examination on an obstetric patient report

What is an obstetric examination?

The obstetric examination is a type of abdominal examination performed in pregnancy. It is unique in the fact that the clinician is simultaneously trying to assess the health of two individuals – the mother and the fetus. In this article, we shall look at how to perform an obstetric examination in an OSCE-style setting.

What is included in the evaluation of the Obstetric Patient?

Evaluation of the Obstetric Patient 1 History. Family history should include all chronic disorders in family members to identify possible... 2 Physical Examination. A full general examination, including BP, height, and weight, is done first. 3 Treatment. Problems identified during evaluation are managed.

Which specific outcomes are most likely to be scrutinized in obstetric ultrasound examination?

In the case of obstetric ultrasound examination, specific outcomes that are most likely to be scrutinized include the following: Accuracy of gestational age assessment by correlation of eventual delivery date and gestational age at birth

What are obstetric ultrasound examination cases?

Obstetric ultrasound examinations represented the majority of medical malpractice cases involving ultrasound. Ultrasound examination is a noninvasive, safe procedure that has a high degree of patient acceptance and can yield a wealth of information.

How do you assess obstetrical patients?

Obstetric examination focuses on uterine size, fundal height (in cm above the symphysis pubis), fetal heart rate and activity, and maternal diet, weight gain, and overall well-being. Speculum and bimanual examination is usually not needed unless vaginal discharge or bleeding, leakage of fluid, or pain is present.

What should an obstetric history include?

Obstetric HistoryGravidity. Number of times pregnant.Parity. Number of live births.Miscarriages.Terminations.Previous Pregnancies. Length, mode of delivery.Length of Pregnancy. Gestational age at delivery.Induction. Spontaneous / induced.Mode of Delivery. Vaginal, forceps, suction, elective / emergency caesarean.More items...

How do you document obstetric history?

Accompanied by Arabic numbers, G, P, and A (or Ab) describe the patient's obstetric history. Roman numerals are not used. Separate GPA sections by commas. Alternatively, spell out the terms in lower case.

What are the things to assess in patient in an OB ward?

Each evaluation should include:assessment of maternal status;description of uterine activity;assessment of fetal status;description of findings on vaginal exam, if performed, including cervical dilation and effacement, fetal station, change in status of membranes, and progress since last exam;More items...

What is obstetric data?

An obstetric data analyzer (fetal status data analyzer) is a device used during labor to analyze electronic signal data obtained from fetal and maternal monitors. The obstetric data analyzer provides clinical diagnosis of fetal status and recommendations for labor management and clinical interventions.

What is physical examination in pregnancy?

Physical exam Your health care provider will typically check your blood pressure, measure your weight and height, and calculate your body mass index to determine the recommended weight gain you need for a healthy pregnancy.

Why is obstetric history important?

A carefully obtained obstetric history can provide the family physician with useful clues to his patients' health risks. A previous infant's birth weight and certain congenital malformations may indicate a predisposition to vascular hypertensive or diabetic illness.

What is a gravida 1 para 1?

Para OR Parity is the number of completed pregnancies beyond 20 weeks gestation (whether viable or nonviable). The number of fetuses delivered does not determine the parity. A woman who has been pregnant once and delivered twins after 20 weeks would be noted to be a Gravid 1 Para 1.

What is a gravida 2 para 1?

Are you thinking, 'What is G2 P1, and can I catch it?' Don't worry, G2 P1 is medical shorthand for gravida 2 para 1, a quick way to explain how many pregnancies and births a female has had. The term gravida comes from the Latin word gravidus.

What is assessment of patient?

Patient assessment commences with assessing the general appearance of the patient. Use observation to identify the general appearance of the patient which includes level of interaction, looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

What is physical assessment in nursing?

Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment should be adjusted to the patient, based on his needs.

What is obstetric patient?

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

What is obstetric history?

Obstetric history, with the outcome of all previous pregnancies, including maternal and fetal complications (eg, gestational diabetes, preeclampsia, congenital malformations, stillbirth) Family history should include all chronic disorders in family members to identify possible hereditary disorders ( genetic evaluation ).

Why do we do a speculum pelvic exam?

In the initial obstetric examination, speculum and bimanual pelvic examination is done for the following reasons: To check for lesions or discharge. To note the color and consistency of the cervix. To obtain cervical samples for testing.

What are the symptoms of a woman's labor?

Women should be advised to seek evaluation for unusual headaches, visual disturbances, pelvic pain or cramping, vaginal bleeding, rupture of membranes, extreme swelling of the hands or face, diminished urine volume, any prolonged illness or infection, or persistent symptoms of labor.

How long does it take for a 50g test to show insulin resistance?

Polycystic ovary syndrome with insulin resistance. If the 1st-trimester test is normal, the 50-g test should repeated at 24 to 28 weeks, followed, if abnormal, by a 3-hour test. Abnormal results on both tests confirms the diagnosis of gestational diabetes.

How long does it take to measure a rump?

Measurement of fetal crown-rump length during the 1st trimester is particularly accurate in predicting EDD: to within about 5 days when measurements are made at < 12 weeks gestation and to within about 7 days at 12 to 15 weeks.

When should a woman have her rh blood tested?

Rh (D) antibody levels should be measured in pregnant women at the initial prenatal visit and again at about 26 to 28 weeks.

What is the sum of parity and abortus?

Sum of parity and abortus equals gravidity. Parity is often recorded as 4 numbers: Number of term deliveries (after 37 weeks) Number of premature deliveries ( > 20 and < 37 weeks) Number of abortions. Number of living children.

What is obstetric cholestasis?

Obstetric cholestasis is a multifactorial condition that is characterised by abnormal liver function tests, jaundice and intense pruritis (typically affecting the palms and soles of the feet). The disease usually presents in the third trimester and is associated with an increased risk of intrauterine death and premature delivery.

What is fetal lie?

Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother. Assess the gravid uterus to determine the fetal lie: 1. Place your hands on either side of the patient’s uterus (ensuring you are facing the patient). 2.

What should be done if a transabdominal examination is not definitive?

If a transabdominal examination is not definitive, a transvaginal scan or transperineal scan should be performed whenever possible. a. The uterus (including the cervix) and adnexa should be evaluated for the presence of a gestational sac. If a gestational sac is seen, its location should be documented.

What should be documented in adnexal mass?

The presence, location, appearance, and size of adnexal masses should be documented. The presence and number of leiomyomata should be documented. The measurements of the largest or any potentially clinically significant leiomyomata should be documented.

What are the recent advances in ultrasound technology?

•#N#Recent years have seen dramatic advances in ultrasound technology, including improved spatial and contrast resolution, routine use of three-dimensional (3D) and four-dimensional (4D) imaging, volumetric scanning, expanded indications for color and spectral Doppler, new and improved ultrasound scanning probes, and improved digital review workstations.

Why is cavitation so difficult to document?

Cavitation has been difficult to document in mammalian fetuses, because, for the most part, there is not an air-water interface, which is needed for the cavitation mechanism.

Does the specialty of the examiner matter?

As long as the examining physician is adequately trained and performs the minimum standard obstetric ultrasound examination, as per the guidelines of the American College of Radiology (ACR), AIUM, and ACOG, the specialty of the examiner does not matter. However, we do not believe in the practice of self-referral.

Can ultrasounds harm a developing fetus?

Despite numerous claims for the safety of ultrasound to the mother and fetus, a number of studies have noted possible adverse effects of diagnostic ultrasound to the developing fetus. These studies have focused primarily on thermal and cavitation mechanisms leading to possible injuries to the developing fetus.

Is ultrasound safe for a fetus?

Although there is high-quality evidence that ultrasound is safe for the fetus when used appropriately, consensus statements conclude that Doppler examination of fetal vessels in early pregnancy should not be performed without a clinical indication.

How many fellowships are there in obstetrics?

In the United States, there are approximately 40 family medicine fellowships in obstetrics.10Physicians in these programs are trained to perform obstetric ultrasound examination,11 and many subsequently practice in rural and/or underserved areas.

Can a family physician perform an ultrasound?

Family physicians can acquire skills for performing obstetric ultrasound examination during their family medicine residency training or a post-residency fellowship. Obstetric ultrasound examination courses organized and presented by family physicians and sponsored by the AAFP have been offered since 1989.

What are high risk obstetric patients?

High-risk patients who need anaesthetic input include those with airway problems, cardiorespiratory disease and rare genetic conditions, such as malignant hyperthermia and suxamethonium apnoea. Anaesthetic options for labour analgesia as well as anaesthesia for operative delivery will need to be discussed in detail with the patient if a delivery management plan is to be constructed. Input from other medical teams, such as cardiologists or haematologists, are often needed. Ultimately, these measures should reduce maternal morbidity and mortality.

How many cases of failed intubation in obstetrics?

For over 2 decades, despite various advances in the management of the pregnant patient, the incidence of failed intubation in the obstetric population remains around 1 in 300 cases, which is approximately 10 times higher than in the general population. At the same time airway complications remain the leading cause of anaesthetic death amongst parturients. Majority of cases of failed intubation have occurred in the context of an emergency CS under general anaesthesia (GA) , which is associated with a greater risk of maternal mortality than neuraxial anaesthesia.

What is the normal range of extension for a laryngoscopic view?

This simple test is performed by asking the patient to maximally extend her head while in the sitting position. The normal range is around 35° extension and correlates with the ability to assume the ‘sniffing the morning air’ position which is optimal for obtaining a good laryngoscopic view. A reduction in the extension range of ≥12° correlates with difficult intubation.

Is a pregnant woman considered a high risk patient for CHD?

There is also the issue of managing the pregnant patient with a prosthetic valve. Cyanotic heart disease is associated with higher maternal morbidity and mortality but all pregnant women with CHD should be considered high risk, especially those with pulmonary hypertension, cyanotic conditions, Marfan’s syndrome, complex surgically repaired conditions (e.g., Fontans or Mustard procedures) and metal prosthetic heart valves.