Obstetrics history

1. The Obstetric History
Pregnancy can be a time of great excitement to the patient, but it can also be a time of danger,
and there are certain serious illnesses of pregnancy to be aware of.
Below, we will provide a framework for capturing a basic obstetric history.
1. Previous Obstetric History
A good starting point is to ask about number of children the patient has given birth to. Next,
sensitively ask about miscarriages, stillbirths, ectopics and terminations.
Term Pregnancies
For each previous pregnancy carried beyond 24 weeks, inquire about the following:
• Gestation – previous preterm labour is a risk factor for subsequent preterm labour.
• Mode of delivery – spontaneous vaginal, assisted vaginal or Caesarean.
• Gender
• Birth weight – a previous small for gestational age (SGA) baby increases the risk of a
subsequent one.

2. • Complications – e.g. pre-eclampsia, gestational hypertension,
gestational diabetes, obstetric anal sphincter injury (3rd, 4th degree
tears), post-partum haemorrhage.
• Assisted reproductive therapies (ART) – e.g. ovulation induction with
clomiphene, IVF.
• Care providers – was the patient’s care completely with a midwife or
was there previous obstetric input, if so, why
• ART pregnancies are often conceived after a long period of time and
after much psychological distress; it is important to be aware of this. In
addition, use of ARTs can increase the risk of pre-eclampsia during
pregnancy.

3. • Other Pregnancies
For pregnancies not carried beyond 24 weeks, inquire about:
• Gestation – miscarriages can be classified into early pregnancy (12
weeks or less) or second trimester (13-24 weeks).
• Miscarriages – outcome (spontaneous, medical management, surgical
management – evacuation of retained products of conception).
• Terminations – method of management: medical or surgical.
• Identified causes of miscarriage / stillbirth – e.g. abnormal parental
karyotype, fetal anomaly.

4. For ectopic pregnancies, ask about:
• Site of the ectopic
• Management: expectant (monitoring of serum hCG levels), medical
(methotrexate injection), surgical (laparoscopy or laparotomy;
salpingectomy (removal of tube) or -otomy (cutting of tube and suctioning
of trophoblastic tissue))

5. Gravidity and Parity
• Gravidity is the total number of pregnancies, regardless of outcome.
• Parity is the total number of pregnancies carried over the threshold of
viability.
• Examples
• Patient is currently pregnant; had two previous deliveries = G3 P2
• Patient is not pregnant, had one previous delivery = G1 P1
• Patient is currently pregnant, had one previous delivery and one previous
miscarriage = G3 P1+1 (the +1 refers to a pregnancy not carried to 24+0).
• Patient is not currently pregnant, had a live birth and a stillbirth (death of
fetus after 24+0) = G2 P2
• Patient is not pregnant, had a twin pregnancy resulting in two live births = G1
P1

6. 2. Current Pregnancy
• First, ask about the gestational age of the pregnancy.
• Gestation is described as weeks+days (e.g. 8+4; 30+7; 40+12 – post-dates).
• The last menstrual period date (LMP) can be used to estimate gestation, with Naegele’s
rule the most common method (to the first day of the LMP add 1 year, subtract 3 months,
add 7 days). This can be imprecise, as it requires accurate recall of LMP dates as well as
regular menstruation.
• In the history of current pregnancy, ask about:
• Has there been use of folate prior to conception and currently
• Agreed estimated date of delivery (EDD): this date is when the woman will be 40+0.
• Singleton or multiple gestation.
• At 18+0 to 20+6, women are offered a scan to check for fetal anomalies. Be sure to review
the findings of this scan:
• Fetal anomalies – presence or absence.
• Placenta position – check it is clear of the internal os.
• Amniotic fluid index – oligohydroaminos, normal or polyhydraminos
• Estimated fetal weight – parameter for growth

7. 3. Past Medical History
• Ask the usual questions about past medical history, abdominal or pelvic
surgery and mental health conditions.
• Remember that the medical co-morbidities that are most likely to affect
women of childbearing age include:
• Asthma
• Cystic fibrosis
• Epilepsy
• Hypertension (older women)
• Congenital heart disease
• Diabetes – check if type 1 or type 2
• Systemic autoimmune disease e.g. systemic lupus erythematosus (SLE),
rheumatoid arthritis
• Haemoglobinopathies: sickle-cell disease, thalassaemias
• Blood-borne viruses: HIV, hepatitis B, hepatitis C

8. 4. Mental Health
• Mental health is extremely important – in the Saving Mothers’ Lives
..nearly 25% of deaths occurring six months to a year post-partum were
due to psychiatric causes.
• The following are ‘red flags’ to arranging urgent senior psychiatric
assessment:
• Recent significant change in mental state or emergence of new
symptoms
• New thoughts or acts of violent self-harm
• New and persistent expressions of incompetency as a mother, or
of estrangement from the infant
• Inquire about previous psychiatric disorder, to include depression,
anxiety disorders, bipolar affective disorder, schizophrenia, previous self-
harm or suicide attempts.

9. 5. Drug History
• In addition to asking about drug allergies and intolerances, be aware
that the embryonic (first 12 weeks) period of pregnancy is thought to be
the time of most sensitivity for drugs to cause fetal structural defects
(teratogenicity). Thus, inquire about drugs taken around conception
and during the first 12 weeks.
• Inquire about drugs currently being taken
(include herbal/complementary therapies). Ask about illicit drugs and
alcohol – recommend the patient to stop these drugs, and to offer
referral to help-to-quit services too.
• Recommend that the patient takes 400μg folic acid per day for the first
12 weeks, to reduce the chance of the baby developing a neural tube
defect.

10. 6. Family History
• Although not usually regarded as a substantial part of the obstetric
history, there is increasing evidence that certain conditions are
associated with adverse pregnancy outcomes.
• Conditions such as cystic fibrosis and sickle-cell disease are heritable –
the patient should be counselled as to the risk of her baby developing
these conditions (based on the parental genotypes).
• A family history of type 2 diabetes in a first degree relative is considered
a risk factor for developing gestational diabetes.

11. 7. Social History
• Pregnancy can be a time of great elation, intense anxiety – and quite possible a
mixture of anything and everything between.
• Ask the patient about her thoughts of the pregnancy; be sensitive if the pregnancy
is unplanned.
• Ask about current / previous occupation, and plans for returning to work (or
otherwise).
• Inquire about home circumstances: e.g. who does the patient live with – partner /
spouse? Children in the home? Ask also about support networks, e.g. parents / in-
laws, neighbours, friends.
• Inquire about financial circumstances – the cost of caring for a child in addition to
being out of work can potentially have an adverse impact on the patient’s ability to
cope financially. Is the patient eligible for social security / child benefit payments?
• Ask about smoking – how many per day; what drug (tobacco, cannabis, others);
duration of smoking. Would the patient like to quit, and would they like help with
this? Reiterate the association between smoking and small-for-gestational-age
babies and offer her help to quit.
• It is also important to remember that at least once during the course of the
pregnancy, women should be asked whether they are victim to domestic abuse.

12. Obstetric examination
• Obstetric examination focuses on uterine size, fundal height (in cm
above the symphysis pubis), fetal heart rate and activity, and
maternal diet, weight gain, and overall well-being.
• Speculum and bimanual examination is usually not needed unless
vaginal discharge or bleeding, leakage of fluid, or pain is present.

13. Evaluation of the Obstetric Patient
• Ideally, women who are planning to become pregnant should see a
physician before conception; then they can learn about pregnancy risks
and ways to reduce risks.
• As part of preconception care, primary care clinicians should advise all
women of reproductive age to take a vitamin that contains folic acid 400
to 800 mcg (0.4 to 0. 8 mg) once a day.
• Folate reduces risk of neural tube defects. If women have had a fetus or
infant with a neural tube defect, the recommended daily dose is 4000
mcg (4 mg).
• Taking folate before and after conception may also reduce the risk of
other birth defects .

14. • Once pregnant, women require routine prenatal care to help safeguard
their health and the health of the fetus.
• Also, evaluation is often required for symptoms and signs of illness.
• Common symptoms that are often pregnancy-related include
i. Vaginal bleeding
ii. Pelvic pain
iii. Vomiting
iv. Lower extremity edema

15. • The initial routine prenatal visit should occur between 6 and 8 weeks
gestation.
• Follow-up visits should occur at
• About 4-week intervals until 28 weeks
• 2-week intervals from 28 to 36 weeks
• Weekly thereafter until delivery
• Prenatal visits may be scheduled more frequently if risk of a poor
pregnancy outcome is high or less frequently if risk is very low.
Prenatal care includes
• Screening for disorders
• Taking measures to reduce fetal and maternal risks
• Counseling

16. Physical Examination
• A full general examination, including blood pressure (BP), height, and
weight, is done first. Body mass index (BMI) should be calculated and
recorded. BP and weight should be measured at each prenatal visit.
• In the initial obstetric examination, speculum and bimanual pelvic
examination is done for the following reasons:
i. To check for lesions or discharge
ii. To note the color and consistency of the cervix
Iii To obtain cervical samples for testing
• Also, fetal heart rate and, in patients presenting later in pregnancy, lie of
the fetus are assessed

17. • During subsequent visits, BP and weight assessment is important.
• Obstetric examination focuses on uterine size, fundal height (in cm
above the symphysis pubis), fetal heart rate and activity, and maternal
diet, weight gain, and overall well-being.
• Speculum and bimanual examination is usually not needed unless
vaginal discharge or bleeding, leakage of fluid, or pain is present.

18. Testing
• Laboratory testing
• Prenatal evaluation involves urine tests and blood tests. Initial laboratory
evaluation is thorough; some components are repeated during follow-up
visits.
• if a woman has Rh-negative blood, she may be at risk of developing Rh(D)
antibodies, and if the father has Rh-positive blood, the fetus may be at
risk of developing erythroblastosis fetalis.
• Rh(D) antibody levels should be measured in pregnant women at the
initial prenatal visit and again at about 26 to 28 weeks. At that time,
women who have Rh-negative blood are given a prophylactic dose of
Rh(D) immune globulin. Additional measures may be necessary to prevent
development of maternal Rh antibodies.

19. • Urine is also tested for protein. Proteinuria before 20 weeks gestation
suggests kidney disease. Proteinuria after 20 weeks gestation may
indicate preeclampsia.
• Generally, women are routinely screened for gestational diabetes
between 24 and 28 weeks using a 50-g, 1-hour glucose tolerance test.
However, if women have significant risk factors for gestational diabetes,
they are screened during the 1st trimester. These risk factors include
Gestational diabetes or a macrosomic neonate (weight > 4500 g at
birth) in a previous pregnancy
• Unexplained fetal losses
• A strong family history of diabetes in 1st-degree relatives
• A history of persistent glucosuria
• Body mass index (BMI) > 30 kg/m2
• Polycystic ovary syndrome with insulin resistance

20. • in some pregnant women, blood tests to screen for thyroid disorders
(measurement of thyroid-stimulating hormone [TSH]) are done. These
women may include those who
• Have symptoms
• Come from an area where moderate to severe iodine insufficiency occurs
• Have a family or personal history of thyroid disorders
• Have type 1 diabetes
• Have a history of infertility, preterm delivery, or miscarriage
• Have had head or neck radiation therapy
• Are morbidly obese (BMI > 40 kg/m2)
• Are > 30 years

21. • Ultrasonography
• Most obstetricians recommend at least one ultrasound examination
during each pregnancy, ideally between 16 and 20 weeks, when
estimated delivery date (EDD) can still be confirmed fairly accurately and
when placental location and fetal anatomy can be evaluated.
• Estimates of gestational age are based on measurements of fetal head
circumference, biparietal diameter, abdominal circumference, and femur
length.. Ultrasonography during the 3rd trimester is accurate for
predicting EDD to within about 2 to 3 weeks.

22. Specific indications for ultrasonography include
• Investigation of abnormalities during the 1st trimester (eg, indicated by
abnormal results of noninvasive maternal screening tests)
• Risk assessment for chromosomal abnormalities (eg, Down syndrome)
• Need for detailed assessment of fetal anatomy (usually at about 16 to 20
weeks), possibly including fetal echocardiography at 20 weeks if risk of
congenital heart defects is high (eg, in women who have type 1 diabetes
or have had a child with a congenital heart defect)
• Detection of multifetal pregnancy, hydatidiform mole, polyhydramnios,
placenta previa, or ectopic pregnancy
• Determination of placental location, fetal position and size, and size of
the uterus in relation to given gestational dates (too small or too large)

23. • Other imaging
• Conventional x-rays can induce spontaneous abortion or congenital
malformations, particularly during early pregnancy. Risk is remote (up to
about 1/million) with each x-ray of an extremity or of the neck, head, or
chest if the uterus is shielded. Risk is higher with abdominal, pelvic, and
lower back x-rays. Thus, for all women of childbearing age, an imaging
test with less ionizing radiation (eg, ultrasonography) should be
substituted when possible, or if x-rays are needed, the uterus should be
shielded (because pregnancy is possible).
• Medically necessary x-rays or other imaging should not be postponed
because of pregnancy. However, elective x-rays are postponed until after
pregnancy.

24. TREATMENT
• Problems identified during evaluation are managed.
• Women are counseled about exercise and diet and advised.
• Nutritional supplements are prescribed.
• What to avoid, what to expect, and when to obtain further evaluation
are explained.
• Couples are encouraged to attend childbirth classes.

25. • Physical activity
• Exercise during pregnancy has minimal risks and has demonstrated benefits for
most pregnant women, including maintenance or improvement of physical
fitness, control of gestational weight gain, reduction in low back pain, and
possibly a reduction in risk of developing gestational diabetes or preeclampsia.
• Moderate exercise is not a direct cause of any adverse pregnancy outcome;
however, pregnant women may be at greater risk of injuries to joints, falling, and
abdominal trauma.
• Abdominal trauma can result in abruptio placentae, which can lead to fetal
morbidity or death.
• Most experts agree that exercise during pregnancy is safe and can improve
pregnancy outcomes (eg, reduced excessive gestational weight gain, gestational
diabetes ).
• Sexual intercourse can be continued throughout pregnancy unless vaginal
bleeding, pain, leakage of amniotic fluid, or uterine contractions occur.

26. Travel
• The safest time to travel during pregnancy is between 14 and 28 weeks,
but there is no absolute contraindication to travel at any time during
pregnancy. Pregnant women should wear seat belts regardless of
gestational age and type of vehicle.
• Travel on airplanes is safe until 36 weeks gestation. The primary reason
for this restriction is the risk of labor and delivery in an unfamiliar
environment.
• During any kind of travel, pregnant women should stretch and straighten
their legs and ankles periodically to prevent venous stasis and the
possibility of thrombosis. For example, on long flights, they should walk
or stretch every 2 to 3 hours. In some cases, the clinician may
recommend thromboprophylaxis for prolonged travel.

27. • Immunizations
• Vaccines for measles, mumps, rubella, and varicella should not be used during pregnancy.
• The hepatitis B vaccine can be safely used if indicated, and the influenza vaccine is strongly
recommended for women who are pregnant or postpartum during influenza season. Booster
immunization for diphtheria, tetanus, and pertussis (Tdap) between 27 and 36 weeks gestation or
postpartum is recommended, even if women have been fully vaccinated.
• Although the COVID 19 vaccine has not been specifically evaluated in pregnant women, the
American College of Obstetricians and Gynecologists (ACOG) recommends that COVID-19 vaccines
not be withheld from pregnant women who meet the criteria for vaccination based on the Advisory
Committee on Immunization Practices (ACIP) recommended priority groups. Various COVID 19
vaccines have received authorization for emergency use from the Food and Drug Administration
(FDA) and the World Health Organization (WHO) as listed on its Emergency Use Listing.
• Because pregnant women with Rh-negative blood are at risk of developing Rh(D) antibodies, they
are given Rh(D) immune globulin 300 mcg IM in any of the following situations:
• After any significant vaginal bleeding or other sign of placental hemorrhage or separation (abruptio
placentae)
• After a spontaneous or therapeutic abortion
• After amniocentesis or chorionic villus sampling
• Prophylactically at 28 weeks
• If the neonate has Rh(D)-positive blood, after delivery

28. Modifiable risk factors
• Pregnant women should not use alcohol and tobacco and should avoid
exposure to secondhand smoke.
They should also avoid the following:
• Exposure to chemicals or paint fumes
• Direct handling of cat litter (due to risk of toxoplasmosis)
• Prolonged temperature elevation (eg, in a hot tub or sauna)
• Exposure to people with active viral infections
• Women with substance abuse problems should be monitored by a
specialist in high-risk pregnancy. Screening for domestic
violence and depression should be done.
• Drugs and vitamins that are not medically indicated should be
discouraged

29. • Symptoms requiring evaluation
• Women should be advised to seek evaluation for unusual headaches,
visual disturbances, pelvic pain or cramping, vaginal bleeding, rupture of
membranes, extreme swelling of the hands or face, diminished urine
volume, any prolonged illness or infection, or persistent symptoms of
labor.
• Multiparous women with a history of rapid labor should notify the
physician at the first symptom of labor.

30. examination under anesthesia
• Pelvic examination under anesthesia (EUA) is performed when a
patient cannot be adequately examined without sedation or general
anesthesia (eg, for reasons of physical or psychological discomfort) or
to provide information that will help guide a subsequent surgical
procedure.
• In addition, clinical staging of cervical or vaginal cancer is performed
under anesthesia.