OBSTETRICS

Obstetrics History taking

1. Patient Particulars
a) Name: Identification, Psychological benefit, Caste, religion identification,
b) Age/ Sex: A women having her first pregnancy above the age of 30 or more (FIGO- 35 yrs:
Federation of International Gynecology and Obstetrics). Both extreme ages are dangerous teen
and elderly.
Dangers of elderly primigravida

Dangers

To mother during:
Abortion, Pregnancy induced hypertension, Abruptio placenta( PIH),
a) Pregnancy Pelvic conditons like fibroids, Post term pregnancy, Medical
complications like HTN, DM, Cardiac disease, IUGR

b) Labour Preterm labour, Obstructed labour, Prolonged labour, Retained

placenta due to uterine atony, maternal and fetal distress, increased
ceaserean section

c) Puperium Increased morbidity due to operative interference, failure of lactation

To Fetus Preterm( Iatrogenic, Spontaneous), Post maturity, IUGR, Congenital

anomalies

c) Address: Identity, Socio- economic status, Prevalence of diseases in certain geographical

locations.
d) Religion: Cultural practices differs from religion to religion
e) Duration of Marriage: Pregnancy long after marriage without use of contraception suggests
low fecundity but soon after marriage suggests high fecundity. But importantly yo pani sodnnu
parxa ki husband sangae bassi rakko xa ki xaina, duration lamo bhaerra pharak pardaina tara
sangae xaina bhanne it cant be called low fecundity.
e) Occupation Interpreting symptoms of fatigue like stress, physical work,
occupational hazard, anticipation of likely complications
that might occur in low socio economic group. Also labour
is easy in women who are physically more active.
f) Occupation of husband
g) Education status: Giving information to patient differs accordingly to education status
h) Date of admission ( mention time if can) from emergency or opd.

2. Chief Complain
> To be mentioned in patient’s language
> Chronological order
> Mention duration

Eg: In ANC CASE

Cessation of menstruation X …… months( in cases pf early pregnancy) OR IN CASES OF
ADVANCED PREGNANCY SAY PREGNANCY FOR ….(AS PER JUNU MAM)
Excessive vomiting/ PV bled/ PV leak/ Less fetal movement X …….

Presentation- …..with hx of amenorrhoea for….months and chief

complains of…..

3. History of Present Illness

Elaboration of chief complains in terms of onset, duration, severity, any use of medications,
progress. Management in hospital till the date of hx must be written. Everything investigation
surgical consultation if any must be written. Current situation also write.

History of Present Pregnancy

She is a booked case of…….
Pregnancy is a spontaneous/ induced, planned/ unplanned conception
( always say 1st positive history first)
1st trimester
 When, where, and how was pregnancy first diagnosed?
 No of visits she did in 1st trimester and when
 Number of usg and when; and if the dr said was the date from LMP and from scan
matching and also what was the usg report( good condition). In earlier pregnancy
never say that breech was seen as in 20 weeks % of breech is 90%, and also about
placentation for which repeat USG at 32 weeks( if it is complete PP) and at 34 weeks
( low lying PP)

1st trimester USG scan(dating scan) gives idea on

: Confirm pregnancy- with through following
a) Gestational sac at 5th week, Yolk sac at 5.5 weeks
b) Fetal cardiac activity at 6th week( Dopplers picks up the cardiac
activity at 10th week)
: Intra uterine or extrauterine pregnancy
: Multiple pregnancy
: Molar pregnancy
: Fetal heart sound
: Date( POG): through CRL at 7th to 12th week
: Congenital anomaly like anencephaly
: Screening for aneuploidy
: Vaginal bleeding
: Evalution of pelvic and adnexal mass

 Symptoms of- amenorrhoea, morning sickness, increased frequency of

micturation, burning micturition, breast discomfort

Morning sickness 1. Simple vomiting in pregnancy

2. Hyperemesis Gravidarium
Increased frequency of It is seen mainly in6th- 8th weeks and subsides by
micturation 12th week.
1. Due to change in maternal osmoregulation
causing increased thirst and polyuria
2. Congestion of bladder mucosa
3. Due to exaggerated anteverted uterus compressing
the bladder
Burning micturation 1. Uterus compression the bladder causing
incomplete evacuation
2. Progesterone having relaxing effect on the ureter
causing stasis
Breast discomfort 1. Due to hyperplasia and hypertrophy of breast
tissue
2. Axillary tail gets enlarged and painful

 Any hx of PV bleeding or discharge

PV bleeding Causes
1. Bleeding related to pregnancy:
a) Abortion( 95%)
b) Ectopic pregnancy
c) Hydatidiform mole
d) Implantation bleeding
2. Bleeding associated with pregnancy: cervical erosion,
cervical polyp, ruptured varicose vein, malignancy
PV discharge Infections eg trichomonas vaginalis

 Any investigations carried out?

 Any medications taken like folic acids
 Any history of fever with rash?(torch infections)
  Any chronic illnesses the patient suffered from?
 Any history of radiation exposure like x ray, MRI, CT
2nd trimester
 No of visits she did in 2nd trimester and when
 Number of usg and when
Indication of doing 2nd (anomaly scan)and 3rd trimester USG(growth scan)
:Gestational age estimation- it is determined using BPD, HC, AC, FL. It is most
accurate when done between 12/ 14- 20th week
: Fetal growth- AC is the best parameter for fetal growth
: Anomaly scan- 18th to 20th week
: Placental location
: Cervical insufficiency
: Liquor volume
: Placenta previa/ abruption
: Uterine malformation
: Fetal presentation
: Fetal well being

 Symptoms of-cholasma, breast changes, pigmentation, burning micturation

 Any hx of pre monitorring symptoms of preeclampsia- blurring of vision,
epigastric pain, headache, vomiting, edema causing excess weight gain
Instead we should ask if during ANC VISIT doctor said bp is high and if she
had to take any medictaion or got admitted for it.
 Any hx of PV bleeding or discharge.
 1st fetal movement felt or not? And when? ( In multi 16th wk and in primi 18h
wk)
 Tetanus vaccine administration done or not. If done at how many times and at
what interval. ( NORMALLY 0.5ml i.m after 16-20 wks and 2nd dose with a gap
of 4-6 wks – this regimen is for TT. But in MTH Td is given which SHOULD BE
GIVEN AT 16TH- 20TH WEEK AND 4 week before delivery AS IT HAS BEEN
SEENN TO BE MORE EFFICACEOUS, BUT HERE THE SAME ABOVE
REGIMEN OF GIVING 2ND DOSE 4 WEEK APART IS BEING DONE)
 Any hx of abnormal weight gain.
 Any investigations carried out?
 Any medications taken like iron and calcium
Iron need: As there is negative iron balance during pregnancy and dietary iron is
not sufficient to meet the demand. Supplementary iron therapy is needed for all
preganan women from 16th weeks of pregnancy. Above 10 gm% of hb 1 tablet of
ferrous sulphate containing 60mg of elemental iron is enough but the dose needs to
be increased as the hb level lowers.
Also supplementary vitamins could be given
Calcium role 1) needed for fetal skeletal maturation or simply fetal bone growth-
1gm/ day
2) As prophylactically in cases of PIH eg 2gm/ day

WE DOSTANDARD
NOT START ANC IRON IN 1ST TRIMESTER as iron causes GI irritation which
may exaggerate the vomiting thus absorption wont be sufficient.
1. as soon as pregnant
IN 2ND TRIMESTER: FE AND CA SHOULD NOT BE GIVEN TOGETHER AS
CA INHIBITS
2. every monthly till 28th weeks Thus Ca in morning and Fe in night(also gastric
FE ABSORPTION.
irritation if given in morning).
3. every 2 wks till 36th weeks
 Any chronic illnesses the patient suffered from?
4. Any
everyhistory
wks tillofdelivery
radiation exposure like x ray, MRI, CT

3rd trimester

 No of visits she did in 3rd trimester and when

 No of USG and when( esp done for fetal growth)
 Continues perception of fetal movement or not?
 Whether there was any relief of symptoms of other breathing difficulty and other pressure
symptoms
 Any hx of burning micturation, rise of bp -headache, blurring of vision, swellings of leg
and face, abnormal weight gain
 Any hx of PV bleeding or discharge, leakage
 Any investigations carried out?
 Continued medications like Calcium and Fe tablets
 Any chronic illnesses the patient suffered from?
 Any history of radiation exposure like x ray, MRI, CT
WHO RECOMMENDATION OF ANC

1. 1st = 16th wk

2. 2nd = 28th wk

3. 3rd = 32-36th wk

4. 4th = 36th wk

Reasons- as per Anjali maam

1. 16th week-To see for any congenital anomaly, for vaccination(td), folic acid/ Fe/ Ca
supplementation, for any chronic illness like HTN
2. 28th week- is the period of viability where at least the weight should be 1kg. and
from this week will the fetal monitoring start.
3. 32 week- for PIH, preeclampsia, IUGr, anemia, APH, administering Corticosteroid.
4. 36 weeks- Growth, liquor, Htn disorder
USG scan

1st trimester: dating scan (+/- 1wk)

2nd trimester: anomaly scan (=/- 2 wk)

3rd trimester: ( +/- 3 wks)

 Eg. PNC- postnatal

Patient’s intro… and is on ….puperium ( in case of vaginal) or post partum

day( surgery- c/s) day following vaginal { or c/s: mention elective( done certain
days after admission) or emergency( done on same date) , mention indication-
for…… }at ………weeks of gestation -with (outcome) single live m/f baby of
weight…… and today she complains of

Commonly pain at incision site

(generally in 1st Post op day complains of hemorrhage, pain at incision site,
anesthetic complication- Cough, SOB)
Wound complications occur in 3rd or 4th day.
Breast complications also 3rd day or 4th and normal milk flow and secretion occurs
in this day.

 Fever pueperial pyrexia

 Mastalgia breast engorgement, if with fever mastitis, chills rigor abscess.
 Cough ( suspecting atelectasis, pneumonia which is due to recumbent position during c/s
lower lobe may get collapse..
 Burning micturation uti ; pyelonephritis, cystitis.
 Any leg swelling DVT , THROMBOPHLEBITIS.
 Pain at epistomy wound
 Any incision site pain, soakage of dressing
 Bowel and bladder habit: Generally constipation is a common finding as the women is
not given any food a day before surgery, the day of surgery and following day after
surgery so constipation is a common finding. However if flatus has or has not be passed
should be asked otherwise it suggests intestinal obstruction.
 HOPI: Describe about the pain
Pain
Site: lower abdomen
Onset: following surgery
Character: burning, dull aching
Radiation: no
Aggravated with movement
Relieved with rest and medications
Timing: continuous throughout the day
Severity of which is (if it is 2nd 3rd day) then we say the severity of which as compared to
previous days is decreasing in its intensity and duration.

Description about lochia: there is associated P/v discharge which is colour ( mostly red),
amount( scanty), smell( non foul smelling)

Negative hx- no hx of fever, cough, Sob, burning micturition, breast pain, calf pain,
soakage of dressing, AND THE P/V BLEEDING AS COMPARED IS DECREASING.
NORMAL things allowed in that day write about that
Following operation in
12-24 hrs: kept in separate room, kept NPO, iv medications( antibiotics, analgesics)
given
1st post op day: shifts to PNC, switched to oral medications, advised to take liquid diet
2nd post op day: Removal of catheter, semi-solid diet, is asked to move around.
3rd post op day: Solid food start, dressing done.

NOW ANTENATAL- Patient presented ……days back with hx of amenorrhea for ……

months and c/c of …………. In……MTH/ or other health center on ………what was
done….…..and why was c/s indicated.
Thus for the above indication c/s section was performed on ……at……am/pm with baby
outcome of
: single/ multiple
: male/ female
: weight
: cried immediately after birth, condition of baby, congenital anomaly
: vaccination, breast feeding
Following c/s then from 0 to present write.
In case of vaginal delivery
Patient’s intro… and is on ….puperium following vaginal/ instrumental-
indication at ………weeks of gestation -with (outcome) single live m/f baby of
weight…… and today she complains of
Commonly pain at episiotomy site
(generally in 1st day complains of hemorrhage, pain at episiotomy site, PV
discharge)
Wound complications occur in 3rd or 4th day.
Breast complications also 3rd day or 4th and normal milk flow and secretion
occurs in this day.

 Fever pueperial pyrexia

 Mastalgia breast engorgement, if with fever mastitis, chills rigor abscess.
 Cough ( suspecting atelectasis, pneumonia which is due to recumbent
position)
 Burning micturation uti ; pyelonephritis, cystitis.
 Any leg swelling DVT , THROMBOPHLEBITIS.
 Pain at epistomy wound
 Bowel and bladder habit

…..is on …….pupuerium following (normal/ instrumental) vaginal delivery( if

instrumental then indications for it) at……wks of gestation with an outcome of
single/ multiple M/F baby of weight ….

And today
In case of vaginal delivery with no In case of vaginal delivery with
complains episiotomy
….and presently she doesn’t have any …..and today she complains of pain at
complains. episiotomy site.
Description about lochia: there is Site: lower abdomen
associated P/v discharge which is Onset: following delivery
colour ( mostly red), amount( scanty), Character: burning, dull aching
smell( non foul smelling) Radiation: no
Also there is hx of PV bleeding- Aggravated with movement
amount, colour, no of pad soaked, Relieved with rest and medications
clots, AND THE P/V BLEEDING AS Timing: continuous throughout the
COMPARED IS DECREASING. day
Presently Severity of which is (if it is 2nd 3rd
1. Diet – day) then we say the severity of which
2. Urine and stool as compared to previous days is
3. Ambulation- decreasing in its intensity and
duration.
 4. Suckle the baby-

Negative hx- no hx of fever, cough,

Sob, burning micturition, breast pain, Description about lochia: there is
calf pain, chest pain, foul smelling associated P/v discharge which is
P/V discharge colour ( mostly red), amount( scanty),
smell( non foul smelling)
Also there is hx of PV bleeding-
amount, colour, no of pad soaked,
clots, AND THE P/V BLEEDING AS
COMPARED IS DECREASING.
Presently
5. Diet –
6. Urine and stool
7. Ambulation-
8. Suckle the baby-

Negative hx- no hx of fever, cough,

Sob, burning micturition, breast pain,
calf pain, chest pain, foul smelling
P/V discharge

How to diff PV discharge and bleed is that discharge will have fishy smell, will
form a yellowish tan over undergarment but blood will be bright red in colour
will soak her garments and will be using pads.

BABY OUTCOME
: Sex, weight
: Baby cried or not
: Condition of baby, Congenital anomaly
: Baby passed urine or stool or not
: Breast feeding done or not
: BCG vaccination done or not
As per mam say as: The baby is by the side of mother, with normal condition, no
congenital anomaly, has been breast fed the same day of delivey has been
vaccinated and has passed meconium and stool
 Delivery history:
Patient presented ……days back with hx of amenorrhea for ……months and c/c
of …………. In……MTH/ or other health center on ………time…… if referred
explain everything
Description of the labour pain? Spontaneous?

After she presented what was done and findings?

(eg- after she presented hx and examination was done where she was said to have
labour pains and the cx was said to be ….cm dilated. She was then admitted done
blood investigations,( sometimes USG) and was monitored (for contractions and
FHS)
Status of membrane: Rupture of membrane( ROM) Spontaneous/ Artificial /
Premature rom. When it ruptured as if prolonged > 24hrs then PROM/ duration of
delivery following rupture of membrane
> Following rupture of membrane :Colour of liquor: White/ Blood stained/ Meconium
stained/ any other

Progress of the labour

….how many cm was she dilated at what time
Or if labour had to be induced then the reason or augumented then reason
Medically/
Surgically

She was fully dilated at ……time thus

> Duration of 1st stage of labour

> Duration of 2nd stage of labour

> Delivery after… hrs of admission/ labour at…..am/pm by normal vaginal delivery/
instrumental- indications
> If episiotomy was done or not

> Delivery of placenta active management done or not?

Following delivery were there any immediate complications of 3rd stage labour( eg
immediate PPH, retained placenta, extension of perineal tear, uterine inversion)- It can
be said as the immediate post partum period was uneventful

6. Menstrual history
 Age of 1st menarche
  Cycle of mens, regular/ irregular
 Duration of menstruation
 No of pads used/ cloth, clots passed, heavy bleeding wake up at night( menorrhagia).
Normal 20-80 ml.
Normal: cycle; 21-35 days,
bleed 4-5 days
menopause: 45 to 50
menarche 12 to 16 mean 13.
 Pain during period
 LMP

Importance: Correct LMP helps to estimate POG, EDD. If person is taking oral contraceptive
ovulation may not occur as it should have been i.e. LMP might not be accurate and in that
case we need to rely on USG. Irregularity 6mnths to 1 yr back should be taken into
significance.
Also flow is also important as in certain cases spotting might be considered as LMP eg Asar
10 ma mens bhayo bhanxa considering spotting as bleeding ani jabba sodha normal flow
kahile ya katti agi bhakko bhanda 1 mahina agi bhanda our LMP is Jesth 10 not Asar 10. So
flow is essential to know if it was normal mens or spotting.

7.Obstretic history
 LMP
 EDD( expected date of delivery): Calculated as per Naegele’s formula by adding 9
calendar months and 7 days from 1st day of LMP
 POG( period of gestation): The duration of pregnancy is mentioned in completed weeks.
A fraction of week of 3 or more days is considered a complete week.
Gestational age can be incorrect in cases the hx of LMP is incorrect or if the person had
used OCP as in such cases ovulation doesn’t occur normally as it should i.e. 2 wks after
LMP. In such cases USG should be relied upon.

For calculation of POG

# If 3 months add 12+ 1 =13 weeks

e.g. 7 months, then,

3months= 13 wks

3months= 13 wks

1month= 4 wks

Total= 30 wks
Methods of calculating EDD and POG:
a) Naegele formula: Addition of 9 calender months and 7 days to the first day of last menstrual
period( 280 days).
3 calendar months back with 7 days add.
b) Date of fruitful coitus: We add 266 days( 280-14 days) to the date of fruitful coitus, if one
remembers with certainty
c) Date of quickening: Addition of 22 wks in primi( condidering 18 weeks of quickening) and 24
wks in multi( considering 16 weeks)
d) Measurement of symphysio fundal height which should correspond to the date of gestation in
weeks
e) Record of positive pregnancy test at 1st missed period
f) Ultrasonographic findings
eg. Usg at 10th magh – 10weeks of gestation and todays date 10th chaitra so POG= 10th magh to
10th chaitra= 2 months( 8weeks) + 10 weeks= 18 weeks

10 lunar months , 280 days. 40 weeks.

 Obstretic formula: G P A L D
 Past Obstretic hx: why? If previous preterm,abruptio, pp,iufd, obstructed labour they can
recur
In chronological order, date, any antenatal hx of pt showed some imp events of any
illness, labour events, method of delivery- spontaneous/ cs/ instrumentation, post partum
period, about baby- weight, sex, did the baby breast feed, any complications, cried after
delivery or not and immunization, any congenital anomaly
Minimum gap btw 2 baby is 2 year.
8. Contraceptive history: direct question, if large gap btw 2 pregnancy.
After taking pills for 4-6 wks samma irregular so LMP MAY BE WRONG IN SUCH CASES.
Eg of implants: 1. 2 rod implant( implanon)- Gov of Nepal recommends
2. 6 rod implant- Norplant not used now
How long used, when removed, were cycles regular following that
9. Past history: any hx of chronic illness like Tb, HTN, D.M.

Surgical hx: any general or obstetric or gynecological.

Any hx of blood transfusion,
drug hx: Corticosteroid, any drug allergy, previous tetanus, any anti d immunoglobin

10. Fmaily history: hx of chronic illness like Tb, HTN, D.M., conjenital anomaly, twinning,
inherited conditions, if hyperemesis dekhi aaxha bhane is there family hx.
11. Personal hx
> Smoking, alcohol consumption
> Diet
> Sleep, bowel, bladder, appetite

12. Socio economic hx : Sangeeta mam le

Housewife ki works, husbnad occupation, family size. Dont classify high ir low class.

SUMMARY: Mrs…, of age….., primi/…. At ….. wks of gestation with chief complaints of …….
Impression: Primigravida at….wks with ….(diagnosis)

SUMMARY: for PNC

Age, Para(number), on …….puperium day following vaginal delivery( normal/ instrumental-
indication) with an outcome of……..
With positive findings in history of
And examination finding of
GC-
Vitals-
With normal systemic examination
With PA findings of ………..well involuted if 1st day and well contracted if 2nd day
With Perineal findings of
and presently she is doing well.

DIAGNOSIS:
Age…..Para( number) on …..puperium following following vaginal delivery( normal/
instrumental) with or without episiotomy and has been doing well.

Investigations ordered in a pregnant women

a) Blood test esp for Hb
b) Blood grouping- ABO/ Rh system
c)Blood sugar
d) Routine examination urine, urinary glucose
e) Serological test: HIV, HBs, HCV, VDRL,
f) Screening for TORCH infection
g) USG
Cervical cytology: pap is done routinely in some clinics.
Vaccines contraindicated in pregnancy: All live attenuated vaccines
Measles, Mump, Rubella, Varicella, Yellow fever,
Special test: genetic screen : alpha fetoprotein, triple test at 15-18 weeks for mother with risk of
NTD, DOWNS .
Repeat investigation: hb at 28th and 36th , urine for protein, sugar.

Amniotic fluid index ( 8 to 20 )

We divide abdomen into 4 quadrants taking refecrence of fundus, symphysis pubis and
umbelicus. Then in USG we measure the vertical pockets( which are devoid of any fetal parts
and placenta) which resemble hyperechoic area. The sum of the vertical pokets of each area
measured in mm divided by 100 comes in cm.
<7 – oligohydramnious
>25- polyhydramnios
And is single pocket <2 oligo and >7 poly

POINTS

Abortion/ Miscarriage: It is the interruption in the continuity of pregnancy before the period of
viability. Within 12 weeks slight bleeding occurs, until the choriodecidual space is obliterated by
the fusion of deciduas perietalis with deciduas capsularis. In that condition pregnancy continues.
Types of abortion
a) Inevitable abortion: where changes have progressed to a level from which continuation of
pregnancy is impossible. In this condition there is dilatation of internal os.
b) Complete abortion: where entire product of concept is expelled.
c) Incomplete abortion: where partially the product of concept is expelled and a part of it is
remained inside uterine cavity.
d) Missed abortion: when the fetus is dead and is retained inside the uterus for variable period of
time. No cardiac activity is seen.
e) Septic abortion: when an abortion is associated with clinical evidence of infection of the
uterus and its content.
f) threatened abortion: it is type in which process of miscarriage has started but has not reached
to a state from which recovery is impossible.
If bleeding occurs in 2nd trimester it is called antepartum haemorrhage which may be due
to P previa or abruption placentae.
 ANTENATAL HX
HYPERTENSIVE DISOREDERS IN PREGNANCY
TERMS
a) Hypertension: BP >= 140/90 mmHg measured two times with at least 4 hr interval but not
more than 7 days apart.
b) Proteinuria: Urinary excretion of >=0.3 gm/24 hr specimen or 0.1gm/ L
c) Gestational hypertension: BP >= 140/90 mmHg for the first time in pregnancy after 20weeks
without proteinuria.
d) Pre- eclampsia: Gestational hypertension with proteinuria
e) Eclampsia: Women with pre eclampsia complicated with grand mal seizure and/or coma.
f) Chronic hypertension: Known HTN before pregnancy or diagnosed before 20 weeks of
gestation.
History linne tarika
Features of hypertension
a) Blurring of vision
b) Headache
c) Epigastric pain
d)Vomiting
e) Pedal edema causing weight gain in abdomen finger..

…..with hx of amenorrhoea for ….months and raised b.p of …..mmHg during normal
ANC.
In cases of Chronic hypertension: Raised bp since…..months
In HOPI:
…..was apparently well…back after which she developed (symptom)…elaborate yedi cha
bhanne. OR well…months back. And on normal ANC she was diagnosed to have raised bp
of….which was measured….hrs apart( 4 hr apart mannu parxa). She was then admitted and
started with medications after which …was bp controlled or not? If not what was done …like
med added or not.
-ve hx of hypertension ko symptom lekha ani aru normal –ve history of tht trimester lekha.

NORMAL LABOUR
Labour: these are the series of events that takes place in genital organ in an effort to expel the
viable products of conception e.g. fetus, placenta, membrane out of th womb through vagina.
It is characterized by
a) Regular uterine contraction
b) Dilatation and effacement of cervix
c) Fetal descent
Parturation: It is the process of giving birth
Parturient: A women in labour
Delivery: It is the expulsion or extraction of viable fetus out of the womb. It may be vaginal
( spontaneous, aided) or may be abdominal. Delivery wan occur without labour as in effective
c/s section.
Criteria for a Normal Labour( Eutocia)
a) Spontaneous at onset
b) It should be term
c) With vertex presentation
d) Natural termination with minimal aid
e) Without having any complication affecting the health of the mother or the baby.
Abnormal labour( dystocia): Any deviation of normal labour is called abnormal labour like
presentation other than vertex or having some complicatiokns even with vertex presentation,
modification the natural termination or adversely affecting the health of the mother of fetus.
Labour dates:
a) At EDD: 4%
b) 1 wk before and 1 wk after: 50%
c) 2 wk before and 1 week after: 80%
d) at 42 wks: 10wks
e) at 43 wks: 4%
TRUE LABOUR PAIN
a) Painful uterine contraction at regular interval
b) Frequency of contraction gradually increases
c) Intensity and duration of contraction increases progressively.
d) Associated with show
e) Progressive effacement and dilatation of cervix
f) Descent of the presenting part
g) Formation of bag of forewater
h) Not relieved by enema or analgesics
FALSE LABOUR PAIN
a) Dull in nature
b) Confined to lower abdomen and groin
c) May be associated with hardening of uterus
d) They have no other features of true labour pain
e) Usually relieved by analgesics
STAGES OF LABOUR PAIN
1st stage: Onset of the labour pain to full dilatation of cervix( cervical stage of labour).
Primi: 12hrs
Multi: 6hrs
a) Latent: labour pain to 4cm dilatation of cervix
b) Active: 4cm to later…10CM
2nd stage : Full dilatation of cervix to expulsion of fetus
a) Propulsive phase: Full dilatation of cervix to descent of the presenting part to the pelvic floor
b) Expulsive or active phase: Descent of presenting part to delivery of fetus.
Primi: 2hrs
Multi: 30 mins
3rd stage: Expulsion of fetus to expulsion of placenta and membrane
Both in primi and multi: 15 mins but in active management: 5mins
4th stage: 1hr after the expulsion
MECHANISM OF LABOUR
1. Engagement of the maximum transverse diameter of the presenting part crossing the pelvic
brim
2. Flexion such that even if it is a deflexed head there occurs complete flexion
3. Internal rotation of occiput such that the denominator comes under pubic symphysis.
4. Crowning: slowly the fetal heads descends under pubic symphysis
5. Delivery of head by extension
6. Restitution ie there is restitution of the neck that has been twisted along the direction of
shoulder
7. External rotation: now the head rotates which is visible externally so called external rotation
8. Delivery of shoulder and trunk by lateral flexion
DIAGNOSIS OF PREGNANCY
Gestational age/ Mentrual age: Calculated from first day of last menstrual period
Fertilization/ ovulatory phase: Subtracting 14 days from 280 days.

First trimester(1-12weeks)
a) Amenorrhoea
However there may be cyclical bleeding upto 12 weeks. This is called as placental sign
b) Morning sickness- nausea and vomiting
It appears soon after missed period and rarely last beyond 16 weeks
c) Frequency of micturation
Cause
- Resting of bulky uterus onto the bladder due to exaggerated anteverted position.
- Congestion of bladder mucosa
- Change in maternal osmoregulation causing thirst and polyuria
After 12th week uterus straightens up relieving the symptom
c) Breast discomfort
It is the sense of fullness and pricking senses. These changes are important in primigravida as in
multigravida breast are enlarged and often contains milk for years. There is enlargement with
engorgement evidenced by delicate veins visible under the skin. Nipple and areola become
darkly pigmented with prominent Montgomery tubercle.
d) Fatigue
e) Per abdomen: uterus remains as pelvic organ till 12 week.
f) Pelvic changes
Signs:
a) Jacquemier’s or Chadwick’s sign: It is a dusky discoloration of anterior vaginal wall and
vestibule at 8wk of pregnancy due to vascular conjestion.
b) Osiander’s sign: There is increased pulasation felt though the lateral fornices at 8th week
c) Cervical sign( Goodell’s sign): Cervix becomes soft as early as 6th week and feels like lip of
mouth while in non pregnant state it feels like tip of nose. On speculum examination there is
blusih discolouration due to increased vascularity.
d) Uterine sign:
At 6th week: size of hen’s egg
At 8th week: size of cricket ball
At 12th week: Size of fetal head
Piskacek’s sign: If there is lateral implantation where one half feels more firm than the other. But
as pregnancy proceeds the symmetry is restored.
Hegar’s sign: It can be demonstrated between 6 to 10th week and earlier in multipara where
- Upper part of the body of the uterus is enlarged with growing fetus
- Lower part of the body is empty and extremely soft and cervix is comparatively firm.
Thus on bimanual examination there two fingers are placed in anterior fornix and abdominal
fingers behind the uterus these two fingers try to oppose below the body of uterus.
Palmer’s sign: It is elicting regular and rhythmic contraction during bimanual examination.
Here, the uterus is cupped between the internal and external fingers for 2-3mins. During
contraction uterus becomes firm and well defined but on relaxation it becomes soft and ill
defined. With increasing duration of pregnancy
I am presenting a case of Mrs Sharda B. K., 21yrs of age hiindu by religion from
Bhairav Tole, who has studied up to 12 class is lab assistant by occupation,
husbands name is Tej Bdr Barali who is businessman by occupation, their duration
of marriage is 3 yrs, is a bookd case of Manipal Teaching hospital ius on 1st day of
puperium following vaginal delivery at 39+4 weeks of gestation with an outcome
of single M baby of wt 3.2 Kg and today she complains of
Pain at episiotomy site X 1day
The site of the pain is in the perineum which is acute in onset, dull aching in
character with no radiation, intermittent on/off, aggravated with movement and
during urination and relieved on rest and medication and the severity of pain is
decreasing.
She also gives history of PV discharge which is scanty, non foul smelling and
bright red colour. There is also history of PV bleeding which is scanty bright red in
colour, the amount of which is decreasing as compared to yesterday.
Presently she is able to move around, has passed urine but has not passed stool but
has passed flatus, is having a normal diet and is able to suckle her baby.negative hx
of pueperium
The baby is by the side of mother, started breastfed on the same day, has been
vaccinated, with no congenital anomaly, has passed urine and meconium and is in
good condition.
History of labour
She presented 1 day back ie on 17th of Feb at 8:30 am in the morning with pain in
the lower abdomen which was gradual in onset, progressively increasing, dull
aching in character with no radiation, no aggravating or relieving factors. After she
presented history and examination was done where she was said to have labour
pains but the cervix was not dilated. She was thus admitted certain blood tests and
Usg done. The labour was spontaneous in onset but at 3 pm she was only 3cm
dilated so was augumented medically. So the total duration of !st stage of labour
( from 9 am to 9 pm) was about 12 hrs. Thus the delivery occurred at 9 56 pm
vaginally with episiotomy being done so the 2nd stage of labour was about 10-
15mins.
Following delivery active management of 3rd stage was being done and delivery of
placenta occurred within 10 mins.
There was no history of any immediate post partum complications thus was
uneventful( like hemorrhage, extension of episiotomy tear, retention of placenta
and uterine inversion)
History of present preganancy
This pregnancy was spontaneous and planned preganancy and is a booked case of
MTH
1st trimester:
She did ANC visits every monthly and had normal findings. She confirmed her
pregnancy 1 month following her last menstrual period at her home by urine test.
She did USG scan at 1st month which showed normal findings and was told that the
date calculated from LMP and from USG was matching.
She took Folic acid but other than that she didn’t take other drugs
She experienced symptoms of morning sickness but did not have burning
micturition, increased frequency of micturition and breast discomfort.
No medical or surgical illness.
No hx of PV bleed/ discharge
No hx of fever with rash
No radiation exposure

2nd trimester
She did ANC visits every monthly and had normal findings.
USG scanning was done in 4th and 5th month which showed normal findings
She perceived fetal movements at 4 month
She took Fe/ Ca tablets
She took tetanus vaccination 2 doses 1st at 4th month and next dose at 5th month
No hx of PV bleed/ PV discharge
No hx pertaining to rise in bp
No hx of chronic illness

3rd trimester
She did ANC visit vert monthly and had normal finings
USG scanning was done at 7th month which showed normal findings
She continued perceiving fetal movements and also continued taking Fe/ Ca tablets
Her weight gain in the pregnancy is about 12 kg( 71 kg from 59 kg)
No hx of PV bleed/ PV discharge/ PV leakage
No hx pertaining to rise in bp
No hx of chronic illness
One day prior she presented with pain in the lower abdomen

Menstrual hx:
Age at menarche: 15yrs
Cycle of mens: 28+/- 2 days, regular
Duration of mens: 4-5 days
Amount: 1-2 pads/ day
No clots, no pain
LMP: Jestha 1 2076
EDD: Falgun 8 2076
POG at delivery: 39+ 4 days

Obstetric history
P1 L1 A1
1. Her 1st pregnancy was 2 yrs back : At 4th week of gestation , she had PV
bleeding following which she has spontaneous and complete abortion. The
post abortal period was uneventful
Contraceptive history
Absent
Rest same

Examination
Examination
She is conscious, cooperative, well oriented to time place and person, average built
with weight of 71 kg and height of 160 com thus her BMI is 27.7 kg/m2, lying
supine, with canula of 18G in her left hand.
Vitals
Pulse- 78 bpm….
BP- 110/70 mmHg…..
Temp 98 F…..
RR- 20 breaths/min
NO Pallor, Icterus, Edeme
Thyroid normal
Breast examination:
On inspection: Size, shape, contour of b/l breast is normal. There is no redness. On
inspection of nipple, areola complex- the nipples are everted with no cracks and
fissure and no abnormal nipple discharge and 2ndary areola is present.
On palpation- No local rise of temperature, no tenderness, no lump being felt and
no abnormal nipple discharge.
CVS examination- S1 S2 Mo
Respi examination- B/l equal vesicular sounds heard
On per abdominal examination
Inspection-
The shape of the abdomen looks normal
Umbelicus is central and inverted
All quadrants are moving equally with respiration
There is presence of liner pigmented mark extending from xiphisternum to pubic
symphysis suggestive of linea nigra.
There is presence of streach marks over the lower abdomen suggestive of linea
albicans.
There are no other scar maeks, venous prominences and hernieal orifices are intact.
Palpation
There is no local rise of temperature. There is no tenderness
Uterus::
The fundus is at the level of umbilicus.
The symphysiofundal height as being measured from upper border of pubic
symphysis to fundus is cm. the feel of uterus is non tender, firm and globular

Ausultation: 3 bowel sounds/ min

Perineal examination
There is presence of an episitomy wastage of labourund where the stiches are
intact, with no redness, edema, swelling and no abnormal discharge
On examination of lochia the discharge is scanty, colour is red, odour- non foul
smelling.

Summary
21 yrs P1L1A1 on 1st day of puperium following vaginal delivery with episiotimy
with positive findings in hx of
Presentation in early stage of labour which was spontaneous in onset being
augumented later and previous history of spontaneous complete abortion 2 yrs ago
at 4th weeks of gestation
And with positive finding in examination of
General condition: Fair
Vitals- stable
Per abdominal findings of
Uterus size corresponding to 24 wks, SFH 17cm, well involuted
Per vaginal findings of
Episiotomy wound- with intact stiches, no redness edema and swelling
PV discharge scanty, non foul smelling, reddish in colour
And has been doing well