Obstetric History Flashcards
Basic things to remember when taking an obstetrics history.
What topics must you cover in an obstetrics history?
1 Menstrual history 2 Obstetric history 3 Symptoms 4 Sex and contraception 5 Other
What should you establish in the menstrual history?
Date of last menstrual period (LMP; 1st day of bleeding) or menopause. Was the last period normal? Cycles: number of days bleeding/number of days from day 1 of one period to day 1 of next (eg 5/26). Are they regular? If heavy, are there clots or floods? How many pads/tampons are needed (an unreliable guide)? Are periods painful? Any bleeding between periods, postcoitally, or since the menopause? Age at menarche?
What should you establish in the obstetric history?
How many children? For each pregnancy: antenatal problems, delivery, gestation, outcome; weights of babies; puerperium? Terminations/miscarriages—at what stage, why, and (terminations) how?
What should you establish about other symptoms?
If she has pain what is it like? Uterine pain may be colicky and felt in the sacrum and groins. Ovarian pain tends to be felt in the iliac fossa and radiates down front of the thigh to the knee. Ask about dyspareunia (painful intercourse). Is it superficial (round the outside) or deep inside? If she has vaginal discharge what is it like (amount, colour, smell, itch)? When does she get it? Ask about prolapse and incontinence. When? How bad? Worse whilst standing? Ask about bowel symptoms (irritable bowel can cause pelvic pain), and faecal incontinence.
What should you establish about sex and contraception?
Is she sexually active? Are there physical or emotional problems with sex? What contraception is she using and is she happy with it? What has she tried previously? Has she had problems conceiving? If so, has she had treatment for infertility? What about sexually transmitted infections? Date and result of last cervical smear?
What ‘other’ things should you establish?
General health, smoking. Previous gynaecological treatment.
