Obstetrics History taking/ Examination

EXAMINATION OF AN OBSTETRICS CASE
MODERATOR:
DR. A.V.RAJESHWAR RAO,
H.O.D & ASSISTANT PROFESSOR OF
DEPARTMENT OF GYNECOLOGY AND OBSTETRICS.
DATE: 16-03-2016
PRESENTER:
DR. VAMSHIKRISHNA DUSSA,
P.G XVIII BATCH, MD-PART-1
DEPARTMENT OF HOMOEOPATHIC PHARMACY.

CONTENTS
• Introduction
• Aims and objectives
• History taking
• Examination Part:
1. Keywords Before Examination
2. General physical examination
3. General systemic review
4. Obstetrical Examination:
A- Abdominal.
B- Vaginal & Cervical.

Introduction
• Systematic supervision (Examination and
Advice) of a woman during pregnancy is
called Antenatal (prenatal care) care.
• The supervision should be of a regular
and periodic nature in accordance with
the principles laid down or more
frequently according to the need of the
individual.

• The care should start from the beginning of
the pregnancy and end at delivery.
• Careful History Taking and Examination
(General and Obstetrical) is a part of Antenatal
care.

Aims & Objectives:
• To screen the High risk cases.
• To treat the complications detected early by
examination.
• To educate mother by demonstrating the
labour.
• To ensure continued Medical Surveillance and
Prophylaxis.

• To remove the fear about the delivery and to
gain confidence before labour.
• To ensure normal pregnancy with delivery of
healthy baby.
• To motive the couple about to need of family
planning.
• To give appropriate advice to couple seeking
MTP.

History Taking:
AN OBSTETRIC CASE SHOULD INCLUDE
• Vital statistics.
• Complaints.
• History of present illness.
• History of Current/Present pregnancy.
• Obstetric history.
• Past gynecological history.

• Past medical and surgical history.
• Drug history and allergies.
• Social history.
• Personal history.
• Family history.

VITAL STATISTICS:
 Name:
 Date of first examination:
 Address:
 Age: A woman having her first pregnancy at
the age of 30 or above (FIGO-35 YEARS) is
called Elderly primigravida.
- Extremes of age (Teenage and Elderly) are
obstetrics risk factors.

 Gravida & Parity :
- Gravida: Denotes a pregnant state both
present and past, irrespective of the period of
gestation.
- Parity: Denotes a state of previous pregnancy
beyond the period of viability.
- Gravida and Para refer to pregnancies and not
to babies.
- As such, a women who delivers twins in first
pregnancy is still a Gravida one and Para one.

• A pregnant woman with a history of two
abortions and one term delivery can be
referred as fourth Gravida but first primipara.
• It is customary in clinical practice to
summarize the past obstetric history by two
digits affixing the letter P (doesn’t denote
parity here).
• Eg: P(2+1)= 2 denotes two viable births, 1 is
one abortion.

But in some centers it is expressed by 4 digits.
Example: P(A-B-C-D)
A = Number of TERM PREGNANCIES(37-42 Wks)
B = Number of PRETERM PREGNANCIES
(28 weeks to < 37 weeks)
C = Number of MISCARRIAGES (< 28 weeks)
D = Number of BABIES ALIVE at present.

 Duration of marriage:
- This is relevant when dealing with pregnancy
- Helps in noting fertility or fecundity of a
woman.
- Pregnancy early after marriage - High
fecundity.
- Pregnancy lately after marriage - Low
fecundity.

 Religion:
 Occupation: Helps in dealing occupational
hazards.
 Occupation of husband :
- Gives fair idea about the socio-economic
status of the patient.
- By this we can know likely complications with
her status like anemia, prematurity,
preeclampsia.

 Period of Gestation:
- The duration of pregnancy is to expressed in
terms of completed weeks.
- A fraction of a week of more than 3 days is to
be considered as completed week.
- In calculation the weeks of gestation in early
part of pregnancy, counting is to be done from
the first day of Last Normal Menstrual Period (
L.N.M.P) and later months of pregnancy,
counting is to be done from expected date of
delivery (E.D.D)

• Most reliable clinical parameter of gestational
age assessment is an Accurate LMP.
• In case of persons who had used oral
contraceptives(OC) LMP may be inaccurate.
• In case of OC use, ovulation may not have
occurred 2 weeks after the LMP.
• In such situation the estimation of gestational
age is more accurate with ultrasonography in
the first trimester.

COMPLAINTS:
- Categorically, the genesis of complaints are to
be noted.
- Even if there is no complaint, enquiry is to be
made about the sleep, appetite, bowel habit
and urination.

HISTORY OF PRESENT ILLNESS:
- Elaboration of the chief complaints as regard
their onset, duration, severity, use of
medication and progress is to be made.

HISTORY OF CURRENT PREGNANCY:
Shall be noted in following ways:
• First Trimester
• Second Trimester
• Third Trimester

HISTORY OF IST TRIMESTER: ( First 12 weeks)
• Amenorrhea during the reproductive period in
an otherwise healthy individual having
previous normal periods, is likely due to
pregnancy unless proved otherwise.
• If H/o Amenorrhea (6-8 weeks), Bleeding p/v
(dark, continuous) is associated with lower
abdominal pain (acute, colicky) (on sides
initially and later whole abdomen) chances of
Ectopic pregnancy.

• Placental sign- Cyclic bleeding till 12 weeks of
pregnancy.
(This happens until Decidual space is obliterated
by the fusion of D. vera with D. capsularis)
• Tiredness, Malaise
Other normal physiological symptoms:
• Nausea/Vomiting- if severe- Hyper-emesis
Gravidarum.
• Heart-burn, Constipation, Insomnia.

• Increased frequency in urination- noted
between 8-11th weeks of gestation.
• Cannot be seen after 12th week due to
straightening of uterus (again seen in 3rd
trimester when uterus pressure increases due
to engagement of fetal head)

HISTORY OF SECOND & THIRD TRIMESTER:
• History of fetal movements- Quickening- 18th
week (2 weeks early in Multigravidae)- more
in 3rd trimester.
• Symptoms of Anemia, Miscarriage, Hyper
emesis gravidarum.
• If H/o Amenorrhea, Bleeding p/v (slight, bright
red), painless (dull lower back pain), and if
bleeding first and pain later- suggestive of
Abortion.

• If H/o Amenorrhea, bleeding p/v ( recurrent,
sudden), painless- Placenta previae.
• If Symptoms of heavy bleeding, partial
expulsion of products of conception which
resemble grapes with nausea and vomiting,
cramping lower abdominal pain, history of
ovarian cysts- Molar pregnancy.
• Ask for vaccination H/o ( Tetanus and Rh.
Immunization)

Results of all Antenatal blood tests-
• Routine and Specific.
• Results of Anomaly and other scans (Details of
results can be cross checked with the notes).

Note:
• Remember that the pain may be unrelated to
the pregnancy so keep an open mind!
Causes of abdominal pain in pregnancy include:
• Obstetric: Preterm/Term Labour, Placental
Abruption, Ligament Pain, Symphysis Pubis
Dysfunction, Pre-eclampsia/HELLP Syndrome,
Acute Fatty Liver Of Pregnancy.
• Gynaecological: Ovarian cyst rupture, Torsion,
Uterine fibroid degeneration.

• Gastrointestinal: Constipation, Appendicitis,
Gallstones, Cholecystitis, Pancreatitis, Peptic
Ulceration.
• Genitourinary: Cystitis, Pyelonephritis, Renal
stone pain & Ureteric Colic.

OBSTETRICS HISTORY:
- Related to multigravida
- Previous obstetrics events are to be recorded
chronologically as per the proforma.
- Proforma in next slide
- To be relevent, enquiry is to be made whether
she had antenatal and intranatal care before.

•
No. Year
And
Date
Pregnancy
Events
Labour
Events
Methods
Of Delivery
Puerperium Baby Weight,
Sex Condition At
Birth, Duration
Of Breast
Feeding
Immunization
1
2
3

For each pregnancy, note:
• Age of the mother when pregnant.
• Antenatal complications.
• Duration of pregnancy.
• Details of induction of labour.
• Duration of labour.
• Presentation and method of delivery.
• Birth weight and sex of infant.

• Also enquire about any complications of the
puerperal period.
Possible complications include:
• Postpartum hemorrhage.
• Infections of the genital and urinary tracts.
• Deep vein thrombosis.
• Perineal complications such as breakdown of
the perineal wounds.
• Psychological complications (e.g. postnatal
depression).

Obstetrics H/o can be summed up as:
• Status of Gravida, Parity, Number of deliveries
(Term, Preterm), Miscarriage, Pregnancy,
Termination (MTP) and Living issue.
E.g.: Mrs. R.L, (P 2+0+1+2), G4, P2, Miscarriage
1, Living 2 at 36 weeks of present pregnancy.
2 = Number of TERM PREGNANCIES .
0 = Number of PRETERM PREGNANCIES.
1 = Number of MISCARRIAGES.
2 = Number of BABIES ALIVE at present.

PAST GYNAECOLOGICAL HISTORY
• Method of contraception before conception.
• Cervical smear history.
• Coital problems.
• Any sexually transmitted diseases
• Menstrual History.

• Menstrual history:
- Cycle, duration, amount of blood flow and first
day of the last normal menstrual period (
L.N.M.P) are to be noted.
- From the L.N.M.P., the expected date of the
delivery (E.D.D) has to be calculated.
- Calculation of the expected date of delivery (
E.D.D).
- THIS IS DONE BY NAEGELE’S FORMULA.

• NAEGELE’S FORMULA:
- Calculation of the expected date of delivery
(EDD): this is done accordingly
- Adding 9 months and 7 days to the first day of
the last normal (28 day cycle) period.
- Alternatively one can count back 3 calendar
months from the first day of the last period
and then add 7 days to get the expected date
of the delivery.
- Former method is more commonly employed.

• Ex: The patient had her first day of last
menstrual period on 1ST jan. By adding 9
Calendar months it comes to 1st October and
then add 7 days i.e. 8th October which
becomes the E.D.D
• For IVF pregnancy, date of L.M.P IS 14 DAYS
PRIOR TO THE DATE OF EMBRYO TRANSFER (
266 DAYS)

PAST MEDICAL/ SURGICAL HISTORY
• Some medical conditions may have impact on the
course of the pregnancy or the pregnancy may
have an impact on the medical condition
examples:
• Heart disease.
• Hypertension.
• Diabetes.
• Epilepsy.
• Thyroid diseases.
• B Asthma.
• Any previous surgery.

• Kidney disease.
• UTI.
• Autoimmune disease.
• Psychiatric disorders.
• Hepatitis.
• Venereal diseases.
• Blood transfusion.

DRUG HISTORY AND ALLERGY
• Current medications.
• Medications taken at any time during the
pregnancy.
• If currently pregnant, ensure the patient is
taking 400mcg of folic acid daily until 12
weeks gestation to reduce the incidence of
Spina Bifida.
• Any allergies and their severity (Anaphylaxis or
a rash?)

FAMILY HISTORY:
• Any history of hereditary illnesses or
congenital defects is important and is required
to ensure adequate counseling and screening
is offered.
• Familial disorders such as thrombophilias.
• Previously affected pregnancies with any
chromosomal or genetic disorders in maternal
side.
• Multiple gestations.
• Consanguinity.

PERSONAL HISTORY:
• Contraceptive history prior to pregnancy:
- LMP may be a withdrawal bleed following pill
usage. The first ovulation may be delayed by 4-6
weeks
• Smoking and Alcohol habits: They have got some
relation with their low birth weight of the baby
• Previous history of blood transfusion,
corticosteroid therapy, immunization against
tetanus, prophylactic administration of anti-D
immunoglobulin are to be enquired.

SOCIAL HISTORY:
Ask about:
• Her partner age, occupation, health.
• How stable the relationship is.
• Any domestic violence.
• If she is not in a relationship, who will give her
support during and after the pregnancy?
• Ask if the pregnancy was planned or not.
• If she works, enquire about her job and if she
has any plans to return to work.

Keywords Before Examination
• Before examination, explain to the patient the
need and the nature of the proposed
examination.
• Obtain a verbal consent.
• The examiner (either male or female) should
be accompanied by another female.
• Respect her privacy and examine in a private
room.

• Expose only relevant parts of her anatomy for
examination .
• Ensure the patient is comfortable and warm.
• Ask patient to empty the bladder .
• Patient should lie in the dorsal position with
thighs slightly flexed.
• Stand right to her.

• She is slightly rolled to the left side to prevent
compression of the inferior vena cava by the
enlarged uterus (inferior venacaval syndrome
or supine hypotensive syndrome).
• Ask for any tender area before palpating the
abdomen.

Dorsal
position/Supine
position with
thighs slightly
flexed

General Examination
• VITAL DATA
• NUTRITIONAL STATUS
• HEIGHT
• FACIAL FEATURE/EXPRESSION
• SKIN
• ICTERUS
• LEGS
• NECK
• BREAST

General Examination
• VITAL DATA:
1. Blood pressure :
• Record while she is in sitting and Semi-Recumbent (
45 degrees) posture.
• Record in every visit.

• Usually unaffected or Slightly lower than
normal due to SVR ( SYSTEMIC VASCULAR
RESISTANCE).
If BP > 140/90 mm Hg on 2 separate
occasions 6 Hrs apart:
• Chronic Hypertension: if recorded before 20
weeks of pregnancy or may be persisted
before pregnancy. With + family history.
• Gestational Hypertension : if recorded after
20 weeks of pregnancy.

2. Pulse rate: Slightly increased
3. Heart rate : Increased. Murmurs heard-
normal- continuous hissing murmur- systolic
type-also called mammary murmur- at left
tricuspid area over 2nd and 3rd intercostal
spaces.
4. Respiratory rate: usually unaffected. feels
shortness of breath with slight exertion due
to elevated diaphragm.

5- Temperature: may rise by 0.4 ºF
• i.e..98.6 ºF to 99 ºF
• Due to increased metabolic rate

• NUTRITIONAL STATUS:
• Nails- white spots in zinc deficiency, brittle
nails in magnesium deficiency.
• Tongue- May be Large in iodine or niacin
deficiency. May be pallor in Fe++ deficiency.
Cyanotic in CHD. Site- dorsum of tongue.
• WEIGHT- The abnormal nutritional status
can be described as obesity and emaciation.
• Check weight in every visit.
• Parameter- Body mass index (BMI)

• Weight gain for a woman with normal BMI
( 20-26) is 11-16 kgs.
• Weight gain for a obese woman ( BMI > 29 )
should be less than 7kgs.
• Weight gain for a under weight woman ( BMI
< 19 ) is 18 kgs.
• Parameters helps in early intervention of
preeclampsia ( in obese ) and IUGR of fetus
( in under weight ).

• HEIGHT
• Short stature women are mostly to suffer with
small pelvis.
• May cause IUGR OF FETUS.

• FACIAL FEATURE/EXPRESSION
• Some facial appearances are pathognomonic
of disease.
• Here the patient may be having thyrotoxicosis.
• The appearance of the patient’s face may also
provide information regarding psychological
makeup: is the person happy, sad, angry or
anxious

• SKIN : Extreme pigmentation around neck,
face, forehead. Common in pregnancy
• Palmar erythema – due to high estrogen
• Hirsutism – mild common, if more – Cushing
syndrome .
• ICTERUS- Bulbar conjunctiva, under surface of
tongue, Hard palate- to rule out any LIVER
pathology
• LEGS-EDEMA – common- physiological
• other causes- Preeclampsia, Anemia, Cardiac
Failure, Nephrotic Syndrome

Pigmentation of Neck, cheeks
oedema of feet

• NECK- Neck veins, Thyroid gland ( diffuse
enlargement common in pregnancy-50 % of
cases), Lymph gland enlargement ( any H/o of
Kochs/ other pathologies of lymph nodes).
• BREAST- Examination of breast is mandatory
not only to note presence of pregnancy
changes ,but also to note the nipples/skin
around areola.
• The breast changes are evident between 6-8
weeks.

• The nipple and the areola become more
pigmented specially in dark women.
• Montgomery’s tubercles are prominent.
• Thick yellowish secretion (colostrum) can be
expressed as early as 12th week.
• Breasts are enlarged with vascular
engorgement evidenced by the delicate veins
visible under the skin.

• Breast changes are valuable only in
primigravidae, as in multigravidae the breasts
are enlarged and often contain milk for years.
• **Purpose is to correct the abnormalities
(cracks/fissures) early so that to make easy
breast feeding more safely too infant after
delivery.

Neck
- Diffuse swelling
- common- 50 %
cases of pregnancy
Abnormal swelling

BREAST
Normal in pregnancy
Abnormal in pregnancy

General Systemic Review
• CNS
• GIT
• GENITALIA
• URINARY SYSTEM
• LOCOMOTORY SYSTEM

• CNS: following finding are checked
- sleeplessness, mental irritability due to some
psychological background
- Any depression/psychosis
- Anaesthesia of the thighs – due to
compression of Lateral Cutaneous Nerve.
- Carpel tunnel syndrome- median nerve
compression in later months of pregnancy.

• GIT:
- Gums –usually congested and spongy
- Esophageal reflux- due to relaxed sphincter-
by progesterone.
- Constipation- due to atony
- Other signs of any disturbances should noted
clearly.
- Chances of gall stones- due to raised
cholesterol- advise USG if pain in Rt
hypochondria.

ABDOMINAL EXAMINATION
• Can be examined in three parts
• 1- INSPECTION
• 2- PALPATION
• 3- AUSCULTATION

INSPECTION
- Size of the uterus:
• If the length & breadth are both increased 
multiple pregnancies, polyhydramnios
• If the length is increased only  large baby
- Shape of the uterus:
• Length should be larger than broad this
indicates longitudinal lie. But if the uterus is
low and broad indicates transverse fetus lie.
• Pendulous abdomen- in primigravidae is sign
of inlet contraction.

INSPECTION
• If there is lateral implantation of the placenta
then the uterus enlargement will be
asymmetrical- piskacek’s sign.
- Look for fetal movements.
(More prominently seen in 3rd trimester / Less
in oligohydramnios)
- Look for scars.
- Herniations.

INSPECTION
- CUTANEOUS SIGNS - Linea nigra, Striae
gravidarum, Striae albicans, Umbilicus flat or
everted, Superficial veins.
- SKIN CONDITIONS- Ringworm/Scabies
LINEA NIGRA
EVERTED UMBILICUS
FETAL PARTS

PALPATION
Aim :
• Palpation of fetal parts
• Active fetal movements
• Height of the uterus (symphysis-fundal height)
• Gestational age
• Foetal poles
• Foetal lie
• Presentation part- cephalic(head), breech,etc
• Attitude

• Level of engagement of presenting part.
• Uterine contractions.
• Estimate fetal weight.
• Amniotic fluid.
• Any cephalo-pelvic disproportion
Of the above parameters
• To assess FETAL POLE, FETAL LIE, FETAL
PRESENTING PART, ATTITUDE AND
ENGAGEMENT OF FETAL HEAD- LEOPOLD’S
MANOUEVRE IS FOLLOWED

1) Palpation of fetal parts
- Distinctly felt after 20th week
- Usually done to estimate the fetal
pole/presenting part.
2) Active fetal movements
- Gives positive evidence of pregnancy.
- Felt at intervals by placing the hand over the
uterus as early as 20th week. Indicates live
fetus.
- Intensity more in last trimester.

3) Height of the uterus (Symphysis-Fundal Height):
• The distance from the symphysis pubis to the
uterine fundus (top of the uterus)- size of the
uterus directly related to the size of the fetus.
Technique:
• Place ulnar border of the left hand on the highest
part of the uterus (fundus).
• Mark this point with a pen after obtaining her
permission.
• The distance between the upper border of the
symphysis pubis upto the marked point is measured
by tape.
• This corresponds to gestational age

FUNDAL REGION
SYMPHYSEAL REGION
TAPE

4) Gestational age :
• The distance from the symphysis pubis to the
uterine fundus (top of the uterus) corresponds
to the gestational age/duration of pregnancy.
• After 24 weeks of pregnancy, the distance
measured in cm normally corresponds to the
period of gestation in weeks.

5) Fetal Pole, Lie , Presenting Part , Engagement And
Attitude Of Fetal Head are assessed by LEOPOLD’S
MANOUEVRE.
LEOPOLD’S MANOUEVRE: Done by four
obstetric grips
• 1- Fundal grip - To assess fetal pole
• 2- Lateral grip - To assess fetal lie
• 3- Pawliks grip - To assess presenting part
• 4- Deep pelvic grip – To assess engagement
and attitude of fetal head.

1) Fundal grip:
• Both hands placed over the fundus and the contents
of the fundus determined.
• A hard smooth, round pole indicates a fetal head.
• Broad, soft and irregular mass suggestive of breech.
• In transverse lie no parts are palpated.

2) Lateral Grip or umbilical grip:
• Move both hands in a downward direction
from the fundus along the sides of the uterus
to determine the "lie" of the fetus.
• "Lie" is the relationship btw the longitudinal
axis of the fetus and the longitudinal axis of
the mother.
• The "lie" is usually longitudinal, hence baby is
lying length-wise in the same direction as
mother's longitudinal axis.

• Other "lies" are :
• Transverse Lie: fetus lies across the
longitudinal axis of mother and
• oblique lie: fetus lies at an oblique angle to
the mother's longitudinal axis.
• Can also determine which side the foetal back
is situated by feeling the firm regular surface
of the foetal back on one side and the
irregular, lumpy surface as the foetal limbs on
the other side.

Longitudinal Lie Transverse Lie

3) Pawliks grip: (second pelvic grip )
• The thumb and four fingers of the right hand
are placed over the lower pole of uterus
keeping the ulnar border of palm on the
upper border of the suprapubic area to
determine the presenting part.
• Presenting part of fetus is the lowest most
part of the fetus at the inlet of the pelvis.

Presentation:
Presenting part of fetus occupying the lower
pole of uterus
i.e.
1. Cephalic.
2. Breech.
3. Shoulder.

• In transverse lie, pawliks grip is empty.
• If not engaged the presenting part can be
grasped and moved side to side.
Presenting Part-
cephalic
Presenting Part- breech

4) Deep pelvic grip: ( first pelvic grip )
• Determines two points about the fetus
1) The attitude of the fetal head
2) Engagement of the fetal head
1) The attitude of the fetal head :
The examiner turns around to face patients feet.
• Each hand placed on either side of the fetal
trunk lower down.
• The hands moved downwards towards the
fetal head.

• Note made as to which hand first touches the fetal
head (This point called cephalic prominence).
• Cephalic prominence helps determine the attitude
(i.e. flexion, deflexed or extended) of fetal head.

• If cephalic prominence (sinciput) is on the
opposite side of fetal back, fetal head is well
flexed (Normal Position).
• If cephalic prominence (occiput) on the same
side as fetal back, fetal head is extended
(abnormal position).
• If examiners hands reach the fetal head
equally on both sides (both sinciput and
occiput), fetal head is deflexed (Military
position, indicating mal-position)

2)Engagement of the fetal head:
- Engagement of the fetal head defined as having
occurred once the widest transverse diameter of the
fetal head (bi-parietal diameter) has passed through
the pelvic inlet into the true pelvis.
- Procedure: Continue moving both hands down
around the fetal head, determine how far around the
head you can get.
- Examiner should be able to palpate part of fetal head
still in the lower abdomen (also called the 'false'
pelvis but cannot palpate the part of fetal head in the
true pelvis).

Abdominal palpation to determine engagement of the
head
A- Divergence of fingers- Engaged Head
B- Convergence of fingers- Not Engaged

- If you divide the fetal head into five-fifths, you
estimate how many fifths of the fetal head can
be felt.
- If 5,4 or 3 fifths can still be palpated, most of
the head is still up, hence the widest part of
the head has not engaged into the pelvis.
- If only 2,1 or 0 fifths of fetal head felt, the
widest part of the head has engaged into the
pelvis.

• Diagrammatic representation showing the
difference between an engaged and a fixed
head by use of egg cups and eggs.

6) Amniotic fluid :
- Useful in assessing the well being and
maturity of fetus
- Excess or less volume of liquor amnii is
assessed by AMNIOTIC FLUID INDEX (AFI)
- AFI: Maternal abdomen is divided into 4
quadrants taking the umbilicus, symphysis
pubis and the fundus as the reference points.
- With ultrasound, the largest vertical pocket in
each quadrant is measured.
- The sum of the four measurements(cm) is AFI.

• AFI helps to diagnose the clinical conditions
called oligohydramnios and polyhydramnios.
• Normal level of amniotic fluid at Term- 40
weeks is 600-800 ml.
Other values:
• at 12 weeks: 50 ml,
• at 20 weeks: 400 ml,
• at 36-38 weeks: 1 liter.
• There is gradual decrease in levels after 38
weeks

7)Uterine contractions:
Braxton-Hicks:
• Felt bimanually.
• During early months of pregnancy- usually in
2nd trimester begin.
• Irregular, Infrequent, Spasmodic, Painless
• Increases by near term.
• Elicited by rubbing the uterus.
• Absent in abdominal pregnancy.

• Palmer Sign
• In early weeks of pregnancy palmer sign is
elicited to diagnose the pregnancy.
• This method is done to note the uterine
contractions.
• Done by- cupping uterus between internal
fingers and external fingers for about 2-3
mins.
• During contraction- uterus is firm and well
defined.
• During relaxation – soft and ill defined

8) Estimate foetal weight:
• Difficult and requires practice.
• Approximate prediction of the fetal weight is
more important than the mere estimation of
the uterine size.
• This is more important prior to induction of
labour or elective caesarian section.
• Following methods are useful :
1- Fetal Growth Velocity :
2- Johnsons Formula:

1- Fetal Growth Velocity :
• Normal growth-26.9 gm/ day
• More during 32-36 weeks
• Declines by 24 gm/day after 36 weeks
• ** individual fetal growth varies.

2- Johnson's formula:
• Applicable only in vertex presentation
• Fundal height (cm) noted above the pubic
symphysis
• Fundal height (cm)- 12 (if Vertex above Ischial
Spine ) × 155 = weight
• Fundal height (cm)- 11 (if vertex below Ischial
Spine) × 155 = weight
This will be fetal weight in grams.
• • e.g., 32 (Fundal height)-12(constant) x155(
constant) => 20 x 155=3100gms.

8) Cephalo-pelvic disproportion:
- State were the normal proportion between
fetal size and size of the pelvis is disturbed.
Two methods:
1. Abdominal method.
2. Abdomino-vaginal method. (explained in
vaginal examination)

Abdominal method-
• Patient is placed in dorsal position with the
thighs slightly flexed and separated.
• The head is grasped by the left head
• Two fingers, index and middle fingers, of the
right hand are placed above the symphysis
pubis keeping the inner surface of the fingers
in line with the anterior surface of the
symphysis pubis to note the degree of
overlapping, if any, when the head is pushed
downwards and backwards.

• No disproportion- if the head can be pushed
down in the pelvis without pelvis overlapping
of the parietal bone on the symphysis pubis.
• Disproportion- if the head cannot be pushed
down and instead the parietal bone overhangs
the symphysis pubis displacing the fingers.
• Abdominal method is difficult to elicit in
deflexed head.
• It can be used as screening method.

AUSCULTATION
• Importance: for monitoring FETAL HEART SOUNDS
• Helps in diagnosis of live baby but its location
of maximum intensity can resolve doubt about
the presentation of the fetus.
• FHS are best audible through back in vertex
and breech presentation where the convex
portion of the back is in contact with the
uterine wall.
• How ever in face presentation, FHS are heard
through fetal chest.

• FHS is maximum below the umbilicus in
cephalic presentation and
• FHS is maximum around the umbilicus in
breech.
• Location of FHS depends on the position of
the head and degree of decent of the head
even in cephalic presentation.

• In Occipito anterior position, FHS is heard in
middle of the spino-umbilical line.
• In occipito-posterior –> towards the mother
flank on same side
• In occipito-lateral -> towards laterally .
• In left occipito-posterior position –> FHS is
most difficult to locate.

Types of monitoring:
1. Pinnard stethoscope:
• The heartbeat of the baby may be checked
by a simple instrument which looks like a
short trumpet that is held against the
pregnant tummy.
• This is called a Pinnard stethoscope (or
fetoscope) and can be used by a midwife or
doctor to listen to the heartbeat periodically.
• A fetoscope can detect and transmit fetal
heart sounds at 18 to 20 weeks and beyond.

2. Regular stethoscope : useful in monitoring
heart beat after 18 to 20 weeks (same as
pinnards fetoscope)

3. Ultrasound fetoscope:
• Toward the end of the first trimester, usually around
the 10th or 11th week of gestation, it is possible to
hear fetal heart tones. It is possible only by
ultrasound fetoscope.

4. Doppler: Doptone machine
• Doppler machines may be very simple and report
only the rate and rhythm of the beat, but more
sophisticated models will provide additional
information about blood flow in the umbilical artery.

Vaginal Examination
• A vaginal examination (speculum or digital
examination) is not part of a routine obstetric
examination but may be indicated to diagnose
the pregnancy, to see any rupture of
membranes, onset of labour by checking
cervix, cephalopelvic disproportion.
• Can be done bimanually by hands and by
speculum.

• Technique of vaginal examination:
Mother in Supine, Hips Flexed And Abducted,
Knees Flexed.
Aseptic technique as much as possible.
 Note: In Placenta previae & Abruptio
placentae- usually vaginal examination is
avoided. Only vulval examination done.

• Diagnosing pregnancy:
- Osianders sign- increased pulsation felt in the
lateral fornices – 8th week.
- Walls- softened.
- Jacquemiers sign: Dusky Hue discoloration of
the vaginal walls- anterior- 8th week.

• Premature rupture of membranes:
- Check the collected fluid in posterior fornix
(vaginal pool).
• Cephalopelvic disproportion:
- Done by Muller-Munro Kerr method.
- It is a bimanual examination
• It is superficial to abdominal method
• Two fingers are introduced into vagina with
the finger tips placed over the ischial spines
and thumb is placed over the symphysis pubis.

• The head is grasped by the left hand and is
pushed in a downward and backward
direction into the pelvis.
• No disproportion- if the head can be pushed
down up to the level of ischial spines and
there is no overlapping of the parietal bone on
the symphysis pubis.
• Disproportion- if the head cannot be pushed
down and instead the parietal bone overhangs
the symphysis pubis displacing the thumb.

Negatives for vaginal examination: warning signs

Cervical examination :
- Done simultaneously in vaginal examination
- Helps in diagnosing the pregnancy in early
weeks- Goodells sign- (soft cervix-6th week)
- To check the dilatation of cervix, effacement
of cervix in labour.
- Hegars sign: Gently done- Bimanual
examination- two fingers in the anterior fornix
and two abdominal fingers behind the uterus.
+Ve sign- cervix is firm.

• References:
• TEXT BOOK OF OBSTETRICS- D.C DUTTA, sixth
edition-2004.
• D.C. DUTTA’S TEXBOOK OF OBSTETRICS, 8th
edition-2015- Google eBook
• MUDALIAR AND MENONS CLINICAL OBSTETRICS-
9TH edition.
• OXFORD HANDBOOK OF CLINICAL EXAMINATION
AND PRACTICAL SKILLS, 1st edition (vishal).
• GOOGLE IMAGES

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