Comprehensive history taking in obstetrics

1. Professor
Israa Hashim Abid-Alkareem
Head of obstetric department
College of medicine
Tikrit unevirsity
Doctor
Farah Imad Ali
M.B.Ch.B
College of medicine
Tikrit unevirsity
HISTORY TAKING IN OBSTETRICS
PRESENTED BY

2. The Science of Obstetrics is a unique branch of medicine that deals with more than
one person at the same time. The pregnant woman and her foetus(s). It is a branch
unique to the branch of medicine.
INTRODUCTION
Taking a case study is the only way to reach a correct diagnosis, and it cannot be
neglected for any medical student or even a medical practitioner.
Taking a detailed obstetric history to reach the proper diagnosis. So the definitive goal of
our lecture is to reach the complete obstetrical diagnosis

3. History-taking is a special formof the art of communication
This is the beginning of the doctor-patient relationship on which depend both the value of the
patient's history and his confidence in :
❖ His doctor.
❖ Clinical problem as a whole and to set this against the background of the patient's life.
❖ The doctor should think of her self not a diagnostician only but rather as someone who
elucidates human problems.
❖ The doctor must put the patient at ease and encourage her to talk freely.
AIMS AND OBJECTIVES

4. ❑ Greeting the patient.
❑ Introduce yourself: give your name and your job
(e.g. Dr. Farah Imad, at ward doctor)
❑ Identity: confirm you’re speaking to the correct
patient (name and date of birth)
❑ Permission: confirm the reason for seeing the
patient (“I’m going to ask you some questions about
your pregnancy, is that OK?”)
❑ Positioning: patient sitting in chair approximately a
metre away from you. Ensure you are sitting at the
same level as them and ideally not behind a desk.
HISTORY TAKING

5. ❑ Triple Name :
❑ Age :
Women have the best chance of getting pregnant in their 20s (21-29 years). This is the time when
you have the:
❖ Highest number of good quality of eggs available.
❖ Less pregnancy risks.
Advanced maternal age: is usually defined as age 35 or more. It's effects in pregnancy :
➢ risk of early pregnancy loss.
➢ risk of chromosomal abnormalities like Down's syndrome.
➢ incidence of stillbirths.
➢ pre-existing medical diseases like diabetes, hypertension.
➢ incidence of twins.
➢ incidence of operative delivery.
DemographicDetails
❖ The findings should be recorded under the following formal heading:

6. Teenage pregnancy : is a pregnancy in a woman 19 years of age or younger. It's effects in pregnancy:
❖ Higher risk for anemia.
❖ Pregnancy-induced hypertension
❖ Lower genital tract infections.
❖ low birth weight babies.
❖ Premature birth (PTL).
❖ Surgical, increase incidence of caesarean section.
❖ Assistant operative delivery.
❑ Address.
❑ Religion.
❑ Marital status:
❑ The husband's personal history:
✓ Should be taken as it reflects some important social and health issues.
✓ Ask about: Name of the husband, age, consanguinity, occupation , residence , blood
group and Rh. and ethnic background.

7. ❑ Blood Group and Rh :
Rh- negative mother
When the mother is Rh- negative and the father is Rh- positive , the mother will then
produce anti-Rh antibodies, which will attack any Rh- incompatible fetus which causing
hemolytic disease of newborn ((erythroblastosis fetalis)).
Figure 1: Blood group and pregnancy[6]

8. ❑ Gravida and Parity :
Gravida : Describes the number of pregnancies.
Nulligravida : Describes a woman who is not now and never has been pregnant.
Parity : Describes a woman who has delivered s fetus.
Nulliparous : Describes a woman who has never delivered a fetus.
Primipara : Describes a woman who has delivered only once.
Multipara : Describes a woman who delivered more than once.
Abortion : Expulsion of an embryo or fetus before 24 week of gestational age
❑ Date of admission:
❑ Time of admission to the hospital:
[5]

9. ❑ Duration of the current pregnancy (GA) :
✓ The first complaint in any obstetric case should be cessation of menstruation since the last
menstrual period (LMP). If the LMP was uncertain, we can say “cessation of menstruation …
Months ago”.
✓ Gestational age can be calculated in weeks using differentmethods:
A. Menstruation delivery interval: (Naegele’sformula):
Used when the first day of the last menstrual period (LMP) is certainly known. The
expected date of delivery (assuming that human pregnancy is 40 weeks) is calculated by
adding seven to the first day of the last menstrual period and counting back three months
the expected date of confinement is reached. The characters of the LMP are should be
normal in characters, preceded by 3 consecutive normal cycles, and not preceded by
hormonal contraception's.
B. Expected datescan be calculatedby ultrasound < 20 weeks by:
➢ The crown–rump length is used between 10 weeks 0 days and 13 weeks 6 days.
➢ Head circumference from 14 to 20 weeks.
[3]
[3]

10. ✓ It is important to define the EDD at the booking visit, as accurate dating is important in later
pregnancy for assessing fetal growth. In addition, accurate dating reduces the risk of premature
elective deliveries, such as induction of labour for post-mature pregnancies and elective caesarean
sections.
C. Other methodsof calculating GA:
❖ Ovulation-delivery interval:
EDD= ovulation date – 7days + 9 months
❖ Single coitus- delivery interval:
EDD= date of coitus- 7 days + 9 months
❖ Date of embryo transfer:
EDD= date of ET – 5 days + 9 months
❖ Date of quickening :
EDD = date of quickening + 20 w in primipara, or + 18 w in multipara
[2]
[3]

11. First ask open question: what brought you in?
"Then ask the below questions if it wasn't mentioned in patient's story"
✓ Time of admission: When did you come to the hospital? Which day & what time?
✓ Route of admission: Were you admitted through ER, Electively' through OPC, or referral?
✓ The duration : ( since when? for how long?) of each symptom alone.
✓ Complaining of: What are you complaining of? What did you feel, for each symptom
alone (record the answer in the patient's own words)
" Make sure that you write it in patient's own words"
Chief Complaint(CC) :

12. HistoryOf Present Illness (HPI) :
" Ask close question to narrow the list of possible diagnosis "
✓ When did it start? What was the first thing noticed?
✓ Ever had it before?
✓ To evaluate abdominal/pelvic pain, use the SOCRATES Questions:
❑ Site:
❑ Onset: Rapid? Gradual? Continuous? Intermittent?
❑ Character: Stabbing? Burning? Cramp? Amount? color?
❑ Radiation (if the symptom is pain or discomfort)
❑ Alleviating factors: Movement? Eating? Coughing?
❑ Timing: Noticed when? Better or worse in night or day?
❑ Exacerbating factors: Movement? Eating? Coughing?
❑ Severity: Interfere with normal activity?

13. ✓ To evaluate reduced or absence fetal movement:
Can be associated with fetal distress and absent fetal movements may indicate early fetal demise.
✓ To evaluate vaginal bleeding:
Causes include cervical bleeding (e.g. ectropium, cervical cancer), placenta praevia and placental
abruption (typically associated with abdominal pain).
✓ To evaluate abdominal pain:
Causes may include urinary tract infection, constipation, pelvic girdle pain and placental abruption.
✓ To evaluate vaginal discharge or loss of fluid:
Abnormal vaginal discharge may be caused by sexually transmitted infections such as gonorrhoea and
the loss of fluid from the vagina indicates rupture of the amniotic membranes.
✓ To evaluate headache, visual disturbance, epigastric pain and oedema:
These are typical clinical features of pre-eclampsia. Mild oedema is common and normal in the later
stages of pregnancy.
✓ To evaluate pruritis:
Associated with obstetric cholestasis (typically affecting the palms and soles of the feet).

14. ✓ Associated symptoms related to the same system as the CC.
✓ Constitutional symptoms: fever, cough, night sweats, loss of appetite, weight loss .
✓ To evaluate unilateral leg swelling:
Consider and rule out deep vein thrombosis.
✓ To evaluate chest pain and shortness of breath:
Pregnant women are at increased risk of developing pulmonary emboli.
✓ To evaluate systemic symptoms:
Fatigue (e.g. anaemia), fever (chorioamnionitis) and weight loss (e.g. hyperemesis gravidarum).
In HPI you should come up with the system involved, pathology, and the severity.

15. Ask about:
• The gestational age of the pregnancy and expected day of delivery.
• Using of folate supplementation prior to conception and currently pregnancy.
• Singleton or multiple gestation.
• Regular/ irregular ANC.
• History of teratogenic drug taking .
• Prenatal diagnostic results (ex: previous ultrasound findings)
• History of maternal infectious diseases and immunization.(ex: congenital TORCH infections).
• History of vaginal bleeding or fluid leakage during the current pregnancy.
• Presence and frequency of fetal movement and uterine contractions .
• Any associated GIT& Urinary symptoms.
HistoryOf Current Pregnancy :

16. ❖ First trimester
➢ Morning sickness.
➢ Drugs , radiation, febrile illnesses.
➢ Pain, bleeding, discharge.
❖ Second trimester
➢ Pain, bleeding, discharge.
➢ Edema, UTI.
➢ Quickening.
❖ Third trimester
➢ Pain, bleeding, discharge.
➢ Fetal movement.
➢ Febrile illnesses.
➢ Symptoms of labour.
Questions in every trimester of pregnancy :

17. a) Pregnancy induced : Pre-eclampsia, ante- partum hemorrhage, PROM, fetal
malformation, fetal death, Rh- iso- immunization,…etc
b) Pregnancy aggrevated: RHD, SLE, HTN,GDM.
Previous Diseases or Surgical procedures that can affect the management of the
Current Pregnancy :
e.g., Maternal cardiac disease, diabetes mellitus, uterine anomalies or fibroids, previous
uterine scar, … etc
Complications of the Current Pregnancy :

18. Consists of :
Menstrual History:
I. Date of the LMP
II. Age of menarche
III. Rhythm and length of cycle.
IV. Duration, regularity, flow and associated symptoms (e.g., dysmenorrhea , mittelschmerz)
V. Inter-menstrual period.
Figure 2: The normal duration of menses [7]

19. ❖ Duration of Marriage: This is important when dealing with pregnancy and helps in noticing a
woman's fertility.
✓ Past obstetric history is one of the most important areas for establishing risk in the current pregnancy.
✓ Ask about the number of children the patient is given birth , miscarriages, stillbirths, ectopic
pregnancy or termination.
PastObstetricHistory :
For each prior pregnancy, the following information should be obtained:
1. Estimated gestational age at the time of delivery.
2. Weight of infant.
3. Anesthesia.
4. Mode of delivery:
a. SVD: spontaneous vaginal delivery .
b. VAVD: vacuum-assisted vaginal delivery .
c. FAVD: forceps - assisted vaginal delivery .
d. Cesarean section, including indication and type of uterine incision :
❑ Low transverse: incision in the lower uterine segment in transverse fashion .
❑ Classical: vertical incision through the muscular portion of the uterus. [5]

20. ❑ Recurrent miscarriage (increased risk of miscarriage, fetal growth restriction [FGR]).
❑ Preterm delivery (increased risk of preterm delivery).
❑ Early-onset pre-eclampsia (increased risk of pre-eclampsia/FGR).
❑ Abruption (increased risk of recurrence).
❑ Congenital abnormality (recurrence risk depends on type of abnormality).
❑ Macrosomic baby (may be related to gestational diabetes).
❑ Unexplained stillbirth .
The features that are likely to have impact on future pregnancies include:
[3]

21. ❑ The age of the mother when she becomes pregnant.
❑ Duration of pregnancy.
❑ Antenatal and postpartum complications.
❑ Details of labor induction and the duration of labor.
❑ Delivery method.
❑ Fetal birth weight and gender of the baby
In every pregnancy the following should be noted:
❑ Postpartum hemorrhage.
❑ Urinary and genital tract infections.
❑ Deep vein thrombosis (DVT).
❑ Perineal complications such as perineal wound collapse.
❑ Psychological complications (such as postpartum depression).
Possible postpartum complications that may include :

22. Term Definition
Early pregnancy gestational age < 8 weeks.
1st trimester gestational age 1- 14 weeks
2nd trimester gestational age 14-28 weeks
3rd trimester 28-42weeks
Medico-legal
viability of
pregnancy:
It is the gestationalage after which the fetus is officially
considereda citizene.g. regarding birthand death
certificates. It is 28 weeks according to Egyptian law.
Obstetricviability: when the gestationalage is completed37 weeks or more. It
means that when the fetus is born after that age it can live
unassisted extra-uterine life.Delivery of a fetus with
gestational age between20-37 weeks is termedpre-term
birth.
Term pregnancy is that with a gestationalage 38-42 weeks.Post-term
pregnancy is that with a gestational age of more than 42
weeks.When pregnancy is of gestational age 40-42 weeks
it may be termedprolongedpregnancy
Table 1: Term definition of gestational age during pregnancy [7]

23. ➢ Periods: menarche, regularity.
➢ Contraceptive history.
➢ Previous infections and their treatment.
➢ When was the last cervical smear? Was it normal?
➢ Previous gynaecological surgery.
➢ Previous ectopic pregnancy.
➢ Recurrent miscarriage.
➢ Previous history of sub-fertility and IVF .
GynaecologicalHistory:

24. ❑ Diabetes mellitus.
❑ Hypertension.
❑ Bronchial asthma.
❑ Renal disease.
❑ Epilepsy.
❑ Venousthromboembolic disease.
❑ Human immunodeficiency virus infection.
❑ Connective tissue diseases , SLE
❑ Any previous surgery.
❑ Psychiatric history:
❑ Postpartum blues or depression.
❑ Depression unrelated to pregnancy.
❑ Domestic violence.
PastMedical and Surgical History:

25. ➢ Diabetes, hypertension, genetic problems, psychiatric problems, etc.
➢ Thromboembolic disorders and pre-eclampsia .
➢ Congenital anomalies.
➢ Haemoglobinopathies.
➢ Tuberculosis (TB).
➢ Multiple pregnancy.(twin, triple)
➢ Malignancies (e.g. Breast).
➢ Allergies , smoking/alcohol/drugs
➢ Occupation, partner’s occupation.
➢ Who is available to help at home?
➢ Are there any housing problems?
Familyand Social History:

26. ➢ Folate supplementation.
➢ Any regular medications.
➢ Allergies.
Query about other systems.
➢ Central Nervous System.
➢ Respiratory System.
➢ Cardio vascular System.
➢ Gastrointestinal System.
➢ Musculoskeletal System.
Drug History:
SystematicReview:

27. ➢ Any vaginal bleeding during pregnancy.
➢ Any gush of fluid per vaginum.
➢ Abdominal cramping.
➢ It persistent headache especially in 2nd and 3rd trimester.
➢ Any blurring of vision.
➢ Oedema of hands or face .
➢ Persistent vomiting.(hyperemesis gravidarum)
➢ Any decrease or absent fetal movements.
Warning Features During Pregnancy

28. Bad ObstetricHistory(BOH)
❑ The term bad obstetric history (BOH) is used
loosely to signify that a woman has previously
had problems with previous pregnancies.
❑ This may include miscarriage, stillbirth, or other
adverse and undesirable conditions.
❑ The details about it are important to prevent
similar situations and increase the chances of a
successful pregnancy and a live birth.

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Obstetrics and Gynaecology 2016 (pp. 291-304).
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McGraw-Hill. New York. 2010.
3. Kenny LC, Myers JE. Obstetric history and examination. In Obstetrics by Ten Teachers 2017 May
18 (pp. 1-12). CRC Press.
4. Stalin V:HISTORY TAKING FOR THE BEGINNER CHAPTER 1 Introduction. In: Stalin
Viswanathan; 1st edition. 2016.
5. Pfeifer SM. NMS obstetrics and gynecology–7 2) thed) Two Commerce Square, 2001 Market
Street. Philadelphia, PA 19103, 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer
business. 2012.
6. Mr. Joydeb Pradhan, Mrs. Tanusri Bera Pradhan. blood group and pregnancy. Available from:
http://medicoinfo.org/blood-group-and-pregnancy/ [Accessed 22th January 2021].
7. Osama M. Warda, MD. Clinical rounds in obstetrics. Egypt; Mansoura university. 2019 Sep 17.
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