Obstetrics History

Question 1

1.

Introduction Obs Hx

Answer 1

Wash hands
Introduction and consent
Confirm: NAME, AGE, G+P, EDD/GA
 Single or multiple pregnancy
 Note the ethnicity of patient

Question 2

Presenting Complaint

Answer 2

patient and foetal health (ask about FM if >20/40)
 Any symptoms: PV bleeding, contractions, pain, fluid
loss or discharge
 Any other problems with pregnancy
 Symptoms of pre-eclampsia: H/A visual disturbances,
epigastric pain, oedema

Question 3

HOPC

Answer 3

Timeframe, SOCRATES
 Any U/S performed – why?
 Any hospital admission

Question 4

Current pregnancy

Answer 4

LMP – confirm reliability by bleeding/cycle length and
regularity
 How was pregnancy confirmed?
 Investigations – Rh group, GBS, anomaly scan, etc.
 Breast feeding intentions

Question 5

Past Obs Hx

Answer 5

List previous pregnancies in order, sex, mode of delivery
and neonatal outcomes
 Any problems with previous pregnancies and labour
o Miscarriages and stillbirths
o Preterm delivery
o Early onset preeclampsia
o Abruption
o Small for date (SFD) or macrosomia
o GDM

Question 6

Past Gynae Hx

Answer 6

Contraception
 Smear – when and result
 Any conditions or operations – ovarian cysts, fibroids,
etc.
 Recurrent STI or PID

Question 7

PMH

Answer 7

DM – macrosomia, foetal growth restriction (FGR),
congenital abnormality, pre-eclampsia, stillbirth,
neonatal hypoglycaemia
 HTN – pre-eclampsia
 Renal disease – worsening renal disease, pre-eclampsia,
FGR, preterm delivery
 Epilepsy – ↑ fits, NTDs (antiepileptics)
 VTE – ↑ risk in pregnancy, ↑ risk pre-eclampsia and
FGR
 HIV – vertical transmission
 Connective tissue disease – pre-eclampsia, FGR
 Myasthenia gravis/myotonic dystrophy - ↑ foetal
neurological effect, ↑ fatigue in labour

Question 8

PSH

Answer 8

Procedure, anaesthesia used + reactions

Question 9

Psych

Answer 9

Condition + severity
 PN blues, depression, or psychosis.

Question 10

FH

Answer 10

First degree relatives with: DM (↑ risk GDM),
thromboembolic disease (↑ risk of thrombophilia,
thrombosis), pre-eclampsia, serious psychiatric disorder
(↑ risk puerperal psychosis)
 Congenital abnormalities
 Multiple pregnancies

Question 11

Medications/ allergies

Answer 11

Regular and OTC
 Folate supplement
 Vaccinations
Allergies and reactions

Question 13

Social

Answer 13

SADJAP
Thank patient and close

Question 14

Nagle’s Rule for EDD

Answer 14

= (LMP – 3 months) + 7 days

Question 15

Macrosomia weight

Answer 15

Macrosomia - ≥4500g