Obstetric History Taking – OSCE Guide

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An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies. Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential.

Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history taking format, therefore it’s important to understand what information you are expected to gather.

It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy).

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

Key pregnancy details

It is useful to confirm the gestational age, gravidity and parity early on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely.

Gestational age, gravidity and parity should also be included at the beginning of your presentation of a patient’s history.

Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).

Parity (P) is the total number of times a woman has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth).

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Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

• “What’s brought you in to see me today?”
• “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

• “Ok, can you tell me more about that?”
• “Can you explain what that pain was like?”

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History of presenting complaint

Once the patient has had time to communicate their presenting complaint, you should explore the issue with further open and closed questions.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Site

Ask about the location of the symptom:

• “Where is the pain?”
• “Can you point to where you experience the pain?”

Onset

Clarify how and when the symptom developed:

• “Did the pain come on suddenly or gradually?”
• “When did the pain first start?”
• “How long have you been experiencing the pain?”

Character

Ask about the specific characteristics of the symptom:

• “How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
• “Is the pain constant or does it come and go?”

Radiation

Ask if the symptom moves anywhere else:

• “Does the pain spread elsewhere?”

Associated symptoms

Ask if there are other symptoms which are associated with the primary symptom:

• “Are there any other symptoms that seem associated with the pain?” (e.g. shortness of breath in pulmonary embolism)

Time course

Clarify how the symptom has changed over time:

• “How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better:

• “Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction may find going up or down the stairs makes things worse)
• “Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux may find that antacid medication helps with their symptoms)

Severity

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

• “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Obstetric symptoms

Once you have completed exploring the patient’s history of presenting complaint, you need to move on to more focused questioning relating to the symptoms that may be relevant to pregnancy (if not already discussed). We have included a focused list of key symptoms to ask about when taking an obstetric history, followed by some background information on each, should you want to know a little more.

Nausea and vomiting

Nausea and vomiting are very common in pregnancy, but are typically mild, requiring only reassurance and basic hydration advice.

Nausea and vomiting typically begin between the fourth and seventh week of gestation, then peak between the ninth and sixteenth week and resolve by around the 20th week of pregnancy.

Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance, weight loss and ketonuria. ¹

Reduced fetal movements

Women typically start to feel fetal movements between 16 to 24 weeks gestation (primigravida women will often not feel fetal movements until after 20 weeks gestation). A mother will know what is the “usual” amount of fetal movements she experiences, therefore, if a reduction in fetal movements is reported, it should be taken very seriously.

Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal growth restriction, placental insufficiency, and congenital malformations. ²

You should always ask about fetal movements once the patient is of the appropriate gestation to be able to feel them:

• “Have you noticed any change in the amount of your baby’s movement?”

Vaginal bleeding

Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynaecological diseases.

It is important to ask about pain, associated trauma (including domestic violence), fever/malaise, recent ultrasound scan results (e.g. position of the placenta), cervical screening history, sexual history and past medical history to help narrow the differential diagnosis.

You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-syncope/syncope).

Vaginal discharge

All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking an obstetric history.

You should ask the patient if they have noticed any changes to the following characteristics of their vaginal discharge:

• Volume
• Colour (e.g. green, yellow or blood-stained would suggest infection)
• Consistency (e.g. thickened or watery)
• Smell (e.g. fish-like smell in bacterial vaginosis)

Urinary symptoms

Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract infections in pregnancy have been associated with increased risk of fetal death, developmental delay and cerebral palsy.

Common symptoms of urinary tract infections include:

• Dysuria: pain whilst passing urine.
• Frequency: increased frequency of passing urine.
• Urgency: a sudden need to pass urine, with no earlier warning.
• Fever

Headache, visual changes, epigastric pain, oedema

Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy.

The key symptoms to ask about include:

• Headache (typically severe and frontal)
• Swelling of the hands, feet and face (oedema)
• Pain in the upper part of the abdomen (epigastric tenderness)
• Visual disturbance (blurring of vision or flashing lights)
• Reduced fetal movements

Other symptoms

Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections, cervical infections, chorioamnionitis).

Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology.

Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. malignancy, anorexia nervosa).

Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects the palms and soles of the feet).

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

• “What do you think the problem is?”
• “What are your thoughts about what is happening?”
• “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

• “Is there anything, in particular, that’s worrying you?”
• “What’s your number one concern regarding this problem at the moment?”
• “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

• “What were you hoping I’d be able to do for you today?”
• “What would ideally need to happen for you to feel today’s consultation was a success?”
• “What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

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

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your current pregnancy.”

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Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

• Systemic: fatigue (e.g. anaemia), fever (e.g. chorioamnionitis, urinary tract infection), weight loss (e.g. hyperemesis gravidarum)
• Respiratory: dyspnoea (e.g. pulmonary embolism, anaemia), chest pain (e.g. pulmonary embolism)
• Gastrointestinal: abdominal pain (e.g. placental abruption), vomiting (e.g. hyperemesis gravidarum)
• Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
• Neurological: visual changes, motor or sensory disturbances, headache (e.g. pre-eclampsia)
• Musculoskeletal: pelvic pain (e.g. symphysis pubis dysfunction)
• Dermatological: rashes, skin lesions, linea nigra

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Current pregnancy

Gestation

Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as “26+5”).

Accurate estimation of gestation and estimated date of delivery (EDD) is performed using an ultrasound scan to measure the crown-rump length.

Scan results

Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks. You should ask about the results of the scan (or check the medical records if the patient is unsure). The key findings to note include:

• Growth of the fetus: clarify if it was within normal limits for the current gestation.
• Placental position: if embedded in the lower third of the uterine cavity there is an increased risk of placenta praevia.
• Fetal anomalies: note any abnormalities identified.

Screening

There are several types of screening that women are offered during pregnancy:

• Down’s syndrome screening
• Rhesus status and the presence of any antibodies
• Hepatitis B, HIV and syphilis.

You should clarify if the patient has opted for screening and if so, what the results were.

Other details of the pregnancy

• Check if this is a singleton or multiple gestation.
• Clarify if the patient took folic acid prior to conception and during the first trimester.
• Explore the planned mode of delivery  (e.g. vaginal or Caesarean section).
• Ask about any medical illness during pregnancy (clarify what type of illness and if the patient is still receiving any treatment).

Immunisation history

Check the patient is currently up to date with their vaccinations including:

• Flu vaccination
• Whooping cough vaccination
• Hepatitis B vaccination (if at risk)

Mental health history

Pregnancy can have a significant impact on maternal mental health, therefore it is essential that patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar disorder, schizophrenia).

Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if relevant.

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Previous obstetric history

It is important to ask about a woman’s previous obstetric history, as this may help inform the assessment of risk in the current pregnancy and have implications for the mode of delivery.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Term pregnancies (>24 weeks)

Gestation at delivery:

• Previous pre-term labour increases the risk of pre-term labour in later pregnancies.

Birth weight:

• A high birth weight in previous pregnancies raises the possibility of previous gestational diabetes.
• A low birth weight (small for gestational age) in a previous pregnancy increases the risk of a further small for gestational age baby.

Mode of delivery:

• Spontaneous vaginal delivery
• Assisted vaginal delivery (e.g. forceps)
• Caesarean section (will have implications for the choice of future mode of delivery)

Complications:

• Antenatal period: pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia and shoulder dystocia.
• Postnatal period: post-partum haemorrhage, perineal/rectal tears during delivery and retained products of conception.

Assisted reproduction:

• Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies.

Stillbirth

As stated below, asking about stillbirths need to be done in a sensitive manner.

A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy.

Sensitivity clarify the gestation of the stillbirth if this is not already documented.

Other pregnancies (<24 weeks)

Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive manner in a private setting. It can be very difficult for women to discuss these topics. These questions should only be asked when relevant and by a person who is competent to do so.

Miscarriage

A miscarriage is the loss of a pregnancy before 24 weeks gestation.

Gestation:

• Clarify the trimester at which the miscarriage occurred (miscarriage is most common in the first trimester).

Other details:

• Clarify if medical or surgical management was required for the miscarriage and if any cause was identified for the miscarriage (e.g. genetic syndromes).

Termination of pregnancy

Termination of pregnancy is the medical process of ending a pregnancy so it doesn’t result in the birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical procedure.

Clarify the gestation at which the termination of pregnancy was performed and the method of management (e.g. medical or surgical).

Ectopic pregnancy

An ectopic pregnancy is when a fertilised egg implants itself outside of the uterus, usually in one of the fallopian tubes.

Clarify the site of the ectopic pregnancy and how it was managed (e.g. expectant, medical, surgical).

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Gynaecological history

Cervical screening:

• Confirm the date and result of the last cervical screening test.
• Ask if the patient received any treatment if the cervical screening test was abnormal and check that follow up is in place.

Previous gynaecological conditions and treatments:

• Sexually transmitted infections
• Endometriosis
• Bartholin’s cyst
• Cervical ectropion
• Malignancy (e.g. cervical, endometrial, ovarian)

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Past medical history

A patient’s past medical history is particularly relevant during pregnancy, as some medical conditions may worsen during pregnancy and/or have implications for the developing fetus.

Ask if the patient has any medical conditions: 

• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:

• Abdominal or pelvic surgery: may influence decisions regarding delivery due to the presence of scar tissue and adhesions.
• Previous Caesarean section: increased risk of uterine rupture in subsequent pregnancies.
• Loop excision of the transitional zone (LETZ): increased risk of cervical incompetence.

Allergies

It’s essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced.

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Drug history

It is essential to gain an accurate overview of the medications the patient is currently and has previously taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from drugs, as this is when organogenesis occurs.

Prescribed medications

Clarify the prescribed medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped (including drug name, dose and route).

• “Are you currently taking any prescribed medications or over-the-counter treatments?”
• “Have you stopped taking any prescribed medication since you became pregnant?”

Ask if the patient was using contraception prior to becoming pregnant and if so, clarify what method of contraception was being used. Check the patient has stopped their contraception or had their contraceptive device removed (e.g. coil, implant).

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

• “Have you noticed any side effects from the medication you currently take?”

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Family history

Taking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus during pregnancy. This can also help inform discussions with parents about the risk of their child having a specific genetic disease (e.g. cystic fibrosis).

Some important medical conditions to ask about include:

• Inherited genetic conditions: such as cystic fibrosis and sickle cell disease.
• Type 2 diabetes: if first-degree relatives are affected there is an increased risk of gestational diabetes.
• Pre-eclampsia: most relevant if maternal mother or sister is affected as this is associated with an increased risk of developing pre-eclampsia.

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Social history

Understanding the social context of a patient is absolutely key to building a complete picture of their health. Social factors have a significant influence on a patient’s pregnancy.

General social context

Explore the patient’s general social context including:

• the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
• who else the patient lives with and their personal support network
• what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Offer smoking cessation services (see our smoking cessation guide for more details).

Smoking increases the risk of a small for gestational age baby.

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Excess alcohol use during pregnancy can result in conditions such as fetal alcohol syndrome.

Recreational drug use

It is important to ask about recreational drug use, as these can have significant consequences on the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption).

If recreational drug use is identified, patients can be offered input from drug cessation services.

Diet and weight

Ask if the patient what their diet looks like on an average day.

Ask about the patient’s current weight (obesity significantly increases the risk of venous thromboembolism, pre-eclampsia and gestational diabetes during pregnancy).

Occupation

Ask about the patient’s current occupation and if there are plans in place for maternity leave.

Domestic abuse

It is important to privately ask all pregnant women if they are a victim of domestic abuse to provide an opportunity for them to seek help.

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Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

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Reviewer

Dr Venkatesh Subramanian

Obstetrics & Gynaecology Registrar in London

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References

1. NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy. Published: June 2017. Available from: [LINK].
2. BMJ. Reduced fetal movements. 2018; 360. Published March 2018. Available from: [LINK] 
3. MBRRACE-UK. Saving Lives, Improving Mother’s Care. Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009. Available from: [LINK].

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