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OB 101

1
Prepared by ACLB
Obstetrical History
General Data: Initial, Age, Gravity, Parity, LNMP, If pregnant include EDC (-3, +7), AOG, Date, Time of
Admission.
Chief complaint: (If for prenatal check up- State its order of chronology eg. If it is 1
st
or 2
nd
& so on)
-bleeding, pain (specific site), Mass, Vaginal discharge, Urinary & vaginal symptoms, Infertility,
protrusion of vagina.
HPI: PQRST for Pain (Provoking, Palliating, Quality, Radiation, Region, Severity, Timing- constant or
intermittent).
-Unusual Correlations (Associated symptoms)
-other symptoms CODIERS:
1. Chronology of complaints- sequence of events lead up to the current problem?

2. Onset: When did the problem begin?

3. Description/duration: where, like/how long/constant or sporadic

4. Intensity: how severe, getting better or worse?

5. Exacerbation: what enacts or makes it worse?

6. Remission: what relieves or makes it go away?

7. Social: how affected work, family, self image, activities?

ANDREA MANKOSKIS PAIN SCALE (for pain Severity)

o Pain free No med
1 Very minor annoyance
Occasional minor twinges
No med
2 Minor annoyance - occasional strong
twinges.

No med
3 Annoying enough to be distracting. Mild pain killer effective
effective (i.e., aspirin,
ibuprofen).
4 Can be ignored if you are really involved in
your work, but still distracting.
Mild painkillers relieve pain
for 3-4 hours.

5 Can't be ignored for more than 30 minutes Mild painkillers reduce pain
for 3-4 hours.

6 Can't be ignored for any length of time, but
you can still go to work and participate in
social activities.

Stronger painkillers
(Codeine, Vicodin) reduce
pain for 3-4 hours.

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Prepared by ACLB
7 Makes it difficult to concentrate, interferes with
sleep You can still function with effort. Stronger
painkillers are only partially effective.
Strongest painkillers relieve
pain (Oxycontin, Morphine).

8 Physical activity severely limited. You can
read and converse with effort. Nausea and
dizziness set in as factors of pain.

Stronger painkillers are
minimally effective.
Strongest painkillers reduce
pain for 3-4 hours.

9 Unable to speak crying out or moaning
uncontrollably near delirium.

Strongest painkillers are only
partially effective
10 Unconscious. Pain makes you pass out.

Strongest painkillers are only
partially effective.

Most Common chief complaints:

Complaint onset Provoking palliating Quality Radiation/
region
Severity/
intensity
Timing/
duration
Relations descrip
tion
Pain When? Physical
activities
Relieved
by what?
Sharp
dull
Lumbo
Sacral?
Pain scale How long
Intermittent?
Constant?
Days?

Bleeding When? Exacerbated
By coitus?
Phy act?
Terminate
preg?
Meds?
Bed rest?
Profuse
to
Mild?
Mild
becoming
profuse
Mild
1 pad
Mod
2-4 soak
Profuse
5 or >
Well soak
Blood clots?

Days?


Post
partum
bleed
When? meds Days? Type of
delivery

Lacerations
?
Describ
e
deliver
Manage
ment of
labor
Vaginal
discharge
When? Follicular
phase?
Scanty?

Amount? Days? Sex?
Social
effect
Fever?
Descrie
d
dischar
ge
Amenorrhe
a
When?
LNMP?
Meds?
Hormones?
Days, weeks,
months, years
Breast
changes
Nausea &
vomiting
Weight gain
Spotting
pain

Vulvar
pruritus
When? During
urination?
Food or drug
intake?
Undies?
Remission
?
Sudden? Intense? How long? Weight
gain?
describ
e
infertility When? Drugs?
Contraceptives
?
How long?




OB 101
3
Prepared by ACLB




Systems review: (for non-pregnant patients)

General
Fever, chills, usual weight,
usual state of health, wt
changes, weakness,
fatigue, sweats, heat/cold
intolerance, anemia,
bleeding tendencies, blood
transfusion, rxns, exposure
to radiation?
Neck
Lumps, goiter, pain on
movement, hx. Of swollen
neck, thyroid mass, thyroid
surgery, tenderness
GIT
Appetite
Excessive hunger or thirst?
Nausea, vomiting,
swallowing?, constipation,
Diarrhea, Heartburn,
Abdominal pain, changes in
stool color, caliber,
consistency, frequency of
bowel movement, blood
vomiting, rectal bleeding,
black tarry stools, laxative
or antacids?
Excessive belching, food
intolerance, change in
abdominal size,
hemorrhoids, infections,
jaundice, rectal pain, X-
rays, hepa, liver dis,
gallbladder dis.
Musculoskeletal
Weakness, Paralysis,
Muscle stiffness, limitation
of movement, joint pain,
joint stiffness, arthritis,
gout, back problems,
muscle cramps, deformities
Skin
Rashes, itching, hives, easy
bruising, hx of eczema,
dryness, changes in skin
color, hair changes,
texture, nail changes,
Hx of skin disorders,
lumps, hair dyes
Chest
Cough, pain, shortness of
breath, sputum (quantity,
appearance), TB, Asthma,
pleurisy, bronchitis,
coughing out of blood,
wheezing, x-ray, BCG?
Head
Dizziness
Headaches
Pain
Fainting
Hx. Of head injury
Stroke hx
Heart
Pain, BP, palpitations,
Shortness of breath during
exertion or lying flat, while
sleeping, hx of heart attack,
Rheumatic fever, ECG
findings others
Urinary
Frequency, urgency,
difficulty in starting the
stream, incontinence,
excessive urination,
burning, blood, infections,
stones, bed-wetting, flank
pain. Awakening to urinate,
retention, urine color, odor
Eyes
Eyeglasses
Current vision
Change in vision
Double vision
Excessive tearing
Pain, eye exams?, unusual
sensations, redness,
discharges, hx of
glaucoma, cataracts,
injuries
Vascular
Pain in legs, calves, thigh,
or hips, pain while walking,
varicose veins,
thrombophlebitis, coolness
of extremity, loss of hair on
legs, discoloration of
extremities, ulcers
Female Genitalia
Lesions, itching, discharge,
pap smear result, pain in
sex, frequency of sex,
contraceptives, fertility
problems, happy with sex?,
hernias, STD hx and
treatment, menarche,
intervals, duration, amount,
LMP, bleeding between
periods, number of
pregnancies, abortions,
term pregnancies,
complications in preg,
describe labor, number of
living children, menstrual
pain, age of menopause,
menopausal symptoms,
postmenopausal bleeding
Ears
Hearing impairment?
Hearing aid
Discharges
Dizziness, pain, ringing
infections
Breasts
Lumps, discharges, pain,
tenderness, self-exam
findings?
Neurologic
Fainting
Dizziness
Blackout
Paralysis, strokes,
Numbness, tingling,
burning, tremors, loss of
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Prepared by ACLB
Nose
Bleeds
Infection
Discharges
Frequency of colds
Nasal obstruction
Hx. Of injury
Sinus infection, hay fever
Mouth & throat
Teeth condition
Gums, frequent sore
throats, burning of tongue,
hoarseness, voice changes,
postnasal drip
Male genitalia
Lesions of the penis
Discharges, impotence,
pain, scrotal masses,
hernias, frequency of
intercourse, happy with
sex?, Fertility, prostate,
STD & treatment
memory,
Psychiatric disorders,
mood changes,
nervousness, speech
disorders, unsteadiness of
gait, general behavioral
change, loss of
consciousness,
hallucinations,
disorientation


Antenatal course for pregnant patients:

First trimester (0 13 completed weeks)
Weight prior to pregnancy
Was preg. test done?
Signs & symptoms like Fatigue, vomiting, nausea, weight
gain or loss, fever, spotting, amenorrhea, urination,
areola, nipple changes, breast changes (when?)
Date of first prenatal check up?
AOG at prenatal check up?
Place& who did the prenatal?
Baseline BP
Subsequent prenatal visits? Findings?
BP ranges
Medications/ vitamins/ dosage
Vaccines? Number of injections?
Illnesses incurred/ operations/ accidents?
Hypertension?
Diabetes? Lab result? Management? Diet modification
Ultrasound?
Danger signs of pregnancy?

Third trimester (29- 40 completed weeks)
Symptoms gone? Latest symptoms?
Notice an Enlarging Abdomen?
Weight gain?
Place& who did the prenatal?
Subsequent prenatal visits? Findings?
BP ranges
Medications/ vitamins/ dosage
Illnesses incurred
Hypertension?
Diabetes? Lab result? Management? Diet modification
Ultrasound result?
-Fetal age, significant findings
Enlarging abdomen
Danger signs of pregnancy?
Active Fetal movement? Braxton hicks (Duration,
interval, regular or irregular)
Illnesses incurred
Operations/ accidents?
Leopolds maneuver? Findings?

Second trimester ( 14 28 completed weeks)
Signs & symptoms like Fatigue, vomiting, nausea, weight
gain or loss, spotting, bleeding, breast changes or latest
symptoms?
Notice an Enlarging Abdomen?
Place& who did the prenatal?
Subsequent prenatal visits? Findings?
BP ranges
Medications/ vitamins/ dosage
Vaccines? Number of injections?
Illnesses incurred
Hypertension?
Diabetes? Lab result? Management? Diet modification
Quickening (Date)
Ultrasound result?
-Fetal age, significant findings
Enlarging abdomen
Fetal movement? Irregular or Regular
Danger signs of pregnancy?
Illnesses incurred
Operations/ accidents?
SUMMARY

Total weight gain?
Latest weight- prior pregnancy weight= weight gain

Total number of pregnancy visits?

Danger signs all throughout pregnancy?

Treatment? Maintenance?


Danger signs of Pregnancy:

1.Vaginal bleeding- amount, color, intensity (profuse?), associated pain (PQRST)- in abortions
OB 101
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Prepared by ACLB
2. Severe Nausea & Vomiting
3. Fever & chills indicate infection
4.Escape of Clear Fluid (Bag of Water)- in PROM, Preterm labor
5.Severe Headache- may be pre-ecclampsia/ ecclampsia
6.Edema/ swelling of face or fingers
7.Pelvic or Abdominal pain- in abortions, ectopic preg, placental abruption, preterm labor
8.Elevated BP
9.Absence of fetal movement- in fetal demise, fetal distress





Diagnosis of pregnancy:

Presumptive symptoms- nausea w/o vomiting, disturbances in urination, fatigue, perception of fetal
movement, breast symptoms
Probable evidence- abdominal enlargement, changes in uterine size, shape, consistency, cervix
changes, Braxton- hicks, ballotment, outlining of fetus
Positive signs- FHT, fetal movement perceived by examiner, Ultrasound fetal recognition.




MENSTRUAL HISTORY: menarche X Interval X Duration, LMP, PMP
Gyne patients: (detailed) number of pads, intensity or amount, color of blood, odor, interval
(shortest to longest), irregular (> 7 days) blood clots, dysmenorrhea (onset, occurred before,
during or after menarche? day in cycle, radiation, location, duration, pain scale, progressive or
intermittent or constant), LMP, PMP, infertility problem, dysparenuria.

OB HISTORY: if more than 1 pregnancy tabulate.
All Deliveries done in the hospital are placed in the Postpartum note!
Deliveries done outside the hospital like birth centers or home deliveries are place here in
Tabulated form.

No of
pregnan
cy
Year
Wgt
Sex
Duration Type of
delivery

Place of
delivery
Who
delivered
Condition
At birth
Maternal
complication
Fetal
complications
G1 C/S
NSVD,
Forceps
Vacuum
Breech
extractio
n
Clinic
hospital
OB
Physician
Traditional
Birth
attendant
Dead
Alive
Needed
resuscitation
Ecclampsia
bleeding
Congenital
anomalies


-Number of pregnancies, full term? Complications, abortions, and congenital anomalies what age of
gestation, D &C (why & where is it done?)

CONTRACEPTIVE HISTORY
Pills or any contraceptive? When started using, duration, and side effect?
If not discontinued, did she know how to use? Describe the technique
If discontinued, why discontinued, when discontinued?
IUD? Why removed?

SEXUAL HISTORY
Asked only if suspecting the ff: has STD, PID, Ca of the cervix, abnormal vaginal discharges, pruritus,
infertility
OB 101
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Prepared by ACLB
-Age of 1
st
coitus, number of sex partners, single, post coital bleeding, dysparenuria, Last sexual contact,
frequency.

PAST MEDICAL ILLNESS/ OPERATIONS
Medical condition
Medications
Allergies
Surgical procedures
Hospitalizations



FAMILY HISTORY
Heredofamilial diseases: Ca, DM, Myoma, Relevant kidney dis.
Who in the Family? Mother, Father, grandpa, etc
Difficulty of labor, twins, congenital malformation

SOCIAL/PERSONAL HISTORY
A. Birth day, birth place, Nationality, Religion, occupations
B. Year of marriages, duration of infertility, --separated?
C. husbands age, occupation, religion, state of health
D. Home condition- maternal or paternal side
-Medication, years, dosage
-Diabetic, Asthmatic
-Food or drug allergies, which one?
-Family members with diabetes or asthmatic, drug maintenance, allergies (which side)
E. Stress level- related to recent life event, or occupation or finances
F. Habits: smoking, years, packs or sticks/day; coffee
G. Educational attainment

NUTRITIONAL HISTORY
A. Description and amount ( 3 meals/day) of Previous meal.
B. Appetite & regularity of meals
C. Dentition, false teeth, chewing
D. Food likes & dislikes
E. Food allergies
F. Snacks
G. Budget for food/day

BMI (Kg/m2) = wt in kg
Ht in m2

Calorie index=

Ideal Body weight:
Women: Ideal Body Weight (kilograms) = [Height (cm) - 100] + ([Height (cm) - 100] x 15%)
Men: Ideal Body Weight (kilograms) = [Height (cm) - 100] - ([Height (cm) - 100] x 10%)

Total Energy Requirement (TER):
BER= Weight in Kilograms X (24 (hrs.) x Calorie requirement/hr)
NB: For every Kg of Body weight 1.2 1.3 kilo Calorie is required/ hour

Sedentary - none or very little exercise = BMR X 1.2 (others 1.3)
Light activity for average of 2 days/week = BMR X 1.375
Moderate activity level exercising 4 days/week = BMR X 1.5
High activity levels exercise & sports more than 6 days/week = BMR X 1.7
OB 101
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Prepared by ACLB
Higher activity levels = up to 2 x BMR

Calorie requirement for sedentary Patients: 1.2 -1.3; average 1.25
BER= 44.87 x (24hrs x1.25) = 1346.1
TER= 1076.88 + 300 = 1646.1 calories
NB: 300 calories additional requirement for pregnant women.
TER= (IBD in Kg X 30) + 300

POSTPARTUM NOTE (History of postpartum)
-date of admission
-Date & time of delivery
-type of delivery
-condition of baby, sex, weight

GYNECOLOGICAL NOTE (post operative note)
-Date & time of surgery
-type of surgery
-indications

PHYSICAL EXAM (Do complete PE but with emphasis on the Breast, Abdomen, pelvis)
Vital signs
BREAST: Inspection- Symmetry, Engorgement, prominent veins, Nipple & Areola- inversion,
pigmentation, discharges, inflammatory lesions

PALPATION: Masses- multiple or solitary, Tenderness, Lymphadenopathy

ABDOMEN: OB PE methods
-Inspection Shape: Globular, flabby, flat? Symmetrical? Scars, striae, linea Alba, fundal height,
-Palpation- Masses, Leopolds maneuver, contractions if present (Intensity, Duration, Interval)

Leopolds: Report Interpretation
LM 1 Breech fetal buttocks
Cephalic fetal head

LM 2 Fetal back directed to L or R Hard, resistant convex structure

LM 3 Cephalic, unengaged, floating
Or Breech Fetus fixed into cervix or not

LM4 Cephalic prominence on L or R Engage= Negative;
Not engaged= cephalic prominence is palpated

FETAL ATTITUDE:
Lie Longitudinal, transverse, oblique
Position LOP, LOT, LOA, ROA, ROT, ROP
Presentation- Vertex, Sinciput, Brow, Face
Contractions- Duration, Interval, Intensity

-Percussion- Dullness?

-Auscultation- bowel sound, FHT? Location of FHT (by quadrant)

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