PRE NATAL HISTORY

TAKING

VIVIAN S. CONSOLACION RN
Clinical Instructor BSN –level 2
➢ An obstetric history involves asking
questions relevant to a patient’s
current and previous pregnancies.
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.
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
❑ 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).
❑ LMP ( 1st day of Last Menstrual Period)
❑ EDC ( Expected date of Confinement)
❑ Naegele’s rule : add 7 days to the 1st day of LMP and the subtract 3 months + 1 year.

❑ Example: LMP = 11 / 01 /2017

❑ -3/ +07/ + 01

❑ EDC = 08/ 08/ 2018


 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.
General communication skills
Demonstrating these skills will ensure your consultation remains
patient-centred and not checklist-like

 Some general communication skills which apply to all patient consultations include:
 • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
 • Active listening: through body language and your verbal responses to what the patient
has said.
 • An appropriate level of eye contact throughout the consultation.
 • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning
slightly forward in the chair).
 • Making sure not to interrupt the patient throughout the consultation.
 • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
 • Signposting: this involves explaining to the patient what you have discussed so far and
what you plan to discuss next.
 • Summarising at regular intervals.
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 acronym is a useful tool for exploring each of

the patient’s presenting symptoms in more detail.
Site
Onset character
Radiation
Associated symptoms
Time course
Exacerbating or relieving factors
Severity
  Site
Ask about the location of the symptom:
Onset
“Where is the pain?” Clarify how and when the symptom
“Can you point to where you experience developed:
the pain?” “Did the pain come on suddenly or
gradually?”
“When did the pain first start?”
“How long have you been experiencing the
pain?”
 Character

 Radiation
Ask about
Ask if the
the specific characteristics of symptom moves anywhere else:
the symptom:
“Does the pain spread elsewhere?”
“How would you describe the pain?” (e.g.
dull ache, throbbing, sharp)
“Is the pain constant or does it come and
go?”
 Associated symptoms
Ask if there are other symptoms which
are associated with the primary symptom:

“Are there any other symptoms that seem Time course

associated with the pain?” (e.g. shortness of
breath in pulmonary embolism) Clarify how the symptom
has changed over time:

“ How has the pain changed over time?”

➢ 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.
 Key obstetric symptoms to ask about include:
Nausea and vomiting: common in pregnancy and mild in most cases. Hyperemesis
gravidarum represents a severe form of vomiting in pregnancy associated with
electrolyte disturbance, weight loss and ketonuria.
Reduced fetal movements: can be associated with fetal distress and absent fetal
movements may indicate early fetal demise.
Vaginal bleeding: causes include cervical bleeding (e.g. ectropium, cervical cancer),
placenta praevia and placental abruption (typically associated with abdominal pain).
Abdominal pain: causes may include urinary tract infection, constipation, pelvic girdle
pain and placental abruption.
• Vaginal discharge or loss of fluid: abnormal vaginal discharge may be caused by
sexually transmitted infections such as gonorrhoea and the loss of fluid from the vagina
indicates rupture of the amniotic membranes.
• Headache, visual disturbance, epigastric pain and oedema: these are typical clinical
features of pre-eclampsia. Mild oedema is common and normal in the later stages of
pregnancy.
• Pruritis: associated with obstetric cholestasis (typically affecting the palms and soles of
the feet).
• Unilateral leg swelling: consider and rule out deep vein thrombosis.
• Chest pain and shortness of breath: pregnant women are at increased risk of
developing pulmonary emboli.
• Systemic symptoms: fatigue (e.g. anaemia), fever (chorioamnionitis) and weight loss
(e.g. hyperemesis gravidarum).
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.
  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.
 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:
1. Spontaneous vaginal delivery
2. Assisted vaginal delivery (e.g. forceps)
3. Caesarean section (will have implications for the choice of future
mode of delivery)
NORMAL / SPONTANEOUS VAGINAL DELIVERY
& ASSISTED VAGINAL DELIVERY ( VACUUM/ FORCEP)
 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.
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).
Gynecological 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)
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.
Medical conditions which are particularly important to be
aware of during pregnancy

 Diabetes (type 1 or 2): blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications
(e.g. macrosomia).

 Hypothyroidism: untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact.

 Epilepsy: seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage) and many anti-epileptic drugs are teratogenic.

 Previous venous thromboembolism (VTE): pregnancy is a pro-thrombotic state, therefore, women who have previously developed a venous
thromboembolism are at significantly increased risk of developing further VTEs without prophylactic treatment (e.g. low molecular weight heparin).

 Blood-borne viruses: HIV, hepatitis B, hepatitis C pose a risk to the fetus during childbirth (vertical transmission).

 Genetic disease: it is important to identify any genetic diseases (e.g. cystic fibrosis, sickle-cell disease, thalassaemia) carried by both the mother and
father as this may influence the management of the patient and their pregnancy (e.g. arranging input from the paediatric team immediately after
delivery).
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?”
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.
 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:
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.
Aspirin
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.
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.

 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).
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).
 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.
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.

 References
 https://geekymedics.com/obstetric-history-taking/
 NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy.
Published: June 2017. Available from: [LINK].
 BMJ. Reduced fetal movements. 2018; 360. Published March 2018.
Available from: [LINK]