Clerking an Obstetrics Patient — Complete History Taking Guide

1. Biodata / Patient Identification

• Name, age, race/ethnicity
• Marital status, occupation
• Address / contact
• Gestational age (in weeks)
• Parity (Gravida/Para notation: G_P_)

2. Presenting Complaint (PC)

• Routine antenatal visit
• Vaginal bleeding / discharge
• Leaking liquor
• Reduced fetal movement
• Abdominal pain / contractions
• Headache, visual disturbance, swelling (pre-eclampsia symptoms)
• Vomiting, dysuria, fever, etc.

3. History of Presenting Complaint (HPC)

4. Obstetric History (Core Clerking Element)

• G = Gravida (total number of pregnancies including the current one)
• P = Para (pregnancies ≥ 20 weeks that resulted in birth)
• A = Abortus (losses < 20 weeks — miscarriage, TOP, ectopic)
• L = Living children

For Each Previous Pregnancy, Ask:

Any previous poor obstetric outcome (stillbirth, preterm, SGA, GDM, pre-eclampsia) significantly increases recurrence risk and shapes current pregnancy management. — Creasy & Resnik's Maternal-Fetal Medicine

5. History of Current Pregnancy

Menstrual History → EDD

• LMP (Last Menstrual Period): date, certainty, was it normal in flow/duration?
• Cycle regularity: length, regularity (adjust EDD for cycles ≠ 28 days)
• EDD by Naegel's Rule: LMP + 9 months + 7 days (or LMP − 3 months + 7 days)
• Confirm/revise EDD with first-trimester ultrasound if LMP uncertain

Current Pregnancy Timeline

• When was pregnancy confirmed? How (home test, clinic)?
• First prenatal visit — gestational age at booking
• Antenatal care received so far: where, how many visits
• Fetal movements: when first felt (quickening ~18–20 wks primiparous, ~16 wks multiparous), currently adequate?
• Complications this pregnancy: bleeding, pain, vomiting, infections, hypertension, diabetes screen results

Antenatal Investigations Done (ask for results if available)

• Blood group & Rh status, antibody screen
• FBC, haemoglobin
• VDRL/RPR (syphilis), HIV, hepatitis B/C
• Rubella immunity, GDM screen (24–28 weeks)
• Urine protein/glucose at each visit
• First trimester screen (PAPP-A, NT, β-hCG)
• AFP/Quad screen (16–18 weeks)
• Anatomy scan (18–20 weeks)
• GBS swab (35–37 weeks)

6. Medical & Surgical History

• Chronic conditions: hypertension, diabetes, epilepsy, thyroid, cardiac, renal, autoimmune (e.g., SLE, APS — which increases risk of VTE and adverse obstetric outcomes)
• Previous surgeries: especially uterine/pelvic (CS scar, myomectomy, cervical procedures like LLETZ)
• Current medications, including OTC and herbal remedies
• Allergies

7. Gynaecological History

• Menstrual history (as above)
• Cervical smear history / HPV vaccination
• Previous gynaecological conditions: fibroids, ovarian cysts, endometriosis, PID, STIs
• Contraception used before this pregnancy
• Infertility treatment (IVF/ovulation induction — relevant to multiples, dates)

8. Family History

• Hypertension, diabetes, pre-eclampsia in mother/sisters
• Twin pregnancies (dizygotic — genetic component)
• Congenital anomalies, genetic conditions (thalassaemia, sickle cell, chromosomal disorders)
• Thrombophilias (DVT, PE family history → thrombophilia screen)

9. Social History

• Smoking: number of cigarettes/day, duration — increases risk of preterm birth, placenta praevia, IUGR
• Alcohol: units/week — teratogenicity, fetal alcohol spectrum disorder
• Illicit drug use: type, frequency — neonatal withdrawal, placental abruption (cocaine)
• Occupation: physical demands, teratogen/chemical exposure, stress
• Domestic situation: social support, partner/spouse, domestic violence (screen)
• Nutritional status: dietary restrictions, obesity or underweight
• Exercise habits
• Financial/housing concerns (access to antenatal care)

10. Systems Review (Symptom Screen)

11. Immunisation History

• Tetanus (Td/dTpa recommended in each pregnancy ~28 weeks)
• Influenza (recommended each pregnancy)
• Rubella immunity — if not immune, vaccinate postpartum
• COVID-19 vaccination status

12. Summary of Key Obstetric Notation

"Mrs X is a G3P2 (2 prior NVDs at term, no complications), currently 32 weeks by certain LMP confirmed on first trimester USS, booking EDD [date], with no significant past medical history, presenting with..."

Key Points to Remember

• Always calculate and document GA and EDD at booking
• The first prenatal visit is the most important — sets baseline, identifies risk, starts investigations (Textbook of Family Medicine, 9e)
• Women with previous adverse outcomes need enhanced/accelerated care (Creasy & Resnik's)
• Screen for domestic violence, substance use, and psychosocial stressors routinely — these are often not volunteered
• Maternal Rh-negative status → document and plan anti-D prophylaxis