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
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