Obstetrics Clerking

Posted: July 15, 2010 by gerardloh in O & G

1.IDENTIFICATION DATA :

  • Name:
  • Age:
  • Race:
  • Gravida/ para:    (twins/abortion/molar pregnancy)
  • Last normal menstrual period(LNMP):
  • Expected date of delivery(EDD):      ( if pregnant)
  • Period of amenorrhea (POA)/ gestation (POG) :
  • Date of admission :
  • Date of delivery/ operation:
  • Date of discharge:

Gravidity = total number of pregnancy regardless of its outcome, including present one

Parity = Number of live births and stillbirths delivered after stage of viability (24wks)

Eg: 1) lady on her 1st pregnancy – G1P0

2)woman had twins and pregnant now (24wks) – G2P2

3)a woman has had 4 miscarriages and is pregnant again with only one live baby, she is at 26 wks of gestation now – G6P1+4

4)a lady in her 6th pregnancy, with history of 1 abortion and 1 molar pregnancy – G6P3+1 abortion, 1 molar pregnancy.

EDD

Naegele’s rule :

add 7 days to LMP, substract 3 months from

the  month.

OR

Add 7 days from LMP and add 9 months to

month.

1)      Day of visit : 20/10/09

LMP            : 26/01/09

EDD (LMP+7days+9months) : 03/11/09

POA            : 40 wk – (11d + 3d) = 40 wk-2wk

(by EDD)                                        = 38wks

2)      DOV : 21/06/09

LMP : 17/04/09

EDD : 24/01/10

POA  (by LMP) : 2 mth + 4d = (2×4 wk) + 4d

= 8 wks 4d

*For POA finding, every 3 month should add 1 more week.

Eg.  DOV : 22/02/09

LMP : 10/11/08

EDD : 17/8/09

POA :  3 mth + 12d = (3×4) + 1wk +12d

= 13wk +12d = 14wk + 5d

3) DOV : 24/06/09

LMP : 26/01/09

EDD : 03/11/09

POA : 4mth + 24d +5d = (4×4)+1wk+29d

= 17wk + 4wk +1d = 21wks + 1d

4) DOV : 05/03/09

LMP : 20/12/08

EDD : 27/9/09

POA : 2 mth + 5d + 11d = (2×4) + 16d

= 8wk + 2 wk + 2d = 10wks +2d

QUESTIONS : FINDS THE EDD AND POA

1)      DOV : 20/03/10

LMP : 03/07/09

2)      DOV : 01/08/09

LMP : 23/01/09

3)      DOV : 14/07/09

LMP : 27/03/09

2.CHIEF COMPLAINTS(c/o):

1)        Contraction pain? Duration? Regular/ Irregular?

2)      With or without show (blood-stained mucous from vagina)

3)      Leaking liquor? Time? Amount? Colour?

4)      Antenatal pyrexia?

5)      FM (fetal movement) – good/less/not moving? – ‘Fetal kick chart’

6)      Anaemia

7)      s/s of URTI / UTI ?

CHECK LIST FOR OBSTETRIC CASE

  1. History of Present Illness
  2. Past Obstetric History
  3. Contraception History
  4. Gynaecological History
  5. Past Surgical History
  6. Past Medical History
  7. Past Family History
  8. Social History

PRESENTING AN OBSTETRIC CASE

INTRODUCTION SENTENCE

Madam Ling Siew Choo is a 25 year-old Gravida 3 para 2 Chinese,at 32 weeks POA who is

admitted for painless PV bleeding of 1 day duration for further management.

SECOND SENTENCE

Her LMP was on the 15th of September last year. She has regular 28-30 days menstrual cycle.

Therefore, her EDD is on the 22nd of June, 2002 and she is currently at 32 weeks POA.

TAKING THE GYNAE / MENSTRUAL HISTORY

  • Menses  – regular/irregular and what is the range ?  Formula = 12( 28-30days)

(   5-7days   )

– flow normal / minimal / heavy ?

– duration of flow ?

– Any dysmenorrhoea

  • Sexual Intercourse – Any dyspareunia ?

– Superficial or deep ?

  • Any other gynae problems such as PV discharge ?
  • Any pap smear done ?

PAST OBSTETRIC HISTORY

LIST THE PREVIOUS PREGNANCIES

  1. Year of deliveries
  2. The health institution for the delivery etc.
  3. TYPE OF DELIVERIES – SVD, LSCS
  4. POA at delivery
  5. Any medical problems
  6. Miscarriage – POA, cause ?, ERPOC?
  7. Post delivery cx
  8. Babies – weight, sex, abN, neonatal cx, alive/dead

Eg. She had delivered 5 children between 1992 till 1997 which were all uneventful spontaneous vaginal delivery with babies weight ranging between 2.8 to 3.5 kg.  All the children were normal, alive and well.

v      If the POH is complicated, give the main findings first.

CLERKING A COMPLICATED PAST OBSTETRIC HISTORY

  • Past h/o Miscarriage

– Which trimester was it ?

– Was it a confirmed pregnancy ?UPT/Ultrasound?

– Was any ERPOC performed ?

– Was there any complication such as infection /

foul smelling PV discharge, delayed period ?

PRESENTING A COMPLICATED PAST OBSTERIC HISTORY –h/o Miscarriage

She had delivered 5 children between 1992 till 1997 with a history of one miscarriage in the third pregnancy.

ü      The miscarriage at 9 weeks POA was a confirmed pregnancy diagnosed by ultrasound. An ERPOC was performed and there was no complication following the procedure.

ü      The rest of the pregnancies were delivered by     spontaneous vaginal delivery The babies weights ranged between 2.8 to 3.5 kg.  All the children were normal, alive and well.

CONTRACEPTION HISTORY

Clerking the Contraception History

  1. How many children does the couple wants ?
  2. Is the family complete ?
  3. What form of contraception are they practising or intend to use ? What have they used before ?
  4. Do you think their compliance can be assured ?
  5. What contraception do you think is the most suitable for them based on their history and your assessment ?
  6. Are they aware of the side-effects and complications as well as the advantages and disadvantages ?
  7. How long do you suggest they should use this method ?

PAST MEDICAL / SURGICAL History

Past history of pre-existing diseases :

  • Hypertension,
  • diabetes mellitus,
  • asthma, COPD,
  • heart disease,
  • epilepsy,
  • renal dss,
  • venous thromboembolic dss,
  • HIV infection,
  • CT dss,
  • myasthenia gravis/myotonic dystrophy etc

Any relevant past history of hospitalization (including past operation done)

ü      e.g appendectomy, hernial repair, Bowel operation etc

ü      Mention the year of diagnosis

ü      Mention the status of condition

ü      Eg: Hypertension-10 years on regular treatment

Diabetes type II – 6 years on dietary control

FAMILY HISTORY

v      Relevant family history e.g  Diabetic, hypertension, heart disease, twins, breast cancer, Ovarian cancer etc

v      Of Siblings and parents

v      Twins, congenital abnormality

v      Hereditary

PERSONAL & SOCIAL HISTORY

  • – marital status
  • – patient / husband’s occupation and income
  • – smoking, alcohol or drug abuse
  • – who is taking care of children
  • – recent travels
  • – domestic condition
  • – Sexual activity

Drug History

  • Prescribed drugs
    • Name, Dose, Duration or what is it for, what colour, how many times a day, how long.
    • On prescribe drugs (over the counter)
    • Herbal or complementary therapy
    • History of allergies to drugs
      • Name of the drugs, what actually happens when patient took the drugs
      • Rashes, swelling of face & difficulty breathing are important allergic reactions
      • Nausea, vomiting or diarrhea are not necessarily allergic reactions
      • Allergy to certain food?

SUMMARY

Date :                                                            Time :

Age / Race / Sex :

G ? P? :                                                          EDD :

LMP :  ( SOD / USOD – BF, OCP ) POA / POG :

C/O :

ANC (Antenatal clinic)/ Booking @ ?/52 + ?/7 :

  • VDRL / TPHA / HIV
  • B/G
  • BW, Ht
  • MOGTT  – Indications : obesity, multipara, family history, previous GDM, >35 y.o, history of stillbirth
  • Urine – proteinuria? Glucosuria?
  • MBG
  • Hb
  • Latest scan @ ?/52 + ?/7
  • Past Obstetrics hostory
  • Past Gynaecology history
  • Contraceptive history
  • Past Medical / Surgical history
  • Family history
  • Social history

O/E : -alert, conscious, pink

-comfortable

V/S : -BP

-PR

-RR

-Body Temperature

CVS : DRNM

Lungs : Clear

P/A :

  1. soft, non-tender
  2. SFH (symphysis fundal height)
  3. UT@TS (Uterus at term size)
  4. S / L / C
  5. EFW (Estimated Fetal Weight )
  6. Head of fetus – palpable or not ( ?/5)
  7. Liquor – Oligo- / Poly- / Normohydramnios
  8. Auscultate fetal heart sound by Pinard stethoscope
  9. Presence of scar on abdomen? – LSCS

VE :

  1. V/V NAD  (Vulvar and Vagina, no abnormality detected)
  2. Os dilation = ?cm
  3. Cx (Effacement) – soft / median / tubular,  1 / 2 cm
  4. Station of the presenting part – foetus vertex

+2, +1, 0, -1, -2

  1. MI / MA  – CL (Clear liquor)

– LMSL (Light meconium-stained liquor)

– MMSL (Moderate mec-stained liquor)

– TMSL (Thick mec-stained liquor)

  1. Cord / Placenta

Caput / Moulding

Imp. :

1) 1 prev scar

2) No VBAC  ( vaginal birth after Caesarean)

3) Keen for TOS (trial of scar)

Ix :

  1. FBC
  2. GSH (group screen hold)
  3. HVS (high vaginal swab) – in case of PROM / PPROM
  4. UFEME (Urine Full Examination Microscopic Elements)

Plan : ( in labour room)

  1. V/S  & FHR 4 hrly monitoring
  2. Time  contraction
  3. Plot Partogram
  4. CTG
  5. LPC (Labour progress chart) / FKC
  6. IM Analgesia as required :

– IM Pethidine 75mg , PRN (pro re natal)

– IM Phenergen 25mg , PRN

  1. NRVE on strong & regular contraction / SROM / 4 hourly.
  2. Scan by M.O.

Comments
  1. anonymous says:

    Correction: the birth of multiples (twins, triplets, etc.) is still just parity 1, regardless of the number of babies

    So if a lady had twins before and now pregnant, she should be G2P1

  2. lulu says:

    a more detail on EDD or LMP or REDD should be obtain.

    how about if patient is on OCP, or her menstrual is not regular, or she had premaritial sex, and she lied aout her LMP. or maybe she conceived while she was still breast feeding her previous child, how do we get her EDD or REDD correctly?

    this is important when u r facing a date+10d or a pregnant lady came in labor with SFH only 32cm…

  3. annonymous says:

    i disagree with the first comment. according to d 10 teachers book, a person who has delivered twins and comes back pregnant at 12 weeks is G2P2 (twins).

  4. annony says:

    can u tell me more how to calculate POA?

    • gerardloh says:

      you can calculate POA using naegele’s formula..examples can be found in the HOW obstetrics guide part 1..suggest you to download and read that.

      personally, I’d prefer to use the obstetric wheel or you may download any mobile aps that can assist you..
      nobody calculates the POA manually anymore…And obstetric wheel is all you need

      ps: POA is used only if the mother is SOD, you will usually do Ultrasound scans dating to verify her POA.
      It there are discrepancies or she is USOD you would give her an REDD, then calculate her period of gestation using the REDD

  5. naimah says:

    is there a note on gynae case clerking?

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