Published on September 21st, 2010 | by Lewis Potter
Obstetric History Taking
Obstetric history taking has a number of questions that are not part of the standard history taking format and therefore it’s important to understand what information you are expected to gain when taking an obstetric history.
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s 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?”
Last Menstrual Period – first day of LMP
EDD – estimated by scan or via dates (LMP + 9 months + 7 days)
- Duration – normal 28 day cycle?
- Flow? – heavy/light – can be useful to ask number of sanitary towels/tampons
Contraceptive use? – COCP, POP, Depot, Implant
How was the pregnancy confirmed? – home testing kit / hCG blood test / USS
Any other scans or tests whilst been pregnant? - dating scan / anomaly scan
Symptoms of Pregnancy
Nausea / Vomiting - if severe may suggest hyperemesis gravidarum
Urinary frequency – pressure on the bladder causes this – however important rule out UTI
Breast Changes – increase in glandular tissue – lactation
Fetal Movements - usually experienced at around 18-20 weeks gestation (earlier in multips)
Cravings – vary extensively between women
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
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 there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient;
- What you have covered - “Ok, so we’ve talked about your symptoms & your concerns regarding them”
- What you plan to cover next - ”Now I’d like to discuss your past medical history and your 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) | Y = (number lost before 24 weeks)
Details of each pregnancy:
- Date / Year
- Place of birth
- Gestation length
- Mode of delivery
Baby – sex / weight /current health
- Antenatal - IUGR / Hyperemesis gravidarum / Pre-eclampsia / etc
- Labour - failure to progress / perineal tears / shoulder dystocia / etc
- Postnatal - postpartum haemorrhage / retained products of conception / etc
Miscarriages & Terminations - needs to be asked sensitively in an appropriate setting
Past Gynae History
Last Cervical Smear – what was the result? – CIN grading
- Loop excision of transitional zone (LETZ) -↑ risk of cervical incompetence
- Previous C-sections - ↑ risk of uterine rupture / placenta accreta /adhesions
Gynae investigations / treatment for:
- Ectopic – ↑ risk of future ectopics
- PID - chlamydia is the most common cause – ↑ risk of ectopic
Past Medical History
Thromboembolic disease - previous PE/DVT - high risk in following pregnancy
Diabetes - tight glycaemic control is essential - congenital defects, macrosomia
Epilepsy - some medications are teratogenic - needs neurologist input
Hypothyroidism - TFT’s need close monitoring – congenital hypothyroidism
Hypertension - patients BP may rise through pregnancy – PIH/Pre-eclampsia
Any hospital admissions?- when / why?
Any operations – abdominal or gynae?
Pregnancy medication - folates, iron / anti-emetics / antacids
Teratogenic drugs – avoid at all costs - ACEi / Retinoids / Sodium Valproate /Methotrexate
OTC Drugs - make sure to ask patient about these, to ensure nothing is unsafe / teratogenic
Recreational drug use – cocaine use can cause placental abruption / alcohol can cause FAS
Medical conditions - gestational diabetes
Inherited genetic conditions – cystic fibrosis
Pregnancy Loss - recurrent miscarriages in mother & sisters
Pre-eclampsia - in mother or sister? – increased risk
Smoking – How many smoked and for how long? – strongly encourage to stop
Alcohol – Get specific! – How much?, How often?, Everyday? Type of alcohol?
Recreational drug use - IV drug use (Hepatitis, HIV) / Cocaine (Placental abruption)
Living Situation – House or bungalow? Stairs? Who do they live with?
Relationship Status – Single / In a relationship
Activities of Daily Living - How are they coping at home?
Occupation - Maternity leave arranged / light duties?
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. reduced urine output in fluid overload
Choosing which symptoms to ask about depends on the presenting complaint & your level of experience
Cardiovascular - Chest pain / Palpitations / Cyanosis / SOB / Syncope / Orthopnoea / Ankle swelling
Respiratory - Cough / Sputum / Chest Pain / SOB / Wheezing / Stridor/ Haemoptysis
GI - Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss /Pain / Bowel habit
Urinary - Frequency / Dysuria / Polyurea / Urgency / Hesitancy / Nocturia / Incontinence
Nervous System - Vision / Headache / Weakness / Sensory disturbance / LOC / Seizures / Incontinence
Musculoskeletal - Bone & Joint pain / Muscle pain / Joint swelling / Difficulty mobilising
Dermatology - Rashes / Skin breaks / Ulcers