Management of a woman during pregnancy, childbirth and puerperium involves differentiation of normal physiological changes associated with pregnancy from pathological conditions. 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. Such an approach will aid effective management by involving multidisciplinary input when required. Contemporaneous, accurate, detailed and legible clinical note keeping is a cornerstone of ‘basic clinical skills’.
After studying this chapter you should be able to:
Knowledge criteria
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Explain the relevance of a detailed history of the index pregnancy
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Discuss the importance of previous obstetric, medical, gynaecological and family history
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Explain how to conduct a detailed, general, obstetrical and pelvic examination
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Discuss the pathophysiological basis of symptoms and physicals signs in pregnancy
Clinical competency
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Take a detailed obstetric history in a normal pregnancy and a pregnancy with complications in the index or previous pregnancy
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Carry out general and obstetric examination in a normal pregnancy and that with maternal or fetal complications, including:
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Measurement of blood pressure in pregnancy
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Perform and interpret urinalysis in pregnancy
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Perform an abdominal examination in women during pregnancy (over 20 weeks)
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Auscultate the fetal heart
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Summarize and integrate the history, examination and investigation results and formulate a management plan
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Provide explanations to patients in language they can understand
Professional skills and attitudes
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Reflect on the components of effective verbal and nonverbal communication
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Understand the need to be flexible and be willing to take advice in the light of new information
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Recognize the acutely unwell patient in obstetrics
Taking a relevant and comprehensive history
History taking forms a cornerstone of medical 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 current (or index ) pregnancy followed by previous obstetric (including modes of birth and complications) and gynaecological history.
History of present pregnancy
The date of the first day of the last menstrual period (or 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 14th 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 last menstrual period 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 last menstrual period (14 days are added for the period between menstruation and conception). In a 28-day cycle, the estimated date of delivery 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 EDD. The calculation of 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.
If a woman’s normal menstrual cycle is less than 28 days or is greater than 28 days, then an appropriate number of days should be subtracted from or added to the estimated date of delivery. For example, if the normal cycle is 35 days, 7 days should be added to the estimated date of delivery.
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:
Nausea and vomiting commonly occur within 2 weeks of missing the first period and it is believed to be secondary to human chorionic gonadotrophin (hCG). Although, it is described as morning sickness, vomiting may occur at any time of the day and is often precipitated by the smell or sight of food. Morning sickness commonly occurs in the first 3 months but, in some women, it may persist throughout pregnancy. Severe and persistent vomiting leading to maternal dehydration, ketonuria and electrolyte imbalance is termed hyperemesis gravidarum . This condition requires prompt diagnosis, rehydration and correction of metabolic and electrolyte derangements.
Increased frequency of micturition occurs in early pregnancy and 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, i.e. into the larger abdominal cavity. Persistence of increased frequency as well as associated symptoms (dysuria, haematuria) should prompt analysis of urine to exclude urinary tract infections. 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.
Excessive lassitude or lethargy is a common symptom of early pregnancy and may become apparent even before the first period is missed. Often, it disappears after 12 weeks of gestation.
Breast tenderness and heaviness, which are really an extension of those experienced by many women in the premenstrual phase of the cycle, are common during early pregnancy. It is due to the effect of increasing serum progesterone as well as an increased retention of water.
First maternal perception of fetal movements , also called ‘quickening’ is not usually noticed until 20 weeks gestation during 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.
Some women may experience an abnormal desire for a particular food and this is termed pica .
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.
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 is 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 500 g. 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: 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 also may influence the management of subsequent pregnancies, e.g. history of DVT requires thromboprophylaxis during the antenatal as well as postnatal periods.
Previous medical history
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), 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 their family history.
Detailed and relevant information obtained with regard to demographics (e.g. maternal age, increased BMI), past obstetric, medical and surgical (e.g. laparotomy, caesarean section, myomectomy) history and family history will help perform appropriate tests as well to make a care plan.
Examination
Examination during pregnancy involves general, systemic (cardiovascular system, respiratory system, general abdominal and in specific circumstances a neurological examination) as well as a detailed obstetric (uterus and its contents) examinations.
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 calculation of Body Mass Index (BMI = weight in kg/height in m 2 ).
Measuring blood pressure in pregnancy Blood pressure is recorded with the patient supine and in the left lateral supine position to avoid compression of the inferior vena cava by the gravid uterus ( Fig. 6.2 ). If blood pressure is to be recorded in the sitting position, then it should be recorded in the same position for all visits and on the same arm. The effect of posture on blood pressure has been noted in Chapter 3 . Vena caval compression in late pregnancy may cause symptoms of syncope and nausea and this is associated with postural hypotension, the condition being known as the supine hypotensive syndrome. If this is not recognized for a prolonged period, fetal compromise may occur secondary to a reduction in uteroplacental circulation.
Although in the past the diastolic pressure has always been taken as Korotkoff fourth sound, where the sound begins to fade, it is now agreed that where the fifth sound, i.e. the point at which the sound disappears, is clear, this should be used as representing the diastolic pressure. If the point at which the sound disappears cannot be identified because it continues towards zero, then the fourth sound should be used.
Heart and lungs
A careful examination of the heart should be made to identify any cardiac murmurs. 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. 6.3 ).
The presence of all other murmurs should be investigated by a cardiologist, as the early identification of any valvular pathology has implications for the management of the pregnancy, labour and the puerperium.
Examination of the respiratory system involves assessment of the rate of respiration and the use of any accessory muscles of respiration. 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
Many women develop a brownish pigmentation called chloasma over the forehead and cheeks, particularly where there is a frequent exposure to sunlight ( Fig. 6.4 ). The pigmentation fades after puerperium.
The colour of the mucosal surfaces and the conjunctivae should be examined for pallor, as anaemia is a common complication of pregnancy. The general state of dental hygiene should also be noted, as pregnancy is often associated with hypertrophic gingivitis and dental referral may be needed.
Some degree of thyroid enlargement commonly occurs in pregnancy, but unless it is associated with other signs of thyroid disease it can generally be ignored.
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. 6.5 ). 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.
