History Taking History Taking Post Pic O&G

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.

Presenting complaint

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?”

 

Pregnancy history

Last Menstrual Period – first day of LMP
EDDestimated by scan or via dates (LMP + 9 months + 7 days)
Menstrual cycle

  • Regularity
  • 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
Tiredness
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

Ideaswhat are the patients thoughts regarding their symptoms?

Concernsexplore any worries the patient may have regarding their symptoms

Expectationsgain an understanding of what the patient is hoping to achieve from the consultation

 

Summarising

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

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

Graviditydefined 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 

 

Babysex / weight /current health

Complications:

  • AntenatalIUGR / Hyperemesis gravidarum / Pre-eclampsia / etc
  • Labourfailure to progress / perineal tears / shoulder dystocia / etc
  • Postnatalpostpartum 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

 

Gynaecological surgery

  • Loop excision of transitional zone (LETZ) -↑ risk of cervical incompetence
  • Previous C-sections - ↑ risk of uterine rupture / placenta accreta /adhesions

 

Gynae investigations / treatment for:

  • Infertility
  • Ectopic – ↑ risk of future ectopics
  • PID - chlamydia is  the most common cause – ↑ risk of ectopic
Past Medical History

Medical conditions

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 operationsabdominal or gynae?

Drug History

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

ALLERGIES

Family History

Medical conditions - gestational diabetes
Inherited genetic conditions –
cystic fibrosis 
Pregnancy Loss - 
recurrent miscarriages in mother & sisters 
Pre-eclampsia - in mother or sister? – increased risk

Social History

SmokingHow many smoked and for how long? – strongly encourage to stop

AlcoholGet specific! – How much?, How often?, Everyday? Type of alcohol?

Recreational drug use - IV drug use (Hepatitis, HIV) / Cocaine (Placental abruption)

Living SituationHouse 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

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

 

CardiovascularChest 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

MusculoskeletalBone & Joint pain / Muscle pain /  Joint swelling / Difficulty mobilising

DermatologyRashes / Skin breaks / Ulcers

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