Obstetrics History taking and Clinical examination for medical students

Obstetric history taking and examination guide for MBBS students

👤01 DEMOGRAPHIC DETAILS

Name:

Age:

Address:

Education:

Occupation:

Husband's Name:

Husband's Occ.:

Family Income:

Nearest Facility:

Booking Status: Booked Unbooked Referred

Immunization:

LMP: 📅 EDD: 📅

POG (Current Gestation):

❤️02 PRESENTING COMPLAINTS

Obstetric Formula

🔴Complaint(s):

⏱Onset:

⏰Duration:

📈Progression:

⚡Severity:

🔗Associated Symptoms:

📅Date of Admission:

📝03 HISTORY OF PRESENT ILLNESS (HOPI)

Details of chief complaints
Progression of symptoms
Treatment taken
Hospital course (if referred)
Previous antenatal visits
Booking status

🤰04 PRESENT PREGNANCY HISTORY

🌱 FIRST TRIMESTER (0–13 WEEKS)

Conception

Spontaneous
Assisted (ART)

Method of Diagnosis

Registration

Booked
Registered
Unbooked

Drug Intake

Folic acid
Iron
Other medications
Teratogenic drug exposure

Chronic Illnesses

• Hypertension • Diabetes • Thyroid disorders • Epilepsy • Renal disease • Cardiac disease

Antenatal Visits

No. of visits:

USG findings:

NTNB:

Double marker test:

Symptoms

Nausea / Vomiting
Hyperemesis gravidarum
Burning micturition
Bleeding PV
Vaginal discharge
Fever with rash
Radiation exposure
Reduced urine output
Altered bowel habits

Infections (TORCH)

Toxoplasmosis
Rubella
CMV
Herpes simplex

🌿 SECOND TRIMESTER (14–27 WEEKS)

Antenatal Visits

No. of visits:

Investigations performed:

Quickening

Primigravida → ~20 weeks
Multigravida → ~18 weeks

Symptoms

Vomiting
Bleeding PV
Weight gain
Swelling of feet
Headache
Disturbed sleep
Giddiness
Epigastric pain
Blurring of vision
Seizures

Immunization

TT1 TT2 Booster dose

Drug Intake

Iron supplementation
Calcium supplementation
Folic acid

Screening Tests

Triple marker screening
Blood sugar profile

🌳 THIRD TRIMESTER (28 WEEKS–TERM)

Antenatal Visits

Frequency of visits:

BP records:

Weight gain:

Symptoms

Headache
Pedal edema
Blurring of vision
Decreased fetal movements
Leaking PV
Bleeding PV
Labour pains
Dyspnea
Pruritus
Jaundice

Investigations

Growth scan
Doppler studies
Blood sugar monitoring
NST / CTG (if indicated)

💧05 DIABETES IN PREGNANCY NOTES

Fasting Blood Sugar (FBS): Done during 1st trimester screening
75 g OGTT: Usually performed at 24–28 weeks

7-Point Blood Sugar Profile

Fasting	Pre-BF	1 hr Post-BF	2 hr Post-BF	Pre-Lunch	Post-Lunch	Bedtime

👶06 PREVIOUS OBSTETRIC HISTORY

Pregnancy (Year)	GA at Delivery	Conception (Spont./ART)	ANC Visits	Complications (PIH / GDM / APH / IUGR)	Delivery (FTND / Instr. / LSCS)	Baby (Sex, Wt, Alive/Dead)	Remarks

GA: Gestational Age

FTND: Full Term Normal Delivery

Instr.: Instrumental

LSCS: Lower Segment Cesarean Section

🔍10 EXAMINATION

A. General Physical Examination (GPE)

General Appearance

Conscious Comfortable Well oriented to T.P.P

Anthropometry

Height: cm Weight: kg BMI:

Nutrition

Well nourished Moderately nourished Poorly nourished

Vitals

Pulse

/min

🩸 BP

mmHg

/min

🌡️ Temp

°C

SpO₂

PICCLe

Pallor Icterus Cyanosis Clubbing Lymphadenopathy Edema

B. Systemic Examination

❤️Cardiovascular system:

🫁Respiratory system:

🔬Breast examination:

🦋Thyroid examination:

🩺Other systems:

C. Obstetric Abdominal Examination

Inspection

•Shape & contour:

•Symmetry:

•Movement with respiration:

•Distension:

•Umbilicus:

•Linea nigra:

•Striae gravidarum:

•Dilated veins:

•Sinuses:

•Scars:

•Hernia orifices:

Palpation

Fundal height:

Symphysio-fundal height:

Fundal grip:

Lateral grip:

Pawlik's grip:

Pelvic grip:

Lie, Presentation, Position, Attitude:

Engagement:

Estimated fetal weight:

Uterine contractions:

Fetal movements:

Fetal heart sounds:

Obstetrics History taking and Clinical examination for medical students

OBSTETRIC HISTORY & EXAMINATION

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