History Taking in Obstetrics and Gynecology

History taking in O&G follows the general medical history framework but with specific reproductive, menstrual, and obstetric elements woven in. Here's a structured approach:

1. Biodata

Name, age, marital status, occupation, religion (relevant for some cultural/consanguinity practices), and address.

2. Chief Complaint(s)

In the patient's own words, with duration (e.g., "bleeding per vagina x 3 days", "amenorrhea x 2 months", "labor pains x 6 hours").

3. Menstrual History

Age at menarche
Cycle length and regularity (e.g., 28-30 days, regular/irregular)
Duration and amount of flow (number of pads/day, presence of clots)
Dysmenorrhea (pain with periods)
Date of Last Menstrual Period (LMP) - critical for calculating gestational age and Expected Date of Delivery (EDD) using Naegele's rule: LMP + 7 days - 3 months (+1 year)
Age at menopause if applicable, and method (natural, surgical, drug-induced)
Intermenstrual or postmenopausal bleeding/spotting

According to Schwartz's Principles of Surgery, the key elements of a focused gynecologic history include date of LMP, contraceptive/hormone use history, obstetric history, age at menarche/menopause, menstrual bleeding pattern, cervical screening history, history of pelvic infections, sexual history, and prior gynecologic surgeries - Schwartz's Principles of Surgery, p. 1815.

4. Obstetric History

This is documented using the Gravida-Para (GPA) formula:

Gravida (G): total number of pregnancies, including the current one
Para (P): often expanded as a 4-digit formula - TPAL
- T = Term deliveries
- P = Preterm deliveries
- A = Abortions (spontaneous or induced) / ectopic pregnancies
- L = Living children

For each previous pregnancy, record:

Year and place of delivery
Mode of delivery (vaginal, instrumental, cesarean - and indication if cesarean)
Gestational age at delivery
Birth weight and sex of baby, and current status of the child
Antenatal, intranatal, or postnatal complications (pre-eclampsia, gestational diabetes, PPH, etc.)
Any pregnancy losses (miscarriage, stillbirth, ectopic, termination) with gestational age and management

For the current pregnancy (if applicable):

LMP and calculated EDD/gestational age
Confirmation of pregnancy (urine/serum bCG, ultrasound dating - especially first-trimester dating scan)
Booking visit details, antenatal visits, and investigations done
Symptoms: nausea/vomiting, fetal movements (quickening), bleeding, leaking, contractions
Any high-risk factors identified (hypertension, diabetes, anemia, previous cesarean, etc.)
Immunizations (tetanus, Rh status if Rh-negative - anti-D given?)

5. Contraceptive History

Current and past methods used, duration, side effects, reason for discontinuation, and pregnancy intention.

6. Sexual History

Age at first intercourse, number of partners, dyspareunia, protection use - handled sensitively and non-judgmentally, as it guides STI risk assessment and testing.

7. Past Gynecological History

History of vaginal discharge, pelvic pain, or infections (including HPV/HIV status)
Cervical cytology (Pap smear) history - frequency and results
Prior gynecological surgeries (D&C, myomectomy, hysterectomy, tubal surgery, etc.)
History of infertility and any treatment

8. Past Medical and Surgical History

Chronic illnesses (diabetes, hypertension, thyroid disease, cardiac disease, epilepsy, thromboembolic disease), previous surgeries, hospitalizations, and blood transfusions.

9. Drug and Allergy History

Current medications (including herbal/OTC), known drug allergies, and any teratogenic exposures if pregnant.

10. Family History

Twin pregnancies, congenital anomalies, hereditary conditions, hypertension, diabetes, and any familial cancers (breast, ovarian, endometrial - relevant to gynecologic oncology risk).

11. Personal and Social History

Diet, smoking, alcohol, substance use, occupation (exposure risks), and psychosocial support - important for both general health and issues like domestic violence screening, which should be asked about privately.

Quick reference table (adapted from Schwartz's Principles of Surgery, p. 1815)

Element	What to explore	Why it matters
Menstrual history	Menarche, menopause, bleeding pattern, meds affecting bleeding	Endocrine, structural, infectious, oncologic clues
Obstetric history	Number of pregnancies, dates, delivery type, losses, complications	Predisposes to certain conditions (e.g., gestational trophoblastic disease), surgical risk
Sexual history	Partners, practices, protection, pregnancy intention	STI risk, testing sites, counseling
Contraceptive history	Current/past use, type, duration	Pregnancy risk during procedures, side effects
Cytologic screening	Frequency, results	Cervical cancer screening status

This structure applies whether the setting is a routine antenatal visit, a gynecology outpatient consult, or an emergency presentation (labor, bleeding, pain) - though in acute/emergency settings you prioritize the presenting complaint and focused relevant history first, then fill in the rest once the patient is stable.

Would you like me to go deeper into any specific part - for example, a detailed antenatal history-taking checklist, how to calculate the obstetric score (GPA/TPAL) with examples, or history taking for a specific complaint like abnormal uterine bleeding or infertility?

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