Maternal and Newborn

Physical Assessment:

The Obstetrics History

Eunice Oppong Kyekyeku
Obstetrics History:

It is the account of clients’

pregnancy and any associated
general health concerns as obtained
or gathered from the client.

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Like all things in health science there
is a tried and tested method of
obtaining and documenting the
obstetrics history.

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By end of the history taking the
practitioner should have an idea of:

-the state of pregnancy

-possible complications
-possible causes of illness.

It is an active process that needs to

guide patient into giving out
information.
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Booking Visit
The booking visit is the first contact a
pregnant client makes with the health
service provider for the purpose of
antenatal care.

Basic information; demographic,

medical, surgical are collected to form
basis of care through pregnancy.
Any pre-existing condition in client
can be identified.

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The standard history framework

• Current Pregnancy

• Past Obstetrics History

• Past Gynaecological History

• Past Medical History

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 …..history framework contd

• Drug Allergies and Reactions.

• Family history (FHx)

• Social history (SHx)

• Any other relevant history

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If illness exists at booking or at any
time during pregnancy.:

• Presenting complaints (PC)

• History of presenting complaints (HPC)

• Systemic enquiry (ODQ)

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If no illness exist continue with…

• Current Pregnancy

• Past Obstetrics history

• Past Gynaecological History

• Past Medical History

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 …..history framework contd

• Drug Allergies and Reactions.

• Family history (FHx)

• Social history (SHx)

• Any other history

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History:
• Demographic details

• Name,
• Age, DoB
• Address / Locality / General Residential
area/Town
• Contacts/NOK
• Other relevant information
– Email
– Telephone number
– Social media contact
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Current pregnancy

• Obstetric Index
• Gravidity - pregnancy
• Parity - delivery

• Gestational Age:
• Last Menstrual Period (LMP)
– Was period normal
– Usual menstrual cycle?
– Regular cycles
– Use of oral contraceptives
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• Estimated Date of Delivery (EDD)
– How to calculate: +7 to days, +9 to months or -3 from
the months.
– Calculated using the LMP of the client.

Foetal movements
20 weeks in primates
18 weeks subsequent pregnancies

- Ask about client’s general health

- Explore any presenting complaints

- Lab tests results or USG done

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Past obstetrics history

Ask about all previous pregnancies: durations;

miscarriages, terminations and ectopic
pregnancies, multiple pregnancies

Labour and delivery methods

Inquire about the puerperal period for each

episode of pregnancy

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• Past gynaecological history

Record all gynaecological problems with

investigations conducted;
full details of diagnosis that were made;
treatment received;
outcomes of treatment.

Include a full contraceptive history.

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When the client present with symptoms:
• Document the symptoms as: Presenting Complaints
(PC)

• For each symptom find out the exact nature of

symptom (and repeat for every symptom)

• If a medical term is used ask what the client meant by

it.

• The onset
• Date it began
• How it began (sudden, gradual)
• If long standing or recent
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• Periodicity and frequency
• Is the symptom constant
• How long does it last each time
• What brings it on and off

• Severity of symptom
• Change over time
• Is it improving or deteriorating over a period
• Any radiation or ‘migration’

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• Relieving factors
• What makes the symptom better?

• Associated symptoms
• Any other symptom that occurs when the main
complaint is occurring.

‘SOCRATES’:
mnemonic for presenting complaints on pain.
can be adapted to other symptoms.

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• About a discharge from the body enquire about:
• Volume or how copious
• Its colour
• Consistency
• Odour
• Whether blood stained
• Frequency
• Itching

• For fever, enquire about:

• Chills
• Rigors
• Sweating.

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Systemic Enquiry:

find out if there are symptoms in other

organ systems that the client had not
mentioned for any reason.

Also referred to as
‘on direct questioning’ (ODQ)

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• You need to place the PC into a body system the
systematically enquire about the relevant and
associated body systems.

• It is useful in finding out symptoms that the

patient did not mention for several reasons.

• It may also identify both related and unrelated

symptoms of the main complaints.

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Past Medical History
• Information about past major illness and surgical
procedures with dates and location of each
event.

• Elicits past illnesses which were treated or still

on treatment.

• For each condition condition ask

• When it was diagnosed
• How it was diagnosed
• How it has been treated
• If client still on treatment.
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Some conditions to specifically ask for:

• DM Jaundice Hypertension
• Asthma TB Epilepsy
• Stroke Hyper cholesterol
• Blood disorders
• Locally endemic diseases
• Epidemic outbreaks

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Drug Allergies and Reactions:

• Ask if the client has any allergies or is

allergic to anything.

• If allergy is reported, obtain exact nature of

the reaction and the particular drugs that
trigger. Document the information on the
front folder.

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Family History
• Make up of current family.

• Health status of family.

• Diseases running in family.

• Deaths in family

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Drug History (DHx)

• Medications that the client is taking including

• Compliance
• Completion
• Side effects
• Adverse reactions. May also be part of PMHx)

• Patients may not consider certain medications

as drugs:
• Eye drops
• Oral contraceptives
• Supplements
• Herbal drugs
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Social History
• Social lifestyle

• Diet
• Exercise
• Substance use
• Occupation

• Travel history

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QUESTIONS

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