Obstetric History-Taking

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Insight into the status and complications of a patient's current and previous pregnancies can aid in the early diagnosis and management of any issues that may arise.

Presenting Complaints

Per Vaginal Bleeding
Fresh blood / clots
Per Vaginal Discharge
Colour, consistency, associated symptoms
Abdominal Pain
Nature, severity, onset, location, radiation
Site
Localised to upper / lower / left / right, generalised
Onset
Sudden / gradual, situation
Character
Sharp / dull, colicky, cramping
Radiation
To elsewhere in the abdomen, chest, shoulder(s), back
Associations
Nausea / vomiting, diarrhoea / constipation, reflux, visual changes
Timing
Constant / colicky, changes throughout the day
Exacerbating Factors
Certain foods, movement, foetal movement, passing bowel motions
Alleviating Factors
Rest, vomiting, passing bowel motions
Severity
Scale of 1-10 with 10 being the worst pain
Urinary Symptoms
Frequency, dysuria
Severe Nausea / Vomiting
Onset, frequency, contents, blood, fluid status
Onset
Sudden / gradual, situation
Character
Dry retching, voluminous
Vomitus
Colour, volume, consistency, frank blood, coffee grounds
Associations
Abdominal pain, refluex, diarrhoea, fevers, vertigo, visual changes
Timing
Frequency & number of times vomited
Exacerbating Factors
Certain foods, foetal movements, head injury, hyperglycaemia
Alleviating Factors
Rest, antiemetics
Symptoms of Pre-Eclamptic Toxaemia
Headache, visual changes (blurring / stars), abdominal pain, seizures
Galactorrhoea

Current Pregnancy

Confirmation of Pregnancy
How was the pregnacy diagnosed?
Urine test, blood test, ultrasound
Dates
LMP, EDD, GA
Last Menstrual Period
Estimated Delivery Date
By dates or by ultrasound
Current Gestational Age
Scans
Size, location, morphological issues
Other Investigations
ABO group, rhesus group, rubella status
Number of Pregnancies
Foetal Movements
Complications of This Pregnancy
Gestational diabetes, pre-eclampsia
Medications for this Pregancy
Folic acid, iron, antiemetics
Plan for Delivery
Vaginal / caesarean

Obstetric History

Gravidity
Number of times pregnant
Parity
Number of live births
Miscarriages
Terminations
Previous Pregnancies
Length, mode of delivery
Length of Pregnancy
Gestational age at delivery
Induction
Spontaneous / induced
Mode of Delivery
Vaginal, forceps, suction, elective / emergency caesarean
Past Complications of Pregnancy
Before / during / after delivery
Antenatal
Hyperemesis gravidarum, PET, IUGR
Peripartum
Failure to progress, shoulder dystocia, perineal tear
Postpartum
Postpartum haemorrhage

Gynaecologic History

Past Subfertility
Amount of time attempting pregnancy, medications, IVF
Menstrual Periods
Regularity, duration, flow, pain
Pap Smear
Last smear, result
Past Gynaecologic Disease
Ectopic pregnancy, STDs, PID
Past Gynaecologic Surgery
D&C, LETZ

Past Medical History

Past Medical Issues
Doctor visits, hospital admissions
Hypertension
Latest BP readings, meds, complications
Diabetes
Diagnosis, control, management, complications
Thyroid Disease
Hypothyroidism / hyperthyroidism
Epilepsy
Frequency / last seizure, type of seizures, Rx
DVT / PE
Where, when, ?provoked, management
Asthma
When diagnosed, severity, medications

Medications

Obstetric Medications
Click for a summary of important drugs
Current Medications
Indication, dose & frequency, length of course
Potentially Teratogenic Medications
Check pregnancy class of drugs
Vitamins / Supplements
Alternative Medicines
Herbs, homeopathic remedies
Allergies / Adverse Drug Reactions
When? What was the reaction?
Vaccinations
Up to date?

Family History

Known Genetic Conditions
Cystic fibrosis
Other Conditions in the Family
Heart disease, cancer, diabetes, autoimmune Dx
Family Obstetric History
Twins, recurrent miscarriage

Social History

Vocation
Education, occupation, souce of income, leave
Education
Level of education attained
Occupation
Current job, past jobs, level of activity, toxin exposure
Source of Income
Occupation / pension / partner
Leave
Planning for maternity leave
Relationship Status
Single / de facto / married / separated / divorced
Social Supports
Partner, family, friends
Diet
On an average day
Recent Travel
Especially to developing countries
Exercise
Amount per week

Substance History

Alcohol
Average per day / week, CAGE
Smoking
Pack-years, years since quitting
Recreational Drugs
Especially IV drug use

On this page: Presenting Complaints Current Pregnancy Obstetric History Gynaecologic History Past Medical History Medications Family History Social History Substance History

Read More...

Abu-Heija AT, El-Jallad F, Ziadeh S. Placenta previa: effect of age, gravidity, parity and previous caesarean section. Gynecologic and obstetric investigation. 1999 Jan 7;47(1):6-8. Elling SV, Powell FC. Physiological changes in the skin during pregnancy. Clinics in dermatology. 1997 Jan 1;15(1):35-43. Olesen AG, Svare JA. Decreased fetal movements: background, assessment, and clinical management. Acta obstetricia et gynecologica Scandinavica. 2004 Sep 1;83(9):818-26. Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstetrics & Gynecology. 2003 Jul 1;102(1):181-92. Verberg MF, Gillott DJ, Al-Fardan N, Grudzinskas JG. Hyperemesis gravidarum, a literature review. Human reproduction update. 2005 Sep 1;11(5):527-39.

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