Obstetrics - History Taking

Patient Identification
Name
Age years old
Ethnic
Sex Female
Occupation
Address

Date of admission
Date of clerking
Informant

Gravida
Para
Abortion
saymiscarriage
FollowLMP it irregular
Present as POA
REDD (Revised EDD) (U/S) menses Present as POG
I
different EDD
POA
onHCP
onBF
LMP + 7d - 3mth + 1yr
Count from LMP
am
bermesterDoe Lmp
I Present as weeks, days
Trimester
Etty 1 mth = 4w + 2d
2 mth = 8w + 5d
Imax
3 mth = 12w + 1w

Chief Complain (complain + duration)

History of Presenting Illness (HOPI)

Is patient in labour? Show-blood stained mucus passed PV | Leaking liquor | Contraction pain (regular)
If symptoms present Fetal movement | What is done in hospital?
 History of Presented Pregnancy (HOPP)
Suspect pregnancy Why? Missed period
Quickening
Abdominal distention
When?

Confirm pregnancy When?

Where?
Who?How

Booking 12W When? (Red Card)

(1st antenatal checkup) Where?
Height cm
Weight kg
BP mmHg
Fundal height cm
Blood group (Rh)
Hb
Urine glucose
Urine protein
VDRL Reactive/ Non-Reactive

Subsequent Attend all ANC follow schedule?

antenatal checkup (ANC) Monthly till 28w
Fortnightly till 36w
There should be a progressive
increase in weight of approximately Weekly till delivery
10 – 12.5 kg (25% of her non- Normal parameters? Weight gain
pregnant weight) throughout the
pregnancy. Generally the weight BP
gain should be about 0.5 – 0.75 kg/
summary Uterine size
month for the first 20 weeks and throughout
Hb
0.5 – 0.75 kg/week from 20 weeks pregnancy
onwards. Urine glucose, protein
Ultrasound done? When?
11-14w for correct dating Abnormalities? (state)
20-24w to detect congenital abnormalities

Quickening When?
(1st fetal movement) ↑ Intensity, Frequency?
Primagravida - 18-20w (5mth)
Multigravida - 16-18w (4mth)

Signs & Symptoms Nausea, vomiting

of Pregnancy Breast discomfort/ engorgement
Frequency
Constipation
Ankle edema
Backache

Immunization Anti-tetanus toxoid (ATT) I or 2

Hepatitis B (3X)
Rubella (usually in school)
could 19 Defoe

Booster
Past Obstetric History (POH) (not required if primigravida)
Marital status When married?
Married at age?
1st married? The only married?
Consanguineous married?

No of children boys girls

For Each Pregnancy (1-4 children)

Age
Sex
Where deliver?
When? Full term? POG if preterm?
Method of delivery
Birth weight (Normal - 3.5-4kg)
Complications (antepartum, intrapartum, postpartum)
Breastfeed till? (Normal - 2yr, if early/ bottle feeding - why?)
If all deliveries are normal - summarize - no AP, IP, PP Cx (at end of presentation of POH)

Abortion POG?
(how many?) Why?
Signs, symptoms before abortion
Dilatation, curettage (D&C) done?
D&C - incomplete abortion | No D&C - complete abortion

For Each Pregnancy (If >5 children)

Any uneventful deliveries? FTSVD with no Cx
Age of eldest child
Age of youngest child
Birth weight (range)
Breastfeeding
Mention abnormal deliveries separately

Spacing Good (> 2 years apart)

Abnormal (> 6 years)
Why? Contraception? Subfertility?

Contraceptive Method OCP/ Injection/ Implantation

(Yes? No?) IUDC
Condom
Others

Menstrual History
Menarche (1st menstrual) years old Normal - 9-16 y/o
Menstrual cycle Regular/ Irregular
Cycle Normal - 21-35d
Flow Normal - 2-8d
Heavy flow Normal - 1st-3rd day
Pad used (volume) Normal - 30ml
Past Gynaecology History
Problems
Dysmenorrhoea (painful)
Menorrhagia (prolonged, increased, >80ml)
Intermenstrual bleeding
Postcoital bleeding
Dyspareunia (painful coital)

Pap smear How many times?

When was last one?
Result normal? If her last is >3yr as recommended, say
unfortunately, pt didn’t repeat pap smear after 3yr

Past Medical & Surgical History

History of Chronic Illness Hypertension
DM
Heart disease
Asthma
TB

Any surgery?

Family History
ITO ATO
a
ATE d
Personal & Social History
Education level
Husband's age, occupation, income
House condition
How frequent husband visit?
Who take care of children during admission?
How does she contact her children?
Smoke/ Alcohol? (patient, husband)

Drug History
Iron
Folate
Vitamin B12, C
Over-counter drugs
Traditional med.
Allergy

Dietary
Adult diet
Allergy
If diabetic, details required - dishes for every meals

Summary
Age, Gravida, Para, POA, Chief Complain
Systemic Review
Respiratory SOB
Night sweat
Fever
Cough
Haemoptysis
CVS Hypertension
Ankle swelling
Chest pain
Palpitation
Musculoskeletal Muscle pain, joint pain
Deformity
Muscle wasting
CNS LOC
Paralysis
Tremor
Drowsiness
Headache
GIT LOW
LOA
Abdominal pain
Pain in swallowing
Vomiting
Nausea
Hematemesis
Diarrhoea
Constipation
Endocrine Swelling in neck
Diabetes mellitus