Obstetrics is the field of medicine which encompasses the care of a woman during pregnancy and childbirth. In that way it is very unique, as when assessing these patients, your actually also assessing another the child. Consequently, the approach to history taking in Obstetrics whilst similar to other fields of medicine, includes a number of additional components.
The following is a guide to taking an Obstetric History, that will ensure you miss none of the key components.
What is the problem that brought you to the hospital/clinic?
Some common presenting complaints include;
- ◘ Bleeding
- ◘ Abdominal Pain
- ◘ Hypertension
- ◘ Physiological complaints due to pregnancy
History of Presenting Complaint
Often there will be overlap between the history of the presenting complaint and the history of the current pregnancy.
History of Current Pregnancy
The history of current pregnancy should ideally be considered by the different trimesters to date. This will be useful for understanding common issues that arise at each stage, and also determining appropriate antenatal care and management.
- ◘ Last menstrual Period (LMP)
- ◘ Estimated delivery date and approximate Gestational Age.
- ◘ Any concerns about your pregnancy
- ◘ What are your expectations regarding your pregnancy
- ◘ Further details regarding menstrual history (as below)
- ◘ Was the Pregnancy planned?
- ◘ How was the pregnancy confirmed?
- ◘ Signs and symptoms of pregnancy.
- ◘ How/has the pregnancy been dated (e.g. dating Ultrasound Scan)?
- ◘ What tests and scans have you had to date?
- ◘ Current medical illnesses and medications.
- ◘ Any problems during second 3 months?
- o Bleeding, vaginal discharge, urinary problems and so on.
- ◘ Last visit to the doctor?
- o Has an Ultrasound scan (e.g. morphology scan) been done?
- o Blood tests to date?
- o Blood pressure?
- o Growth of foetus, placenta location.
- ◘ Any issues after the first 6 months of your pregnancy?
- o Bleeding, vaginal discharge, urinary problems, labour pain.
- o Blood pressure
- o Glucose
- o Test results
- ◘ Any plans or ideas about method of delivery.
Past Obstetric History
Gravidity: the number of times a woman has been pregnant, regardless of the outcome.
Parity: the number of times a female has given birth to a baby.
There are many different methods and protocols by which Gravidity and Parity are denoted, please be aware of your local policy and documentation guidelines.
A simple system commonly used in the UK is;
A woman who has never given birth is a nullipara, a nullip, or para 0.
A woman who has given birth two or more times is multiparous and is called a multip.
A woman in her first pregnancy and who has therefore not yet given birth is a nullipara or nullip. After she gives birth she becomes a primip.
A woman who has given birth once before is primiparous, and would be referred to as a primipara or primip.
Details of each pregnancy
- ◘ Dates of deliveries
- ◘ Length of pregnancies
- ◘ Singleton/twin and so on
- ◘ Induction of labour/Spontaneous
- ◘ Mode of Delivery
- ◘ Weight of babies
- ◘ Gender of babies
- ◘ Complications before, during and after delivery
Number of miscarriages, terminations and/or ectopics – with appropriate details.
- ◘ This question should be asked as some patients will not consider the above situations as pregnancy.
Any difficulties conceiving and any treatment/management to date for sub-fertility.
Past Gynaecological History
If it hasn’t been so already, you should first gain a Menstrual History as appropriate.
- ◘ 1st day of last menstrual period
- ◘ Duration and regularity of normal cycle
- ◘ Flow: heavy/light, clots, number of tampons/pads used
- ◘ Pain
- ◘ D&C
- ◘ Loop excision of transitional zone (LETZ)
- ◘ Previous C-Sections
This may be an appropriate place to take a Sexual History (see sexual history for further details).
Past Medical & Surgical History
Current or past illnesses
- ◘ Hypertension
- ◘ Diabetes
- ◘ Epilepsy
- ◘ Thyroid (hypo or hyper)
- ◘ Thromboembolic disease
- ◘ Asthma
- ◘ when, where, why and details concerning procedure
- ◘ abdominal or gynaecological procedures
- ◘ problems with anaesthesia
- ◘ problems with bleeding (requiring transfusion) or clotting
Current Medications & Allergies
Medications can be divided into prescribed medications and non-prescribed medications/herbal remedies. The latter should not be missed, and approached in non-judgemental way.
Allergic to any medications?
- ◘ Medical conditions
- ◘ Obstetric complications
- ◘ Genetic conditions
- ◘ Occupation
- ◘ Relationship Status
- ◘ Diet/physical activity
- ◘ Smoking
- ◘ Alcohol
- ◘ Drug use
- ◘ Living Situation
- ◘ Travel History
- ◘ ABC of labour care – Obstetric emergencies http://www.bmj.com.ezproxy.library.uq.edu.au/content/318/7194/1342
- ◘ Borton, Chloe (November 12, 2009). “Gravidity and Parity Definitions (and their Implications in Risk Assessment)”.
- ◘ The Medical Significance of the Obstetric H… [Am Fam Physician. 1983] – PubMed – NCBI.