how to take history in detail from an obstetric pt

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Taking a Detailed Obstetric History

A thorough obstetric history is systematic and covers several domains. Here is the full framework used in clinical practice.

1. Identifying Information / Demographics

Full name, age, address
Occupation (hers and her partner's)
Ethnicity (relevant for sickle cell, thalassaemia, cystic fibrosis screening)
Marital/relationship status
Referring source

2. Chief Complaint

State in the patient's own words - the reason for this visit (e.g., first booking visit, pain, bleeding, reduced fetal movement, labour, etc.).

3. History of Present Pregnancy (Current Obstetric History)

Menstrual History (key for dating)

LMP (Last Menstrual Period) - first day, certain or uncertain
Cycle length and regularity (28-day cycle is the reference for Naegele's rule)
Contraceptive use just before conception (especially OCP - cycles may be irregular)
EDD (Estimated Due Date) - calculated as LMP + 9 months + 7 days, or from early dating scan
Gestational age at present visit

Confirmation of Pregnancy

Pregnancy test (home or clinical) - when done
Ultrasound scans: dating scan (ideally 11-14 weeks), anatomy scan (18-20 weeks), any extra scans - dates, findings, any abnormalities noted

Symptoms in This Pregnancy

Go through trimester by trimester:

1st trimester: nausea/vomiting, bleeding (threatened miscarriage?), vaginal discharge, urinary symptoms, cramping
2nd trimester: fetal movements (when first felt - quickening), anatomy scan results, amniocentesis/CVS if done
3rd trimester: fetal movement count, Braxton Hicks, leaking fluid (PROM?), bleeding (placenta praevia? abruption?), headache/visual disturbance/epigastric pain (pre-eclampsia?), swelling of hands/face/ankles

Antenatal Care This Pregnancy

Where booked, with whom
All investigations done: blood group, Rh status, Rubella immunity, HIV, Hep B/C, syphilis (VDRL/TPHA), FBC, urinalysis, GBS swab
Screening tests: Down syndrome screen (combined test, NIPT/cell-free fetal DNA)
Vaccinations given (Tdap, influenza, COVID-19 in pregnancy)
Any complications: hypertension, gestational diabetes, anaemia, infections, hospitalisation

4. Past Obstetric History (GOPTAL notation)

Record every previous pregnancy in order, including:

Parameter	What to Ask
G (Gravida)	Total number of times pregnant (including current)
P (Para)	Number of deliveries at ≥20 weeks (or ≥500g)
T (Term)	Deliveries ≥37 weeks
P (Preterm)	Deliveries 20-36+6 weeks
A (Abortus)	Miscarriages + terminations
L (Living)	Number of living children

For each previous pregnancy, ask:

Year, gestational age at delivery
Mode of delivery: SVD, instrumental (forceps/ventouse), LSCS (elective or emergency - and why)
Place of delivery
Duration of labour
Complications: APH, PPH (amount), hypertension, GDM, malpresentation, cord prolapse, shoulder dystocia, perineal tears (degree), retained placenta
Baby: sex, birth weight, APGAR score, NICU admission, neonatal problems
Miscarriages/terminations: how many, gestation, type (spontaneous/induced), surgical intervention needed (ERPC/D&C), Rh prophylaxis given
Any previous uterine surgery (myomectomy, metroplasty) - relevant for mode of delivery

5. Gynaecological History

Last cervical smear (Pap) - result
History of STIs (gonorrhoea, chlamydia, HSV, HPV)
Fibroids, ovarian cysts, endometriosis, PCOS
Previous pelvic surgery, D&C, cone biopsy, LLETZ/LEEP (risk for cervical incompetence)
Contraception history
Infertility treatment (IVF, ovulation induction - increases multiple pregnancy risk)
Menstrual abnormalities prior to pregnancy

6. Past Medical History (PMH)

Conditions particularly relevant in obstetrics:

System	Conditions to Ask About
CVS	Hypertension, cardiac disease (congenital, valvular), DVT/PE, thrombophilia
Endocrine	Diabetes (Type 1/2), thyroid disease, Addison's
Renal	CKD, recurrent UTIs, single kidney
Respiratory	Asthma, TB
Neurological	Epilepsy, MS, migraine
Haematological	Anaemia (type), sickle cell, thalassaemia, ITP, thrombophilia
Autoimmune	SLE, antiphospholipid syndrome, rheumatoid arthritis
GI/Hepatic	Liver disease, IBD, cholestasis of pregnancy (in prior pregnancies)
Mental health	Depression, anxiety, bipolar disorder, eating disorders, previous perinatal mental illness
Infections	HIV status, Hepatitis B/C, TB, history of TORCH infections

7. Surgical History

Any previous surgeries, especially abdominal/pelvic
Blood transfusions - when, why, how many units
Anaesthetic complications

8. Drug History

Current medications (prescribed and OTC)
Folic acid supplementation (started when, dose - 400 mcg standard, 5mg if high risk)
Vitamin D supplementation
Iron, aspirin (for pre-eclampsia prevention)
Any teratogenic drugs taken in early pregnancy
Traditional/herbal remedies

9. Allergy History

Drug allergies with type of reaction (rash, anaphylaxis)
Food, latex, other allergies

10. Family History

Hypertension, diabetes, cardiac disease, autoimmune conditions in first-degree relatives
Congenital anomalies or genetic conditions (chromosomal disorders, neural tube defects, congenital heart disease) - in either partner's family
Twins in family (maternal side determines dizygotic twin risk)
Haemophilia, cystic fibrosis, sickle cell, thalassaemia (consanguinity increases recessive disorder risk)
Pre-eclampsia, eclampsia in mother or sisters

11. Social History

Domain	Specifics
Smoking	Current/ex-smoker, number of cigarettes/day, willing to quit?
Alcohol	Units per week, type; CAGE screening; any binge drinking in early pregnancy
Recreational drugs	Cannabis, cocaine, heroin, methadone (if on OST - dose, compliance)
Diet	Vegetarian/vegan (iron, B12 supplementation?), food aversions/cravings, pica
Housing	Stable housing, overcrowding, hygiene
Support	Partner support, family support, single parent
Occupation	Work environment risks (radiation, chemicals, heavy lifting); maternity leave plans
Domestic violence	Ask sensitively and privately: "Do you feel safe at home?"
Travel	Recent travel to malaria-endemic or Zika-affected areas
Immigration status	May affect healthcare access and screening history

12. Systemic Review (Brief)

Screen for symptoms not yet volunteered:

General: weight gain pattern, fatigue
Urinary: frequency, dysuria, haematuria (UTI, pre-eclampsia)
GI: heartburn, constipation, abdominal pain
MSK: back pain, pelvic girdle pain, carpal tunnel symptoms
Respiratory: breathlessness, cough
Neurological: headaches, visual disturbance, numbness

Summary: The "Obstetric Mnemonics"

OBSTETRIC framework at the bedside:

O - Obstetric history (G/P/A/L)
B - Booking details and scans
S - Symptoms in current pregnancy
T - Tests and investigations
E - Episodes of illness / medical history
T - Treatments / medications
R - Risk factors (social, genetic, medical)
I - Investigations already done
C - Concerns of the patient

Special Points to Always Clarify

Blood group and Rh factor - if Rh negative, anti-D prophylaxis history?
GBS status - known carrier?
Consent for interventions - any birth preferences or refusals (e.g., Jehovah's Witness - blood refusal)
Mental health screen - Whooley questions for depression are part of routine antenatal care
Safeguarding - any child protection concerns, vulnerable adult concerns

Primary reference: Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice (clinical evaluation and prenatal care chapter); standard UK/WHO antenatal care guidelines.

Create a printable checklist for obstetric history-taking in clinic

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Obstetric History Checklist
Word Document · DOCX

The document is A4, print-ready, and includes:

14 colour-coded sections with teal headers:
1. Patient Identification
2. Presenting Complaint
3. Menstrual History & Pregnancy Dating
4. Current Pregnancy History
5. Antenatal Care This Pregnancy
6. Past Obstetric History (with GPAL notation line)
7. Gynaecological History
8. Past Medical History
9. Surgical & Anaesthetic History
10. Medications & Allergies
11. Family History
12. Social History (incl. domestic violence screen prompt)
13. Systemic Review
14. Mental Health Screen (Whooley questions included)
Checkbox column (empty squares) for ticking off each item as you ask
Notes/Findings column alongside every item for writing in results
Clinician sign-off block at the bottom (summary, plan, signature, date)
Header with title + Date / Clinician / Clinic fields to fill in

Open in Word or LibreOffice, print A4 single- or double-sided.

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