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Obstetric History-Taking

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

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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