OB-GYNE EVALS 1

TRANS 2
Obstetric History and PE

OUTLINE Chief Complaint: Dizziness

1. Obstetric History (Page 1) PAST MEDICAL/SURGICAL HISTORY

a. General Data (Page 1)
b. Chief Complaint (Page 1) ● previous medical illness
c. Past Medical/Surgical History (Page 1) ● previous surgeries (ask further questions: where, when, how
d. Family History (Page 1) was it done, etc.)
e. Personal/Social History (Page 1) ● hospitalizations
f. Menstrual History (Page 2) ● immunizations (Hep B, HPV, Tetanus)
g. Obstetrical History (Page 2) ● Neurological Disorders
h. Gynecological History (Page 2) ● Cardiovascular Disorders/HPN
i. Sexual History (Page 2) ● Pulmonary Disorders
j. Contraceptive History (Page 2) ● Renal/Urinary Tract Disorders
k. History of Present Pregnancy (Page 2) ● Hepatic/Biliary/Pancreatic Disorders
l. Review of Systems (Page 3) ● Endocrine Disorders
2. General Survey (Page 3) ● Hematological Disorders
a. Physical Examination (Page 3) ● Connective Tissue Disorders
b. Regional Examination (Page 3) ● Dermatological Disorders
c. Leopolds Maneuver (Page 4) ● Neoplastic Disorders
d. Genital Exam (Page 5) ● Infectious Diseases
3. Laboratory Test (Page 5) ● Psychiatric Disorders
4. Nutritional Counseling (Page 5)
5. Summary (Page 6) Note: ALWAYS start with the POSITIVES before negatives. Elicit all
information as much as possible. Ask for complications and confirm
if there were any.
Ask how long patients stayed in the hospital if they were admitted.
OBSTETRIC HISTORY
Lab
NOI-POI-DOI-TOI -> Nature, Place, Date, Time of Incident
GENERAL DATA

FAMILY HISTORY
Must contain the following:
● Patient’s Initials (no mentioning of names)
● Age
● OB Score = G_P_ (T_P_A_L_)
● Civil Status FROM Lecturer
● Nationality
● Religion “Same with Past Medical History except that it talks about the
● Place of Birth “kamag-anak” - Doc (so conyo dudeparechong chz)
● Current Residence
● Consulted DLSUMC-OPD/Private for the ___ time on
____(date) at ___(time) ● Heterofamilial Illness: Hypertension, Diabetes Mellitus,
Cancer
Note: Don’t need to indicate the gender ● Communicable diseases: PTB, Hepatitis
● History of multifetal pregnancies, congenital anomalies
CHIEF COMPLAINT
➢ POSITIVES then negatives.
● Subjective
➢ relationship/consanguinity to patient
● Immediate reason
● Reason why patient consulted/was admitted ➢ similar to Past Medical History

Example: Patient had an irregular menstruation for two months but Note: Identify the risk factors.
during the day of consultation, she woke up feeling dizzy and
decided to go for a checkup. PERSONAL/SOCIAL HISTORY

OBSTETRICS AND GYNECOLOGY: OBSTETRIC HISTORY AND PE 1/6

Dr. P.E. Contemplacion
OB-GYNE: Obstetric History and PE EVALS 1 TRANS 2
● Date
Start with the patient, then the partner, then the place where they ● Age of Gestation (term or preterm)
are living-in. ● Manner of delivery (vaginal, assisted (use of forceps), caesarian
(why it is done).
A. Patient ● Gender
● Blood type ● Birthweight
● Educational attainment ● Place/attendant (In a lying in? By Obgyne, midwife or hilot)
● Employment/source of income ● Present status
● Smoking: # of sticks/day ● Complications
○ When started/when stopped ● if CS: nominal order (Primary, Secondary Repeat) type of
○ (pack years: # of sticks per day/20 x #of years incision (Most common: Low Transverse, Classical) Indication:
smoked) (Breech, Cephalo-pelvic disproportion (maliit ang sipit-sipitan)
● Alcohol intake ● Complications: maternal/fetal (ante-,intra-,postpartum)
○ when started/stopped frequency/quantity GYNECOLOGICAL HISTORY
● Illicit drug use
○ when started/stopped frequency/quantity ● Reproductive Tract, Breast
● Recreational activities ○ Ask for the condition of all parts - outer to inner
● Infections
B. Partner ● Diseases
● Blood type ● Surgery (diagnosis, type, date, place, biopsy, result,
● Educational attainment complications
● Employment/source of income ● Papsmear (date, results, meds)
● Smoking: # of sticks/day
○ When started/when stopped
○ (pack years: # of sticks per day/20 x #of years Note: Ask if there is itchiness, color of discharge, vaginal warts, and
smoked) IMPORTANTLY, counter check the histopathology result, to know
● Alcohol intake if truly benign or malignant. Confirm if there is medications given
○ when started/stopped frequency/quantity
● Illicit drug use
○ when started/stopped frequency/quantity SEXUAL HISTORY
● Intimate Partner Violence
● Coitarche - First coitus (year and age, the earlier the coitus =
C. Household higher risk of cervical cancer)
● Members of the household (enumerate) ● No. of lifetime sexual partners
● House ● Associated Signs and Symptoms:
○ bungalow/2-store ○ Dyspareunia - pain during sexual contact, identify the
○ concrete/wood/etc. source of pain
○ lighting/ventilation ■ Vaginal Pain - poor lubrication
○ water source/drinking/cooking ■ Hypogastrium Pain - might be infection or
○ toilet type mass
○ garbage disposal (segregation, etc.) ○ Post-coital bleeding
● Regularity
● Satisfaction
MENSTRUAL HISTORY ○ To confirm IPV (Intimate Partner Violence)
● Date of last sexual contact
M - enarche (start of your menstruation)
I - nterval (regular vs irregular) normal range: 21-35 days. If your
patient cannot recall just write regular monthly period CONTRACEPTIVE HISTORY
D - uration
A - mount (how many pantyliners per day) Maximum blood flow: 80 ● Natural (calendar, abstinence, withdrawal, basal body
ml per day temperature, cervical mucus method)
S - igns/symptoms (headache, dysmenorrhea, pain in the hypogastric ● Artificial (oral contraceptives, intrauterine device, bilateral
tubal ligation, vasectomy, condoms, subdermal implant -
area, lumbar pain, give the pain scale, medication: frequency &
most recent)
dosage) ● When started? When stopped? Reason?
● Adverse Effects (be very specific: headaches, weight
OBSTETRICAL HISTORY loss/gain, vomiting, epigastric pain)
●
● OB score: GP(TPAL) No. of pregnancy

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OB-GYNE: Obstetric History and PE EVALS 1 TRANS 2
HISTORY OF PRESENT PREGNANCY SIGNS AND SYMPTOMS POSSIBLE CAUSES
Pyelonephritis,
● Last Normal Menstrual Period (LNMP) - first day of last normal Chills and fever
menstrual period wherein there is a free-flowing fresh blood; chorioamnionitis
kailan ang unang araw ng huling normal na regla? Persistent vomiting Hyperemesis gravidarum
○ Pagbabawas - spotting is not considered menstruation
Dysuria Urinary tract infection
○ Best time to use Pregnancy Test is 10 days after the
Expected Menstrual Period Swelling of face and fingers Severe preeclampsia
● Past Normal Menstrual Period (PNMP)
○ First day of menstruation prior to LMP Severe or persistent headache Severe preeclampsia
● Expected Date of Delivery (EDD) - Naegele’s rules; subtract 3 Blurring of vision Severe preeclampsia
from the month then add 7 to the day
Placenta previa, placenta
● Age of Gestation (AOG)
Vaginal bleeding abruptia, spontaneous
abortion
Preterm labor, severe
Abdominal pain
preeclampsia (epigastric pain)
Fluid leakage from vagina Rupture of fetal membrane
FROM Lecturer
Sudden change in frequency
Sample AOG Computations and intensity of fetal Fetal compromise
movements
Sample 1 of AOG Computation:
● LNMP: November 10, 2019 GENERAL SURVEY
● November – 20 days
● December - 31
PHYSICAL EXAMINATION
● January – 24 (date today)
● 75 days /7 = 10 weeks and 5 days
A. Vital Signs
○ BP, RR, HR, Temp
Sample 2 of AOG Computation:
○ Weight (Antepartum and present)
● LNMP: Sept 8, 2019
○ Height
● September - 22
○ BMI with Interpretation
● October - 31
● November - 30
B. Clinical Pelvimetry
● December - 31
○ Pubic arch
● January - 24
○ Diagonal Conjugate
● 138 days / 7 = 19 weeks and 5 days
○ Sacrosciatic Notches
○ Side walls
● Quickening
○ Spines
● Past Consultations
○ Sacral inclination
○ When was the first check up?
○ Sacral curvature
○ AOG?
○ Bituberous diameter
○ Missed Menstrual Period?
○ Coccyx
● Subjective
○ 10 Danger Signs of Pregnancy
C. Internal Exam
● Objective
○ CERVIX
○ Previous Findings? Tests done? Prescription?
■ Dilatation (1cm)
● Assessment
■ Effacement (50%)
● Plan
■ Position (post, mid, ant)
■ Amniotic membrane (intact, leaking,
Note: If the chief complaint is not for regular Pre-Natal Check up but
ruptured)
for problem - HPI (History of Present Illness) needs to be presented
■ Presentation (cephalic...)
before HPP (History of Present Pregnancy)
■ Station (-2...)

D. Regional Exam
REVIEW OF SYSTEMS
○ ABDOMEN
○ INSPECTION
10 Danger Signs of Pregnancy:
■ linea nigra, striae, “scars”, telangiectasia
○ PALPATION

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OB-GYNE: Obstetric History and PE EVALS 1 TRANS 2
■Fundic Height (20-34 weeks)
■ <20 weeks – Abortion – do Internal/Pelvic LM 1: FUNDAL GRIP
Exam
■ Leopold’s Maneuver 1. Doctor is facing the mother
○ AUSCULTATION 2. Place Both hands and palpate for the uterine fundus, the
■ Fetal Heart Tone (location) uppermost part of the uterus to determine which fetal part
■ (110-160 bpm) occupies the uterine fundus
■ *In Labor: uterine contractions (interval, 3. Breech - nodular, soft parts
duration, intensity) 4. Head - hard, round, ballotable, mobile
5. Reporting: LM1 = Breech or Head.

LM 2: UMBILICAL GRIP

1. The doctor is facing the mother

2. Palpate the sides of the maternal abdomen and determine where
the spine is (smooth, curved and resistant) and small knob-like
parts
3. Convex part of the fetus is on the left maternal side
4. Reporting: LM 2 = fetal back is on the left maternal side

LM 3: PAWLIK’S GRIP

1. Doctor is facing toward the mother

2. Determines the presentation of the baby
3. Non-dominant hand is placed on the fundus and applies
pressure while the dominant hand is placed above the
symphysis pubis with the index finger and thumb trying to
palpate which part of the baby is occupying the area
4. Breech - nodular, soft
5. Head - hard, round, ballotable
Fundic Height - Lips: Mild, Nose: Moderate, Forehead: Strong 6. Reporting: LM3 = Breech or Cephalic

LM 4: PELVIC GRIP

AOG LOCATION 1. Doctor facing the feet of the mother

2. Area above the symphysis pubis is palpated to locate the fetal
8-12 weeks Level of symphysis pubis presenting part and determines how far the fetus has descended
3. Determines whether the fetus is engaged (passed through the
16 weeks Midway between symphysis
inlet and stuck in the pelvic bone)
pubis & umbilicus
4. Converging hands/fingers - baby is still bouncing and ballotable
= unengaged
20 weeks Umbilicus
5. Unconverged hands/fingers = engaged
6. Reporting: LM4 = Engaged or Unengaged
36 weeks Xiphoid process

As AOG progresses (37 – 40 weeks), the fundic height decreases

because the baby starts to descend

Note: What is the consistency of cervix if the patient if the cervix is

not pregnant? The nose because it’s firm

Reminder: As much as possible, complete the PE Neurologic exam:

if warranted
Indicate if “not done” -- STATE THE REASON WHY

LEOPOLD’S MANEUVER

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OB-GYNE: Obstetric History and PE EVALS 1 TRANS 2
a. Cervix dilatation and effacement
i. *Insert 2 fingers into the vagina and palpate
for the cervix, while the non-dominant
hand will be placed on top of the uterus
(fundus)
b. Position
i. Anterior, mid, posterior
c. Amniotic membrane
i. *Palpate if it is intact, ruptured or leaking
(only if the cervix is already dilated usually
at 1cm)
d. Presentation
e. Station
f. *BEFORE doing the examination, observe the
surrounding area first
4. Clinical Pelvimetry
a. Adequacy of the pelvic bones
i. Adequate, doubtful, inadequate
Figure 2. Leopold’s Maneuver positions
5. Notes for Genital Examination
LM1 = Top left; LM2 = Top right; LM3 = Bottom left; LM4 = bottom right
a. 12 weeks - fundus is at the level of the symphysis pubis
b. 20 weeks - the fundus is at the level of the umbilicus
FETAL HEART TONES
c. The cervix is 2-3cm long
d. If the physical exam cannot be completed, always state
Fetal Heart Tones (Best heart at the fetal back)
WHY
Ex.: Cephalic - LLQ; Breech - LUQ; Transverse- Periumbilical (back
e. Urological exam may be done only if the patient
down/back up)
warrants it

LABORATORY TEST

Laboratory Test Reason

Complete Blood Count Anemia
Blood Type with Rh Always with Rh
ABO incompatibility
Rh (+) or (-) especially if with
foreigner partner
Blood Transfusion - If the
patient delivers vaginally, ½
liter of blood will be lost; if
caesarean section, 1 liter of
blood
Figure 3. Leopold’s Maneuver
Hepatitis B Serology Increased incidence of Hep B
Transverse Lie- LM1: empty, LM3: empty, fetal head is on the right maternal
side
in the Philippines.
Blood Sugar Test Endemic Diabetes VDRL/ RPR
GENITAL EXAMINATION (Syphilis)
HIV Universal Request/Test
1. External Exam Urinalysis/Urine Culture Infection
a. Scars, lesions, masses, erosions, inflammation, warts, Pap Smear During the first prenatal
varicosities, etc. check-up for Cervical
b. Presence of Bartholin’s cyst Cancer/Infection
2. Speculum Exam Electrophoresis Thalassemia
a. Check cervix for color, erosions, masses, discharge and Phenylalanine Phenylketonuria
color
b. Describe as you see it NUTRITIONAL COUNSELING
3. Internal exam

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OB-GYNE: Obstetric History and PE EVALS 1 TRANS 2
● Maternal weight gain during pregnancy has a positive ● Comprehensive History Taking
correlation with birth weight o Expected Date of Delivery
● Severe nutritional deficiency = lighter, shorter, thinner babies o Age of Gestation
o OB Score
● Physical Examination
● o Fundic Height
o Leopold’s Maneuver
o Fetal Heart Tone
o Genital: External, Spectrum, Internal

REFERENCES
1. References
● 2. Books
● In normal pre-pregnant BMI, the patient is allowed to have 25- TRANSCRIBERS
35lbs of weight gain throughout pregnancy 1. TRANS GROUP: 17B
● OBESITY 2. SUBTRANSHEAD: EJ Labios
o Increased:
De La Salle – Health Science Institute College of Medicine
▪ Gestational Hypertension/Pre-eclampsia
Batch Twenty Twenty-Two
▪ Gestational Diabetes
▪ Fetal Macrosomia “non sibi sed omnibus”
▪ Caesarian delivery chance
● UNDERNUTRITION
o Increased:
▪ Low birthweight babies
▪ Glucose intolerance
▪ Reactive airway disease
▪ Hypertension, dyslipidemia, coronary artery
disease
● BARKER HYPOTHESIS (Fetal Programming)
o Fetal Health is correlated to adult morbidity and
mortality
o Intrauterine growth retardation, low birth weight and
premature birth have a causal relationship to the
origins of hypertension, coronary heart disease, and
non-insulin dependent diabetes in middle age.

o
▪ Emphasis on Iron
● Normal hemoglobin = 27mg
● Anemic = 100mg

SUMMARY

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