Obstetric History and Examination: Complete Clinical Guide

Clinical safety notice: This is an educational guide for emergency-medicine and midwifery learners. It does not replace Uganda Ministry of Health protocols, senior review, ultrasound, laboratory testing or referral. A pregnant patient who is shocked, convulsing, severely hypertensive, bleeding heavily, febrile, breathless, in severe pain, or reporting reduced/absent fetal movements needs emergency triage while history and examination proceed in parallel.

What this guide covers: a complete, respectful, reproducible approach to history taking, vital observations and examination of a pregnant woman at booking, routine ANC, triage or emergency presentation. The sequence expands the supplied 138-slide obstetric history/examination teaching presentation and aligns the practical checklist with Uganda’s goal-oriented ANC approach and WHO maternal–fetal assessment principles.

Learning objectives

Establish rapport, consent, privacy and safety before touching the patient.
Obtain a focused but complete obstetric, medical, surgical, medication, psychosocial and safeguarding history.
Calculate gestational age and expected date of delivery (EDD), while recognising when ultrasound dating is more reliable.
Measure and interpret maternal vital signs, nutritional status, urine and fetal observations.
Perform and document a systematic general and abdominal obstetric examination, including symphysis–fundal height, fetal heart rate and Leopold manoeuvres.
Recognise red flags requiring immediate treatment, senior review, admission or referral.

1. Why the assessment matters

Antenatal assessment is not simply a ritual examination. It identifies maternal disease, pregnancy complications, fetal growth or viability problems, safeguarding concerns and barriers to timely care. A good assessment answers five questions:

Is the mother currently unstable or in an obstetric emergency?
How far is the pregnancy, and is the gestational age trustworthy?
Is the pregnancy low risk or are there maternal, fetal or social high-risk features?
Are there signs of labour, hypertensive disease, infection, haemorrhage, ruptured membranes, fetal compromise or another acute illness?
What must happen next—reassurance and routine follow-up, investigation, treatment, observation, admission, referral or urgent delivery planning?

2. First contact: safety, communication and consent

Before the interview

Introduce yourself, confirm the patient’s name and preferred language, and explain your role.
Confirm identity with two identifiers and check gestational age if known.
Ask permission to talk and examine; explain what will happen and that she may stop the examination at any time.
Offer a trained chaperone for intimate examination, regardless of the examiner’s sex, and respect the patient’s preference.
Use a private, warm, well-lit room. Expose only the area being examined and keep the abdomen covered when not in use.
Use hand hygiene, gloves for contact with blood/body fluids and clean equipment.
Ask about immediate danger first: “Are you bleeding, having severe pain, difficulty breathing, severe headache/visual change, fits, fever, leaking fluid or reduced baby movements?”

Rapid emergency screen (ABCDE)

Step	Look for	Immediate action while history continues
A—Airway	Obstruction, seizure, reduced consciousness, aspiration.	Call for help, position safely, suction/airway support and protect from aspiration.
B—Breathing	Severe dyspnoea, cyanosis, RR abnormal, low SpO₂, pulmonary oedema.	Upright/left lateral position, oxygen if clinically indicated, monitor and investigate urgently.
C—Circulation	Heavy bleeding, shock, weak pulse, prolonged capillary refill, cold/clammy skin.	Two large-bore IV lines, bloods/cross-match, fluids and haemorrhage protocol according to local guideline.
D—Disability	Convulsion, severe headache, confusion, focal deficit, hypoglycaemia.	Check glucose, prevent injury, treat eclampsia per protocol and call senior obstetric help.
E—Exposure	Fever, rash, abdominal tenderness, uterine activity, vaginal bleeding or fluid.	Maintain dignity and warmth; inspect only with consent and arrange urgent obstetric assessment.

3. History taking: complete structure

Let the woman describe her concern in her own words before using closed questions. Avoid assumptions about marital status, pregnancy intention, HIV status, contraception or partner support.

3.1 Identification and vital statistics

Name, age, residence, telephone/contact person and preferred language.
Date and time of assessment, source and reliability of history, referral facility and accompanying person.
Occupation and workplace hazards (heavy lifting, heat, chemicals, radiation, long travel, violence).
Relationship/partner status only as relevant to support, safety and shared decision-making.
Gravidity and parity, including living children and previous losses; do not confuse pregnancies with babies (twins count as one pregnancy).
Age extremes, very short stature, adolescent pregnancy and first pregnancy at an advanced maternal age should prompt risk review, not judgement.

3.2 Presenting complaint and history of present illness

Record the patient’s exact complaint and use OPQRST (onset, provocation/palliation, quality, region/radiation, severity, timing), then relate symptoms to gestational age.

Symptom	Questions that change urgency	Important differentials to consider
Abdominal or pelvic pain	Sudden/gradual, site, radiation, severity, constant/colicky, fever, vomiting, bleeding, contractions, urinary/bowel symptoms.	Ectopic pregnancy, miscarriage, labour, abruption, pre-eclampsia/HELLP, appendicitis, UTI/pyelonephritis, renal colic, ovarian torsion/cyst, fibroid degeneration, gastrointestinal disease.
Vaginal bleeding	Amount/pads or clots, colour, pain, gestation, intercourse/trauma, dizziness/syncope, fetal movements.	Miscarriage, ectopic, placenta praevia, abruption, cervical lesion, labour; heavy bleeding is an emergency.
Leakage of fluid	Time, gush or trickle, colour/odour, continuous leakage, fever, contractions, fetal movement.	Ruptured membranes, urinary incontinence, vaginal discharge; green/brown fluid suggests meconium.
Headache/visual or epigastric symptoms	Severe or persistent headache, flashing lights, blurred vision, right-upper-quadrant/epigastric pain, nausea, sudden swelling, reduced urine.	Pre-eclampsia with severe features, cerebral disease, migraine or other medical emergency.
Reduced fetal movement	When movements were last normal, usual pattern, number of fetuses, bleeding/fluid/pain.	Fetal compromise or death until assessed; do not reassure without fetal evaluation.
Fever or unwellness	Rigors, cough, dysuria, flank pain, diarrhoea, malaria exposure, sick contacts, rash, medications.	Malaria, UTI/pyelonephritis, chorioamnionitis, sepsis, respiratory or gastrointestinal infection.
Breathlessness/chest pain	Sudden onset, pleuritic pain, cough/haemoptysis, palpitations, orthopnoea, leg swelling, cardiac history.	Pulmonary embolism, cardiac disease, asthma, anaemia, pneumonia or physiological dyspnoea.

3.3 Current pregnancy, trimester by trimester

First trimester (conception–12+6 weeks)

Date and certainty of the last normal menstrual period (LNMP), cycle regularity and contraceptive use before conception.
Pregnancy test, desired/planned status and any fertility treatment or assisted conception.
Nausea/vomiting: frequency, ability to retain fluids, weight loss, dehydration, haematemesis and urine output (screen for hyperemesis).
Bleeding, unilateral pain, shoulder-tip pain, fainting or collapse (ectopic pregnancy warning features).
Medication, herbal remedies, alcohol, tobacco and other exposures since conception; record timing and dose rather than blaming the patient.
Fever, rash, exposure to tuberculosis, malaria, sexually transmitted infections or unsafe food/water.

Second trimester (13–27+6 weeks)

First fetal movement (“quickening”), usually about 18–20 weeks in a first pregnancy and sometimes earlier in a multigravida.
Vaginal bleeding, watery discharge, pelvic pressure, contractions, urinary symptoms and abdominal pain.
Results of booking tests and ultrasound, tetanus-diphtheria vaccination, iron/folate, deworming, malaria prevention and IPTp where applicable.
Symptoms of anaemia, hypertension, diabetes, thyroid disease or recurrent infection.

Third trimester (28 weeks to birth)

Daily fetal movement pattern and any reduction/absence.
Headache, visual disturbance, facial/hand swelling, epigastric pain, breathlessness or reduced urine.
Contractions: frequency, duration, painful or painless tightening; show, bleeding and rupture of membranes.
Fetal presentation concerns, previous ultrasound findings, planned place of birth and transport.
Breastfeeding intention, birth companion, newborn supplies and postnatal/family-planning plans.

3.4 Dating the pregnancy

Gestational age: completed weeks from the first day of the LNMP, not from conception.
Naegele’s rule: EDD = LNMP + 7 days − 3 calendar months (or +9 months and 7 days) for a regular 28-day cycle.
Adjust cautiously for irregular cycles, recent hormonal contraception, lactational amenorrhoea, uncertain LNMP or bleeding mistaken for a period.
First-trimester ultrasound crown–rump length is generally the best dating method when available; use the earliest reliable scan and document the basis of the EDD.
For IVF/embryo transfer, calculate from the documented embryo age and transfer date according to the fertility service.

3.5 Previous obstetric history

Record every pregnancy chronologically, including ectopic and molar pregnancy, miscarriage, termination and stillbirth. For each, document:

Year and maternal age; gestational age at outcome.
Booking and antenatal care; illnesses, hypertension, diabetes, infections or admissions.
Onset and duration of labour, induction/augmentation and complications.
Presentation, method and place of delivery; operative indication if caesarean or assisted birth.
Birth weight, sex, neonatal condition, admission/resuscitation and congenital anomaly.
Puerperium: postpartum haemorrhage, infection, wound breakdown, thromboembolism, breastfeeding difficulty and postnatal depression/psychosis.
Living children, current health, immunisation and custody/safeguarding concerns.

Notation: write the local G-P system clearly and, where used, TPAL/P(A-B-C-D): term births, preterm births, losses before viability and living children. State the definitions used by your school or facility because viability thresholds vary.

3.6 Gynaecological, medical and surgical history

Menstrual pattern, dysmenorrhoea, abnormal bleeding, infertility, fibroids/endometriosis, cervical screening and prior pelvic procedures.
Contraceptive method, last use and complications; prior ectopic or pelvic inflammatory disease.
Hypertension, diabetes, heart disease, renal disease, epilepsy, asthma, thyroid disease, sickle-cell disease, HIV, tuberculosis, hepatitis, malaria, autoimmune disease and psychiatric illness.
Previous operations, anaesthesia problems, transfusions, thromboembolism and hospitalisations.
Current and recent medicines: prescribed, over-the-counter, traditional/herbal and supplements. Ask specifically about antiepileptics, anticoagulants, ACE inhibitors/ARBs, retinoids, methotrexate, steroids and diabetes medicines.
Allergies and the exact reaction (rash, wheeze, angioedema, anaphylaxis), not merely “allergic”.

3.7 Family, personal, social and safeguarding history

Family history of hypertension, diabetes, twins, congenital anomalies, genetic disease, thrombosis, sickle-cell disease and unexplained pregnancy losses.
Smoking, alcohol, khat or other substances; quantify amount and frequency and offer confidential support.
Nutrition, food insecurity, pica, housing, sanitation, transport and ability to pay for care.
Partner support, planned/unplanned pregnancy, work and return-to-work plans.
Ask privately about intimate-partner violence, coercion, sexual safety, exploitation and ability to make decisions. Do not confront an alleged perpetrator or document unsafe details where the partner can access the record.
Screen mental health: mood, anxiety, sleep, trauma, suicidal thoughts, psychosis and previous postpartum mental illness.

4. Vital observations and measurements

Observation	Technique	Interpretation and action
Blood pressure	Rest 5 minutes; correct cuff (bladder around ≥80% arm circumference); arm at heart level; seated or semi-recumbent; repeat abnormal result manually if possible and record arm/position.	≥140/90 mmHg on repeat assessment is hypertension in pregnancy and needs evaluation. ≥160 systolic or ≥110 diastolic is severe-range emergency. Check symptoms and urine protein; do not delay referral.
Pulse	Rate, rhythm, volume and capillary refill; count a full minute if irregular.	Tachycardia with fever, pain, bleeding, dehydration, anaemia, sepsis or pulmonary embolism is concerning; interpret with baseline and clinical context.
Respiratory rate/SpO₂	Count discreetly for one minute; assess work of breathing and oxygen saturation if available.	Abnormal RR, cyanosis or low SpO₂ requires urgent respiratory assessment; consider asthma, pneumonia, cardiac disease, pulmonary oedema or embolism.
Temperature	Use a calibrated device; note antipyretic use.	Fever (commonly ≥38°C) with uterine tenderness, foul liquor, rigors or fetal tachycardia suggests infection/sepsis.
Weight, height and BMI	Measure at booking and track weight trend; height permits BMI and pelvic-risk context.	Unexpected loss, rapid gain/oedema or obesity/underweight changes risk and medication/delivery planning. Do not use weight alone to diagnose pre-eclampsia.
MUAC/nutrition	Measure mid-upper-arm circumference where used by Uganda programmes; assess pallor, diet and pica.	Low MUAC or clinical malnutrition warrants nutrition support and closer follow-up.
Urine	Clean-catch sample when possible; dipstick for protein and glucose; culture if indicated.	Protein with raised BP or symptoms raises concern for pre-eclampsia. Dysuria, nitrites, leucocytes or fever require UTI assessment.
Pain and consciousness	Use a 0–10 scale; AVPU/neurological assessment in an unwell patient.	Severe pain, altered consciousness or seizure is never “normal pregnancy”; activate emergency care.

5. General physical examination

General appearance: distress, pallor, jaundice, cyanosis, hydration, nutrition, fever, breathlessness, confusion, mobility and pain behaviour.
Hands and nails: pallor, clubbing, cyanosis, capillary refill, tremor, palmar erythema and peripheral temperature.
Eyes and mouth: conjunctival pallor, jaundice, dehydration, oral lesions, dental infection and thyroid-related eye signs.
Skin: rash, pruritus/excoriations, hyperpigmentation, bruising, infection and signs of chronic disease.
Oedema: distribution, pitting, sudden onset and associated BP/headache/urine findings; unilateral painful swelling suggests possible DVT.
Neck: thyroid enlargement, lymphadenopathy, raised JVP and respiratory signs.
Cardiovascular: pulse, heart sounds, murmurs, signs of failure and peripheral perfusion.
Respiratory: rate, symmetry, air entry, wheeze, crackles and pulmonary oedema.
Neurological: mental state, reflexes and clonus when hypertensive disease is suspected; focal deficit or seizure is an emergency.
Breasts: privacy and consent; inspect nipples, fissures, infection, masses and previous surgery, and provide breastfeeding preparation without routine harmful nipple manipulation.

6. Obstetric abdominal examination

Position: Ask the woman to empty her bladder. Lay her semi-recumbent or supine with a small left lateral tilt to reduce aortocaval compression; flex knees slightly and expose from xiphisternum to pubic symphysis while preserving dignity. Warm your hands, explain each step and ask about tenderness before palpation.

6.1 Inspection

Contour and size: uterine enlargement appropriate to gestation, multiple pregnancy or polyhydramnios (large in both length and breadth), large fetus (length disproportionately increased), small-for-dates uterus or growth restriction.
Shape: longitudinally elongated versus broad/transverse lie; pendulous abdomen and scars may alter examination.
Skin: linea nigra, striae gravidarum/albicans, superficial veins, umbilicus (flat/everted), hernias, lesions and previous caesarean or other scars.
Observe visible fetal movements, contractions, tenderness, guarding and respiratory distress.

6.2 Palpation and symphysis–fundal height (SFH)

Start gently away from the painful area. Assess uterine tone, tenderness and contractions.
Locate the fundus with the ulnar border of one hand. Place the zero end of a non-stretch tape at the superior border of the symphysis pubis and measure along the curve of the uterus to the fundus; record centimetres and gestational age.
After about 24 weeks, SFH in centimetres often approximates weeks of gestation, but maternal size, fibroids, multiple pregnancy, polyhydramnios, fetal position and dating errors affect accuracy.
Plot serial measurements rather than reacting to one isolated value. A lag or excess should prompt review of dates, repeat examination and ultrasound when indicated.

6.3 Leopold’s four manoeuvres

Manoeuvre	How to perform	What it answers
1. Fundal grip	Face the woman; palpate the fundus with both hands.	Which pole occupies the fundus: hard, round, ballotable head or soft, broad, irregular breech. An empty fundus may indicate transverse lie.
2. Lateral/umbilical grip	Slide both hands down the uterine sides.	Lie (longitudinal, transverse or oblique) and fetal back (smooth, firm surface) versus limbs (irregular small parts). This guides the best site for fetal heart auscultation.
3. Pawlik/suprapubic grip	Grasp the lower uterine pole just above the symphysis using thumb and fingers.	Presenting part—cephalic, breech or shoulder—and whether it is mobile/ballotable.
4. Deep pelvic grip	Face the woman’s feet; place hands on each side of the lower uterus and move down towards the pelvis.	Attitude of the head and engagement. A flexed head is favourable; deflexion/extension suggests malposition. Estimate fifths palpable above the brim.

Engagement: the biparietal diameter has passed through the pelvic inlet. If 5–3/5 of the head is palpable abdominally it is not engaged; 2–0/5 suggests engagement. Document this as an estimate and confirm clinically/with ultrasound when uncertain.

6.4 Fetal heart rate and fetal movement

Use a Doppler or fetoscope over the fetal back; distinguish the fetal rate from the maternal pulse by palpating the maternal radial pulse simultaneously.
Document rate, rhythm, method, site and gestational age. A commonly used reassuring baseline is approximately 110–160 beats/minute; persistent bradycardia or tachycardia requires immediate reassessment and escalation according to local fetal-monitoring protocol.
Ask about the woman’s usual movement pattern. Reduced or absent movements require same-day fetal assessment, not a home “kick-count” delay.

6.5 Uterine activity, liquor and fetal size

Count contractions for 10 minutes: frequency, duration, strength, regularity and painfulness.
Assess uterine tenderness, rigidity and relaxation between contractions.
Estimate fetal size only approximately; clinical estimates are less reliable in obesity, fibroids, multiple pregnancy and abnormal liquor volume.
Do not diagnose polyhydramnios or oligohydramnios by palpation alone—arrange ultrasound when clinically indicated.

7. Pelvic, vaginal and cervical examination

Perform only when indicated, with informed consent, chaperone, privacy, adequate light and appropriate infection prevention. Explain discomfort and stop if the patient asks.

External inspection: bleeding, liquor, lesions, ulcers, vesicles, swelling, trauma, prolapse and signs of infection.
Speculum examination: useful for source of bleeding, suspected ruptured membranes, cervicitis or lesions; take appropriate swabs. Avoid unnecessary digital examination when placenta praevia is possible.
Digital vaginal examination: in labour or when clinically necessary, document cervix (dilatation, effacement, consistency, position), presenting part, station, membranes, moulding/caput and pelvis. Limit repeated examinations, especially after membrane rupture.
Do not perform a digital examination in unexplained antepartum bleeding until placenta praevia has been excluded and senior obstetric guidance obtained.

8. Recognising urgent findings

Finding	Why it matters	Immediate response
Shock, collapse or heavy bleeding	Haemorrhage, ectopic, abruption, miscarriage or other life-threatening cause.	ABCDE, call senior team, IV access, bloods/cross-match, resuscitate and urgent referral/transfer.
BP ≥160/110, severe headache, visual symptoms, RUQ pain, clonus or seizure	Severe pre-eclampsia/eclampsia.	Left lateral position, protect airway, magnesium sulphate/antihypertensive per protocol, monitor urine/reflexes/respiration and expedite obstetric care.
Fever, rigors, uterine tenderness, foul discharge or maternal/fetal tachycardia	Maternal sepsis/chorioamnionitis.	Sepsis bundle, cultures where feasible, antibiotics and source control per guideline; do not delay escalation.
Persistent FHR <110 or >160, absent movements or abnormal CTG	Possible fetal compromise.	Reassess maternal position/vitals, urgent fetal assessment and obstetric review.
Ruptured membranes with fever, bleeding, cord presentation or preterm gestation	Infection, cord prolapse or preterm birth risk.	Avoid unnecessary digital exams, assess fetal status, urgent referral and antibiotics/steroids/management as indicated.
Unilateral leg swelling/pain or sudden chest pain/dyspnoea	DVT/PE.	Urgent assessment; do not massage the limb. Stabilise and follow thromboembolism protocol.

9. Documentation and clinical presentation

Write findings immediately, legibly and objectively. Record normal findings that were specifically assessed; do not write “NAD” without detail.

Identification, date/time, gestational age and basis of EDD.
Presenting complaint and focused HPI with relevant negatives.
G/P or TPAL, previous outcomes and current pregnancy history.
Medical, surgical, gynaecological, drug/allergy, family, social and safeguarding history.
Maternal observations, urine, general examination and abdominal findings.
FHR, fetal movement, lie, presentation, position, engagement, SFH and contractions.
Investigations reviewed/ordered, assessment of risk, differential diagnosis and plan.
Advice, danger signs explained, follow-up date, referrals and who received handover.

10. OSCE and bedside checklist

Hand hygiene, introduction, identity, explanation, consent, chaperone and privacy.
Emergency screen and pain assessment before routine questions.
Demographics, LNMP/EDD/gestational age, complaints and trimester-specific symptoms.
Obstetric, gynaecological, medical, surgical, medicine/allergy, family, social and safeguarding history.
BP with correct cuff, pulse, RR, temperature, SpO₂ when indicated, weight/height/BMI, MUAC and urine.
General inspection, pallor/jaundice/oedema, cardiorespiratory and neurological review.
Abdominal inspection, tenderness, SFH, Leopold manoeuvres, fetal heart rate, movements and contractions.
Pelvic examination only when justified and safe; exclude placenta praevia before digital examination in antepartum bleeding.
Summarise, explain findings, give danger-sign advice, document and arrange next action.

11. Worked clinical examples

Example A: suspected pre-eclampsia

A 32-week patient reports severe headache and flashing lights. BP is 168/112 mmHg and urine dipstick has protein. Stop routine ANC, call senior help, place left lateral, repeat BP with correct cuff, assess airway/neurology/reflexes, establish IV access and follow the facility’s magnesium sulphate and antihypertensive protocol. Check fetal status and arrange urgent obstetric management. Do not send her home because she “feels better”.

Example B: bleeding with abdominal pain

A 36-week patient has painful dark bleeding and a tender, firm uterus. Treat as possible abruption until assessed: ABCDE, quantify blood loss, IV access/cross-match, monitor mother and fetus, avoid digital vaginal examination, and arrange emergency obstetric review.

Example C: reduced fetal movement

A 35-week patient reports no movement since morning. Confirm time and baseline pattern, check maternal observations and fetal heart immediately, then arrange urgent fetal assessment. A normal brief Doppler sound does not by itself exclude compromise.

12. Teaching points for respectful, high-quality care

Pregnancy physiology can change examination findings, but severe or new symptoms must not be normalised.
Use interpreters rather than children or partners for sensitive information.
Explain each result in plain language and use teach-back: ask the woman to repeat when and where she will seek help.
Include the woman in decisions; partner involvement is welcomed only with her consent.
Record uncertainty honestly and plan how it will be resolved (repeat BP, ultrasound, laboratory test, senior review).
Every visit ends with a clear next appointment and permission to return earlier for danger signs.

Quick self-test

Which symptoms must be screened before a routine ANC history?
How is EDD estimated from a reliable LNMP, and when is early ultrasound preferable?
What are the four Leopold manoeuvres and the question answered by each?
Why should the maternal pulse be checked while auscultating fetal heart rate?
List three findings that make digital vaginal examination unsafe until senior review.
What observations and actions are required for BP 166/110 mmHg with headache?

Answers

Bleeding, severe pain, fluid leakage, severe headache/visual symptoms, fits, fever, breathing difficulty and reduced fetal movement.
Add 7 days and subtract 3 months (or add 9 months and 7 days); early ultrasound is preferable with uncertain LNMP, irregular cycles or assisted conception.
Fundal grip—fetal pole; lateral grip—lie/back; Pawlik—presenting part; deep pelvic grip—attitude and engagement.
To avoid mistaking maternal pulse for fetal bradycardia or tachycardia.
Unexplained antepartum bleeding/possible placenta praevia, severe pain or haemodynamic instability, and situations where consent/chaperone or safe setting is absent.
Urgent senior review, left lateral position, repeat/confirm BP, assess symptoms/reflexes/urine and fetal status, establish access and follow severe-hypertension/eclampsia protocol.

Further study and source integration

Take-home message: A safe obstetric assessment combines immediate triage, a respectful complete history, accurate maternal observations, systematic abdominal examination and clear escalation. The value is not in performing every manoeuvre mechanically; it is in recognising abnormal findings early and ensuring the woman reaches the right care without delay.

Doctors Revision

History Taking and Examination of a Pregnant Woman: Complete Obstetric Clinical Guide