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Clerking an Obstetrics Patient — Comprehensive History Taking Guide

Opening the Consultation

• Wash hands, introduce yourself (name and role)
• Confirm patient's name, date of birth, and MRN
• Explain you are going to take a history; obtain verbal consent
• Ensure privacy and comfort; have a chaperone present

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1. Key Pregnancy Details (Establish Early)

Note: Before 18 weeks, most obstetric conditions are unlikely — direct questioning toward gynaecological differentials (e.g., ectopic pregnancy, miscarriage).

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2. Presenting Complaint (PC)

• Reduced/absent fetal movements
• Vaginal bleeding
• Abdominal pain / contractions
• Leaking liquor / rupture of membranes
• Headache, visual disturbance, swelling (pre-eclampsia screen)
• Vomiting / hyperemesis
• Dysuria / urinary symptoms
• Vaginal discharge

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3. History of Presenting Complaint (HPC)

• Site: Localised or diffuse?
• Onset: Sudden or gradual? How many weeks gestation when it started?
• Character: Nature of pain/symptom
• Radiation: Does it radiate?
• Associated symptoms: Fever, bleeding, discharge, fetal movement changes
• Timing: Continuous or intermittent? Frequency?
• Exacerbating/Relieving factors
• Severity: 0–10 pain scale

Specific Questions by Complaint

• Amount (pads soaked?), colour, clots?
• Is it painless (think placenta praevia) or painful (think abruption)?
• Any trauma?

• Frequency, duration, regularity?
• Associated with hardening of the abdomen?
• Any show (mucous plug)?

• Time of onset, colour, odour?
• Continuous or intermittent trickle?
• Any fever or foul-smelling discharge (infection)?

• When last felt? Normal pattern?
• Any recent illness or trauma?

• Onset, severity, visual changes (photopsia, scotoma)?
• Epigastric pain? (pre-eclampsia/HELLP)
• Facial/hand/ankle oedema?

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4. Current Pregnancy History

• LMP (first day) → Calculate EDD using Naegele's rule: LMP + 9 months + 7 days
  • Adjust if cycles ≠ 28 days
• Confirm with USS (early USS is more accurate for dating; late USS >24 weeks less reliable)
• Planned/unplanned pregnancy?
• ANC attendance: Where, how many visits, any concerns raised?
• Booking bloods: Blood group, Rh status, antibodies, FBC, VDRL, hepatitis, HIV, rubella immunity
• Anomaly scans: First trimester combined screen (NT + bloods), 20-week anatomy scan — any abnormalities?
• Symptoms to date: Nausea/vomiting (severity), fatigue, breast tenderness, quickening (when first felt)
• Current medications: Especially folic acid, iron, aspirin, progesterone, vitamins
• Teratogen exposure: Alcohol, smoking, recreational drugs, prescribed medications (methotrexate, valproate, warfarin, retinoids, thalidomide, ACE inhibitors, lithium, carbamazepine)
• Contraception used prior to pregnancy (important to know if IUD in situ — must be removed)

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5. Previous Obstetric History (For Each Prior Pregnancy — in Chronological Order)

• Pre-eclampsia / gestational hypertension / eclampsia
• Gestational diabetes (GDM)
• Antepartum haemorrhage (placenta praevia / abruption)
• Postpartum haemorrhage (PPH) — primary or secondary?
• Preterm labour / PPROM
• Fetal growth restriction (FGR)
• Congenital anomalies
• Shoulder dystocia
• Thromboembolism (DVT/PE)
• Previous uterine surgery (myomectomy, previous LSCS — number, type of incision)

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6. Gynaecological History

• Menstrual history: Menarche, cycle regularity, dysmenorrhoea, menorrhagia
• Last Pap smear: Date, result?
• STIs: Previous infections, treatment?
• Gynaecological conditions: Fibroids, PCOS, endometriosis, ovarian cysts, cervical incompetence
• Previous gynaecological surgery: LLETZ, cone biopsy (↑ risk preterm), cervical cerclage, uterine procedures

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7. Past Medical History (PMH)

• Hypertension (chronic vs. gestational)
• Diabetes mellitus (type 1/2; GDM risk)
• Cardiac disease (rheumatic heart disease, congenital, valve disease)
• Renal disease / UTIs
• Thyroid disease (hypo/hyperthyroidism)
• Anaemia (iron deficiency, sickle cell, thalassaemia)
• Autoimmune: SLE, antiphospholipid syndrome (↑ miscarriage, thrombosis, FGR)
• Epilepsy (medication teratogenicity, seizure control)
• Asthma / respiratory disease
• HIV / hepatitis B or C
• Mental health: Depression, anxiety, previous puerperal psychosis
• Thrombophilias: Factor V Leiden, prothrombin mutation (↑ VTE risk)
• Previous abdominal/pelvic surgery

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8. Drug History

• Current medications (name, dose, frequency, route)
• Supplements: Folic acid, vitamin D, iron
• OTC medications and herbal remedies
• Allergies (drug, food, latex) — nature of reaction
• Contraception prior to pregnancy

• Warfarin, ACE inhibitors, valproate, carbamazepine, lithium, retinoids, methotrexate, thalidomide, misoprostol

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9. Family History

• Hypertension, pre-eclampsia, diabetes (GDM risk)
• Genetic disorders: Down's syndrome, cystic fibrosis, sickle cell, thalassaemia, Tay-Sachs
• Recurrent miscarriage / stillbirth in family
• Thromboembolism (hereditary thrombophilias)
• Multiple pregnancies (twins/triplets — increased risk with family history of dizygotic twins)
• Congenital anomalies

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10. Social History

• Relationship status: Support at home, partner involvement
• Occupation: Physically demanding? Exposure to chemicals, radiation, infections (e.g. healthcare worker)?
• Housing: Adequate for newborn? Domestic violence (ask sensitively, alone with patient)
• Smoking: Pack-years, current status — counsel about cessation (↑ IUGR, placenta praevia, abruption, SIDS)
• Alcohol: Units/week — FASD risk with any alcohol
• Recreational drugs: Cannabis, cocaine, opioids — neonatal abstinence syndrome risk
• Domestic violence: Ask directly when alone — "Are you safe at home?"
• Social support network: Family, friends, community resources
• Immigration status / consanguinity: Cultural background, consanguinity (↑ autosomal recessive disorders)
• Nutritional status: Diet, pica, weight gain to date

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11. Systemic Review (Directed)

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12. Ideas, Concerns & Expectations (ICE)

• "What are your thoughts about what might be happening?"
• "Is there anything in particular you are worried about?"
• "What were you hoping we could do for you today?"

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13. Summary & Closure

• Summarise the history back to the patient to confirm accuracy
• Ask: "Is there anything else you'd like to mention?"
• Explain the plan: examination, investigations, management
• Document: G_P_ + gestational age + presenting complaint as your opening line

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Standard Documentation Format

"Mrs X, a G2P1 woman at 32 weeks gestation by LMP (confirmed by USS at 12 weeks), presents with..."

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