History taking in obstetrics Flashcards
Name the types/ things to ask in history taking
Maternal demographics
Obstetric history: present pregnancy
-Previous obstetric history
Previous medical history
Maternal demographics
§ Age, height and weight (Body Mass Index).
§ Socioeconomic status, support at home.
§ History of smoking, substance misuse and alcohol or domestic violence.
§ Previous history of depression or attempted suicides.
§ Involvement with social care services.
Obstetric history: present pregnancy
Obstetric history: present pregnancy
§ Menstrual history (date of LMP, length and regularity of menstrual cycle, use of hormonal contraception
prior to conception), cycle regularity, amount of menstrual bleeding (no. of pads used), blood consistency.
§ Establish expected date of delivery (EDD) using the Naegele’s rule (EDD = 9 months and 7 days to LMP)
§ Calculate the period of amenorrhoea from LMP to calculate the gestational age.
Enquire about common symptoms associated with pregnancy
§ Nausea and vomiting, frequency of micturition, excessive lassitude (fatigue), breast tenderness (high
progesterone).
§ Onset (quickening) and frequency of fetal movements.
Enquire about symptoms that may be associated with abnormal pregnancy
§ Painful swelling of feet or redness (DVT).
§ Headaches, visual disturbances, epigastric pain or reduced urine output (pre-eclampsia).
§ Vaginal discharge/bleeding (antepartum haemorrhage) & leakage of fluid (pre-labour rupture of membranes).
§ Urinary incontinence and sexual dysfunction.
Enquire about common symptoms associated with pregnancy
Nausea and vomiting, frequency of micturition, excessive lassitude (fatigue), breast tenderness (high
progesterone).
§ Onset (quickening) and frequency of fetal movements.
Enquire about symptoms that may be associated with abnormal pregnancy
Painful swelling of feet or redness (DVT).
§ Headaches, visual disturbances, epigastric pain or reduced urine output (pre-eclampsia).
§ Vaginal discharge/bleeding (antepartum haemorrhage) & leakage of fluid (pre-labour rupture of membranes).
§ Urinary incontinence and sexual dysfunction.
-Previous obstetric history
Previous pregnancy losses (miscarriages, ectopic pregnancies and terminations).
§ Previous viable pregnancies, i.e. parity.
§ Stillbirths or neonatal deaths.
§ Method of delivery (spontaneous vaginal, assisted vaginal, failed assisted vaginal and abdominal).
§ Gestational age, birth weight and sex of infants and previous antenatal or postnatal complications.
Previous medical history
Diabetes mellitus (gestational, insulin dependent, non-insulin dependent), cardiac disease, hypertension,
renal disease, infectious disease such as HIV, hepatitis B or C.
§ Deep vein thrombosis or pulmonary embolism.
§ Psychiatric illness.
§ Family history due to genetically-based diseases. Also enquire about medications taken.
