History taking and examination in obstetrics

Learning Outcomes

After studying this chapter you should be able to:

Knowledge criteria

Explain the relevance of a detailed history of the index pregnancy
Discuss the importance of previous obstetric, medical, gynaecological and family history
Explain how to conduct a detailed, general, obstetric and pelvic examination
Discuss the pathophysiological basis of symptoms and physical signs in pregnancy

Clinical competency

Take a detailed obstetric history in a normal pregnancy and a pregnancy with complications in the index or previous pregnancy
Carry out general and obstetric examination in a normal pregnancy and that with maternal or fetal complications, including:
- Measure blood pressure in pregnancy
- Perform and interpret urinalysis in pregnancy
- Perform an abdominal examination in women during pregnancy (over 20 weeks)
- Auscultate the fetal heart
Summarize and integrate the history, examination and investigation results and formulate a management plan
Provide explanations to patients in a language they can understand

Professional skills and attitudes

Reflect on the components of effective verbal and non-verbal communication
Understand the need to be flexible and be willing to take advice in the light of new information
Recognize the acutely unwell patient in obstetrics

It is vital to differentiate the normal anatomical and physiological changes associated with pregnancy from pathological conditions whilst managing a woman during pregnancy, childbirth and puerperium. Basic clinical skills in obstetrics include effective verbal and non-verbal communication in a logical sequence: history, eliciting physical signs (general, systemic and obstetric examinations), differentiating normal pregnancy-associated changes from abnormal deviation and arriving at a provisional diagnosis. Contemporaneous, accurate, detailed and legible clinical note-keeping is a cornerstone of ‘basic clinical skills’. Such a systematic approach will aid effective management by ensuring a multidisciplinary input when required.

Taking a relevant and comprehensive history

Taking a relevant and accurate history forms a cornerstone of good clinical practice, as it helps arrive at a diagnosis. It is essential to appreciate that taking a comprehensive history in obstetrics and gynaecology involves eliciting confidential and often very ‘personal’ information. Therefore, it is essential to build a good rapport with the woman during the consultation and ask confidential and sensitive information towards the end of this history-taking process, after establishing mutual trust and confidence.

Obstetric history

It is advisable to commence obstetric history taking by eliciting details of the current (or index ) pregnancy followed by previous obstetric (including modes of birth and complications) and previous gynaecological history.

History of present pregnancy

The date of the first day of the last menstrual period (LMP) provides the clinician with an idea of how advanced the current pregnancy is, i.e. period of gestation. However, this information is often inaccurate, as many women do not record the days on which they menstruate unless the date of the period is associated with a significant life event or the woman has been actively trying to conceive. Hence, in addition to LMP, an ultrasound scan in the first or early second trimester should be used to date the pregnancy and to confirm the gestational age.

Menstrual history should also include the duration of the menstrual cycle, as ovulation occurs on the fourteenth day before menstruation. The time interval between menstruation and ovulation (the proliferative phase of the menstrual cycle) may vary substantially, whereas the post-ovulatory phase (secretory phase) is fairly constant (12–14 days).

The length of the menstrual cycle refers to the time interval between the first day of the period and the first day of the subsequent period. This may vary from 21 to 35 days in normal women, but menstruation usually occurs every 28 days.

It is important to note the method of contraception prior to conception, as hormonal contraception may be associated with a delay in ovulation in the first cycle after discontinuation. The age of onset of menstruation (the menarche ) may be relevant in teenage pregnancies to determine the onset of fertility.

The estimated date of delivery (EDD) can be calculated from the first day of the LMP by adding 9 months and 7 days to this date. However, to apply this Naegele’s rule, the first day of the menstrual period should be accurate and the woman should have had regular 28-day menstrual cycles ( Fig. 6.1 ). The average duration of human gestation is 269 days from the date of conception. Therefore, in a woman with a 28-day cycle, this is 283 days from the first day of the LMP (14 days are added for the period between menstruation and conception). In a 28-day cycle, the EDD can be calculated by subtracting 3 months from the first day of the LMP and adding on 7 days (or alternatively, adding 9 months and 7 days). It is important to appreciate that only 40% of women will deliver within 5 days of the EDD and about two-thirds of women deliver within 10 days of the EDD. The calculation of the EDD based on a woman’s LMP is therefore, at best, a guide to a woman as to the date around which her delivery is likely to occur.

Fig. 6.1, Calculation of the estimated date of delivery (EDD). LMP, Last menstrual period.

If a woman’s normal menstrual cycle is less than 28 days or is greater than 28 days, an appropriate number of days should be subtracted from or added to the EDD. For example, if the normal cycle is 35 days, 7 days should be added to the EDD.

Symptoms of pregnancy

A history of secondary amenorrhoea in a woman who has been having a regular menstrual cycle serves as a self-diagnostic tool for pregnancy. In addition to this, anatomical, physiological, biochemical, endocrine and metabolic changes associated with pregnancy may result in the following symptoms ( Table 6.1 ).

Table 6.1

Symptoms of pregnancy

Symptoms of pregnancy	Explanation	Deviation from normal
Amenorrhoea	As the fertilization occurs, the corpus luteum enlarges and will increase the production of progesterone. As both progesterone and oestrogen levels rise in pregnancy, they suppress further ovulation, leading to amenorrhoea.	Hypothalamo-hypophyseal hormonal changes Ovarian changes (polycystic ovarian syndrome (PCOS), premature menopause, etc.) Uterine scarring, intrauterine adhesions Contraception Low/high body mass index (BMI) Stress
Nausea and vomiting	It is believed to be secondary to a rise in human chorionic gonadotropin (hCG) and commonly occurs within the first 2 weeks of missing the first period. Although it is commonly described as morning sickness, vomiting may occur at any time of the day and is often precipitated by the smell or sight of food.	Hyperemesis gravidarum is severe or persistent vomiting leading to maternal dehydration, ketonuria and electrolyte imbalance. This condition needs prompt diagnosis, rehydration and correction of metabolic and electrolyte derangements. Gastrointestinal infections and food poisoning can also present with these symptoms.
Frequent micturition	It is considered to be due to the pressure on the bladder exerted by the gravid uterus. It tends to diminish after the first 12 weeks of pregnancy as the uterus rises above the symphysis pubis. Plasma osmolality falls soon after conception, and the ability to excrete a water load is altered in early pregnancy. There is an increased diuretic response after water loading when the woman is sitting in the upright position, and this response declines by the third trimester. However, it may be sufficient to cause urinary frequency in early pregnancy.	Urinary tract infections (UTIs) can present with persistence of increased frequency, as well as associated symptoms (dysuria, haematuria).
Excessive lassitude or lethargy	It is thought that progesterone can cause lethargy and fatigue. It is a common symptom in early pregnancy and may become apparent even before the first period is missed. Often, it disappears after 12 weeks of gestation.	Hypothyroidism can have similar effects, and expectant mothers with excessive fatigue should be tested for it.
Breast tenderness and heaviness	It is due to the effect of increasing serum progesterone and prolactin increasing the breast tissues to be ready for lactation, as well as an increased retention of water.	This can be experienced in the premenstrual phase of the cycle. It can also be caused by infections, abscesses or injuries and sprains. It can also be a side effect of some medicines (contraceptives, antidepressants).
Fetal movements	First perception of fetal movements is called quickening . It is not usually noticed until 20 weeks’ gestation during the first pregnancy and 18 weeks in the second or subsequent pregnancies. However, many women may experience fetal movements earlier than 18 weeks, and others may progress beyond 20 weeks of gestation without being aware of fetal movements at all.	Both the lack of fetal movements and a sudden increase in their activity can be abnormal in pregnancy. A decrease can be caused by chronic fetal distress, as in pre-eclampsia, while a sudden increase may be a sign of placental abruption, although this is not well documented.
Pica	Pica is an abnormal desire for a particular food. In pregnancy, particular cravings are considered to be normal; they are thought to be due to hormonal changes.	Its subject can also be a non-nutrient, like soil, metals, paper or wall paint. It can be a sign of iron deficiency.

Pseudocyesis

Pseudocyesis refers to development of symptoms and many of the signs of pregnancy in a woman who is not pregnant. This is often due to an intense desire for or fears of pregnancy that may result in hypothalamic amenorrhoea. In modern obstetric practice, with the widespread use of ultrasound scanning in early pregnancy, it is unlikely to proceed into late pregnancy unless the woman presents late to a booking clinic.

The presence of a negative pregnancy test and ultrasound scan information will provide confirmation that the woman is not pregnant. However, a sympathetic approach and support are essential to resolve the underlying anxieties that led to pseudocyesis. Menstruation usually returns after the woman is informed of her condition.

Previous obstetric history

The term gravidity refers to the number of times a woman has been pregnant, irrespective of the outcome of the pregnancy, i.e. termination, miscarriage or ectopic pregnancy. A primigravida is a woman who is pregnant for the first time, and a multigravida is a woman who has been pregnant on two or more occasions.

This term gravidity must be distinguished from the term parity, which describes the number of live-born children and stillbirths a woman has delivered after 24 weeks or with a birth weight of 500g. Thus, a primipara is a woman who has given birth to one infant after 24 weeks.

A multiparous woman is one who has given birth to two or more infants, whereas a nulliparous woman has not given birth after 24 weeks. The term grand multipara has been used to describe a woman who has given birth to five or more infants.

Thus, a pregnant woman who has given birth to three viable singleton pregnancies and has also had two miscarriages would be described as gravida 5 para 3: a multigravid multiparous woman.

A parturient is a woman in labour, and a puerpera is a woman who has given birth to a child during the preceding 42 days.

A record should be made of all previous pregnancies, including previous miscarriages, and the duration of gestation in each pregnancy. In particular, it is important to note any previous antenatal complications, details of induction of labour, the duration of labour, the presentation and the method of delivery, as well as the birth weight and sex of each infant.

The condition of each infant at birth and the need for care in a special care baby unit should be noted. Similarly, details of complications during labour, as well as puerperium, such as postpartum haemorrhage, infections of the genital tract and urinary tract, deep vein thrombosis (DVT) and perineal trauma, should be enquired. It is vital to appreciate that these complications may have a recurrence risk and may influence the management of subsequent pregnancies; e.g. history of DVT requires thromboprophylaxis during the antenatal and postnatal periods.

Previous medical history

The effects of pre-existing medical conditions on pregnancy, as well as the effect of anatomical, biochemical, endocrine, metabolic and haematological changes associated with the physiological state of pregnancy on pre-existing medical conditions, should be considered.

The natural course of diabetes, renal disease, hypertension, cardiac disease, various endocrine disorders (e.g. thyrotoxicosis and Addison’s disease) and infectious diseases (e.g. tuberculosis, HIV, syphilis and hepatitis A or B) may be altered by pregnancy. Conversely, they may adversely affect both maternal and perinatal outcome (see Chapter 9 ).

Family history

Most women will be aware of any significant family history of the common genetically based diseases, and it is not necessary to list all the possibilities to the mother, as it may increase her anxiety. A general enquiry as to whether there are any known inherited conditions in the family will be sufficient, unless one partner (or both) is adopted and not aware of his/her family history.

Detailed and relevant information obtained with regard to demographics (e.g. maternal age; increased body mass index [BMI]); past obstetric, medical and surgical history (e.g. laparotomy, caesarean section, myomectomy); and family history will help in performing appropriate tests, as well as in making a care plan.

Examination

Examination during pregnancy involves general, systemic (cardiovascular system, respiratory system, general abdominal and, in specific circumstances, a neurological examination) and detailed obstetric (uterus and its contents) examinations ( Table 6.2 ).

Table 6.2

Examination in pregnancy

System	Change and explanation	Deviation from normal
Skin	Face: Many women develop a brownish pigmentation called chloasma over the forehead and cheeks, particularly where there is frequent exposure to sunlight ( Fig. 6.3 ). The pigmentation fades after puerperium.	Chloasma (or melasma) can also be a symptom of Addison’s disease, haemochromatosis or lupus and a side effect of light-sensitive drugs.
	Abdomen: Examination of the abdomen commonly shows the presence of stretch marks, or striae gravidarum ( Fig. 6.4 ). The scars are initially purplish in colour and appear in the lines of stress in the skin. These scars may also extend on to the thighs and buttocks and on to the breasts. In subsequent pregnancies, the scars adopt a silvery-white appearance. The linea alba often becomes pigmented and is then known as the linea nigra . This pigmentation often persists after the first pregnancy.	Stretch marks can also occur during rapid weight loss or weight gain and can also be found on other parts of the body. The hormone cortisone weakens the connective tissue; therefore increased production, e.g. Cushing’s syndrome or higher intake of corticosteroid medications, can also present with stretch marks.
Heart and lungs	Heart: Benign ‘flow murmurs’ due to the hyperdynamic circulation associated with normal pregnancy are common and are of no significance. These are generally soft systolic bruits heard over the apex of the heart, and occasionally a mammary souffle is heard, arising from the internal mammary vessels and audible in the second intercostal spaces. This will disappear with pressure from the stethoscope ( Fig. 6.5 ). Lungs: Examination of the respiratory system involves assessment of the rate of respiration and the use of any accessory muscles of respiration.	Other cardiac murmurs can be signs of severe cardiac disease. If a murmur is heard in systole, it can indicate aortic or pulmonary stenosis or mitral or tricuspid regurgitation, whereas a murmur in diastole can be caused by mitral or tricuspid stenosis or aortic or pulmonary regurgitation. In these cases, cardiology review is necessary, as worsening of these conditions due to the cardiovascular changes in pregnancy can lead to heart failure. Gross lung pathology may adversely affect maternal and fetal outcome and should therefore be identified as early in the pregnancy as possible.
Head and neck	Mucosa: The colour of the mucosal surfaces and the conjunctivae should be examined for pallor, as anaemia is a common complication of pregnancy. Teeth: The general state of dental hygiene should also be noted, as pregnancy is often associated with hypertrophic gingivitis and dental referral may be needed. Periodontitis and gingivitis can be associated with increased risk of infection and pre-term birth, although this is still debated in the literature. Neck: Some degree of thyroid enlargement commonly occurs in pregnancy, but unless it is associated with other signs of thyroid disease, mild thyroid enlargement can generally be observed.	Anaemia can also occur due to prolonged gastrointestinal bleeding, haemorrhoids and excessive menstrual bleeding (menorrhagia or dysmenorrhoea). It can be a sign of various haematological conditions as well. Gingival hypertrophy can occur due to poor hygiene and inadequate diet. Inflammatory changes due to infections can have similar presentation. It can develop as a side effect of some medications, such as anticonvulsants, antihypertensives or immunosuppressants. If signs of hyperthyroidism (diarrhoea, nervousness, hyperactivity, sweating, weight loss etc.) or hypothyroidism (tiredness, weight gain, increased cold sensitivity) appear, further investigations are needed.
Breasts	The breasts show characteristic signs during pregnancy, which include enlargement in size with increased vascularity, the development of Montgomery’s tubercles and increased pigmentation of the areolae of the nipples ( Fig. 6.6 ).	Although routine breast examination is not indicated, it is important to ask about inversion of nipples, as this may give rise to difficulties during suckling, and to look for any pathology such as breast cysts or solid nodules in women who complain of any breast symptoms. Breast cancer during pregnancy is reportedly associated with rapid progression and poor prognosis. Hence, any complaint of a ‘lump’ in the breast should prompt a detailed breast examination.
Abdomen	Hepatosplenomegaly should be excluded, as well as any evidence of renal enlargement. The uterus does not become palpable as an abdominal organ until 12 weeks’ gestation.	Any other abnormal examination findings require further investigations. The diagnosis of appendicitis in pregnancy is difficult, as the growing uterus alters the anatomy; therefore extra caution is needed when examining a patient with abdominal pain.
Limbs, skeletal changes	Limbs: The legs should be examined for oedema and for varicose veins. They should also be examined for any evidence of shortening of the lower limbs, as this may give problems with gait as the abdomen expands. Spine: Posture also changes in pregnancy as the fetus grows and the maternal abdomen expands, with a tendency to develop some kyphosis and, in particular, to develop an increased lumbar lordosis as the upper part of the trunk is thrown backwards to compensate for the weight of the developing fetus ( Fig. 6.7 ). This often results in the development of backache and sometimes gives rise to sciatic pain.	Other causes of oedema are liver, heart and kidney disease. Contraceptive pills, corticosteroids, malnutrition and prolonged immobility or standing can present with oedema. Other spinal deformities can be congenital, degenerative, idiopathic or caused by a disease (tumours, infections). They can interfere with labour as the pelvic diameters change in these conditions. The patient should be informed about her options for delivery.

General and systemic examination

At the initial visit to the clinic, i.e. the booking visit, a complete physical examination should be performed to identify any physical problems that may be relevant to the antenatal care.

Height and weight are recorded at the first and all subsequent visits, and this will help in the calculation of BMI (BMI = weight in kg/height in m ² ).

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