopenia can lead to
bleeding during C section), TLC (infection, UTI common cause of increased pressure of the
gravid uterus, backache, respiratory infection, blood infection)
• RBS: 120-140 mg/dl
• FBS: 90 my/dl
• Urine DR: color of urine, proteinuria (preeclampsia, hypertensive mother)
Glucosuria (gestational diabetes)
Leukocytes (Infections, UTI)
• Premature contractions.
 (Ascending infections occur when infectious pathogens residing in the external genitalia of
the mother (urethra, vagina) access the amniotic sac. Upon infection, the amniotic sac may
become compromised and rupture and it can lead to preterm labor)

• Routine examination of Blood pressure and Weight (either increase or decline. normal 11 to
13kg increase in normal pregnancy) gestational DM/ preexisting diabetes leads to
macrosomic baby, C sections chances increase. Baby is at risk of bone fracture during
delivery.

• Per Abdominal Examination:

For fetuses after 24 weeks' gestation, the measurement is made by identifying the upper
border of the symphysis pubis and the uterine fundus and measuring the distance between
with a tape measure. The measurement in centimetres correspond to the weeks.

• Fetal Position:
Longitudinal (baby's spine is parallel to mother's spine, between his head and tailbone)
Oblique ( The baby's head is against the mother's hip, high above the birth canal. No
particular part of their body is against the cervix)
transverse (The transverse lie position is where the baby's head is on one side of the
mother's body and the feet on the other)

• Fetal heart sounds for 1 min: 110bpm-160bpm

Below 110: bradycardia (due to hypoxia, sedatives)
Above 160: Tachycardia

• Visits: Primary Gravida: 10 visits.

Multi Gravida: 7 visits.
Dating Scan: 11th to 14th week mostly.
18-20 weeks: visits monthly (Anomaly scan)
30 -36 weeks: two visits.
36 to 54 weeks: per week.

3. MECHANISM OF LABOR:

LABOR:
It is a process in which there is cervical dilatation and effacement which leads to the expulsion of the
baby, placenta, and membranes by regular uterine contractions. Maternal pelvis and fetal head anatomy
is important. Bregma to Occipital is 9 cm (Occipito-bregmatic diameter) in length and this part is first
delivered.
Female pelvis: Inlet, middle part, outlet
Pelvic boundaries: ischium, pubis, pubic symphysis, sacrum.

7 CARDINAL MOVEMENTS OF FETUS:

Engagement
Flexion
Descent
Internal rotation
Extension
Restitution
External Rotation.

ENGAGEMENT:
Widest part of fetus passes through pelvic inlet and is engaged there. Baby is usually engaged in
transverse position.

FLEXION:
Flexion is bring about by uterine contractions. Baby’s head strike with pelvic floor muscles.

DESCENT:
Descent is baby going downwards. First three processes occur simultaneously.

INTERNAL ROTATION:
Baby’s head rotates internally due to rapid contractions.

EXTENSION:
Baby’s head will extend outward and it will now become visible (crowning)

RESTITUTION:
When the head aligns with the shoulder of the baby it is called restitution.

EXTERNAL ROTATION:
Head rotates externally. Anterior shoulder comes out first than posterior shoulder. Then, whole body is
delivered.

All baby’s head movements occur in 1/8th of the circle.

STAGES OF LABOR:
First stage: Cervical dilation and uterine contractions.
Second stage: Baby delivers.
Third stage: Placenta delivers.

4.ANEMIA

DEFINITION:
Anemia is a condition in which one lacks enough healthy red blood cells to carry adequate oxygen to the
body's tissues. Having anemia is also referred to as low hemoglobin.
CLASSIFICATION:
Anemia can be classified as microcytic, normocytic or macrocytic, depending on MCV.

How to differentiate between Iron deficiency Anemia and Thalassemia?

In Iron deficiency Anemia, MCHC and MCV both are low while in thalassemia only MCV is low while
MCHC is normal.

SYMPTOMS OF ANEMIA:
Fatigue
Weakness
Pale or yellowish skin (palmar crease, conjunctiva)
Irregular heartbeats
Shortness of breath
Dizziness or lightheadedness
 Chest pain
Cold hands and feet
Headaches

ANEMIA DURING PREGNANCY:

1ST TRIMESTER:
During 1st trimester of pregnancy, Hb of 11 g/dl is the cut off value for confirming anemia. Less than 11
g/dl of Hb suggests anemia. Anemia during first trimester is due to hemodilution ( With normal
pregnancy, blood volume increases, which results in a concomitant hemodilution. Although red blood
cell (RBC) mass increases during pregnancy, plasma volume increases more, resulting in a relative
anemia)

2ND AND 3RD TRIMESTER:

Hb of less than 10 g/dl suggests anemia during 2nd and 3rd trimester, which is due to low levels of
hemoglobin as per demand of the body.

MANAGEMENT:
IRON TABLETS:
No IV is given during first trimester as it can lead to anaphylactic reaction and it can cross placenta.
Blood transfusion is plausible after 34 weeks.

IV IRON (VENOFER)
It takes 2 weeks to build up iron. Oral iron takes 4 weeks to build up. While there is 0.8 -1 g increase
with 1 unit in blood transfusions.
Values for blood transfusions:
Severe- less than 7 g/dl of Hb (cut off value)
Morbid – 7-9 g/dl of Hb.
Mild- 9-11 g/dl of Hb.

COMPLICATIONS:

Severe iron deficiency anemia during pregnancy increases the risk of premature birth (when delivery
occurs before 37 complete weeks of pregnancy).

Iron deficiency anemia during pregnancy is also associated with having a low birth weight baby and
postpartum depression.

It can also cause low BP, shock and ultimately death.

THE END!