Antenatal Physical Examination - Part 1

Obstetrics and Gynecology


Introduction
This is
<Mrs. Murphy>,
a
<28 year old>
<schoolteacher>,
from
<Dublin>,
who is
<38 weeks pregnant>
with her
<third>
baby. The reason she is in hospital is
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.

Past medical surgical history
On briefly reviewing Mrs. Murphy's past medical and surgical history...

Family history
In her family history...

In particular, there is
<no family history>
of diabetes, and
<no>
twins in the family.

Social history
With regard to social history,
<Mrs. Murphy>
works as a
<schoolteacher>.
<She also works at home looking after her children>.
She is due to go on a
<3 month>
maternity leave in
<1 week>.

She is residing in
<a 2 bedroom apartment>.
Her husband works as a
<lawyer>.

Her children are being looked after by
<the children's grandmother>.

<Mrs. Murphy>
<does not smoke || smokes ... cigarettes a day>
Prior to the pregnancy, she
<did not smoke || smoked ... cigarettes a day>.
She has
<not taken any alcohol || has restricted herself to ... units of alcohol per week>
since finding out she was pregnant.

She
<is>
taking iron and folic acid supplements.

Gynecological history
With regards to
<Mrs. Murphy's>
past gynecological history...

Her last smear test was in
<1996>,
it was
<normal>,
and
<all of her smear tests have been normal>.

Obstetrical history
Turning our attention to
<Mrs. Murphy's>
previous obstetrical history, she has
<two girls>,
aged
<2 and 4 years>.
They are
<both well>.

If an abnormal pregnancy, full details:

In her first pregnancy, she
<was induced>
at
<39 weeks>,
and after
<2 hours || 6 hours [depending on if making start of labour as when enter labour ward]>,
<under went a Cesarean section>
because of
<fetal distress>.
The cesarean section was performed
<under epidural>.
The baby weighed
<2.5kg>
at birth and
<was not admitted || was admitted for ... days>
to the neonatal unit.
She had
<no post-operative complications || post-operative complications of ...>.

If a normal pregnancy, brief:
In her second pregnancy, she
<went into spontaneous labor>
at
<40>
weeks
and had
<a normal vaginal delivery>.
The baby weighed
<3.0kg>.

If a miscarriage, also brief:
<Mrs. Murphy>
also had
<1>
miscarriage
<14>
months ago
at
<10 weeks>
and
<underwent ERPC>.

Current pregnancy: LMP
Focusing our attention on this pregnancy, the first day of
<Mrs. Murphy's>
last menstrual period was
<Sept 18th>.
She is
<certain || uncertain>
of the date, because she
<wrote it in her diary || remembers the day of conception>.

She has a
<regular>
<28 day>
cycle, and
<stopped the combined oral contraceptive pill>
<6 months>
before becoming pregnant.

By Nageles's rule, her estimated date of delivery is
<June 25th>.

Current pregnancy: planned
The pregnancy was
<planned || unexpected>
and
<Mrs. Murphy>
<was || was not>
taking periconceptual folic acid.

[If contraception like OCP failed, you may wish to ask her why it didn't work].

Current pregnancy: confirmation
She had a positive pregnancy test at
<5>
weeks.

She booked into hospital at
<13 weeks>
and an ultrasound scan
<confirmed her menstrual dates>.

<She felt quickening at ... weeks>.

Current pregnancy: Rhesus/rubella
She is
<Rhesus positive || Rhesus negative || uncertain of her Rhesus status>
and
<rubella immune || not rubella immune || uncertain of her rubella status>.

Current pregnancy: breastfeeding
She
<breastfed || bottlefed>
her previous children and intends
<breastfeeding || bottlefeeding>
for this baby.

If breastfeeding and first child:
<She is comfortable with breastfeeding because she has taken a class>.

Current pregnancy: antenatal care
She opted for antenatal care with
<her general practitioner || this hospital>.

Her antenatal course was
<normal until she was admitted to hospital on this occasion || normal except for a ... at ... weeks gestation>.

Current pregnancy: pre-admission events
<Mrs. Murphy>
was admitted to hospital
<4 days>
ago. She complained of
<...>

Current pregnancy: hospital events
Since coming into hospital, the investigations she have had are
<....>
which showed
<...>.

<Mrs. Murphy>
tells me that she is being kept in the hospital
<for observation>.

Summary of history
In summary, therefore, this is
<Mrs. Murphy>,
a
<28 year old>
<schoolteacher>,
from
<Dublin>,
who is
<38 weeks pregnant>
with her
<third>
baby.

The reason she is in hospital is
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.

<Mrs. Murphy>is being kept in the hospital
<for observation>.