An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies. Some of the questions are highly personal and 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 and therefore it’s important to understand what information you are expected to gain.
It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely and therefore your history should focus more on the gynaecological aspect (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy).
Opening the consultation
- Introduce yourself (including your name and role)
- Confirm the patient’s details (name and date of birth)
- Explain the need to take a history
- Gain consent
- Ensure the patient is currently comfortable
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 would also usually be included at the beginning of any documentation or presentation of the patient.
- 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 pregnancies carried over the threshold of viability (typically 24 + 0 weeks).
Example of Gravidity and Parity calculation
A patient is currently 26 weeks pregnant and already has two other children of her own. She also reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks.
- G5: The patient’s gravidity is 5 because she has had 5 pregnancies in total, regardless of the outcome.
- P4: The patient’s parity would be 4 because she has had 4 pregnancies which were carried beyond 24+0 weeks gestation and a miscarriage lost at 10 weeks gestation.
How does Parity work for twins?
- A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational age should be defined as P1.
- However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2.
- As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable gestational age will often be referred to as P2, but from an academic perspective, they would be deemed as P1.
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?”
History of presenting complaint
Once the patient has had time to communicate their presenting complaint, you should then begin to explore the issue with further open and closed questions.
- When did the symptom start?
- Was the onset acute or gradual?
- How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)
- How severe does the patient feel the symptom is?
- Is it impacting significantly on their day to day life?
- Is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous:
- Is the symptom always present or does it come and go?
- If intermittent, how frequent is the symptom?
- Are there any obvious triggers for the symptom?
- Does anything appear to improve the symptoms?
- Are there other symptoms that appear associated (e.g. fever/malaise)?
- Has the patient experienced this symptom previously?
- When did they last experience the symptom?
The acronym SOCRATES provides a useful framework for asking about pain (e.g. abdominal pain), as shown below.
- Where is the pain?
- When did it start?
- Was the onset sudden or gradual?
- Is the pain sharp or a dull ache?
- Is the pain intermittent or continuous?
- Does the pain radiate anywhere?
- Are there any other symptoms associated with the pain?
- What is the overall time course of the pain? (e.g. worsening, improving, fluctuating)
Exacerbating or relieving factors:
- Does anything make the pain worse or better?
- 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?
Once you have completed exploring the history of presenting complaint, you need to move on to more focused questioning relating to the symptoms that may be relevant to pregnancy. We have included a focused list of the 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.
Key symptoms to ask about
- Nausea and vomiting (hyperemesis gravidarum)
- Reduced fetal movements (may be a sign of fetal distress)
- Vaginal bleeding (antepartum haemorrhage, placenta praevia, cervical causes)
- Abdominal pain (urinary tract infection, placental abruption, constipation, pelvic girdle pain)
- Vaginal loss (abnormal vaginal discharge or spontaneous rupture of membranes)
- Headache/Visual disturbance/Epigastric pain (pre-eclampsia)
- Pruritis (obstetric cholestasis)
Nausea and vomiting
Nausea and vomiting are very common in pregnancy but are usually mild and only require reassurance and advice.
Nausea and vomiting in pregnancy usually begin between the fourth and seventh weeks of gestation, peaks between the ninth and sixteenth weeks and resolves 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 should 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 and 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 therefore always ask about fetal movements one the patient is of the appropriate gestation to be able to feel them:
- “Have you noticed any change in the amount of baby’s movement?”
Abnormal 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) if large blood loss is suspected.
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 if the patient has noticed any changes to the following characteristics of their vaginal discharge:
- 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 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 when passing urine
- Frequency – increased frequency of passing urine
- Urgency – a sudden need to pass urine, with no earlier warning
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 relevant 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 can occur in obstetric cholestasis.
Ideas, Concerns and Expectations (ICE)
- Clarify what the patient’s thoughts are regarding their symptoms
- What do you think is going on?
- Explore any worries the patient may have regarding their symptoms
- Is there anything that you’re concerned about at the moment?
- Is there anything that is troubling you at the moment?
- Gain an understanding of what the patient is hoping to achieve from the consultation
- What were you hoping you’d get out of our consultation today?
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 so far.
It also provides an opportunity for the patient to correct any inaccurate information and expand further on relevant aspects of the history.
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 so far: “Ok, so we’ve talked about your symptoms.”
- What you plan to cover next: “Now I’d like to discuss your past medical history.”
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.
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 you should ask about 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
There are several types of screening that women are offered during pregnancy. You should clarify if the patient has opted for screening and if so, what the results were.
- Down’s syndrome screening
- Rhesus status and the presence of any antibodies
- Hepatitis B, HIV and syphilis.
Other details of the pregnancy
- Singleton or multiple gestation
- Clarify if the patient took folic acid prior to conception and during the first trimester
- Planned mode of delivery (e.g. vaginal or Caesarian section)
- Medical illness during pregnancy (clarify what type of illness and if they are receiving any treatment)
Check the patient is currently up to date with their vaccinations:
- Flu vaccination
- Whooping cough vaccination
- Hepatitis B vaccination (if at risk)
Mental health history
Pregnancy can have a significant impact on maternal mental health and 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.
Previous obstetric history
It is important to ask about a woman’s previous obstetric history, as this can often 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
- 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)
- Caesarian section (will have implications for choice of future mode of delivery)
- Antenatal period – pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia, shoulder dystocia
- Postnatal period – post-partum haemorrhage, perineal/rectal tears during delivery, retained products of conception
- Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies
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.
- Clarify the gestation of the stillbirth
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.
A miscarriage is the loss of a pregnancy before 24 weeks gestation.
- Clarify the trimester at which the miscarriage occurred.
- Miscarriage is most common in the first trimester.
- Was medical or surgical management required for the miscarriage?
- Was there any cause identified for the miscarriage? (e.g. genetic syndromes)
Termination of pregnancy
A termination of pregnancy (abortion) 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 and method of management (e.g. medical or surgical)
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
- Ask about the management of the ectopic pregnancy (e.g. expectant, medical, surgical)
Cervical screening (known previously as cervical smears):
- Confirm the date of the last cervical screening test
- Confirm the result of the last cervical screening test
- Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up is in place
Previous gynaecological diagnoses and treatments:
- Sexually transmitted infections
- Bartholin’s cyst
- Cervical ectropion
- Malignancy (e.g. cervical, endometrial, ovarian)
Past medical history
A patient’s medical history is highly relevant, as some medical conditions can worsen during pregnancy and/or have implications for the developing fetus.
Examples of medical conditions that are important to be aware of during pregnancy are shown below.
Diabetes (type 1 or 2):
- Blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia)
- Untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact.
- Seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage)
- Many anti-epileptic drugs are teratogenic
Previous venous thromboembolism (VTE):
- Pregnancy is a pro-thrombotic state and therefore women who have previously had a venous thromboembolism are high risk for further VTEs.
- They may require prophylactic low molecular weight heparin to reduce their risk.
- HIV, Hepatitis B, Hepatitis C
- These pose a risk to the fetus during childbirth (vertical transmission)
- Cystic fibrosis, Sickle-cell disease, Thalassaemias
Previous surgical procedures such as:
- Abdominal or pelvic surgery – can result in adhesions that complicate Caesarian sections
- Caesarian section – increased risk of uterine rupture in subsequent pregnancies
- Loop excision of the transitional zone (LETZ) – increased risk of cervical incompetence
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.
Clarify the medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped.
Some examples of drugs that are known to be teratogenic include:
- ACE inhibitors
- Sodium valproate
Ask if the patient was using contraception prior to falling 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).
Medications frequently used during pregnancy
Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat the symptoms of pregnancy.
Some examples of medications commonly used in pregnancy include:
- Folic acid (400μg) – recommended daily for the first trimester of pregnancy to reduce the risk of neural tube defects in the developing fetus
- Oral iron – frequently used in pregnancy to treat anaemia
- Antiemetics – frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis gravidarum)
- Antacids – frequently used to manage gastro-oesophageal reflux symptoms during pregnancy
Over the counter medications
You should clarify if the patient is using any over the counter medications, as some of these have the potential to impact the pregnancy:
- Analgesics – Paracetamol, Ibuprofen, Codeine
- Herbal remedies
It’s essential to clarify any allergies the patient may have and document these clearly in the notes, including the type of allergic reaction the patient experienced.
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 areas to cover include:
- Inherited genetic conditions (e.g. cystic fibrosis, sickle-cell disease)
- Type 2 diabetes (first-degree relative) – increased risk of developing gestational diabetes
- Pre-eclampsia (maternal mother or sister) – increased risk of developing pre-eclampsia
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 and it’s therefore key that a comprehensive social history is obtained.
- How many cigarettes a day?
- How long have they smoked for?
- Would they be interested in support from a stop smoking service?
- Smoking increases the risk of a small for gestational age baby
- How many units a week?
- Clarify the type, volume and strength of the alcohol
- Would they be interested in support from an alcohol cessation service?
It is important to ask about recreational drug use, as these can potentially 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, patient’s can be offered input from drug cessation services.
Diet and weight
- Clarify if the patient is managing to eat a balanced diet whilst pregnant
- Ask about the patient’s current weight – obesity significantly increases the risk of venous thromboembolism, pre-eclampsia and gestational diabetes during pregnancy
- Who lives with the patient?
- Do they feel well supported?
- Are there other children at home?
- Is the patient independent or do they require assistance?
- How is the pregnancy impacting on their ability to carry out activities of daily living?
- If receiving care input, what level are they requiring?
- Ask about the patient’s current or previous occupation
- Ask about plans for maternity leave
- It is important to ask all pregnant women if they are a victim of domestic abuse (in privacy)
- This provides an opportunity for women to seek help
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. excessive vomiting in hyperemesis gravidarum).
Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of potentially relevant systemic symptoms to an obstetric presentation are shown below.
- Urinary tract infection
- Hyperemesis gravidarum
- Dyspnoea (secondary to pulmonary embolism or anaemia)
- Abdominal pain (secondary to placental abruption)
- Vomiting (secondary to hyperemesis gravidarum)
- Frequency, dysuria and urgency (secondary to urinary tract infection)
- Pelvic pain (secondary to symphysis pubis dysfunction)
- A pigmented line on abdomen (linea nigra)
Closing the consultation
- Summarise the history and ask the patient if there’s anything else they’d like to add
- Thank the patient
Dr Venkatesh Subramanian
Obstetrics & Gynaecology Registrar (ST5) in London
1. NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy. Published: June 2017.
2. BMJ. Reduced fetal movements. 2018; 360 doi: https://doi.org/10.1136/bmj.k570 (Published 06 March 2018)
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 here [LINK].