History taking obs gynae
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I now have enough from the textbooks combined with my comprehensive knowledge to give a thorough answer. Here is a structured guide to history taking in obstetrics and gynaecology (obs & gynae):
History Taking in Obstetrics & Gynaecology
A structured obs & gynae history has several components that differ from general medical history. The standard framework is as follows:
1. Patient Details
- Name, age, date of birth
- Parity/gravidity (noted at the start for context)
2. Presenting Complaint (PC)
One or two words describing the main problem in the patient's own words.
- Common gynaecological complaints: abnormal bleeding, pelvic pain, vaginal discharge, prolapse, subfertility, vulval symptoms
- Common obstetric complaints: bleeding in pregnancy, reduced fetal movements, abdominal pain, ruptured membranes, labour
3. History of Presenting Complaint (HPC)
Expand on the PC using the SOCRATES mnemonic or equivalent:
- Site - localised or generalised (e.g. pelvic pain - unilateral or bilateral?)
- Onset - sudden or gradual; relation to menstrual cycle
- Character - type of pain, type of bleeding (fresh/dark, clots)
- Radiation - pain to back, shoulder tip (diaphragmatic irritation - think ectopic)
- Associations - nausea, vomiting, fever, urinary/bowel symptoms, dyspareunia
- Timing - cyclical vs. constant; duration
- Exacerbating/relieving factors
- Severity - impact on daily life
For bleeding, specifically ask:
- Amount (number of pads/tampons per day, flooding, clots)
- Duration and frequency
- Intermenstrual or postcoital bleeding
- Postmenopausal bleeding
4. Menstrual History
This is unique to obs & gynae history:
| Question | Detail |
|---|---|
| LMP (Last Menstrual Period) | Date; was it normal in character? |
| Menarche | Age at first period |
| Cycle length | Normal 21-35 days |
| Duration of flow | Normal 2-7 days |
| Amount | Heavy/light; number of pads; flooding; clots |
| Regularity | Regular, irregular, or absent (amenorrhoea) |
| Dysmenorrhoea | Primary or secondary; severity |
| IMB | Intermenstrual bleeding |
| PCB | Postcoital bleeding |
| PMB | Postmenopausal bleeding (in older women) |
| Menopause status | Age of menopause if applicable; HRT use |
Abnormal uterine bleeding is classified by the PALM-COEIN system: Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia - Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified. - Rosen's Emergency Medicine
5. Obstetric History (GTPAL)
Record for every pregnancy in chronological order:
- G - Gravida (total number of pregnancies, including current)
- T - Term deliveries (≥37 weeks)
- P - Preterm deliveries (24-36+6 weeks)
- A - Abortions/miscarriages/terminations (<24 weeks)
- L - Living children
For each previous pregnancy, document:
- Year, gestation at delivery
- Mode of delivery (SVD, instrumental, CS - and if CS, indication and type: lower segment/classical)
- Complications in pregnancy (pre-eclampsia, GDM, APH, placenta praevia)
- Complications in labour/delivery (PPH, perineal tears, shoulder dystocia)
- Baby's weight, sex, condition at birth (Apgar, NICU admission)
- Neonatal/postnatal complications
6. Gynaecological History
- Cervical smear history - date of last smear, results, any colposcopy/treatment
- Contraception - current and past methods; reason for stopping
- STIs - history of sexually transmitted infections (ask sensitively)
- Subfertility - duration of trying to conceive, any investigations or treatment
- Pelvic inflammatory disease (PID) or previous pelvic surgery
7. Sexual History (ask sensitively, ensure privacy)
- Sexually active? Gender of partners?
- Dyspareunia (superficial or deep)
- Postcoital bleeding
- Screen for STIs if relevant
8. Past Medical History (PMH)
- Medical conditions (diabetes, hypertension, thyroid disease, autoimmune conditions, coagulopathies - especially relevant for menstrual problems)
- Surgical history (especially pelvic/abdominal surgery - risk of adhesions)
- Previous anaesthetic problems
9. Drug History & Allergies
- Current medications including over-the-counter drugs and herbal remedies
- Hormonal medications: OCP, HRT, progestogens, anticoagulants
- Folic acid and iron supplementation (in pregnancy)
- Drug allergies with nature of reaction
10. Family History
- Gynaecological cancers (ovarian, endometrial, breast - BRCA mutations)
- Obstetric complications (pre-eclampsia, VTE)
- Coagulopathies (Von Willebrand disease - relevant in menorrhagia)
- Diabetes, hypertension, congenital anomalies
11. Social History
- Occupation and impact of symptoms on work
- Smoking (pack-years) - risk factor for ectopic pregnancy, cervical cancer, subfertility; also important for antenatal care
- Alcohol intake (units/week) - teratogenicity in pregnancy
- Recreational drug use
- Relationship status, domestic violence screen (ask privately: "Do you feel safe at home?")
- Living arrangements and social support
- Country of origin (relevant for female genital mutilation, sickle cell/thalassaemia screening)
12. Review of Systems
Targeted systems relevant to obs & gynae:
- Urinary: frequency, urgency, incontinence, dysuria, haematuria
- Bowel: constipation, rectal bleeding, change in bowel habit (endometriosis, prolapse)
- Thyroid: weight change, heat/cold intolerance (thyroid causes AUB)
- Skin/hair: acne, hirsutism, weight gain (PCOS)
- Breast: lumps, nipple discharge, galactorrhoea (hyperprolactinaemia)
- Venous: leg swelling, DVT/PE history (VTE risk in pregnancy)
In the Antenatal Setting (Specific Additions)
| Element | Detail |
|---|---|
| Gestational age | LMP, EDD (Naegele's rule: LMP + 9 months + 7 days), dating scan |
| Symptoms of pregnancy | Morning sickness, fetal movements (from ~18-20 weeks), breast changes |
| Booking bloods | Blood group, antibody screen, FBC, rubella, syphilis, HIV, HBsAg, haemoglobinopathy screen |
| Antenatal scans | Dating scan, anomaly scan (20 weeks), growth scans |
| Risk assessment | Pre-eclampsia risk, GDM screening (OGTT), VTE risk |
| Current pregnancy complications | Bleeding, pain, reduced movements, leaking fluid |
| Fetal movements | Established by ~18-24 weeks; reduced movements requires urgent assessment |
Closing the History
- "Is there anything else you would like to tell me or ask?"
- Note any safeguarding concerns (domestic violence, FGM, child protection)
- Establish the patient's ideas, concerns, and expectations (ICE)
Key sources: Berek & Novak's Gynecology (9th ed.); Rosen's Emergency Medicine (principles of AUB history)
Create a quick reference checklist PDF for obs & gynae history
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Your checklist PDF is ready:
ObsGynae History Checklist
PDF Document · PDF
What's included in the PDF (single A4 page, print-ready):
| Section | Contents |
|---|---|
| 1-2 | Patient Details + Presenting Complaint |
| 3 | SOCRATES table for HPC |
| 4 | Menstrual History with PALM-COEIN reminder |
| 5 | Obstetric History (GTPAL) + per-pregnancy checklist |
| 6-7 | Gynaecological + Sexual History |
| 8-9 | PMH + Drug History & Allergies |
| 10-11 | Family History + Social History |
| 12 | Targeted Review of Systems (6 systems) |
| 13 | Antenatal-specific additions |
| 14 | Closing the History (ICE + safeguarding) |
The layout uses colour-coded sections (teal for obstetric, pink for gynaecological), tick boxes throughout, and clinical memory aids (PALM-COEIN, GTPAL, Naegele's rule) built in. Fits cleanly on a single A4 sheet for use during OSCEs or clinical attachments.
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