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OBSTETRIC HISTORY TAKING

Introduction
Introduce yourself name / role
Confirm patient details name / DOB
Explain the need to take a history
Gain consent
Ensure the patient is comfortablePresenting complaint
Its important to use open questioning to elicit the patients presenting
complaint
So whats brought you in today? or Tell me about your symptoms

Allow the patient time to answer, trying not to interrupt or direct the
conversation

Facilitate the patient to expand on their presenting complaint if required


Ok, so tell me more about that Can you explain what that pain was like?
History of presenting complaint
Ask the following questions for each symptom the patient is experiencing.
Onset when did the symptom start? / was the onset acute or gradual?
Duration minutes / hours / days / weeks / months / years
Severity e.g. if symptom is vaginal bleeding how many sanitary pads are
they using?
Course is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? is the symptom always present or does it come
and go?
Precipitating factors are there any obvious triggers for the symptom?

Relieving factors does anything appear to improve the symptoms e.g. an


inhaler
Associated features are there other symptoms that appear associated e.g.
fever / malaise
Previous episodes has the patient experienced this symptoms previously?
Key symptoms to ask about in a pregnant patient
Nausea / vomiting if severe may suggest hyperemesis gravidarum
Abdominal pain may suggest the need for imaging
Vaginal bleeding fresh red blood / clots / tissue
Dysuria / urinary frequency urinary tract infection
Fatigue may suggest anaemia
Headache / visual changes / swelling pre-eclampsia
Systemic symptoms fever / malaise
Ideas, Concerns & Expectations
Ideas what are the patients thoughts regarding their symptoms?
Concerns explore any worries the patient may have regarding their
symptoms
Expectations gain an understanding of what the patient is hoping to
achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the
patient has told you.
It also allows the patient to correct any inaccurate information & expand
further on certain aspects.
Once you have summarised, ask the patient if theres anything else that
youve overlooked.
Continue to periodically summarise as you move through the rest of the
history.
Signposting
Signposting involves explaining to the patient;
What you have covered Ok, so weve talked about your symptoms

What you plan to cover next Now Id like to discuss your past medical
history History of the current pregnancy
Is this the patients first pregnancy?
How was the pregnancy confirmed? home testing kit / hCG blood test / USS
Last menstrual period (LMP) first day of the LMP
Was the patient using contraception? are they still (e.g. COCP / implant /
coil)
Estimated date of delivery (EDD) estimated by scan or via dates (LMP + 9
months + 7 days)
Did the patient take folic acid during the first trimester?
Any other scans or tests whilst been pregnant? dating scan / anomaly scan
Growth of fetus within normal limits?
Placental location placenta praevia may alter delivery plans
Fetal movements usually experienced at around 18-20 weeks gestation
Labour pains more relevant in the third trimester
Planned method of delivery vaginal / c-section
Medical illness during pregnancy if so are they taking any medications?
Previous obstetric history
Gravidity defined as the number of times a woman has been pregnant
regardless of the outcome
Parity X = (any live or still birth after 24 weeks) |
24 weeks)
Details of each pregnancy:
Date of delivery
Length of pregnancy
Singleton / twins / or more?
Spontaneous labour or induced?
Mode of delivery
Weight of babies
Current health of babies

Y = (number lost before

Complications of previous pregnancies:


Antenatal IUGR / hyperemesis gravidarum / pre-eclampsia
Labour failure to progress / perineal tears / shoulder dystocia
Postnatal postpartum haemorrhage / retained products of conception
Miscarriages / terminations needs to be asked sensitively in an appropriate
setting
Gynaecological history
Previous cervical smears when? / results?
Previous gynecological problems & treatments STDs / PID / Ectopic
pregnancy
Current contraception COCP / POP / Depot / Implant / Implanted uterine
device

Gynaecological surgery:
Loop excision of transitional zone (LETZ) risk of cervical incompetence
Previous C-sections risk of uterine rupture / placenta accreta /adhesions
Past medical history
Relevant medical conditions
PE / DVT high risk for further events in following pregnancy
Diabetes tight glycaemic control is essential risk of congenital defects /
macrosomia
Epilepsy some antiepileptics are teratogenic needs neurology input
Hypothyroidism TFTs need close monitoring risk of congenital
hypothyroidism
Previous pre-eclampsia higher risk to develop it in the current pregnancy
Other medical conditions
Any hospital admissions? when and why?
Surgical history previous abdominal and gynaecological surgery of
relevance
Immunisations up to date?

Drug history
Pregnancy medications:
Folic acid
Iron
Antiemetics
Antacids
Teratogenic drugs:
ACE inhibitors
Sodium valproate
Methotrexate
Retinoids
Trimethoprim
Document all regular medications
Over the counter drugs ensure nothing is unsafe / teratogenic
ALLERGIES
Family history
Inherited genetic conditions cystic fibrosis
Pregnancy loss recurrent miscarriages in mother & sisters
Pre-eclampsia in mother or sister increased risk
Social history
Smoking can cause intrauterine growth restriction
Alcohol How many units a week? can cause fetal alcohol syndrome
Recreational drug use cocaine use can cause placental abruption
Living situation:
House / flat stairs / adaptations
Who lives with the patient? important when considering discharging home
from hospital
Any carer input? what level of care do they receive?
Activities of daily living:
Is the patient independent / able to fully care for themselves?

Can they manage self hygiene / housework / food shopping?


Is the pregnancy interfering with these daily activities?
Occupation light duties / maternity leave
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other
body systems.
This may pick up on symptoms the patient failed to mention in the
presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. vomiting in
hyperemesis gravidarum).
Choosing which symptoms to ask about depends on the presenting
complaint and your level of experience.

Cardiovascular Chest pain / Palpitations / Dyspnoea / Syncope /


Orthopnoea / Peripheral oedema
Respiratory Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest
pain
GI Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss /
Abdominal pain / Bowel habit
Urinary Volume of urine passed / Frequency / Dysuria / Urgency /
Incontinence
CNS Vision / Headache / Motor or sensory disturbance/ Loss of
consciousness / Confusion
Musculoskeletal Bone and joint pain / Muscular pain
Dermatological Rashes / Skin breaks / Ulcers

Prenatal Checkup
The First Visit
Your first prenatal visit will probably be scheduled sometime after your
eighth week of pregnancy. Most health care providers wont schedule a visit
any earlier unless you have a medical condition, have had problems with a
pregnancy in the past, or have symptoms such as spotting or bleeding,
stomach pain, or severe nausea and vomiting.1
Because your first visit will be one of your longest, allow plenty of time.