Obstetric History Taking

Obstetric history taking Obstetric history taking involves a series of methodical questioning of an obstetric patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further  investigative testing or treatment of a diagnosed condition. There is a basic structure for all obstetric histories but this can differ slightly depending on the presenting complaint. Because of the nature of  obstetrics there may not even be a presenting complaint. Expectant mothers receive antenatal check-ups and therefore may be referred because of the result of an examination or an investigation so the mother may be asymptomatic. When taking any history in medicine it is essential to understand what the presenting complaint means (if any) and what the possible causes (differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning Basic Structure of an Obstetric History  Ascertain y y y

Menstrual History Name

of patient  Age of patient Consent for questioning

y

1st day of last menstrual period

y

Regularity

y y

Presenting Complaint y

It is important to ask as open a question as possible in

y

Past Medical History

this part of the history and to ensure the complaint is understood as everything else follows on from here

y y

History of Presenting Complaint y

This will differ slightly depending on the presenting complaint (see below) but follows a vague structure: o Onset o Periodicity Duration o Recurrence? o

Past Obstetric History y

Gravidity o o o o o o o

and Parity Dates of deliveries Length of pregnancies Induction of labor/Spontaneous Normal Delivery? Weight of babies Gender of babies Complications before, during and after  delivery

of normal cycle Was this a planned pregnancy? Previous contraception  Any antenatal problems thus far?

y

Drug

Current or past illnesses Hospital admissions Past surgeries

History y y y

Prescribed medications Non-prescribed medications/herbal remedies Recreational drugs

Family History y y

Medical conditions Obstetric complications

Social History y y y y

Occupation Support network Smoking  Alcohol

Other  y

Blood group