Obstetrics History Flashcards
OBSTETRIC HISTORY TAKING?
Obstetric history taking
has a number of questions that are not part of the standard history taking format and therefore it’s important to understand what information you are expected to gain when taking an obstetric history
OPENING THE CONSULTATION
Introduce yourself – name/role
Confirm patient details – name/DOB
Explain the need to take a history
Gain consent
Ensure the patient is comfortable
PRESENTING COMPLAINT
- It’s important to use open questioning to elicit the patient’s presenting complaint
- “So what’s brought you in today?” or “Tell me about your symptoms”
- Allow the patient time to answer, trying not to interrupt or direct the conversation
- Facilitate the patient to expand on their presenting complaint if required
HISTORY OF PRESENTING COMPLAINT
Onset – when did the symptom start? / was the onset acute or gradual?
Duration – minutes / hours / days / weeks / months / years
Severity – e.g. if symptom is vaginal bleeding – how many sanitary pads are they using?
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms
Associated features – are there other symptoms that appear associated e.g. fever/malaise?
Previous episodes – has the patient experienced this symptom previously?
KEY SYMPTOMS TO ASK ABOUT IN A PREGNANT PATIENT?
Nausea/vomiting – if severe may suggest hyperemesis gravidarum
Abdominal pain – may suggest the need for imaging
Vaginal bleeding – fresh red blood / clots / tissue
Dysuria/urinary frequency – urinary tract infection
Fatigue – may suggest anaemia
Headache/visual changes/swelling – pre-eclampsia
Systemic symptoms – fever/malaise
SUMMARISING
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
SIGNPOSTING
- Signposting involves explaining to the patient;
- What you have covered – “Ok, so we’ve talked about your symptoms”
- What you plan to cover next – “Now I’d like to discuss your past medical history”
HISTORY OF THE CURRENT PREGNANCY
- Is this the patient’s first pregnancy?
- How was the pregnancy confirmed? – home testing kit / hCG blood test / ultrasound scan
- Last menstrual period (LMP) – first day of the LMP
- Was the patient using contraception? – are they still? (e.g. COCP / implant / coil)
- Estimated date of delivery (EDD) – estimated by scan or via dates (LMP + 9 months + 7 days)
- Did the patient take folic acid during the first trimester?
- Any other scans or tests whilst being pregnant? – dating scan / anomaly scan
- Growth of the fetus – within normal limits?
- Placental location – placenta praevia may alter delivery plans
- Fetal movements – usually experienced at around 18-20 weeks gestation
- Labour pains – more relevant in the third trimester
- Planned method of delivery – vaginal / C-section
- Medical illness during pregnancy – if so are they taking any medications?
PREVIOUS OBSTETRIC HISTORY
- Gravidity – defined as the number of times a woman has been pregnant regardless of the outcome
- Parity – X = (any live or stillbirth after 24 weeks) | Y =(number lost before 24 weeks)
Details of each pregnancy:
- Date of delivery
- Length of pregnancy
- Singleton / twins / or more?
- Spontaneous labour or induced?
- Mode of delivery
- Weight of babies
- Current health of babies
Complications of previous pregnancies:
- Antenatal – IUGR / hyperemesis gravidarum / pre-eclampsia
- Labour – failure to progress / perineal tears / shoulder dystocia
- Postnatal – postpartum haemorrhage / retained products of conception
Miscarriages/terminations – needs to be asked sensitively in an appropriate setting
GYNAECOLOGICAL HISTORY
- Previous cervical smears – when? / results?
- Previous gynecological problems and treatments – STDs / PID / Ectopic pregnancy
- Current contraception – COCP / POP / Depot / Implant / Implanted uterine device
Gynaecological surgery:
- Loop excision of transitional zone (LETZ) –↑ risk of cervical incompetence
- Previous C-sections – ↑ risk of uterine rupture / placenta accreta /adhesions
PAST MEDICAL HISTORY
Relevant medical conditions
- Thromboembolic disease – high risk for further events in following pregnancy
- Diabetes – tight glycaemic control is essential – risk of congenital defects / macrosomia
- Epilepsy – some antiepileptics are teratogenic – needs neurology input
- Hypothyroidism – TFTs need close monitoring – risk of congenital hypothyroidism
- Previous pre-eclampsia– higher risk to develop it in the current pregnancy
Other medical conditions
- Any hospital admissions?– when and why?
- Surgical history – previous abdominal and gynaecological surgery of relevance
- Immunisations up to date?
DRUG HISTORY
Pregnancy medications:
- Folic acid
- Iron
- Antiemetics
- Antacids
Teratogenic drugs:
- ACE inhibitors
- Sodium valproate
- Methotrexate
- Retinoids
- Trimethoprim
Document all regular medications
- Over the counter drugs – ensure nothing is unsafe/teratogenic
- ALLERGIES
FAMILY HISTORY
- Inherited genetic conditions – cystic fibrosis
- Pregnancy loss – recurrent miscarriages in mother and sisters
- Pre-eclampsia – in mother or sister – increased risk
SOCIAL HISTORY
- Smoking – can cause intrauterine growth restriction
- Alcohol – How many units a week? – can cause fetal alcohol syndrome
- Recreational drug use – cocaine use can cause placental abruption
Living situation:
- House / flat – stairs / adaptations
- Who lives with the patient? – important when considering discharging home from the hospital
- Any carer input? – what level of care do they receive?
Activities of daily living:
- Is the patient independent and able to fully care for themselves?
- Can they manage self-hygiene/housework/food shopping?
- Is the pregnancy interfering with these daily activities?
Occupation – light duties / maternity leave
SYSTEMIC ENQUIRY
- Systemic enquiry involves performing a brief screen for symptoms in other body systems.
- This may pick up on symptoms the patient failed to mention in the presenting complaint.
- Some of these symptoms may be relevant to the diagnosis (e.g. vomiting in hyperemesis gravidarum).
- Choosing which symptoms to ask about depends on the presenting complaint and your level of experience
- Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
- Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
- GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
- Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
- CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
- Musculoskeletal – Bone and joint pain / Muscular pain
- Dermatological – Rashes / Skin breaks / Ulcers / Lesions
