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Chapter: Medicine Study Notes : Reproductive and Obstetrics

History and Antenatal Booking - Obstetrics

Always assume a woman is pregnant until proven otherwise, always assume a pregnancy is ectopic and the mother has pre-eclampsia until proven otherwise (these are the common dangerous and treatable conditions) .

Obstetrics

 

History and Antenatal Booking

 

·        Always assume a woman is pregnant until proven otherwise, always assume a pregnancy is ectopic and the mother has pre-eclampsia until proven otherwise (these are the common dangerous and treatable conditions) 

·        Objectives of antenatal care:

o  Assessment and monitoring of maternal and fetal well-being

o  Preparing woman and family for childbirth

o  Preparing woman and family for parenthood

·        Introduction Data:

o  Age:  NB „Old‟ at 35:

§  Hypertension/diabetes/DVT more common

§  Down‟s: Past aged 35 risk of Down Syndrome > risk of amnio (approx 1 in 200)

o  Gravidity + Parity:  Eg: G4P2 (+TOP + SAB).  SAB = Spontaneous Abortion.

o  LMP – date of first day of bleeding in last period.  Cycles regular? How long?

o  +/- Martial status

·        History of current pregnancy – if yes to any then focused questions 

o  Due date = LMP + 7 days + 9 months (Naegele‟s rule), if 4 weekly cycle. If 6 weekly cycle, add 2 weeks (ovulation set by end of cycle not beginning) 

o  Date it well. Management decisions later in pregnancy depend on dates being accurate. U/S more accurate early on Þ get accurate dates early on:

§  1st trimester (< 12 weeks) accurate +/- 5 days

§  2nd trimester (12 – 24ish weeks) accurate +/- 10 days

§  3rd trimester (24+ weeks) accurate +/- 2 – 3 weeks

o  Morning sickness

o  Contractions/pain

o  Bleeding

o  Discharge/leakage (rupture of membranes)

o   Foetal movements (from 18 – 20 weeks)

o   Urinary symptoms

·        Past Obstetric History: For each pregnancy:

o   When was it

o   If TOP then: 

§  How many weeks. If 6 – 8 then likely to be choice. If after first trimester maternal or congenital problem more likely so need to ask the reason for the TOP

§  Any problems (bleeding, infection, etc) 

o   Antenatal problems/complications: hypertension, diabetes, PTL (Pre-term labour), medical problems 

o   When did you deliver (how close to your due dates were you)? If pre-term then ­risk this time. Was there a reason? 

o   How delivered? If caesarean need to check surgical report for type of incision. If it was low transverse can trial labour, if vertical then not. Skin incision not reliable indicator. 

o   Weight of baby: big ® ?diabetes (were they screened for diabetes – they will remember the sugar load), small ® ?smoking or growth problem 

o   Post partum bleeding, infection, depression

o   Breast feed, if so how did it go

o   How‟s the baby now?

·        Past Gynaecological History.  If indicated.

o   Actively treat any infection

o   Any chronic infections (eg Herpes) 

o   Polycystic ovaries, uterine abnormality or surgery ® ­ risk

o   Gynaecological cancer: pregnancy hormones may exacerbate the disease

o   Contraceptive history – talk about restarting after pregnancy

o   Smear history: last smear date, any abnormal

·        Past Medical and Surgical History (and maybe very brief systems review): 

o   History of hypertension (any signs of renal disease?), DM, heart disease, asthma, epilepsy, RF, bleeding tendency, clots, previous STIs, TB, Hep B, gynaecological problems, kidney disease, clinical depression, autoimmune disease, thyroid 

o   Previous surgery

·        Medications:

o   See also Topic Pharmacology of Pregnancy and Breast Feeding

o   Remember vitamins and non-prescription meds. Vitamin tablets not recommended in pregnancy (OHCS, p 95).

o   On folate (should be from before conception to 13 weeks)

o   Allergies

·        Family History:

o   As for medical history

o   Clotting problems/DVT

o   Hereditary anaemias: Thalassemia (Mediteranian), Sickle Cell Anaemia (Africian)

o   Birth/Congenital defects (including congenital dislocation of hips)

o   Multiple births

o   Sister or mother with fertility or pregnancy problems (HT, miscarriages, DM, premature labour)

·        Social History (key element in determining pregnancy outcome):

o   Adopted

o   Marital/relationship status, subject to domestic abuse

o   Support system

o   Cigarette, alcohol and recreational drug use 

o   Occupation. Interested in exposures. Also stay away from high impact activity and keep HR < 140 (® ¯placenta perfusion)

o   Financial well-being 

o   Low socio-economic status ® ­pregnancy complications (eg poor nutrition, lack of antenatal care, etc) 

o   Enquire about anxieties, etc

·        Offer advice on:

o   Questions or concerns (especially if first pregnancy or previous miscarriage)

o   Ante-natal screening

·        Ante-natal classes

·        Dental check-up

·        Smoking and alcohol 

·        Diet, including folate, iron, listeria (nothing from the Deli unless it‟s piping hot, no imported soft cheeses - unpasturised)

·        Morning sickness: keep glucose up (ie morning barley sugar)

·        Rest

·        Knowledge of social security benefits

·        Mild exercise

·        Intercourse OK if there is no vaginal bleeding

·        Pregnancy write-up: [Name] is a [age] year old G_P_ LMP (date) EDD (estimated date of delivery)/EDC (estimated date of confinement) at _ weeks by [LMP or US at _ weeks] who presents for/complaining of etc…. Her prenatal course has been uncomplicated/complicated by…. Should also include (gestation dependent): 

o  Contractions, abdominal pain

o  Bleeding

o  Rupture of membranes – discharge or leakage

o  Foetal movement – 1st baby about 20 weeks, 2nd baby maybe as early as 18 weeks

 

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Medicine Study Notes : Reproductive and Obstetrics : History and Antenatal Booking - Obstetrics |


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