ECHS

HISTORY TAKING IN OBSTETRICS

Introductory remarks:

Name,

Age,

Gravidity, Parity,,( number of miscarriages should appear as a superscript to the parity)

Last normal menstrual period,

Gestational age (by dates/ early ultrasound/ extrapolation from 1 st SFH),

HIV,

VDRL status

Presenting complaint & duration:

History of presenting complaint:

 Duration
 Aggravating factors
 Relieving factors
 Any medical intervention so far

Review of systems

Index pregnancy:

 Booking visit:
 @ what gestation
 Number of clinic visits so far
 Quickening gestation age
 Booking bloods
o HIV
o VDRL
o Blood group & Rhesus
o Haemoglobin
 Interventions in clinics
o BP checks
o Urine dipsticks for protein,nitrites and leukocytes
o Any ultrasound scans?
 Any hospital admissions

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Past Obstetric History

 Year, mode of delivery with indications inclusive, perinatal outcomes, current state of
the child

Gynae History:

 Age at menarche
 Description of the menstrual cycle
o Duration
o How regular is the cycle
o Flow, quantity, days in menses
o Dysmenorhoea
 Contraceptive history
 Any history of miscarriages
 Cervical cancer screening
 Any history of Sexually Transmitted infection prior to admission
 Any gynae/ pelvic surgeries before

Drug history and intoxications

Medical history

Surgical history:

 Indication, what was done and the outcome

Family & social history

 Marital status
 Source of income
 Dietary probes
 Geographical location of stay
 Familial diseases

SUMMARY OF THE HISTORY

……………………………………………………………………………………………………………………………………………………………

Physical examination

 Nutritional status
 Status at rest

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  Vital signs
 Head to toe examination
o Anaemia
o Thyroid
o Breast, lung, cardiac
o Liver, spleen, ascites, tenderness
o Leopold maneuvers, FHR, SFH
o Pelvic exam
 Inspect external genitalia, speculum inclusive
 Digital bimanual exam
 Groins
 Adenopathy
 Any hernias
o Extremeties

SUMMARY OF THE HISTORY AND PHYSICAL EXAMINATION

………………………………………………………………………………………………………………………………………………………

PROBLEM LIST

Differential diagnosis

Investigations (all investigations should come with a justification) tailored from the DDx
 Bedside
o Fingerprick Hb
o Urine pregnancy test
o Urine dipstick
o Malaria rapid diagnostic test
o Rapid Plasma Reagin Test
 Laboratory investigations
o Full blood count
o Renal function test
o Other
 Imaging
o Xrays
o Scans

Management plan

 Treat as per diagnosis

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