Obstetric History Taking

1. Patient Details
Name –
Husband name & occupation -
Age –
Address –
Occupation-
Education –
Family’s Monthly income –
Nearest health facility –
2. Obstetric Index & Period of Gestation
Obstetric index – Gravida, Para, Live birth, Abortion
POG(today)-______weeks______days.
LMP
EDD
Booked & Immunization –
3. Chief complain
Referred case –
Complains – pain/ Bleeding PV / Leaking , etc.
4. HOPI
Elaborate symptoms -
Etiology/ cause –
Complication-
Fetal wellbeing –
DM/HTN -
5. History of present pregnancy
• 1st trimester
- type of conception – spontaneous /Artificial
- Pregnancy detected by –
- Preg. Confirmed by –
- No. of antenatal visit –
- H/O – excessive vomiting, Fever with Rash, Radiation , BPV, UTI , discharge , Drugs
• 2nd Trimester
- no. of antenatal visits –
- Weight gain -
- Investigations –
- Quickening –
- H/o OGTT , high BP recording , symptoms of Gest. HTN , Pedal odema
- H/o Bleeding PV, Drugs
• 3rd Trimester
- No. of antenatal visits
- Weight gain-
- H/O – Gestational DM , gest. HTN
- H/O – Bleeding PV, Leakage PV , Drugs , Labor pain , Pruritus
6. Menstrual History
Menarche
Cycles – regular, frequency, days of flow, volume , clot , intermenstrual bleed ,
LMP, any abnormality,
any use of OCP
7. Marital History
No. of years of marriage –
Consanguinity degree –
Infertility
8. Previous obstetric history
• Conception – after how many years of marriage , type ,
• H/O – APH , pre-eclampsia , IUGR, gest DM
• Labor – induction , prolonged labor
• Type of delivery – Normal /Assisted/ LSCS
• Episiotomy
• Blood transfusion , PPH
• BABY
- live/still birth
- Weight , anomaly
- Admitted to NICU
- Breastfeeding started after birth ___time , exclusive till__
- Present health
• Puerperium sepsis
• removal of catheter
• Anti- D prophylaxis (ask Blood group)
• Contraception used
• Spacing between children
9a) Previous LSCS
• Emergency / elective
• Labor pain
• Blood transfusion
• Suture removal , catheter removal
• Puerperium fever , sepsis (endomyometritis)
• Baby kept in NICU
• Breast feeding started
9 b) Still birth
• Time/ Week of delivery
• Weight of baby
• H/O labor pain
• Reason - prematurity, anomaly, IUGR, cord compression, Pre-eclampsia, gest. DM
9c) abortion
• Cause
• Period of gestation
• H/O of D& C , procedure
• MTP done where, complications
10.Past history
Surgery – bowel Sx, Myomectomy, Prolapse
Epilepsy –Blood transfusion
Jaundice
TB / STD
Cardiac / DM /Endocrine /Thyroid disorder
Drug allergy
11. Personal History
• On any medications
• Psychiatric disorder
• Sleep
• Appetite & weight
• Bowel & bladder
• Addictions
12. Diet History
• Before admission to hospital
• Now as IPD patient
• Normal intake
13. Family history
• Family H/O -DM, HTN, Multiple preg, Anomaly,
• TB/Bleeding disorders
14.General physical exam
Built- average/well/poor
Hight- cm
Weight- kg
Gait-normal/limp/kyphosis/scoliosis
Anaemia- present/absent
BP
Pluse
RR
Oedema present/absent
Varicose vein-present/absent
Breasts
15.Systemic Exam
Cvs

Resp
Abdomen

Obstetric Exam
Inspection
Contour of abdomen _____________apparent height of uterus _______weeks
Flanks full or not full
Umbilicus everted/not everted
Fetal movement seen/not seen
Scar mark
Palpation
Symphysio-fundal height_________cm________weeks
Fundal grip-
Lateral grip-
Pawlik,s grip
Deep pelvic grip
Lie
Presentation
Position
Attitude
Engagement

F.H.S. Rate site-

Vaginal exam

Clinical diagnosis

Investigations
At first visit
Hb
Urine proteins_______sugar________micro__________
VDRL
Blood group
HIV test
HBsAg
USG
Risk factors:-

Advice

Revisit at ________weeks
Inj.Tetanus Toxoid - 1ST dose_______________2nd dose
Medicines

Plan of delivery
Spontaneous/induction when
Mode-vaginal/instrument assisted/LSCS-Elective/SOS emergency
Place of delivery
Plan for contraception

Summary of history
• ____ year old, obstetric index of _____ & POG ____________weeks_______days.
• came with C/C___ _______________________for ______________ / or referred as a case of
________________ from _____________________________
• With comorbidities – HTN/DM/asthma/ cardiac, etc
• Admitted for evaluation /workup / safe confinement