Obstetrics and Gynecology/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
- Name of patient
- Age of patient
- Consent for questioning
- 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:
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
- 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
- Prescribed medications
- Non-prescribed medications/herbal remedies
- Recreational drugs
- Medical conditions
- Obstetric complications
- Support network
- Blood group