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When you have completed this skills chapter you should be able to:
The purpose of taking a history is to assess the past and present obstetrical, medical and surgical problems in order to detect risk factors for the patient and her fetus.
Does the patient have a normal and regular menstrual cycle? When did she last have a normal menstrual period?
It may be difficult to establish the LMP when she has an irregular cycle.
If the patient is uncertain of her dates, it is often helpful to relate the onset of pregnancy to some special event, e.g. Christmas or school holidays. For example ‘How many periods have you had since your birthday?’ or ‘How many periods had you missed before New Year?’.
The expected date of delivery (EDD) must now be estimated as accurately as possible. A quick estimate can be made by taking the date of the LMP and adding 9 months and 1 week. Therefore, if the LMP was on 2-2-2009, the EDD will be on 9-11-2009. If the LMP is 27-10-2009, the EDD will be 3-8-2010.
It is important to know how many pregnancies the patient has lost. Patients often forget about miscarriages and ectopic pregnancies, and may also not mention previous pregnancies from another husband or boyfriend. Questions which need to be asked are:
All these findings should be recorded briefly on the antenatal record in the Maternity Case Record (Figure 1A-1).
Figure 1A-1: Recording past obstetric history
Patients must be asked about diabetes, epilepsy, hypertension, renal disease, heart valve disease and tuberculosis. Also ask about any other illnesses which she may have had. Asking about allergies and medication often brings to light a problem which the patient may have forgotten, or thought not to be of significance. Always ask whether she has ever had an operation or has been admitted to hospital and, if so, where and why.
Any abnormal findings in the medical history should be recorded, with a brief comment, on the antenatal record in the Maternity Case Record.
The patient’s family planning needs and wishes should be discussed at the first antenatal visit. She (and her partner) should be encouraged to plan the number and spacing of their children. The contraceptive methods used should also be in keeping with these plans. The patient’s wishes should be respected. The outcome of these discussions should be recorded on the antenatal record in the Maternity Case Record.
The following should be assessed:
This can be difficult when the patient has a short, thick neck, or when she is obese. Look for an obviously enlarged thyroid gland (a goitre). The patient should be referred for further investigation when there is obvious enlargement of the thyroid, the thyroid feels nodular, or a single nodule can be felt. A normal thyroid gland is usually slightly enlarged during pregnancy.
The patient must be undressed in order for the breasts to be examined properly. The breasts should be examined with the patient both sitting and lying on her back, with her hands above her head.
When the thyroid is examined, the neck should also be thoroughly examined for enlarged lymph nodes. The areas above the clavicles and behind the ears must be palpated. The axillae and inguinal areas should also be examined for enlarged lymph nodes.
Patients with AIDS usually have enlarged lymph nodes in all these areas.
The patient must be undressed. Look for any of the following signs:
Urine is most conveniently tested using reagent strips. Some strips, such as Lenstrip‑5, will measure pH, glucose, ketones, protein and blood while others, such as Multistix and Combi-9, will also measure bilirubin, specific gravity, urobilinogen, nitrite and leucocytes. However, measuring glucose and protein are most important and, therefore, only glucose and protein need to be measured in routine antenatal screening. You can use Uristix for this. This is the cheapest method.
The strips should be kept in their containers, away from direct sunlight, and at a temperature of less than 30 °C. A cool dry cupboard is satisfactory. The strips should only be removed from their containers one at a time immediately before use, and the container should be closed immediately.
The patient’s urine should be tested at every antenatal visit, and the results recorded on the antenatal chart. Proteinuria of 1+ or more is abnormal while glycosuria must be investigated further.
This test is usually done when a patient has missed 1 or more menstrual periods and when, on clinical examination, one is uncertain whether or not she is pregnant.
The test is based on the detection of human chorionic gonadotrophin in the patient’s urine.
The earliest that the test can be expected to be positive is 10 days after conception. The test will be positive by the time a pregnant woman first misses her period. If the test is negative and the woman has not missed her period yet, the test should be repeated after 48 hours.
The test which is described in this unit is the U-test β-hCG strip foil. If another pregnancy test is used, the method of doing the test and reading the results must be carefully studied in the instruction booklet. All these kits can be stored at room temperature. However, do not expose to direct sunlight, moisture or heat.
The patient should bring a fresh urine specimen.