Complete/Incomplete Spinal Cord injury, Neurological Examination and Asia Chart

Spinal shock can occur and last for about 24-72 hours after spinal cord injury and a/w complete motor and sensory loss, hypotension and bradycardia. (monitor Bp with vasopressor to prevent fluid overload)

Bulbocarvenosus reflex: 
If present, Squeezing of penis/clitoris/pulling of Foley catheter would cause contraction of anal sphincter muscle.

The reflex is spinal mediated and involves S2-S4.

Presence of reflex indicates ends of spinal shock.
(Sometimes absence of reflex could be due to cauda equina syndrome instead of spinal shock)

Sacral Sparing Test was done after ends of spinal shock to determine complete or incomplete spinal injury:
1. flexion of big toe present
2. anal reflex present
3. perianal sensation present (S3-5)

Sacral sparing indicates incomplete spinal cord injury

(pinprick sensation predicts better prognosis of motor function: as lateral spinothalamic is near to lateral corticospinal tract)

spinal cord anatomy:


TYPES OF INJURY:
Central Cord Syndrome


Anterior Cord Syndrome


Brown Sequad


Posterior Cord Syndrome



Determine Level of Spinal Cord Injury/Lesion by using Asia Chart

Difference in level of nerve exit:

Cervical nerve exit above vertebra level, example C4 nerve exit above C4 vertebra and below C3 vertebra

Thoracic nerve exit below vertebra level, example T4 nerve exit below T4 vertebra and above T5 vertebra

Loss of sensation at the dermatomal area and power at myotomal area at C4 spinal cord level would indicates injury at C3 vertebral level. Likewise a radiograph of C3 vertebra injury is expecting sensory and motor impairment to C4 spinal cord level.

In PID (Prolapsed Intervertebral Disc), the location of herniated disc in after level of conus medullaris (L1 vertebra) would determine different type of lesion.

Example, centrally herniated disc would affect nerve of the next vertebral level, lateral herniated disc would affect nerve of the same vertebral level. (Refer diagram below)

ASIA chart impairement score:

Motor power determine grade of impairment:

Summary:

In acute spinal injury (emergency case):
-check patient vitals, bulbocarvenosus reflex to rule out spinal shock, if shock present, manage the shock
-then sacral sparing test to determine complete or incomplete injury
-then neurological examination to determine type and level of injury

1. Neurological Examination (usually exam will specify either upper limb/lower limb):
a. Sensory, dermatome (Light touch, Pin Prick)
b. Motor, (Tone, Power, Reflex)
*always compare both side

2. Determine Type of  Injury:
a. Pure sensory loss
b. Pure motor weakness
c. Combined motor and sensory loss
d. Unilateral/Bilateral

3. Determine Etiology:
Acute: Fracture(burst) 
Gradual: PID, spinal stenosis

4. Confirm diagnosis with special test
eg. Straight leg raising test in PID, perianal sensation to rule out cauda equina syndrome (usually caused by large midline disc herniation or extrusion, emergency and need surgical decompression if patient had urinary retention)

Lower Limb Peripheral Nerve Examination

Femoral nerve (L2,3,4)

motor: iliopsoas, test with hip flexion against resistance, 

           quadriceps, test with knee extension against resistance (also inspect for any wasting, check 

           knee jerk)

sensation: front of thigh, medial of leg and foot

usually caused by hematoma of illacus ( hemophilia or hip extension injuries)

Common peroneal nerve (lateral popliteal) L4,5,S1,2

motor: ant compartment (ant tibialis, extensor hallucis longus, extensor digitorum longus, peroneus tertius)

           peroneal compt (peroneus longus n brevis)

           foot ( extensor brevis)

test dorsiflexion (deep branch) and evertion (sup branch) of foot

sensation: first web of foot,dorsum of foot, front and side of leg

usually caused by if @ fibular neck, trauma (lateral ligament injury of knees or direct blow), pressure (cast/side iron of thomas splint; ganglion), ischemia ( tourniquet)

 if distal to fibular nerve, ant compartment syndrome

Tibial nerve (L4-S3)

motor: post comprt ( gastrocnemius, post tibialis, flexor hallucis longus, flexor digitorum longus)

           all the ms of sole via medial n lateral plantar n

inspect, ms wasting of sole, clawing of toe, trophic ulceration, test for power of toe flexion

sensation, sole of foot, dorsum of toe and nailbed

side of foot by sural nerve (tibial mix common peroneal)

proximal lesion of tibial nerve (wasting and loss of plantarflexion)

causes: proximal tibial fracture. post compartment syndrome, tight cast, diabetic neuropathy, tarsal tunnel syndrome

sciatic nerve (L4-S3)

motor loss: hamstring of thigh, tibial and peroneal nerve palsy

sensory loss: entire sole, foot, dorsum of foot, lateral aspect of leg, lateral half of calf, (if post cutaneous nerve of thigh is involved then back of thigh also lost sensation)

causes, usually post dislocation of hip, wound to post thigh (do not confused with sciatic palsy  2 to root involvement caused by PID)

absent ankle jerk

Lateral cutaneous n of thigh (L2,3)

maybe compressed by inguinal ligament (pain n parasthesia) or by spinal stenosis

sensory: lateral aspect of thigh

test, pressure over the nerve may give parasthesia to the thigh

neurological control of bladder, s2,3,4 supplies detrusor muscle of bladder and internal spincter

if cord transected above L2, thoracic spine fracture, voluntary control loss, still able to empty bladder 200-400ml every 2-4 hours, automatic bladder

if sacral centre damage or damage to cauda,  loss of reflex, atonic bladder

Fever: Taking temperature in a child

Frequently asked questions about fever in children

What is a fever?

The definition of fever depends upon the site where it is measured:

Rectal temperature above 100.4°F (38°C)

Oral temperature above 100°F (37.8°C)

Axillary (armpit) temperature above 99°F (37.2°C)

Ear temperature above 100.4°F (38°C) in rectal mode or 99.5°F (37.5°C) in oral mode

Forehead temperature above 100.4°F (38°C)

How do I measure my child's temperature?

The best method to measure temperature depends upon several factors. In all cases, rectal temperatures are the most accurate. However, measurements of temperature in the mouth (for children older than 4 or 5 years) is accurate when done properly. Temperatures measured in the armpit, in the ear, and on the forehead are least accurate, but may be useful as a first test.

Glass thermometers are not recommended due to the potential risks of exposure to mercury, which is toxic. If another (digital) thermometer is not available, be sure to carefully "shake down" the glass thermometer before use. Instructions for disposing of glass thermometers are available online (www.epa.gov/mercury/spills/index.htm).

Measuring a rectal temperature

The child or infant should lie down on his or her stomach across an adult's lap.

Apply a small amount of petroleum jelly (sample brand name: Vaseline®) to the end of the thermometer.

Gently insert the thermometer into the child's anus. The silver tip of the thermometer should be 1/4 to 1/2 inch inside the rectum.

Hold the thermometer in place. A glass thermometer requires 2 minutes, while most digital thermometers need less than 1 minute.

Measuring an oral temperature

Clean the thermometer with cool water and soap. Rinse with water.

Do not measure the temperature in a child's mouth if he or she has consumed a hot or cold food or drink in the last 30 minutes.

Place the tip of the thermometer under the child's tongue toward the back. Ask the child to hold the thermometer with his or her lips.

Keep the lips sealed around the thermometer. A glass thermometer requires about 3 minutes, while most digital thermometers need less than 1 minute.

Measuring an armpit temperature

Place the tip of the thermometer in the child's dry armpit.

Hold the thermometer in place by holding the child's elbow against the chest for 4 to 5 minutes.

Measuring an ear temperature

To measure temperature in the ear, the parent must pull the child's outer ear backward before inserting the thermometer.

The ear probe is held in the child's ear for about 2 seconds.

If the child has been outside on a cold day, wait 15 minutes before measuring the ear temperature.

Ear tubes and ear infections do NOT affect the accuracy of an ear temperature.

Notes on obstetrics history taking and physical examination (adapted to culture in Asia)

HISTORY

Patient identification

1.      Name

2.      Age

3.      Ethnic

4.      Lady

5.      Occupation

6.      Address

7.      Date of admission and clerking

8.      Informant

9.      Gravida

       - No. of pregnancy irrespective of the outcome

10.  Para

      - No. of delivery of ≥ 24 wks of gestation / > 500g (including stillbirth)

      - Twins are counted as 2

         e.g: never pregnant before G1P0. If she delivered twins & come back next time at

                12 wks, she will be G2P2 (twin)

      - If abortion (delivery < 24 weeks / < 500g), put ‘+ number of abortion’

         e.g: If abortion for 2 times and now she pregnant, she will be G3P0+2

*miscarriage occurred by accident, abortion occurred by planned surgery

11.  Last menstrual period (LMP)

       - 1^st day of last menses (ask hari pertama tak boleh sembayang)

       - LMP reliable must fulfil Naegele’s rule:

  * Sure of date

  * Regular menstrual cycle 28-30 days

  * Not on breastfeeding within 2 mths

            (If exclusively breastfeed, ovulation will not start in 1^st 3^rd month; if not

            exclusively, ovulation will occur at the 3^rd month)

        * Not on hormonal therapy within 3 mths

(mention the Naegele’s rule in history to see one is fulfill

       - If LMP not reliable:

  * Ask about early U/S (<20w)

            # 1^st trimester: difference 1 wk;

               2^nd trimester: difference 2 wk

               3^rd trimester: difference 3 wk

            # If the scan date is corresponding to the EDD, use EDD

            # If not corresponding, use the rEDD

            # POA that is counted from rEDD should be presented as POG (period of gestation)

Mention date for each U/S

For U/S 1^st trimester is the most accurate reading the discrepancy of rEDD compared to real date of delivery is 1 week.

For 2^nd trimester is 2 weeks discrepancy.

For 3^rd trimester is 3 weeks.

12. 

Other ways for dating: - UPT in dilution (1st positive 6-8wk) - quickening - uterine size corresponding to date - histopathology (presence of    chorionic villi- either passed out    spontaneously or from curettage    specimen)

Expected date of delivery (EDD)

- LMP + (9 moths 7days)

13.  Periods of amenorrhea (POA)

- counted from LMP to date of clerking

- present as ?weeks ?days

1 month= 4w + 2 days

2 months= 8w+ 5 days

3 months= 13w

     (prof adibah: every 3mth- add 1 week (3x4+1=13))

Comment:

The LMP is ___. It fulfils the Naegele’s rule. U/s was done at___ weeks which is corresponds to the EDD, therefore the EDD is___/ not correspond to EDD, therefore, the rEDD is___

* u/s scan: normal EFW

 - 24 wk: <1kg

 - 28 wk: 1.4-1.8kg

 - 32 wk: 2kg

 - 36 wk: 2.4kg

* normal weight gain:

 - 1^st 5mths: 0.5kg/mth

 - 2^nd 5 mths: 0.5kg/wk

Chief complaint

- Complaint + duration

History of presenting illness (HOPI)

- ask about chief complaint or any related question (associated sx/ risk factors/ cx)

- at the end of HOPI, ask about:

   * is patient in labour ?

      # contraction pain (how many times in 10mins? each contraction last for how long?

         regular? ↑ frequency and intensity?)

      # show- blood stained mucus passed PV

      # leaking liquor

   * fetal movement (good or ↓?)

     (ask the patient to count how long for fetal kicks for 10x, look  for the pattern of time

      completion- see the FKC)

FKC is a chart given at 3^rd trimester. Counted everyday from 9am-9pm. 1 KICK= 1 kick, or multiple kicks at one time, or 1 rolling. When mother sensed there are 10 kicks in total, she will made a tick at the time of completion of 10kicks(eg. Usually 1pm) at the chart. Another version is fast Fetal Kick Chart which only required counting 10 kicks in 2 hours, for busy mother. If kicks is less than 10 in a day(from 9am-9pm) indicative of reduced fetal movement.

London used Cardiff county method.

Fetal movement reduced, possible causes:

1.      Mother is fatigue, (involved in strenuous activity), less energy provided to baby

2.      Infection, if mother is having fever, fetal temperature is 1 degree Celsius more than the mother

3.      Trauma, in kampong, mother rode motorcycle or multigravida mother, the abdomen was kicked by her naughty children in fight

4.      Mother took sedatives

5.      Mother is malnourished, can be due to taboo(wrong thoughts about some food could cause harm to baby), nausea and vomiting(cannot eat much)

6.      Mother went for lenggang perut, reposition of baby by traditional healer causing cord around neck

7.      Baby is hypoxic, placenta insufficiency

8.      Increased in amniotic fluid or uterine contraction (cannot sense the kicks)

9.      Sometimes can be just due to mother too busy and not correctly count or too worried as she had experienced miscarriage or similar experience in previous pregnancy

10.  IUD is usually dued to abruption placenta, no kick at all.

Hx should mention –ve trauma, -ve sx of infection(eg. UTI sx), -ve goin to traditional healer, and diet balance.

**no need systemic review if all +ve n –ve sx had been illicited

- briefly about what is done in hospital

	Comment: She missed the period for __weeks. She did the UPT and was found to be +ve

 

Systemic review

History of presented pregnancy

Present HOPP in sequence, 1^st, 2^nd, then 3^rd trimester

- suspect pregnancy

  * why- missed period? Quickening? Abdominal distension?

  * when?

Missed period state when, at 6^th week since last period? Did she do UPT herself? When UPT is +ve, did she go to the clinic immediately, if no state why?

*UPT can only be positive at 2 w after ovulation which means 1 mth after the last period

- confirm pregnancy

  * when? where? who?

  * u/s?

Which clinic?

- booking= 1^st antenatal check-up

  * when? where? (bila ambil kad merah?)

  * physical examination

ANC: - Monthly till 28 weeks - Fortnightly till 36 weeks - Weekly till delivery

     # height, weight, BP, fundal height

  * investigations

     # blood test- blood group, rhesus, Hb

Comment: - blood and urine test were done    and were normal - screening test were not reactive - mOGTT was done at __wk with    reading __/__ - BP, height and weight were   normal - For the subsequent ANC, u/s    scan and fundal assessment    show fetal growth correspond to    gestational age and amniotic    fluid is adequate, no congenital    abnormality detected

    # Urine test- glucose, protein

    # VDRL (reactive/non-reactive), HIV

- mOGTT done? Indication? When? Result?

- subsequent antennal check-up

  * when- patient attend all ANC follow schedule?

  * parameter- normal?

  * weight gain 

  * BP

  * Uterine size

  * Hb

  * Urine glucose and protein

  * U/S done?

     - When?

     - Any abnormalities

Things to be stated from booking: Height, weight, bp, urine protein n glucose, hb, blood group, rhesus, VDRL, Hep B, HIV

(try use clerkin in osce/long case, ask the patient whether she remembered the parameters instead of copy from the redbook, if she cant remember, ask if doc comment anythg, any abnormalities)

Antenatal checkup is done every 4w in 1^st tri, every 2 w in 2^nd tri and every week in 3^rd tri

10-12w  : correct dating (dating scan) 20-22w  : to detect any congenital abnormality 28w        : to detect location of placenta 32w        : to final confirm the location of placenta

 

Quickening: - Primigravida= 18-20w (5 months) - Multigravida= 16-18w (4 months)

- Quickening- 1^st fetal movement

  * When?- bila berasa bayi pertama kali bergerak?

  * ↑ intensity and frequency?

- Signs and symptoms of pregnancy

  * nausea and vomiting

  * breast discomfort/engorgement

  * frequency of urination

  * constipation

  * ankle edema

  * backache

- immunization:

  * anti-tetanus toxoid (ATT) - IM 0.5mL

    # Primigravida

       - 1^st dose after quickening (20-24w)

       - 2^nd dose - 4-6 weeks after 1^st dose (24-28w)

       - latest 4 wks before delivery

    # Multigravida

       - One dose only after quickening (usually at 32-36w)

  * Hepatitis B (3X)

  * Rubella (usually during school times)

Past obstetric history (POH) – no need present if primigravida- only marital status

- Marital status

  * When married?

  * Married at age?

  * 1^st married? the only married? (related with pregnancy induced hypertension)

  * Consanguineous married? (related with chance of genetic disease transmission)

- no of children? How many boy and girl?

- for each pregnancy:

  * age

  * sex

  * where deliver- hospital? Clinic?

  * when- full term? POG if preterm?

  * method of delivery

     # spontaneous vaginal delivery

     # induced vaginal delivery: Postdate, PIH, GDM, heart disease etc

     # assisted vaginal delivery- forceps? Vacuum? Why? Prolonged labour, heart dz etc

     # lower segment caesarean section- elective/emergency?

  (a) why? where? POG?

  (b) duration of staying in wad- 5 days if no Cx

  (c) cx- PPH, blood transfusion, fever, scar pain

  (d) any VBAC after the caesarean section?

  * ask the indication except SVD

  * birth weight

     # low birth weight < 2.5kg

if all deliveries are normal, summarize ‘no AP,IP,PP Cx’ at the end of presentation of POH

     # big baby > 4.0kg

  * antepartum Cx- APH, placenta praevia,

  * intrapartum Cx- poor progress, fetal distress

  * postpartum Cx- PPH, lochia changes, fever

  * breastfed till when?

     # normally for 2 yrs (exclusive 6 months)

     # if stop early/bottled feeding-why?

- if abortion

  * POG?

  * why?- spontaneous? Trauma?

  * signs and symptoms before abortion.

  * dilatation and curettage (D&C) done?

# D&C- incomplete abortion

# no D&C- complete abortion

- if >5 children

  * Summarize all the uneventful deliveries (FTSVD with no Cx)

  * eldest what age? youngest what age? birth spacing?

  * all born through FTSVD with no AP, IP, PP Cx

  * BW range

  * breastfeeding

  * developmental growth

  * Mention the abnormal deliveries separately

- spacing

  * good spacing- 2 years apart

  * abnormal-> 6 years, why? contraception? Subfertility?

- contraceptive method:

  * OCP/ injection/ implantation

  * IUCD

  * condom

For complication of C-sec,

1.      Anesthesia, half or full

2.      Bleeding? Any blood transfusion

3.      Injury to organ, bladder? Rectum?

4.      Post-op, well?

Csec: indication to do, complication, venue which hospital

Past Gynaecology History (*combined together and state gynae hx)

- menstrual history

  * when attain menarche (1^st menstrual period)? Normal 9-16 y/o

  * menstrual cycle

Written as: Age of menarche    flow                                   cycle

     # regular/irregular

     # cycle- normal 21-35 days

     # flow- normal 2-8 days

     # heavy flow- normal 1^st-3^rd day

     # pad used-average blood loss 30ml

     # problems

 (a) dysmenorrhoea- painful menstruation

 (b) menorrhagia- prolonged and increased menstrual flow (blood loss>80ml)

 (c) intermentrual bleeding

 (d) postcoital bleeding

 (e) dyspareunia- painful coital

- pap smear history

  * how many times?

  * when was the last one?

  * result normal?

Past medical and surgical history

- hx of chronic illnesses: HPT, DM, heart disease, asthma, TB

- any surgery procedure done before?

Family history

- siblings and parents- health problem

- family hx of HPT, DM

- Family hx of twins preg or congenital abnormality

Personal and social history

- education level

- husband’s age, occupation (type, work place, daily come back), income

- house condition: stair, toilet and etc

- how frequent husband visit her?

- who take care of her children during admission?

- how does she contact her children?

- smoking? alcohol?- both husband and pt

Transportation at home, some pregnant lady ride motorcycle

Nearest clinic from home? Convenient to checkup?

Drug history

- hematinics

  * iron- besi (T. ferrous fumarate 200mg contain 60mg iron)

  * folate- ubat kuning kecil (5mg/tablet)

  * vitamin B12 &C

- over counter drugs: Obimin (contain iron, folate, Vit B12 and etc)

- traditional medication

- allergy/ side effect

Obimin contained all four, iron(ferrous fumarate, folic acid, B12 and Vit C)

Obical include obimin plus calcium

The all four are enough for what required for mother

Dietary history

- normal balance adult diet

- allergy

- if patient is diabetic, details diet history are needed, including dishes for every meals,

  who give the advice? was pt understand, give eg of food?

Summary

Name/ age/ race/ gravida/ para/ POA/ chief complaint/ complication/risk factor/ management that been given/ in labour or not/ fetal movement

lightening: primigravida at 34 wk when head enter the pelvic brim (mother will felt sudden relief of SOB or breathing discomfort)

PHYSICAL EXAMINATION

Before start

- introduce pt to dr

- introduce dr to pt

- ask permission from pt and ask for chaperone

- position: Lying flat

- pt comfortable? With both hands at the side of body

- pt can sit upright if she had sign of cardiac disease or grossly enlarged uterus (cause

  splitting of diaphragm)

General examination

- Inspection:

v  Comfortable, lying flat/ propped up supported with one pillow

v  Alert and conscious

v  Well orientated to time, place and person

v  In pain, in respiratory distress

v  Hydrational and nutritional status

v  Gross deformity

v  Abnormal movement

v  Attachment

v  Height : <148cm and small shoe size→ smaller pelvic capacity→ CPD

v  Weight

v  Hand:

·         Warm/cold, dry/sweat

·        

* Mother with HPT is not advice to wear ring (edema)

Pale

·         Palmar erythema (↑ estrogen level)

·         Koilonychias (iron deficiency)

·         Peripheral cyanosis

·         Clubbing

·         Capillary refilling

·         Collapsing pulse (pathological/physiological d/t hyperdynamic circulation)

v  Vital sign:

·         Pulse rate, volume and rhythm

·         BP (sitting position or prop up 45 degree) pregnancy induced HPT dx after 20 w with measurement of high bp in 2 occasions

·         RR

·         Temperature

v  Neck:

·         JVP- if indicated

·         Thyroid swelling (normal for pregnant mother as they usually experience iodine deficiency)

v  Face and eyes:

·         Jaundice in sclera

·         Pallor on conjunctiva

·         Mouth, lips and tongue:

- Tongue: Moist/ Coated

      - Oral hygiene

      - Central cyanosis

      - Glossitis- nutritional deficiency

      - Angular stomatitis- nutritional deficiency

      - Oral thrust- candidiasis

v  Leg:

·         Pitting edema

·         Dilated vein

v  Examine reflex and fundoscopy for hypertensive patient

Specific examination

(a)  Before start:

v  Ask permission

v  Exposure- xyphisternum to symphysis pubic (not nipple line to mid-thigh!)

Prof Nora- expose from lower border of bra to pubic symphysis (ask chaperone or examiner to expose the patient)

(b) Inspection:

v  Abdomen is distended with gravid uterus evidenced by

·         Linea nigra

·         Striae gravidarum-red, present stretch mark

·         Visible fetal movement

(Prof Nora- show the findings by pointing it with thumb)

v  Striae albicans- white, previous stretch mark

v  Move symmetrically with respiration

v  Umbilical: Centrally located and Inverted/flat/everted

v  Dilated vein

v  Surgical scar

·         Laparoscopy: Umbilical; Small, easy to miss

·         LSCS: Transverse suprapubic/ pfennential scar

·         Upper segment caesarean section: Paramedian

     * If there is scar

        - site, size, shape

        - well heal/infected/keloid

        - surrounding skin- pigmentation, redness, swelling, ulceration, discharge

        - look for scar tenderness during palpation. (palpate around the scar to look for

          uterus tenderness)

v  Inguinal cough impulse

(c)  Palpation: (examiner sit down n patient lie flat!!!!)

v  Superficial palpation: Soft, tenderness

     (comment- the abdomen is soft and not tender)

v  Deep palpation: Contractile uterus

     (comment- the uterus is soft, not tender and not irritable)

     (if present of contraction- palpate at the fundus and time the contraction)

    (don’t perform deep palpation for Prof Nik Haslina)

v  Fundal height

·         Symphysiofundal height

- Palpate the fundus using ulnar border of left hand from xiphisternum

12w- just above suprapubic 22w- umbilicus 36w- xyphisternum

- Put the tape with inch scale on top

- Palpate for symphysis pubic (midline, 1^st bony prominent)

- Measures in cm (1w= 1cm)

·         Clinical fundal height (some dr no need present this…)

- Estimate how many finger breadth the fundal palpable below xyphisternum/above

  umbilical

  (don’t use finger to count- Prof Nik Haslina)

- Count fundal height (1w=1cm)

     * After 36w- below xyphisternum (less 1cm for every week) but there is fullness of  

        flank and cannot get below the costal margin)

     * Mention as ‘’fundal height is __ weight’’

     * Fundal height corresponding to POA?- allow +/- 2cm

Example 1: pt in 38w POA

The symphysiofundal height was 33cm. The fundus was palpable one finger breath below xyphisternum. There was fullness of flank and I could not get below the costal margin. The clinical fundal height was 38w which was corresponding to the POA.

Example 2: pt is in 34w POA

The symphysiofundal height was 34cm. The fundus was palpable 1 finger breath below xiphisternum. There was no fullness of flank and I was able to get below the costal margin. The clinical fundal height was 34w which was corresponding to the POA.

Notes:

- symphysiofundal height is not very reliable in assessing the uterus size if you only see your patient for the 1^st time because it is influenced  by other factors, e.g. obese and thin, amount of amniotic fluid, fetal weight.

- symphysiofundal height is useful when you f/u the patient during antenatal visit. You can assess the ↑ in symphysiofundal height compared to last visit.

Pawlick grip: - can not performed by medical student - using thumb and pointing finger to grip at   the fetal head

(d) Grips (Leopard’s)

- Fundal grip

·         face patient

·         feel the fundus using both hand

- lateral grip

·         face patient

·        

* causes of head not engaged: - placenta praevia - polyhydramnios - pelvic mass/ uterus mass (fibroid) - CPD

fix one hand and palpate with another hand

- pelvic grip

·         face patient’s leg

·         feel with both hands

·         feel for engagement

- comment on:

- singleton/ twins

- Lie- relation of long axis of fetus to the long axis of uterus

  * longitudinal (normal), transverse, oblique

- Presentation- pole of fetus that presents on pelvic brim

  * cephalic (normal), breech

- Engagement (for cephalic presenting)- the largest presenting part enter the pelvic brim

·         If ballotable= not engaged

·         use 5 fingers to measure

·         if 3 fingers palpable per abdomen= 3/5th palpable

·         2/5th palpable per abdomen= engaged

- liquor volume- clinically adequate?

- fluid thrill if excessive liquor

- estimated fetal weight

Polyhydramnio: when palpate hand need to go deep more than 8cm to feel fetal

Oligo: hand less than 2cam

·         Head- round, hard, ballotable ·         Buttock- broad, firm, not ballotable ·         Fetal back- smooth, firm, continuous ·         Fetal parts- bulging ·         Excessive liquor (large fundus, can’t feel fetal parts, + fluid thrill) ·         Reduced liquor (tense abdomen, easy to feel fetal parts, small fundus)

Reason oligo: HPT, placenta insufficient

(e) Auscultation:

·         For fetal heart sound-present/ not present

·         Use pinard (don’t stress on look at patient face,as long as

·         Comfortable n hands off pinard)

·         Listen at anterior shoulder

·         Dont press too hard and both hands off when listen!!

·         Must count HR (normal 120-160)

(f) Complete examination with:

·         Per vaginal examination (C/I- in PV bleeding/ leaking liquor)

·         Breast examination: important for breastfeeding

·         l/n examination

·         Others systems if relevant

Present:

- From inspection, the abdomen was distended with gravid uterus evidenced by presence of linea nigra, striae gravidarum, visible dilated vein and fetal movement. There were __    striae albican and ___ scar (type, length, well healed/not, sign of inflammation, tenderness). The umbilicus is centrally located and ___

- On superficial palpation, the abdomen is soft and not tender.

- On deep palpation, the uterus is soft, not tender and not irritable.

- The SFH was ___ cm correspond to POA/POG. The fundus is palpable __FB below xiphesternum. __ fullness of flank and ___ get below costal margin. The clinical fundus height is ___wk

- There is ___ fetus with ___ presentation, ___ lie. The fetal back is at maternal __side and fetal part at maternal __ side. Fetal head is __/5^th palpable, __ engaged. Fetal movement __ felt and __ uterus contraction. Liquor is clinically __. FW is __kg (range with interval 0.2)

- Fetal heart was heard at __ quadrant using  Pinard and heart rate is __ bpm

# Prof Adibah: evidence of gravid unterus: only fetal movement and fetal heart

Investigate

U/S
: check anencephaly, cord around neck, growth restriction

CTG: Fetal distress: check whether HR normal, whether there is acceleration (normal)

Urine FEME: check UTI

FBC: ANEMIA, INFECTION

Placenta blood flow, check using doppler ultrasound,

Normal position of placenta, upper segment

Mx for reduced fetal mov:

Admission, bedrest, fetal kick chart, CTG daily