The document outlines a comprehensive approach to documenting obstetrical and gynecological history, emphasizing the importance of various factors such as patient identity, chief complaints, and detailed history of present illness. It provides guidelines for assessing gravidity and parity, as well as reviewing pertinent systems and the patient's overall health throughout different pregnancy trimesters. Additionally, it addresses the significance of both past medical and surgical histories, family history, and social factors that could influence the patient's current conditions.

1. OBSTETRICAL HISTORY Ahmed E AlBayaty
 Identity
 Chief complaint (C.C.)
 History of present illness (H.P.I)
 Review of systems (R.O.S)
 History of presenting pregnancy
 History of labor
 the outcome of the delivery
 Obstetric history
 Gynecological history
 past history
1. Patient’s full name for: Communication with the patient, Differentiate the similar names,
Recording & emergency situation.
2. Patient’s age for: Age specific diseases e.g. female complain of vaginal discharge:
-if young (18-35years)>>>>>>>>>UTI (urinary tract infection)
-if middle age(35-55years)>>>>>>Abortion
-if old age (55 & above)>>>>>>>>Malignancy
3. Patient’s occupation(s) for:
 Certain occupations causing certain diseases e.g.
-anesthetist & irradiation exposure>>>>abortion, congenital anomalies.
-heavy work & long standing hours>>>>preterm labor.
 Reflect the socioeconomic status of the patient.
4. Marital status (married, single widowed, divorced or separated), e.g.
-cervical cancer is more common in married women.
5. Husband’s full name for:
 Usually he is the next of kin,
 For any emergency situation,
6. Husband’s age for: Age specific diseases e.g.
-young active man>>>>>>infection.
-old age man>>>>>>>>>>infertility.
7. Husband’s occupation(s) for:
 Certain occupations causing certain diseases e.g.
-sailors >>>>>>>infertility & STD.
-soldiers>>>>>>infertility.
 Reflect the socioeconomic status.
8. Address for:
 Reflect the socioeconomic status.
 Certain areas are endemic with certain diseases e.g.
-SCA (sickle cell anemia)
IDENTITY

2. 9. Gravidity, parity & No. of abortions (G P)
 Gravidity(G): No. of all pregnancies (including the present pregnancy) regardless the
outcome (whether end with viable or non-viable child)
-it is not equal to the No. of children,
-it is the total No. of pregnancies (including the abortion, ectopic & H. mole).
-multiple pregnancy calculated as one gravida.
 Parity (P): No. of children born after 24 weeks (according to WHO definition) or after 28
weeks (according to Iraqi definition) of gestation regardless the outcome (viable or not).
-No. of abortions, ectopic & H. mole should not be included in the calculation of parity.
-twin pregnancy = 2 parity
-present pregnancy should not be included in the calculation of parity.
 Abortion: number of expulsions of products of conception before 24 weeks.
Note: if the patient is not pregnant now, G not calculated, only calculate P& abortion.
10. LMP, EDD & DOA.
 LMP (last menstrual period): the date of the 1st
day of the last menstrual period. It is
important for the calculation of EDD & DOA.
-Criteria of LMP:
 Should be preceded by 3 regular cycles at least,
 Should come at its correct time,
 Should be of same duration,
 Should be of same amount,
 Should not associated with lactation,
 Should not associated with contraception especially the injection.
 EDD (expected date of delivery):is the approximate date of delivery & it is estimated
according to Nagel’s law:
-add 7 days to the day, and 9 months to the month
-4% will deliver at EDD,
-32% will deliver before EDD,
-64% will deliver after EDD.
 DOA or POA (duration or period of amenorrhea):is the duration of pregnancy & usually
estimated in weeks as follows:
-start calculation from LMP if the date of today is close to it,
-or start calculation from EDD if the date of today is close to it, then subtract this duration from
40 weeks.
-1 month=4 wks.(weeks),
-2months=9wks,
-3months=13wks,
-4months=18wks.
11. Blood group & Rh of the patient.
12. Date of admission to the hospital

3. C.C.: is the main problem which bring the patient to seek for medical advice.
Duration of C.C.:
 In acute attack of short duration, it is since the beginning of the attack.
 In case of recurrent attacks, it will be the duration of the last attack.
 In case of progressing severity, it will be the duration of the severest attack.
including 5 important points:
 Analysis of C.C. (will discuss later when discuss each case individually),
 Reviewing the related system (s),
 Patient reaction,
 Hospital admission,
 Patient status now & waiting for what? (for discharge, further investigations, surgery or for
blood transfusion.
R.O.S.: problem(s) patient has at time of her present illness but not related to her C.C., starting
from the system nearby or could be affected by present illness moving to the other systems.
 CNS:
1. Headache,
2. Dizziness,
3. Syncope,
4. Loss of
consciousness,
5. Vertigo,
6. Seizure,
7. Paraesthesia –
numbness,
8. Limb weakness,
9. Tremor,
10. Loss of vision,
11. Blurring of vision,
12. Hearing
disturbance,
13. Smell & taste
disturbance,
14. Tinnitus.
 CVS (Cardio-Vascular System):
1. Chest pain,
2. Palpitation,
3. Leg swelling,
4. Intermittent claudication,
5. Syncope,
6. Cyanosis.
7. Dyspnea, orthopnea & PND
(paroxysmal nocturnal dyspnea),
 Respiratory system:
1. Cough,
2. Sputum & hemoptysis,
3. Dyspnea,
4. Chest pain,
5. Wheezing,
6. Hoarseness,
7. Leg swelling,
8. Cyanosis.
 GIT:
1. Nausea,
2. Vomiting,
3. Loss of appetite,
4. Weight loss,
5. Water brush,
6. Dysphagia & odynophagia,
7. Heartburn,
8. Abdominal pain,
9. Bowel motion (diarrhea or
constipation),
10. Malena & hematochezia,
11. Abdominal distension,
12. Flatulence,
13. Jaundice.
Chief Complaint (C.C.) and Duration
History of present illness (HOPI)
R.O.S.: problem(s)

4.  GUS (Genito-Urinary system):
1. loin pain,
2. polyuria,
3. oliguria,
4. unurea,
5. hematuria,
6. dysuria,
7. frequency,
8. hesitancy,
9. urgency,
10. nocturia,
11. incontinence,
12. vaginal bleeding,
13. vaginal
discharge,
14. vaginal itching.
 Skin:
1. Pigmentation,
2. Striae formation,
3. Itching,
4. Rash,
5. Cloasma,
6. Petechia,
7. Ulcers.
 Musclo-skeletal system:
1. Muscle pain,
2. Muscle weakness,
3. Joint pain,
4. Joint stiffness,
5. Joint swelling,
6. Joint lock,
7. Back pain.
First trimester: ask the patient about:
 General health (tiredness – malaise – other non-specific symptoms)
 Method of conformation of the pregnancy
 Investigations (Ultrasound – blood test – urine test – others)
 Vaginal bleeding or discharge
 Morning sickness (nausea – vomiting – appetite – constipation)
 Micturition (frequency, dysuria, color of urine …….)
 ANC (ante natal care)  go to hospital – take folic acid and vitamins
 Drugs (teratogenic drugs - drugs that increased/decreased its dose in pregnancy)
 Back pain  Edema Abortion Current disease  Hyper emesis gravidarum
 Breast tenderness or pain
Second trimester: ask the patient about:
 Vaginal bleeding or discharge
 Vaccine (like Tetanus toxoid start at 4 months – other vaccines start at 6 months)
 Quickening  the first feeling of fetal movement by the mother. In parous feel in 16 – 18 weeks. In primi
feel in 18 – 20 weeks
 Abortion Weight  Bowel motion Current disease  ANC (ante natal care) Drug history
 Morning sickness (nausea – vomiting – appetite – constipation)  Back pain  Edema
 Micturition (frequency, polyuria …….) Anemia and pre-eclampsia  Premature contractions
third trimester: ask the patient about:
 Vaginal bleeding or discharge  ANC (ante natal care) Weight Bowel motion Edema
 PIH  pregnancy induced hypertension
 Pre-eclampsia and eclampsia (hypertension + proteinuria  albumin in urine)
 Drug history  Abortion Current disease  headache  Fit palpation and chest pain
 SOB  shortness of breath UTI  urinary tract infection IUD  intra uterine death
HISTORY OF PRESENTING PREGNANCY

5. 1- During operation
 At home or hospital
 Onset? (gradual or sudden)
 Duration? >>>>prim gravida>>24hr,,,,,multipara>>16hr.
 Characters of the pain?
 Spontaneous? Induced?
 Term? preterm? post term?
 Vaginal delivery, cesarean section, episiotomy, forceps used or not
 Duration of operation Type of analgesia Catheter Blood transfusion I.V fluid
 Complications during operation
2- Post-operative
 Time of return of consciousness Blood transfusion  I.V fluid  Analgesia Catheter
 Complications Nausea, appetite, vomiting  Bowel motion, flatus
 PPH  post-partum hemorrhage  Micturition after delivery  Walking after delivery
 Breast milk amount
 Live or dead  Male or female Weight of baby Crying after birth  Infant movement  Cyanosis –jaundice
– anemia – blood exchange Fetal distress Admission to the neonatal intensive care unit
 Feeding (breast or bottle or mixed) Neonatal care
 APGAR score (Appearance – pulse rate – grimace (irritability) – activity – respiratory effort)

 Date of marriage
 Age of patient at marriage
 Age of patient at first pregnancy
 Period of infertility (primary infertility – secondary infertility)
 Interval between current pregnancy and 1st pregnancy
 Past pregnancies in sequence and ask the following questions for each child
o Time of pregnancy
o Duration of pregnancy
o Type of delivery
o Site of delivery
o Gender of baby
o Weight of baby
o Congenital anomaly
o NICV admission
o SOB (shortness of breath) cry immediate
o Any problem to baby
o ANC
o Puerperium  ask about any fever, bleeding, depression, breast feeding, any complication.
HISTORY OF LABOR
The outcome of delivery
Past obstetric history

6.  Age of menarche  first menstrual cycle in life
 Menstrual cycle  regular – irregular – duration – frequency - amount of blood loss
– any clot or pain with the menstruation - dysmenorrhea – intermenstrual bleeding
 Vaginal discharge
 Contraception  pill or IUCD (intra uterine contraceptive device)
 Infertility  failure of gestation and producing offspring after months of marriage
without using contraception
 Gynecological operation  Any operation related to gynecological problem - Genital
infections - Date of last cervical smear
#Past medical history
 Childhood: vaccination, rheumatic fever, rickets, mumps, measles, …
 Adulthood: anemia, bleeding tendency, D.M., H.T., chronic renal disease, endocrine diseases (thyroid,
adrenal,), asthma, epilepsy. Syphilis, rubella, arthritis
 Venous thromboembolic disease, HIV, recurrent infections
 Myasthenia gravis – myotonic dystrophy - Connective tissue diseases
 In case of +ve finding ask about the time of onset, duration, treatment or not, drugs taken in preg. or not.
#Past surgical history
 Previous operation (like Caesarian section, appendectomy, cholecystectomy)
 Post-operative complications
 Anesthesia complications
 Blood transfusion
#Drug history
 Allergy to any drug
 Chronic drug usage like antihypertensive and antiepileptic drugs
 Medications taken during pregnancy (like Anti-HT, Anti-DM) and dose
#Family history
 Any chronic disease (hypertension – D.M – thromboembolic disease)
 Consanguineous marriage
 History of pre-eclampsia
 History of twin pregnancy or congenital anomalies or cerebral palsy
 History of Genetic problems like haemoglibinopathies or fetal inborn error of metabolism
 History of malignancy in family
 History of T.B or allergies or Bleeding disorders or psychiatric disorders
 Hx of recurrent abortion
 Hx of twin delivery
#Social history
 Occupation - crowding - housing conditions - living environment
 Marital status - family problems
 Personal (Smoking - alcohol - drug abuse - sleep - diet - bowel habits)
 Level of education - income
 water supply - animal contact
Gynecological history
Past history