Obstetric history-taking

Published on 09/03/2015 by admin

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Last modified 22/04/2025

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3 Obstetric history-taking

Following an introduction to the obstetric patient, establish her name, age, parity and gestation.

Parity

This is defined as the number of times a woman has delivered a potentially viable baby (viability in the UK is taken after 24 completed weeks of a pregnancy).

Gravidity

This is defined as the total number of pregnancies achieved.

Confusion may arise with the use of ‘gravidity’ and so the term ‘parity’ is better to describe the obstetric status of the patient.

Gestation

This is the number of weeks of pregnancy.

Gestation of the pregnancy must be calculated both from ultrasound scan estimation (most accurate up to 20 weeks’ gestation) and from last menstrual period (LMP) dates using Naegele’s rule or by an obstetric wheel. Ultrasound calculation of gestation is done by measuring the crown–rump length (CRL) in the first gestation and by measuring the biparietal diameter (BPD) and/or femur length (FL) in the second trimester.

Naegele’s rule

The estimated date of delivery (EDD) is calculated by subtracting 3 months from the date of LMP, adding 7 days and 1 year. This calculation may not be accurate in women with irregular cycles or in those who had been using the oral contraceptive pill.

Presenting complaint

Establish the presenting complaint or reason for referral or admission of the patient in a short but concise manner. Common causes for admission include abdominal pain, hypertension, bleeding or ruptured membranes. Obstetric patients are often very well informed and can give a precise and detailed account of their admission and so it is always wise to ask them what their doctor has planned. At this stage enquire whether the pregnancy has been uncomplicated to date or outline previous admissions to hospital. Ask what tests have been performed, including ultrasound scans, blood tests and any screening investigations, including prenatal diagnostic tests. Also enquire whether the patient had taken preconception folic acid.

Past history

Past obstetrical history

This includes details on all previous pregnancies. Specifically enquire about terminations of pregnancy or miscarriages. For each pregnancy enquire about date, any antenatal, intrapartum or postpartum problems, gestation at delivery, mode of delivery, birth weight and sex of the baby and any neonatal problems. If the patient has had any operative deliveries in the past, it is useful to establish the circumstances fully, including number of hours in labour, the use of oxytocin, fetal distress, cervical dilatation and perineal trauma and reason for that mode of delivery.

Past gynaecological history

This will include last cervical smear, previous contraception, any fertility investigations and any previous gynaecological surgery. It is important to include relevant points; for example, previous recurrent pregnancy loss, previous fibroid surgery or pelvic floor surgery, all of which would influence the management of this pregnancy.

Past medical history

This will include any previous surgery or medical conditions that may have required investigation. If the patient has any medical history, one must establish the severity of the problem; for example, the mild asthmatic requiring infrequent inhaler use, or the asthmatic on multiple medications requiring frequent hospital admissions. A drug history must be taken, including regular medication, recreational drug usage and allergies, specifically to penicillin.

Family history

Ask about family history of any genetic diseases, twins, hypertension or diabetes.

Personal and social history

A good social history will give valuable insight into the domestic circumstances of the patient, including smoking, alcohol intake, employment, relationships, support structure and accommodation.

At the end of the meeting always ask the patient if she feels there is something else important that you may have missed, and enquire what has been done for her during this admission and what her doctor’s plans are for the management of the remainder of her pregnancy.

Presenting a history

If this history is to be presented to colleagues, then it is useful to construct a short, concise summary of the case.

Related

Essentials of Obstetrics and Gynaecology