Obstetric history taking

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Obstetric history taking

Obstetric history taking involves a series of methodical questioning of an obstetric patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further investigative testing or treatment of a diagnosed condition.

There is a basic structure for all obstetric histories but this can differ slightly depending on the presenting complaint. Because of the nature of obstetrics there may not even be a presenting complaint. Expectant mothers receive antenatal check-ups and therefore may be referred because of the result of an examination or an investigation so the mother may be asymptomatic.

When taking any history in medicine it is essential to understand what the presenting complaint means (if any) and what the possible causes (differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning

Basic Structure of an Obstetric History

Ascertain

Name of patient

Age of patient

Consent for questioning

Presenting Complaint

It is important to ask as open a question as possible in this part of the history and to ensure the complaint is understood as everything else follows on from here

History of Presenting Complaint

This will differ slightly depending on the presenting complaint (see below) but follows a vague structure:

Onset

Periodicity

Duration

Recurrence?

Past Obstetric History

Gravidity and Parity

Dates of deliveries

Length of pregnancies

Induction of labor/Spontaneous

Normal Delivery?

Weight of babies

Gender of babies

Complications before, during and after delivery

Menstrual History

1st day of last menstrual period

Regularity of normal cycle

Was this a planned pregnancy?

Previous contraception

Any antenatal problems thus far?

Past Medical History

Current or past illnesses

Hospital admissions

Past surgeries

Drug History

Prescribed medications

Non-prescribed medications/herbal remedies

Recreational drugs

Family History

Medical conditions

Obstetric complications

Social History

Occupation

Support network

Smoking

Alcohol

Other

Blood group

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