HISTORY OF PRESENTING ILLNESS:

Signs Labour:
of
S nset
it 2

WARD:
①king
of Liquor Characteristic
BED: Radiating
watery? Alleviating for cos
volumes
Unset?
colour?
time/Duration
xacerbating factor
smell?
Severity.
S(x).
All pain? Associating
⑦

NAME : latest scan:? ⑧ sow

rendir?
AGE : frequency of scan?
AlW blood?
PAST OBSTETRIC HISTORY
MYKAD : Colour?
splanned? smell? YEAR MODE OF GESTATION PLACE GENDER WEIGHT COMPLICATION BREAST
GRAVIDA : POA :
LMP :
AlW pain? DELIVERY FEEDING

Ocontraction
EDD : 1ST SCAN :

cc; see
How many
PROBLEM LIST
times per min?
1. How long?
onset?
2.
Regular?
3.
set
4.

5.
①Fetal
Movement
GOOd?
6. FKC complete PAST GYNAE HISTORY
whattime

usually? MENARCHE: HMB

PCB
BOOKING PERIOD CYCLE:
IMB

HEIGHT: cm HAEMOGLOBIN: CONTRACEPTION:

WEIGHT: kg BLOOD GROUP: PAP SMEAR:

BMI: kg/m2 HEP B/ HIV/ VDRL: GYNAE SURGERY:

Water
BP: mmHg MOGTT: Dysmanorrhea?Need meds?
URINE: INDICATION FOR MOGTT: sexually active?

MOGTTDone When? Bleeding after sex?

Pain after sex?
if GPM Ask About:
done when? Urine w/ blood?
① HbAC:-1st
-
latest done when? pain
during urination?
② BSP:-1st dore when?
1
premeal or
postmeal?
!Yatest
pints
done

or
when?

pints?
 PAST MEDICAL HISTORY Speculum/ Vaginal Examination

PAST SURGICAL HISTORY

DRUG HISTORY

ALLERGY Ultrasound

FAMILY HISTORY

SOCIAL HISTORY

INVESTIGATION RESULTS:
PHYSICAL EXAMINATION &
Hands:
Osafunding:

I
-

Asterixis?
GENERAL:
s
cars?
teachments?
A
Vital Signs: splinter hemorrhage?
Branula? K0:
BP : mmHg Meds? Inychid?
Inhaler? Finger clubbing? DIAGNOSIS:
Pulse : beats/minute
comfortable? JL/ON?
Capillary refill time?
o
Temperature : Celsius
Spine/sit?
Palmar erythema?
Cardiovascular : Alert?
Lungs : Pale? peripheral cyanosis?

Abdominal Examination
⑧Eyesi aundicesa
PLAN:
conjunctival pallor?
# &
X am ④ Tongue:
&
Inspection. Angular stomatitis?
And distended by? Oral hygiene?
lined nigrd?
stride albicans?
coated tongue?
s ride gravidamm? Glossitis?
scars?
measured at?
&
alpatiorec
umbilicus?

-
tender?
·Deep: -

fetal lie?
-
back at?
-

sFH9
-presentation?
-

CFH?
EFW?
engagement?
-

head
-

oligo/polyhydramnios?
OBSTETRICS CLERKING SCRIPT

Introduc6on and HOPI

• My pa'ent, Madam ____, a ____ y/o lady, G ____ P ____ currently at ____weeks POA with known case of ____ is admi?ed for ____ a/
w ____.

• Her LMP was on ____.

• EDD is on ____.

Antenatal History

• This is a un/planned & un/wanted pregnancy.

• Her urine pregnancy test (UPT) was tested posi've at ____ weeks POA.
• Da'ng scan was done at ____ weeks POA at ____.

• The early part of the pregnancy was a/w excessive vomi'ng but did not require any admission or medica'on.
• Ini'al booking was done at ____ weeks POA at ____.
- Her weight at that 'me was ____ kg, height ____ cm, BMI ____.
- Her BP was ____/____ mmHg, Hb ____ g/dL, blood group ____, Rhesus +/-.
- Urine test normal/showed proteinuria/glycosuria.
- Hep B/HIV/VDRL screening was not/reac've for ____.
- MGTT was not/done ____ 'mes because ____, was normal/showed signs of hyper/hypoglycemia. Result ____.
- This was followed by BSP (____/____/____/____) taken at ____ weeks.
• Since then, she had a total of ____ follow-ups once per month, ____ weeks POA onwards ____ 'mes per month. All were unevenVul.
• Her latest scan was done at ____ weeks POA at ____ showing parameters equal to date, single/mul'ple fetus, fetal presenta'on
cephalic/breech, longitudinal/transverse/oblique lie, placenta at ____, amnio'c fluid index (AFI) ____, es'mated fetal weight ____ kg.

• The pregnancy has progressed well. She gained weight ____ kg, in/appropriate.

• She had several ultrasounds performed and was told the baby was growing well. Up 'll today, fetal movements were good and there
were no signs of labour.

Past Obstetrics History

• Year Age SVD/LSCS boy/girl ____ kg POA/full term alive and well.

• She had delivered ____ children, ____ boys ____ girls. All of them were delivered via FTSVD/except for ____th child which was delivered
by LSCS due to ____.

• The post opera've period was unevenVul.

• The babies weighed between ____ to ____ kg. All children are normal, alive and well.
• If miscarriage: She had a history of miscarriage in ____th pregnancy at ____ weeks POA, confirmed by ultrasound. An Evacua'on of
Retained Products of Concep'on (ERPOC) was performed and there was no complica'on following the procedure.

• If intrauterine death (IUD): She had a history of IUD in ____th pregnancy at ____ weeks POA. There was no precipita'ng factor and it
was diagnosed following a complaint of decreased fetal movements. The delivery was induced and a baby boy/girl was delivered
vaginally. The baby was macerated but there was no abnormality detected. The placenta had gross infarc'on.
Past Gynae History

• She a?ained menarche at ____ y/o.

• Since then her menses had been ir/regular with ____ days cycle with normal/minimal flow for ____ to ____ days.

• No/dysmenorrhea requiring medica'on/slight dysmenorrhea not requiring any medica'on or MC.

• No history of inter-menstrual, post-coital bleeding, menorrhagia, dyspareunia.

• No history of UTI/STD.
• Pap smear has never/done on ____ showing ____.

• She uses contracep'on ____ from ____ to ____.

• She denies using and contracep've methods.

• For subfer'lity, sexually ac've? marriage how long? long-distance?

Medical History

• No history of DM, HT, asthma, renal disease, drug allergy.

• She is a known diabe'c diagnosed since ____.

• The pa'ent is known ____ medica'ons/vitamins (if any).

• Diabetes is not/well-controlled. No complica'ons secondary to the disease.

Surgical History

• There is no significant surgical history.

• She is a known case of thyrotoxicosis and had undergone thyroidectomy in ____ at ____.
• She is now euthyroid and does not require any medica'on.

• Appendicectomy?

Family History

• There is no family history of DM, HT, malignancy/cancer, congenital malforma'ons, twins.

• She has strong family history of ____.

• Both her parents and one of her siblings are ____ and on treatment.

• Dad ____ y/o ____, mom ____ y/o ____.

Social History

• She is a ____ married to a ____ in ____, ____ years.

• Their total income is RM ____.

• They live at the ____ th floor of ____ with/no li_.

• She claims not smoking/drinking/drug. Husband smoke/drink/drug.

• She wishes to have ____ children. / She claims her family is complete.

• Currently, her children were taken care by ____.

Summary of History
My pa'ent is a ____ y/o lady G____P____ working as a ____, a known case of ____, currently at ____ weeksPOA, admi?ed for ____ a/w

____ and awai'ng delivery.

PHYSICAL EXAMINATION

• My pa'ent, Madam ____, a ____ y/o lady, G ____P ____ with a known case of ____ is admi?ed for ____ a/w ____, is currently at ____
day/hour post SVD/LSCS at ____ weeks POA.

• She was admi?ed at ____ weeks POA in latent/ac've phase of labour with intermi?ent lower abdominal pain with mild/moderate/
strong contrac'ons ____ 'mes in 10 min, a/w leaking liquor.

• Upon admission, vaginal examina'on shows cervix is dilated ____ cm.

• Induc'on of labour (IOL) was done (if applicable) and she progressed to ac've phase of labour a_er ____ hours.

• She was sent to labour room at ____ am/pm and was augmented for ____ hours with pitocin.
• Vaginal exam and ar'ficial rupture of membrane (ARM) (if applicable) was done, which shows that the cervix is dilated ____ cm and
there was clear/meconium-stained liquor.

• She delivered vaginally a_er ____ hours of ac've phase.

• She delivered a baby girl/boy weighing ____ kg with Apgar score of ____ at 1 min and ____ at 5 min.
• Es'mated blood loss was ____ mL, Hb level decreased from ____ to ____ g/dL.

• The placenta was delivered by controlled cord trac'on, weighed ____ g, complete, with blood and cord pH is ____.
• No intra/postpartum complica'on noted.

• Today, the pa'ent is well and alert. On examina'on, she is not pale.
• Vital signs are stable with BP ____ mmHg, pulse rate ____ bpm, temperature ____ °C, not febrile.

• Abdomen is so_ and non-tender.

• Uterus is firm and well-contracted at 18/20 weeks in size.

• Lochia is normal with ____ half/fully-soaked pad/day, no ac've PV bleeding.

• Pa'ent ambulates well, had passed urine and defecated.

• BreasVeeding was established.

• There is no acute complaint such as fever, vaginal discharge or tenderness at site of opera'on (if LSCS).

Check

• Hand, conjunc've — pale

• Breast — engorged

• Nipple — retracted, difficult to breasVeed

• Calf pain — calf non-tender, DVT especially in LSCS

• Advise on Pap smear, Rubella vaccine, Rhesus -ve

Contracep6on Counselling

• She wishes to have ____ children. /She claims her family is complete.

• A_er this pregnancy, she is keen on using ____ contracep've because ____. Space her pregnancy?
• I have explained the pro and cons of this method.

• She is aware of the effects and intends to use it for about ____ years.
• I have explained the importance of a well-spaced pregnancy.
General Examina6on

• On general examina'on, pa'ent is pink/pale/jaundiced/cyano'c.

• Her BP was ____ mmHg, pulse rate ____ bpm, temperature ____ °C.

• Head, neck, heart, lungs and breasts showed no abnormali'es.

Inspec6on

• On abdominal examina'on, the abdomen is distended by a gravid uterus as evidenced by linea nigra and striae gravidarum.

• Umbilicus is centrally located/otherwise and is flat/inverted/everted.

• There is a transverse suprapubic scar measuring about 12 cm which is well-healed/healed with keloid/hypertrophy.

• The scar is tender/non-tender, no incisional hernia noted.

• Say it if fetal movement is observed. Or else do not men'on anything.

Palpa6on

• The abdomen is so_ and non-tender. Uterus is not irritable.

• Clinical fundal height corresponds to ____ weeks of gesta'on, equal/smaller/larger than date.

• Symphysio-fundal height measured ____ cm.

• There is a single fetus/mul'ple pregnancy in longitudinal/transverse/oblique lie with cephalic/breech presenta'on.

• Fetal back is at the maternal right/le_ side.

• The head is ____/5 palpable, not/engaged, s'll ballotable.

• Liquor is adequate/inadequate/excessive as evidenced by a posi've fluid thrill.

• Es'mated fetal weight is ____ kg. (mul'ple pregnancy — es'mated combined fetal weight)
28 w — 1.0 kg
34 w — 2.0 kg

36 w — 2.4 kg
Term — 3.2 kg

Ausculta6on

• I would like to complete my examina'on by listening to the fetal heart using a Pinard stethoscope (>24 w)/Daptone (<24 w).
• I would listen over the anterior shoulder of fetus, around here (show to examiner).