OBSTETRICS &

GYNECOLOGICAL HISTORY
TAKING

DR. ELIOBA J. RAIMON

RESIDENT – OBSTETRICS & GYNECOLOGY

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 GENERAL CONSIDERATIONS
Courteous introduction
A statement as to your status as a student or trainee, Doctor or Specialist
etc.
Describe the process that is about to take place and get an agreement or
verbal consent.
Develop a good rapport and a good professional relationship with the
patient.
Chaperon if adolescent or if patient unable to make informed consent.
Ensure understanding of the language

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 GENERAL FLOW
• Biodata • Past medical history
• Presenting complaint • HIV serostatus
• History of the Presenting complaint • Hx of past medical diseases
• Drug history
• Review of other systems
• Allergies to food and drug substance
• History of current pregnancy
• Past surgical history
• Past Obstetric history
• Family history
• Gynecological history
Menstrual Hx • Social history
Sexual Hx • Summary
Contraception Hx
Past gynecological conditions and
Procedures
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 GENERAL INFORMATION
DEMOGRAPHIC X-TICS CURRENT PREGNANCY
• Name • Gravidity
• Age
• Parity
• Gender
• Address • LNMP
• Tribe • EDD
• Religion • WOA
• Level of education
• Occupation
• Marital status
• Next of Kin
• Nearest Health facility
• Date of admission
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 DEFINITION OF TERMS
Parity – Number of pregnancies carried beyond the age of viability
regardless of the outcome

Nulliparity - a woman who has never completed a pregnancy beyond

the age of viability

Gravidity - a woman who is currently pregnant or has been pregnant

in the past, irrespective of the pregnancy outcome

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 DEFINITION OF TERMS
Primigravida – A woman who is pregnant for the first time

Multiparity - a woman who has completed two or more

pregnancies beyond the age viability

Grand multi-parous – A woman who has had 5 or more births

beyond the age of viability.

Nulligravida - a woman who has never been pregnant

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 PRESENTING COMPLAINT
• This is a statement as to what the patient perceives to be the
problem describing the symptom, problem, condition,
diagnosis, physician-recommended return, or other reasons
for the patient visit
• It is time bound
• Should be chronologically listed
• It should be in Patient’s words

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 HISTORY OF PRESENTING COMPLAINT
• This is the detailed description of the presenting complaint and the degree of
symptomatology.
• Standing chronic illnesses.
• Any investigations done already.
• Any treatment given yet and outcome
• Any complications
• If pregnant
Ask about fetal movements
Ask about unusual pains or bleeding
Ask about any unusual PV discharge
Breaking of the waters, and the color if yes.
If labor is suspected, determine all characteristics of labor.
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 CLARIFICATION FOR PAIN
• Site
• Onset
• Character
• Radiation
• Associated symptoms e.g. fever, vomiting
• Time course
• Exacerbating / Relieving factors
• Severity
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 REVIEW OTHER SYSTEMS
CARDIORESPIRATORY GASTROINSTESTINAL
• Chest pain • Abdominal pain
• Easy fatigability • Dyspepsia
• Palpitation • Dysphagia
• Ankle swelling
• Nausea and/or vomiting
• Orthopnea
• Degree of appetite
• Nocturnal dyspnea
• Weight loss or gain
• Shortness of breath
• Cough with or without • Diarrhea
sputum • Constipation
• Hemoptysis • Rectal bleeding
• Noisy breathing • Jaundice
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• Nocturnal cough 10
 Review of systems Cont.…
GENITOURINARY NEUROLOGICAL
• Hematuria • Headache
• Seizures
• Nocturia
• Loss of consciousness
• Polyuria • Collapses
• Frequency • Dizziness
• Dysuria • Blurring of vision
• Urinary urgency • Hearing
• Abnormal vaginal • Transient loss of function
(vision, speech, sight)
discharge
• Paresthesia
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• Change in mobility 11
 Other Systems
MUSCULOSKELETAL DERMATOLOGICAL
• Pelvic pain • Skin rashes
• Change in gait • Skin lesions
• Joint pains and weakness • Skin discolorations
• Inability to move limbs

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 Current Pregnancy Hx
• Ask if the pregnancy was planned or desired
• Ascertain the LNMP, EDD, WOA
• Ask about any pregnancy related conditions if not mentioned in the
history of presenting complaint.
• Mode of conception
• Fertility issues
• Preconception services offered
• ANC services

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 Current Pregnancy Hx - ANC Attendance
• If attended? (Confirm with documentation)
• How many times?
• Where?
• At what gestational age was the first visit?
• What was done?
• Booking complaints?
• Booking vitals; Bp., Pulse rate, Temperature, Height, Weight, BMI, MUAC
• Screening services offered, e.g. Blood grouping, Rhesus status, Hepatitis B,
HIV, Syphilis, Urine test, RBS, Malaria test, Chromosomal abnormalities.
• Ask and review Obstetric USS done, if any, for Dating, growth of the fetus,
Placental position, Fetal anomalies
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Other Details in ANC History
• Check if it’s singleton or Multiple gestation
• Supplements given like Folic acid, Iron etc.
• Prophylactic treatment given e.g. IPT with (Sulphadoxine / Pyrimethamine),
Mebendazole for Helminthes
• Explore the planned Mode of Delivery
• Any medical illnesses
• Check the vaccination history e.g. Td, Flu etc.
• Any symptoms suggestive of Psychiatric illness
• Health education given

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 PAST OBSTETRIC HISTORY
• The course and outcome of previous pregnancies
• Total Number of pregnancies
• Any early pregnancy losses, Miscarriages, Ectopic pregnancy, or therapeutic termination of
pregnancy.
• The outcome recorded as live birth or stillbirth
• The gestational age at birth
• The mode of delivery
• The birth weight of the previous pregnancies
• Place of delivery e.g. Hospital, Home, TBA etc.
• Any complications before, during or after delivery e.g. Hypertensive disorders, Gestational DM,
Placenta praevia, Shoulder dystocia, PPH, Perineal tear, Assisted vacuum delivery, Episiotomy,
Precipitate labor, Prolonged labor
• Age of the mother at first pregnancy
• Age of the children and general condition
• History of infertility, details of investigations and treatment.
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 Past Gynecological History
• Periods
• Contraceptive history
• Gynecological conditions e.g. Ectopic pregnancy, STIs, Endometriosis, or Malignancy
• Cervical screening
o Confirm the date
o Results
o If any treatment and any follow up plan
o Vaccination status against HPV
• Any Gynecological Surgery or procedures? D&C, Abrasion…
• Pain during intercourse?
• Post coital bleeding?
• Any abnormal vaginal discharge
• Vulvar skin changes and itching
• Menopause:(Date of last period ,any post menopausal bleeding ,any menopausal symptoms)
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 MENSTRUAL HISTORY
• Menarche
• LNMP
• How many days of bleeding
• Length of cycles and the regularity
• Menstrual blood flow;
o How heavy?
o Any clots?
o Flooding?
o Interference with daily activities
• Menstrual pain (Dysmenorrhea)
• Bleeding between periods
• Menopause (if relevant)
• Any other symptoms with the periods
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 CONTRACEPTION
• Knowledge about contraception
• Methods previously used?
• How long were the methods used for?
• Reasons for discontinuation if stopped?
• Desire to change the current method?
• Assess for fertility desires
• Known side effects to certain contraception methods
• Allergies
• Desire to take up a contraception method

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 VAGINAL DISCHARGE
• If troublesome
• Color e.g. green, yellow, etc.
• Consistency e.g. thickened or watery
• Smell
• Amount / Volume
• Presence of blood
• Relationship to menstrual cycle
• Associated itching or soreness
• Ask about symptoms in the partner

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 DYSPAREUNIA
• Refers to pain that occurs during sexual intercourse.
• Find out if it’s superficial or Deep dyspareunia
• The duration of the symptoms
• The location of the pain
• The nature of the pain e.g. sharp, aching, burning etc.
• Any other associated symptoms

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 If Prolapse is Suspected
• Do you have a feeling of something coming down?
• Does the feeling go away overnight or when you lie down?
• Are there occasions when you don’t make it to the toilet in time?
• Do you leak urine if you cough or sneeze?
• When you pass urine, do you feel you have completely emptied your
bladder?
• When you are passing urine, can you squeeze hard enough to stop the
flow?
• How often do you get up at night to pass urine?
• Have you ever seen blood in your urine

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 Past Medical History
• Any previous serious medical problems
• Chronic illnesses; DM, HTN, Heart disease, Rheumatism, Sickle cell,
Asthma, TB, HIV/AIDS
• How well controlled the disease is if on treatment?
• Any complications?
• Hospital admissions
• History of any allergies
• Any medical supplements
• Drug history
• Psychiatric history

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 DRUG HISTORY
• Ask about any prescribed or over the counter medications?
• Document the medication name, the dose, frequency, formulation and
the route.
• Ask about any side effects.
• Hormonal Replacement Therapy (HRT)
o Duration of use
o Method of delivery e.g. Patch, gel pessary etc.
o Frequency of treatment e.g. Cyclic or continuous
o Type of treatment e.g. Combined or estrogen only
• What about inhalers, skin creams or patches, suppositories or tablets to
suck?
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 PAST SURGICAL HISTORY
• History of any previous surgeries
• History of blood transfusion
• Anesthetics used
• Any anesthetic complications
• History of major trauma like fractures or head injury

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 FAMILY HISTORY
• Are there any illnesses that run in your family? DM, HTN, SCD,
• Any family history of Ovarian, Endometrial or Breast cancer.
• Any family history of bleeding disorders.
• Any family history of blood clots.
• Basic family tree of first-degree relatives for familial illness
• Specific questions about occurrence of problems similar to the
patient’s.
• Multiple pregnancies

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 SOCIAL HISTORY
• Alcohol history; Frequency, type and volume
• Smoking history; type and amount
• Recreational drug use
• Occupation
• Type of accommodation
• Personal support network
• Water source
• Diet and weight
• Sleeping under mosquito net
• SGBV
• Social economic status of the partner
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 SUMMARY
• General information about the patient;
• Name, age, gender, gravidity, parity
• Presenting complaint
• Positive associations
• Important negatives
• Ask the patient if they have any Questions or concerns
• Thank the Patient

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REFERENCE
• Micheal Glynn, William M. Drake; Hutchison’s Clinical Methods, An
integrated approach to Clinical practice, 24th Edition. (2018) Chapter
1 and Chapter 5
• Beckmann and Ling; Obstetrics and Gynecology, 8th Edition. (2019)
Section 1.
• DR. Ghadeer Alshaikh, History Taking and Physical examination
OB/GYN 1st Edition. (2020)

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 THANK YOU

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