HISTORY TAKING

Obstetric Case

Overview

• Taking a history and performing an obstetric examination are quite different from their medical and surgical equivalents.

• Not only will the type of questions change with gestation but also will the purpose of the examination

Etiquette

• Always introduce yourself; tell the patient who you are and say why you have come to see them.

• Sensitive to intensely private data. • Some women will wish another person

(chaperon) to be present if the doctor or students is male, even just to take a history, and this wish should be respected.

Components of History Taking

1. Demographic Data: a) Name – to build rapport and reflects good

bedside manner.b) Age – as a general rule, the very young (<18

years) and the elderly (>35 years) are more likely to be associated with problems.

c) Occupation - this would give us an idea of the social class of the patient.

d) Race

2. History of Current Preganancya) Gravida - total number of pregnancy regardless

of how they ended.b) Parity - is the number of live births at any

gestation or stillbirths after 24 (?) weeks.c) EDD: • Naegele’s rule [EDD = (LMP + 1yr + 7dys) – (3

mths). Applied for: 28 day cycle, regular, no recent use of OCP.

• Ultrasound – BPD, AC*, FL, HC• Gestation Calculator (Wheel)d) Singleton/Multiple fetus

3. Antenatal Historya) Menarcheb)Cycle Regularity (28-30 day)c) Duration of Menses – e.g. 7 day with 3 heavy

flow,d)Pads usede)Planned / Unplanned pregnancyf) Booking – date of booking started• Test results: Ht, Wt, BP, VDRL, TPHA, HIV, HepB,

ABO, Rh, FBC, Hgb, etc.• Numbers of check-up attended – where?

Eventful? CTG? • Earlier & Latest USS – when? What finding?

4. Present Complaint a)Reason admittedb)Test done

• Problem must be listed in priority if there are multiple problems and explained concisely and adequately.

• Common problems: UTI, HPT, GDM, Antpartum hge., twins, leaking liquor, etc.

5. Past Obstetric Historya)Previous Pregnancy (first to latest)b)Mode of delivery – SVD, CSc) Alive or Well?d)Term of pregnancy – pre, term, poste)Termination – abortion, miscarriagef) Weight rangeg)Place of deliveryh)Complication – mother? Child?i) Singleton? Twins?

6. Past Gynaecological Historya)Procedure undergoneb)Gynecological problemc) Contraceptiond)Dyspareunia (e.g. vaginasmus)e)Cervical examination: e.g. Pap Smear

7. Past Medical & Surgical Historya)History of: HD, Epilepsy, BA, HPT, DM, Thyroid

disorder, TIA.b)Surgery – anaesthetic, complicationc) Immunizationd)Allergice)Medication

8. Family Historya)Complicated pregnancy and deliveryb)Twinsc) Health condition – HPT, BA, DM etc.

9. Social Historya)Marital status* - single, divorced, married,

partnership, medicolegal.b)Occupationc) Vices – alcohol, smoking, illicit drugs.

Summary

Madam X is a 28 year old housewife, gravida 3, para 2 and presently at 34 weeks maturity. She is sure of her dates. She presents with the problem of one, hypertension in pregnancy that was first detected at 28 weeks, two, a history of previous caeseran section for placenta praevia and three, symptoms suggestive of urinary tract infection. There is no past medical or surgical history of note.