This document outlines the components and considerations for taking a thorough obstetric history. It details sections to cover such as chief complaints, history of present illness, past medical history, menstrual history, obstetric history including details of previous pregnancies, deliveries and puerperiums, antenatal events separated by trimester, labour events, puerperal events, fetal outcome, and physical examination guidelines. The goal is to obtain a comprehensive history addressing any current issues or complications as well as past medical, surgical, menstrual, pregnancy, delivery and postpartum health to properly evaluate and manage the patient's care.

1. Piyush Ranjan Sahoo

2. • Chief Complaints
 pain/fever/wound complication/urinary retention etc.
headache, vomiting
 if not having any, tell-
 __yr female P (no. of child) on __ day of puerperium
with no specific complain.

3. History of Present Illness
 -Describe pain—onset, location, duration, character,
association, aggravating n relieving factors, radiation,
with reln to time.
 -Describe fever (puerperal pyrexia)—type, asso. with
any other factor.
 -Wound complication- Infection, stitch problem,
pain at wound site, any bleeding/discharge, or
swelling.
 -Urinary retention- (look for catheterisation n
accordingly present history) frequency of urination,
urinary output.

4. Hist. of past illness
 medical hist.
 surgical hist.(obs/gynaec/general)

5. Family History
 Mention as routine
 If Any relevant finding, mention.

6. Menstrual history
 Menarche
 prev. cycle
 LMP
 GA on the day of surgery, EDD.
 Cycle- duration of flow, amount of flow, association
(e.g. pain), regular or not.

7. Personal history
 Occupation
 Education
 SES
 wt gain
 Diet
 Addictions
 B/B habit

8. Obs hist.-
No. of
pregnancy
Yr
of
pregnancy
Duration of
Pregnancy
(complication
s
if any)
Duration
of
labour
Mode
Of
delivery
Nature
Of
puerperium

9. Baby
Sex weight Health
of
the child
If dead,
cause of
Death.

11. Antenatal events-
1st trimester events-
 Morning sickness, fever (with rashes or not), vomiting,
bleeding PV, Abd pain (may be due to UTI/ectopic
pregnancy)
 Medication hist.- Folic acid(neural tube development)
 USG done or not( for location of pregnancy & uterine
anomaly)
 ANC (booked case or not).
 Visits-

12. Continued…
2nd trimester events-
 Abd pain, bleeding PV, quickening, PIH(blurring of
vision, pedal oedema), Glucose challenge test ( to
know GDM).
 Medication hist.- Fe(not in 1st trimester, causes
vomiting n GI prob.), Ca+2 (to prevent osteoporosis),
TT( 1st dose at 16 wks, 2nd dose after 4-6wks).
 USG done or not. – ANC

13. Continued…
3rd trimester events-
 Abd pain, PIH, GDM, Bleeding PV.
 Med history-Fe, Calcium ..contd or not.
 USG –ANC.

14. Labour events-
 Pain- duration
 Bleeding
 Leaking

15. Puerperal events-
 Bleeding (for PPH)
 Any complications or illness

16. Fetal outcome-
 Wt-
 Crying, feeding, colour, CRT
 Any abnormality
 Immunization

17. General examn-
 Ht n wt, built, gait, pulse, BP, RR, temp., PICKLE
Breast examn-
 Inspection- skin, nipple n areola, engorged veins, any
discharge
 Palpation-lax, tender or not, any mass
Thyroid examn- (optional)
Abdominal examn- ( same as medicine)
***No percussion is to be done.

18. Thank u