HISTORY TAKING

Date of Clerking:
1. PERSONAL IDENTIFICATION DATA
Name
Age Resident
Registered ID Address
Race & religion Occupation
Marital Status, duration, no. marriage
Gravidity & parity G__ P__ + __ ( )
LMP
EDD, REDD (if any)
POA / POG
Date of admission (DOA)
Blood type

Summary:
a. Presenting my patient, Puan _________________________, ___ years old single / married / widowed ____________
(race & religion) _______(occupation) from __________________________.

b. She is gravida __ parity __ + __ (miscarriage at __ weeks plus __ days POA and confirmed by ______. Primigravida?

c. Her LMP was on ___________ with regular / irregular menses, not / on hormonal / physical contraception and
breastfeeding / not breastfeeding.

d. She was sure of her date by confirmation through _______ (if unsure = she was USOD because of ______).

e. Her EDD would be on the ___________. (If scan during 1st trimester, discrepancy > 2 weeks or scan during 2nd
trimester discrepancy > 7 weeks consider as REDD).

f. Her last child birth was ____ months / years ago. (If Hx of subfertility / miscarriage / IUI / IVF – consider precious
pregnancy).

g. She was admitted to the ward on ___________.

Note:
1. lady on her 1st pregnancy – G1P0
2. woman had twins & pregnant now (24wks) – G2P2
3. a woman has had 4 miscarriages & is pregnant again with only one live baby, she is at 26 wks of gestation now –
G6P1+4
4. a lady in her 6th pregnancy, with history of 1 abortion & 1 molar pregnancy – G6P3+1 abortion, 1 molar pregnancy.
2. CHIEF COMPLAINT

Take note if:

1. GDM / Pre-existing DM : electively admitted for IOL @ stabilization / close monitoring d/t high blood sugar level.
She was not a known case of DM prior to conception, found to have increased blood glucose level, suggestive of
GDM.

2. PlH / CH / PE / lE /etc: electively admitted for IOL @ stabilization / close monitoring d/t high BP

3. This is a referred case from ___ with complain at abnormal lie / breech presentation / excessive or reduced liquor vol

4. Presented with leaking liquor / show / contraction pain / pre-term contraction / per vaginum bleeding / discharge since
___ days ago

3. HISTORY OF PRESENTING ILLNESS (HOPI)

a) Contraction pain, abdominal pain:
- Site, onset, duration, regularity, severity, medication to relieve, exacerbating/relieving factor, associated S/S

b) Vaginal bleeding / show: Onset, duration, amount, anemic (weak, fatigue, pale)

c) Vaginal discharge: Onset, duration, amount, colour, smell

d) Leaking liquor – onset, amount, colour, soak pants / spots, any pad used?

e) Micturition: – frequency, incontinence, pain.

- UTI: dysuria, burning, frequent urgency, fever

f) Constipation

g) Fits / loss of consciousness / loss of attachment

h) GDM: BSP – ______ (normal or abnormal). OGTT if any? _____ & BSP ______
- When: - During routine antenatal visit / checkup (ANC) - At 17 week of gestation
- on follow-up - During subsequent visit
i) High BP:
- On medication?
- Hx of HT in previous pregnancy
- Signs of IE: blurred vision, headache, giddiness, epigastric pain, reflexes brisk, clonus
- Signs of PE: edema, proteinuria, HT
- Signs of Eclampsia: EPH + tonic seizures

j) Hyperthyroidism
- Signs: weight loss, anxiety, heat intolerance, hair loss, muscle aches, weakness, fatigue, hyperglycemia, polyuria,
polydipsia, delirium, tremor, pretibial myxedema, sweating, palpitations, tachycardia, angina (pain radiated to left
/ right arm), nausea, vomiting, diarrhoea, exophthalmos

k) Fever

l) Anemia (Hb; Headache, pallor, lethargy, fatigue, tachycardia, tachypnea, glossitis, cheilitis, hx of transfusions?)

m) Reduced FM:
- ANC problem? Hx of trauma, UTI, candidiasis

n) If there’s admission:
- During the last antenatal visit, she was informed that she required admx at _____________ d/t ___________

o) Current / past treatment:

- During the admission, ultrasound scan / cardiotocogram / vital signs / IV infusion / blood sample / induction was
done or taken.

p) Progression of mother & fetus:

- She was not in labour since there are no show / leaking liquor or contraction pain.
- The fetal wellbeing was good as the fetal heart was heard & the fetal movement was present with good intensity

Summary:
- She was apparently well before this until ________ when she was detected to have ___________
- She was a known case of ___________ since __________ , currently __________.
4. HISTORY OF PRESENTED PREGNANCY (HOPP)
Suspect pregnancy: Confirmed by
- Menstrual delay, ___ days of missing period - Date: , ____ weeks of POA
- Distension - P/E, blood, screening test
- Others (planned / unplanned) - UPT / Dr consultation / USG (KK / Private hospital)

1st antenatal checkup – POA: __/52 + __ / 7

- When? Where? (specific KK)
- Physical examination: i. Height: ______ cm iii. BP ___/___ mm Hg (hypotensive, normo, hyper)
ii. Weight: _____ kg iv. Pulse: ____ bpm
iii. BMI: _______ kg2 / m

Antenatal screening: (Date: , _____ weeks POA ) Investigations:

i. Blood test : ii. VDRL : reactive / non-reactive i) Blood test
Blood group : iii. TPHA : reactive / non-reactive ii) Urine test:
Rhesus : iv. HIV rapid test : reactive / non-reactive - proteinuria
HbA1c : v. Hepatitis B : reactive / non-reactive - glucosuria
Hb : (< 7%) vi. Thalassemia : reactive / non-reactive
MOGTT : vii. Malaria : reactive / non-reactive

Subsequent antenatal checkup: USG

Parameter (normal): i) weight gain i. When? 1st scan at __ weeks POA. Abnormalities? (AFI & size)
ii) BP ii. Latest scan at ___ weeks of POA. Abnormalities
iii) Pulse
iv) Hb Quickening (movement at 13 – 16 weeks): _____ POA
v) Urine glucose & protein  Any increase in intensity & frequency?
BSP: 4x (pre-breakfast, pre-lunch, pre-dinner, pre-bedtime)

S&S (Pregnancy) Anemia Preeclampsia Eclampsia

- Nausea & vomiting - Headache - Edema - PE signs + tonic siozers,
- Breast discomfort / engorgement - Pallor - Proteinuria
- Frequency of urination - Lethargy, fatigue - HT
- Constipation - Tachycardia UTI
- Ankle edema - Tachypnea - dysuria - fever
- Backache - Glossitis - flank pain - GI symptoms
- Cheilitis - pain
Hyperthyroidism
- Weight loss, - Muscle aches - Polyuria - Pretibial myxedema - Angina (radiate to Lt / Rt arm)
- Anxiety, - Weakness - Polydipsia - Sweating - GI: nausea, vomiting, diarrhea
- Heat intolerance, - Fatigue - Delirium - Palpitations - Exophthalmos
- Hair loss - Hyperglycemia, - Tremor - Tachycardia

Immunization Anti-tetanus toxoid (ATT), Hep B, HPV, Covid 19, rubella

 Summary:
a. This is planned / unplanned and wanted / unwanted pregnancy.

b. She suspected that she was pregnant following ___ days of she missed period / quickening / abdo. distension / weight
gain / nausea vomiting.

c. Then, she went to private clinic / KK and she was confirmed to be pregnant after UPT done was positive at ___ weeks
POA. ____ weeks later, she went to KK for antenatal booking at __ weeks POA.

d. Late booker: She did late booking at POA of ___ weeks.

e. During antenatal booking, her height was ___ cm, her weight was ___ kg, hence her BMI was ___ . Her BP was
______ mm Hg, Hb was ____ and her blood group was ____. The screening test results for HlV, Thalassemia,
Hepatitis and VDRL were negative. The urine test results were normal, no protein & glucose were found

f. She attended all her ANC as scheduled for her. ln all her subsequent visits, she was told all the parameters were
normal and her current weight gain was ___ kg.

g. GDM: She was found to have increased blood sugar during her next ANC visit and was advised to have proper
regular diet and was put on insulin. She continued / discontinued the insulin medication against doctor’s advice.
During her subsequent ANC, her blood sugar values were still high.

h. She had first ultrasound scan at ___ weeks POA. She was informed the fetus was normal and growing well according
to dates without any congenital anomalies. (if any : comment on fetal weight, liquor, placenta)

i. She first felt fetal movement at ___ weeks of gestation with good intensity. She continued to perceive fetal
movements well.

j. She received ___ dose anti-tetanus toxoid (ATT) during ___ weeks of gestation and she got Rubella vaccination
during her school times.

5. PAST OBSTETRICS HISTORY (POH) (IF PREMATURE / OVERDUE – WHY?) (WHY C-SEC?)

Year Gestation Gender Birth Mode of Delivery Place of delivery Breastfeeding Premature? Comorbidities?
& age weight (SVD / IVD / (home / hospital) duration Post complications?
(kg) LSCS) & indication Episiotomy? Indication:

 If > 5 child C-section indication

- Summarize all uneventful deliveries (full term SVD w no Cx) ‐ conjoint twins
o No of children ‐ twins with 1st baby in breech presentation
o Eldest what age? Youngest what age? ‐ contracted pelvis
o All born through FTSVD with no AP, IP, PP Cx ‐ total placeta previa / placenta abruption
o BW range (normal: > 2500g), breastfeeding - macrosomic fetus
- Mention the abnormal deliveries separately - cephalopelvic disproportion
- cord prolapse - extended neck
- malposition - primigravida > 35 y/o
 If miscarriage / abortion / molar pregnancy / ectopic pregnancy
- POG
- Was it confirmed / unconfirmed? UPT? USG (describe)? Beta hCG?
- Why? Spontaneous? Trauma?
- S&S
o Incomplete miscarriage: passed out parts of POC, abd pain, PV bleed
o Threatened miscarriage: bleeding, prem contractions
o Missed miscarriage: Lacked fetal movement
o Molar pregnancy: painless PV bleeding, hyperemesis, high beta hCG
o Ectopic pregnancy: Flank pain, cervical excitation + (abd pain elicited on VE) UPT
- Dilation and curettage done?
- IVD or emergency ERPOC?

 Spacing  Contraceptive method

- Good spacing: 2 years apart - OCP / hormonal injection / IUCD
- Abnormal: > 6 years - Barrier method (male condom & female condom)
o Reason: Contraception? Subfertility? - Compliant / non-compliant, reason:

Summary:
a. She was married at the age of ___ years old in _____. This was a single and non-consanguineous marriage.

b. Uneventful – She had delivered ___ children, __ boys __ girls. Her eldest child was __ years old and the youngest
child was ___ years old, which were all uneventful spontaneous vaginal delivery with babies weight ranging between
___ to ___ kg. All the children were normal, alive and well. Otherwise, she had no intrapartum & postpartum
complications.

c. Eventful / Complicated – She had delivered __ children between ____ until ____ with a history of ___ miscarriage in
the ___ pregnancy.
 Ante-partumly, during her ___ pregnancy, she had history of miscarriage at __ weeks of gestation. The
miscarriage was a confirmed pregnancy diagnosed by USG / unconfirmed. No / An ERPOC was performed and
there was no complications following the procedure. During her __ pregnancy, she had GDM on dietary control
// chronic HPT / gestational HT / pre-eclampsia / eclampsia / chronic HT w superimposed preeclampsia.
 Intra-partumly, during her ___ pregnancy, she had retained placenta & MRP was done in the labour room
successfully.
 Post-partumly, during __ pregnancy, she had history of PPH that requires blood transfusion.
 The rest of the pregnancies were delivered by SVD with babies weight ranging between ___ to ___ kg. All the
children were normal, alive and well.

d. She breastfed all her children for __ year.

e. The miscarriage at __ weeks POA was a confirmed pregnancy diagnosed by ultrasound. An ERPOC was performed
and there was no complication following the procedure.

h. She had a good inter-pregnancy spacing 2 years apart. Her last child birth was ____ months / years ago. (If Hx of
subfertility / miscarriage / IUI / IVF – consider precious pregnancy).
6. GYNAECOLOGY HISTORY

Menarche age
Menstrual cycle - Regular / irregular (when start irregular)
- Cycle (normal 21 – 35 days)
(ask WHY if abnormal) - Flow (normal 2 – 8 days)
- Heavy flow (normal 1st – 3rd days)
- Pad used (average blood loss 30ml) [1 pad = 10-20ml]
(is the pad fully soaked / change frequently)

1. Problems
- Dysmenorrhea (painful menstruation)
- Menorrhagia (prolonged and increase menstrual flow) (blood flow > 80ml) / Pad usage?
- Intermenstrual bleeding
- Postcoital bleeding
- Dyspareunia (painful coital)? Superficial or deep?

2. Pap smear history

- When was first time? __________
- How many times?
- Result normal?
- Why do it?
- When was the last one?

Summary:
a. She obtained menarche at the age of __ years old.

b. She had regular menses with ____ (6-7) days duration of flow in ____ (28-30) days per cycle.

c. She used __ pads per day with minimally-soaked blood.

d. She had no history of dysmenorrhea, menorrhagia and other gynaecological problems

e. She had recent Pap smear for second time done in ____ (year) and the result was told to be normal.

f. She denied practicing any type of contraception @ After the birth of her first baby, she was on OCP / injection /
implantation for ___ months / years. She stopped taking OCP / injection / implantation when she was ready to
conceive.
7. PAST MEDICAL HISTORY (PMH) & PAST SURGICAL HISTORY (PSH)
1. History of chronic illness / cancer
- HPT, DM, Heart disease, Asthma, TB, stroke, gout, epilepsy, CKD, VTE, C19, cancer: __________
2. Any surgery procedure done before? Year of diagnosis, status of the condition
• Appendicectomy, hernial repair, bowel operation
3. Previous admission ? – Why, When, management, treatment

Summary:
a. She was not known to have any underlying disease / chronic illness such as DM, HPN, bronchial asthma, renal failure
b. She was a known case of diabetes mellitus since __ years ago. She had good compliance to medication and was on
dietary control for ___ years / months.
c. She had no history of hospitalization before.
d. She had history of hospitalization in _____ because of Acute Appendicitis. She was admitted for __ days / months and
discharged well.
e. She has not undergone any operation before.
f. She had an Appendicectomy performed at the age of __ years old. There was no intra- or post-operative complication.

8. DRUG HISTORY (always ask dose, duration, purpose, compliance, OTC/Prescription)

a. Hematinic: ferrous fumarate, folic acid, vit B complex, ascorbic acid (Zincofer, Ibaret, Maltofer)
b. Traditional medications / herbal / complementary
c. History of drug allergy: Name, AE (take note if rashes, swelling, SOB)
d. Others: Metformin, Anti-HPN (methyldopa, labetolol, nifedipine, hydralazine), OHA, NSAIDS

Summary:
a. She was on haematinics, vitamin B12 and folic acid for her current pregnancy.
b. She was on Anti-HPN / OHA / NSAIDS since __ months / years ago and claimed good compliance to the drugs.
c. Otherwise, she was not taking any prescribed and traditional medication or any other supplement.
d. She was not allergic to any foods, drugs or any other substances.

9. FAMILY HISTORY
1. Siblings: How many? Any health problem? She is the ____ child in family.
2. Parents: Any health problem?
3. Family history of HPT, DM, heart diseases, asthma, TB, gout, epilepsy, CKD, VTE, C19, cancer: __________
4. Family history of twins pregnancy / congenital abnormality / genetic hereditary

Summary:
a. Her father has gout while her mother passed away due to heart problem in ____.
b. She had no family history of DM & HPN.
c. She is the second out of five siblings. All her siblings are fit and well.
d. There was no history of twin and congenital anomalies run in her family.
10. SOCIAL HISTORY

Education level
Occupation
House condition
Rent / Own / Flat / Terrace / Condo / Kpg; Amenities?
Stay with husband?
If not, how frequent husband visit her?
Husband’s age
Is husband related? Cousin? Distant relative?
Husband’s occupation, income
Who take care of children during admission?
How does she contract her children?
Smoking? Alcohol? Drug? Both husband & ptn
Recent travel

Summary:
a. Currently, she lives with her husband and children at single-storey house and well equipped with basic amenities.
b. Her education level was SPM and she is a housewife.
c. She had no unhealthy habits such as smoking and alcoholic.
d. Her husband is doing odd job with monthly income of RM _____. Her husband is a smoker.
e. Currently, her children are taken care by her mother. Her husband visits her every other day.

11. DIET HISTORY

- How many meals a day? (if is diabetic patient – details diet history
- Size (portion) needed – dishes for every meals)
- Carbs / protein / vege / fat (which one is more)
- For GDM: on diet control / insulin?
- Allergy

Summary:
a. She practices a normal adult balance diet. She ate home-cooked meal and had no food taboo.
b. Currently she is under dietary control and she reduced intake of carbohydrate-rich foods.
c. She was not allergic to any foods or any other substances.
d. She was allergic to seafood such as prawns and crabs / oral antibiotics.
PROVISIONAL DIAGNOSIS
Hypertensive disease in pregnancy

Chronic HT - HT at least 140/90 mmHg before 20th wks of pregnancy OR beyond 6 wks postpartum.
- Includes essential & secondary hypertension.

Gestational HT - HT > 20th week POA in previously normotensive woman

- No proteinuria
- Condition normal w/in 6 wks after labour

Pre-eclampsia Mild - SBP: Increase > 30 mm Hg @ > 140 mm Hg

- DBP: Increase 15 mm Hg @ > 90 mm Hg
- Proteinuria: < 2.0 g/day

Severe - SBP: > 160 mm Hg

- DBP: > 110 mm Hg
- Proteinuria: > 5.0 g/day

Chronic HT with - Development of pre‐eclampsia in patient with pre‐existing HT

superimposed pre-eclampsia - Criteria: worsening of hypertension & proteinuria

Eclampsia - PIH + tonic-clonic seizure

HELLP syndrome - Hemolysis, elevated liver enzymes, low platelets associated with PE or eclampsia

DIFFERENTIAL DIAGNOSIS
SYSTEMIC REVIEW: e) GIT
a) General: Weakness / Fatigue / Appetite - Abdominal pain:
- Nausea:
b) CVS : - Vomiting:
- Chest pain (site): - Hematemesis (muntah darah):
- Ankle swelling: - Dysphagia (susah telan):
- Palpitation: - Polydipsia (dahaga):
- Orthopnea: - Bowel habit: normal diarrhea / constipated
- Paroxysmal Nocturnal Dyspnea: - PR bleeding:
- Apex displaced? - Stool colour
- S1 S2 heard?
- Any murmur?
- Palpitations?

c) Respiratory: f) CNS:
- Dyspnea - Headache:
- Wheezing: - Light headedness:
- Cough: - Blackouts:
- Hemoptysis: - Visual disturbance:
- Chest pain: - Auditory disturbance:
- SOB? - Sleep habit:
- Equal chest expansion?
- Normal breath sounds?
- No rhonchi
- No crepitations

d) Renal:
- Groin pain: g) MSK:
- Frequency: - Fits / seizure:
- Incontinence / urgency: - Unsteady gait:
- Dysuria: - Paresthesia:
- Hematuria: - Muscle weakness:
- Difficulty in voiding:
- Colour:

PHYSICAL EXAMINATION IN OBSTETRICS

GENERAL INSPECTION
Summary:
a. She is a middle age lady with medium-built body size.
b. She is comfortably lying supine in flat position with head supported by one pillow.
c. She is alert, conscious and well-oriented to time, place and person.
d. She looks well, not in pain, tachypnea or respiratory distress.
e. There is no obvious discoloration or peripheral attachment.
f. There is no lump, ascites & engorged veins
VITAL SIGNS:
1. Blood pressure : ___/___ mm Hg, right / left arm in sitting position
2. Pulse rate : ___ beats per minute with regular / irregular rhythm, good volume, normal in character
3. Respiration rate : ___ breathes per minute
4. Temperature : ___ °C, febrile / afebrile
5. BMI : ___ (Weight = ___ kg, Height = ___ cm)

GENERAL EXAMINATION: SUPINE POSITION

• Hand
- Dry/moist, warm/cold, pallor/pink & no palmar erythema.
- HR (radial pulse) : rate, rhythm, radiofemoral delay, radio-radiodelay
- Blood pressure : 15° lateral tilt to left (prevent aortocaval compressions)
- Branula?

• Face
- Conjunctiva: pale / pink
- Sclerae: not jaundice
- Mouth: oral hygiene, no central cyanosis, angular cheilitis (iron deficiency anaemia), beefy tongue
(megaloblastic anaemia)

• Neck:
- Any thyroid enlargement / goitre
- Cervical lymphadenopathy

• Leg:
- Presence of bilateral pitting ankle oedema (common)
- Varicose vein (less likely)

Summary:
a. Hand: Her hand was dry/moist, warm/cold, pallor/pink & no palmar erythema. The capillary refilling time was less
than 2 seconds. Her finger nails had no clubbing, leukonychia and koilonychias. Branula was inserted at the dorsum
of her right / left hand.
b. Wrist: Radial pulse was regularly regular with good volume.
c. Eyes: The conjunctiva are pink/pallor and the sclera are white/yellowish.
d. Mouth: The tongue and lips were moist/dry, suggestive of good/poor hydration status. Her oral hygiene was good, no
central cyanosis, glossitis and angular stomatitis.
e. Neck: There was no neck swelling.
f. Lower limb: There was ankle edema and dilated vein was noted.

ABDOMINAL EXAMINATION (specific)

• Make sure introduce yourself again to patient & introduce your
examiner to your patient.
• Any discomfort of patient need to tell us
• Exposure: xiphisternum to pubic symphysis
• Make sure check for presence of Pfannenstiel scar. (May be very
low & may be missed)
• No need to check for inguinal/femoral hernia
ABDOMINAL INSPECTIONS
• The abdomen is distended with gravid uterus
• Linea nigra / striae gravidarum / stria albicans – can be seen
• The umbilicus is centrally located / deviated – Inverted / flat / everted; hyperpigmentation?
• Any scar (Check for site & scar integrity) – No surgical scar seen
- Surgical scar can be seen in suprapubic area / low transverse suprapubic scar
- Scar is well heal with minimum keloid formation / hypertrophy and tender / non-tender
• Fetal movement seen / not seen
• Others: Skin tag / mole; No impulse seen in coughing

Summary:
a. On inspection, the abdomen was distended with a gravid uterus evidenced by cutaneous signs of pregnancy, ie linea
nigra and striae gravidarum.
b. There were striae albicans and prominent vein.
c. The abdomen was symmetrical and move with respiration.
d. The umbilicus is flat and centrally located.
e. There is transverse suprapubic scar measuring about 6 cm, brown in color, well-healed and non-tender.

PALPATION
1. Superficial palpation – the abdomen is soft / tense & non tender / tender

2. Symphysiofundal height palpation  measure uterine size (1cm = 1 week)

- The SFH is _______cm – corresponds to date.
- If does not corresponds, the FSH is larger / smaller than date

3. Deep palpation – there is contraction of uterus / no

4. On fetal palpation (Leopold’s Maneuvers), at:

- No of fetus, fetal lie (longitudinal / oblique), presentation (breech / cephalic), engagement, parts
o Longitudinal lie with breech / cephalic presentation
o Oblique lie. Fetal head is in RIF / LIF / RHC / LHC, & breech is in the RIF / LIF / RHC / LHC. Fetal back
on the maternal left / right.
o Transverse lie. Fetal head is in RL / LL & breech is in RL / LL. Fetal back is facing xiphisternum /
symphysis pubis.
- 12w - suprapubic, 22w - umbilicus, 36w - umbilicus, after 36 weeks there is fullness flank & cannot get below
the costal margin
- Grips:
o Fundal grip: feel broad, firm, non-ballotable structure  fetal buttock
o Lateral grip: Left / right maternal side,
 feel smooth, firm, continuous, bulging & curve structure  fetal back
 feel irregular knobby structure  fetal limbs
o Pelvic grip: feel hard, rounded, ballotable structure  fetal head
 __ /5 (how many fingers in relation to symphysis pubis)
 4-5/5 = ballotable / not engaged; <3/5 = engaged
- Liquor assessment
o Excessive liquor – large fundus, can't feel fetal parts + fluid thrill.
o Reduced liquor – tense abdomen, small fundus, easy to feel fetal parts.
- Estimated fetal weight (EFW)
o Baseline (28w = 1 kg), every 2w increment add up 0.4kg, means 30w = 1.4kg.
AUSCULTATION
Fetal heart sound (appreciated / not appreciated) on _____ quadrant of maternal side.

Summary:
a. On superficial palpation, the abdomen was soft / tense and non-tender / tender.
b. On deep palpation, the uterus was soft and non-irritable, with no contraction.
c. There was no scar tenderness.
d. The clinical fundal height (CFH) is 34 weeks (+/-2cm is accepted) which corresponded / did not correspond (USTD /
ULTD) to the POG and it measured 35 cm (SFH).

So my impression is
a. There is a singleton fetus in longitudinal lie with cephalic presentation.
b. The fetal back is at right maternal side and fetal limb is at left maternal side (If abnormal lie, mention the sites of fetal
pole palpable).
c. For cephalic only: Head is not engaged and it is 4/5th palpable. (Head is engaged when 2/5th or 1/5th palpable)
d. Clinically, the liquor volume is adequate evidenced by positive fluid thrill
e. I estimate the fetal weight is to be around 3.0 – 3.2 kg. (Multiple pregnancy, estimate combined fetal weight).
f. The fetal heart sound is heard and regular at 140 beats/min. (N = 11.0 - 160 bpm).
g. No scar tenderness

Case Multiple Gestation :

a. There are multiple poles palpable.
b. The 1st pole at RHR and it is hard, round and ballotable.
c. The 2nd pole at RIF and it is soft, broad and non-ballotable.
d. The 3rd pole at LIF and it is ____
e. The cumulative EFW is about ___ kg.

CASE SUMMARY:
Mrs ________________________ is a ___ year-old Gravida __ para __ ______________ (race), at ___ weeks POA who
is admitted for __________________________________ with no / prior history of DM / HPT in preconception period.
Her LMP was on the ______________. Therefore, her EDD is on the _______________ and she is currently at ___ weeks
of gestation. On examination, the fetus corresponds / does not correspond to gestational age in cephalic / breech
presentation / oblique lie / transverse lie, with normal / increased / reduced liquor. She came for her regular ANC and was
found to have __________________ and was started on ______________ therapy.

Post Natal Review

________________________ is a ___ year-old Gravida __ para __ ______________ (race), at ___ weeks POA who is
admitted for active phase of labour. She delivered vaginally after __ hrs of active phase, labour following induction of
labour by _____________ / required forceps / vacuum delivery / ELLSCS. She had delivered a male / female baby with
the weight of ____ kg with APGAR score ___ in 1 min and ___ in 5 min. The amount of blood loss was ___ ml, while the
placenta’s weight was ___ kg. There was no intrapartum/postpartum complication noted. Today, the is well/pallor /with
stable vital signs (mention BP, PR, temp). The uterus is well contracted and __ /52 in size. Lochia is normal with
ambulatory well. Breast feeding was established. Pt takes ________ orally, pass urine, bowel habit, contraceptive plan.
INVESTIGATION – OBSTETRICS

Maternal Fetal
Charting – Pad chart, PE chart, labour progress chart (LPC) Charting – Fetal kick chart (FKC), fetal growth chart
(FGC), lie chart
Vaginal (for Modified Bishop Score) & speculum examination Ultrasound
FBC, anemic profile / Work up: Se iron, ferritin, TIBC 1. No of fetus, if twin (chorionicity)
2. AFI
PE profile – FBC, BUSEC, LFT, PT/aPTT, se uric acid, urinalysis 3. Placental localization
MOGTT, FBS, RBS, BSP, HbA1c 4. EFW
TRO UTI & GTI – HVS, urinalysis, UFEME, urine C&S 5. Cord
6. Fetal presentation
β-hCG urine (UPT) 7. Fetal or uterine anomalies
8. Growth parameter = BPD, HC, AC, FL
9. Fetal heart activity
Cardiotocogram (CTG)
Doppler ultrasound

Hypertensive patients
Outpatient ANC: - Every 4 weeks (if not on tx, norm biophysical profile, good fetal growth
- Every 2 weeks if on tx
Tests: urinalysis (proteins), BP, SFH & liq vol, BUSE, FBC, se uric acid
Fetal surveillance: USG monthly, FKC

Inpatient BP every 4 hours I/O chart

SFH & liq volume Fetal surveillance: FKC, CTG, USG
Daily PE chart, urine protein Anti-hypertensive agents: if DBP > 100 mmHg
FBC, BUSE, serum uric acid Dexamethasone if expect early delivery (<34 wks)
LFT (coagulation profile (if suspect HELLP)

Intrapartum • BP/ pulse rate half hourly • CTG monitoring

• To continue oral antihypertensive treatment • Shortened 2nd stage‐ assisted delivery,episiotomy
• Strict I/O chart • X syntometrime/ergometrine!
• Adequate analgesia (epidural analgesia) • Use Syntocinon 10 units

Postpartum • Ssx of IE & pulmonary edema

• BP monitoring:
- 1/2 hourly for at least 2-4 hours before sending to ward
- 4 hourly in the ward 24-48 hours before discharge
- Antihypertensive should be continued & stopped later on postnatal review
- Stop methyldopa (can cause postpartum depression)
- I/O chart
- Daily urine albumin, PE chart

Criteria to Asymptomatic Urine albumin – nil

discharge BP< 140/90 mmHg Mono-antiHT therapy
Reflexes not brisk Review patient in 2 wks & 6 wks
TREATMENT - OBSTETRICS
1. Ante-Partum
- Non-Pharmacological e.g monitoring / advice, VS Pharmacological, watch out complication
- TOD & MOD accordingly. Depend on maternal / fetal condition (uncomplicated / compromised)
- lf high Risk Pregnancy - lnform Paeds, Booking ventilator
2. lP – Depends on 1st, 2nd & 3rd stages of labour, obstetrics EMS – Red alert, inform superior
3. PP – Follow-up / Contraception / Pre-conceptual counseling