Obstetric history
#Identification
Patient: triple name – age – occupation – residence – blood group
Husband: triple name – age – occupation – residence – blood group
Date of marriage
Relationship status
Number of children
Educational background
#Date of admission
#Date of delivery or operation
1. GPA:
G: gravida number of all pregnancies (delivered or aborted).
If the patient is
still pregnant at the time of history taking we can mention the gravida, but if the patient is
already delivered at the time of history taking we not mention the gravida.
P: para or parity number of deliveries after 24 weeks (live or dead)
A: abortion number of expulsions of products of conception before 24
weeks (normal or ectopic حمل خارج الرحمor hydatidiform
حمل
عنقودي
)
2. LMP: last menstrual period
it is the first day of the last menstrual period
the patient certainty of dates ( )يجب التأكد من صحة التواريخ
ask about the regularity of the cycle
ask about the usage of contraception (type-amount-duration)
3. EDD: expected date of delivery
Calculated by Naegele's rule EDD = LMP + 7 days – 3 months (or +9 months)
this for regular cycle (28 day – not lactating – no use of contraception)
For irregular cycle the date of first Ultrasound is around 20 weeks so we can
calculate the EDD from this information
4. GA: gestational age
Number of weeks from the beginning of pregnancy until the end (whether
normal delivery or C.S or abortion)
Calculated as EDD - real date of delivery or EDD - date of history taking
Pre-term: 36 weeks + 6 days or less
Term: from 37 weeks to 40 weeks
Post-date: from 40 weeks to 41 weeks + 6days
Post-term: 42 weeks and more
GA is important to know if the baby is premature so we can support the baby
after delivery
#Date of examination
#Chief complaint
Main complaint (usually one) in patient's own words
Duration of the compliant
#History of present illness
Everything from the start of chief complaint until the delivery
Chronological order
In details
#History of labor
1- During operation
At home or hospital
Difficult or easy
Vaginal delivery, cesarean section, episiotomy, forceps used or not
Duration of operation
Type of analgesia
Catheter
Blood transfusion
I.V fluid
Complications during operation
2- Post-operative
Time of return of consciousness
Blood transfusion
I.V fluid
Analgesia
Catheter
Complications
Nausea, appetite, vomiting
Bowel motion, flatus
PPH
post-partum hemorrhage
Micturition after delivery
Walking after delivery
Breast milk amount
#The outcome of delivery
Live or dead
Male or female
Weight of baby
Crying after birth
Infant movement
Cyanosis –jaundice – anemia – blood exchange
Fetal distress
Admission to the neonatal intensive care unit
Feeding (breast or bottle or mixed)
Neonatal care
APGAR score (Appearance – pulse rate – grimace (irritability) – activity –
respiratory effort)
#History of presenting pregnancy
(1, 2, 3 trimester + Systems)
First trimester: ask the patient about:
General health (tiredness – malaise – other non-specific symptoms)
Method of conformation of the pregnancy
Investigations (Ultrasound – blood test – urine test – others)
Vaginal bleeding or discharge
Morning sickness (nausea – vomiting – appetite – constipation)
Micturition (frequency, dysuria, color of urine …….)
ANC ( ante natal care ) go to hospital – take folic acid and vitamins
Drugs (teratogenic drugs - drugs that increased/decreased it's dose in pregnancy)
Back pain
Edema
Abortion
Current disease
Hyper emesis gravidum
Breast tenderness or pain
Second trimester: ask the patient about:
Vaginal bleeding or discharge
Vaccine (like Tetanus toxoid start at 4 month – other vaccines start at 6 months)
Quickening the first feeling of fetal movement by the mother. In parous feel in 16
– 18 weeks. In primi feel in 18 – 20 weeks
Abortion
Weight
هام
هام
Bowel motion
Current disease
ANC ( ante natal care )
Drug history
Morning sickness (nausea – vomiting – appetite – constipation)
Back pain
Edema
Micturition (frequency, polyuria …….)
Anemia and pre-eclampsia
Premature contractions
Third trimester: ask the patient about:
Vaginal bleeding or discharge
ANC ( ante natal care )
Weight
Bowel motion
Edema
PIH pregnancy induced hypertension
Pre-eclampsia and eclampsia ( hypertension + proteinuria albumin in urine )
Drug history
Abortion
Current disease
headache
Fit
palpation and chest pain
SOB shortness of breath
UTI urinary tract infection
IUD intra uterine death
Review of other systems: ask the patient about:
CVS
(chest pain, dyspnea, palpitations, edema, syncope, claudication)
Respiratory
(cough, sputum, hemoptysis, chest pain, dyspnea, wheeze, cyanosis, clubbing )
GIT
(dysphagia, dyspepsia, abdominal pain, bleeding ,vomiting, weight loss, diarrhea)
CNS
(headache, fit, weakness, vision ,hearing, tremor, incontinence, paresthesia)
Renal
(urine color, amount, dysuria, hematuria, nocturia, frequency, urgency, pain)
Skin and loco-motor
(pigmentations, discoloration, pain, stiffness, function, swelling)
Genital
(incontinence, impotence, discharge)
#Past obstetric history
(history of previous pregnancies in sequence)
Date of marriage
Age of patient at marriage
هام
Age of patient at first pregnancy
Period of infertility (primary infertility – secondary infertility)
Interval between current pregnancy and 1st pregnancy
Past pregnancies in sequence and ask the following questions for each child
o Time of pregnancy
o Duration of pregnancy
o Type of delivery
o Site of delivery
o Gender of baby
o Weight of baby
o Congenital anomaly
o NICV admission
o SOB (shortness of breath) cry immediate
o Any problem to baby
o ANC
o Puerperium ( )فترة النفاس ask about any fever, bleeding, depression, breast
feeding, any complication.
#Gynecological history
Age of menarche first menstrual cycle in life
Menstrual cycle regular – irregular – duration – frequency - amount of blood loss
– any clot or pain with the menstruation - dysmenorrhea – intermenstural bleeding
Vaginal discharge
Contraception pill or IUCD (intra uterine contraceptive device)
Infertility failure of gestation and producing offspring after months of marriage
without using contraception
Gynecological operation Any operation related to gynecological problem - Genital
infections - Date of last cervical smear
#Past medical history
Any serious illness or medical disease or chronic disease like:
D.M and Renal diseases
Hypertension (pre-eclampsia)
Epilepsy, syphilis, rubella, arthritis
Venous thromboembolic disease
HIV, recurrent infections, rheumatic heart disease
Myasthenia gravis – myotonic dystrophy - Connective tissue diseases
In case of +ve finding ask about the time of onset, duration, treatment or not, drugs
taken in pregnancy or not.
#Past surgical history
Previous operation (like Caesarian section, appendectomy, cholecystectomy)
Post-operative complications
Anesthesia complications
Blood transfusion
#Drug history
Allergy to any drug
Chronic drug usage like antihypertensive and antiepileptic drugs
Medications taken during pregnancy (like Anti-HT, Anti-DM) and dose
#Family history
Any chronic disease (hypertension – D.M – thromboembolic disease)
Consanguineous marriage
History of pre-eclampsia
History of twin pregnancy or congenital anomalies or cerebral palsy
History of Genetic problems like haemoglibinopathies or fetal inborn error of
metabolism
History of malignancy in family
History of T.B or allergies or Bleeding disorders or psychiatric disorders
#Social history
Occupation - crowding - housing conditions - living environment
Marital status - family problems
Personal (Smoking - alcohol - drug abuse - sleep - diet - bowel habits)
Level of education - income
water supply - animal contact
*
( يرجى قراءة ملزمة المالحظات
obstetric – notes
)