Obstetrics/ gynae what to ask separately detailed and comprehensible history taking

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Obstetrics & Gynaecology: Comprehensive History Taking

A thorough Ob/Gyn history is divided into two related but distinct components: the gynaecological history and the obstetric history. Both share a common framework but have unique domains that must each be explored systematically.

🔹 General Opening

Before any specific questioning:

Introduce yourself (name and role)
Confirm patient's name, date of birth, age
Explain purpose and gain consent
Ensure privacy and maintain a non-judgmental, respectful tone — many topics are deeply personal
Ask if the patient wishes a chaperone

🔹 PART 1: GYNAECOLOGICAL HISTORY

1. Presenting Complaint (PC)

Use an open question first:

"What has brought you in today?" / "Can you tell me what's been troubling you?"

Then explore with SOCRATES (for pain or any symptom):

Letter	Question
S – Site	Where exactly is it?
O – Onset	When did it start? Sudden or gradual?
C – Character	Dull/sharp/cramping/burning?
R – Radiation	Does it spread anywhere?
A – Associations	Nausea, vomiting, discharge, bleeding?
T – Time course	Constant or intermittent? Worse at certain times (e.g., menses)?
E – Exacerbating/Relieving	What makes it better or worse?
S – Severity	0–10 scale; impact on daily life?

2. Menstrual History (ESSENTIAL in ALL gyn presentations)

Question	What to ask
LMP	Date of last menstrual period (first day)
Cycle regularity	Regular / irregular? How many days between periods?
Duration	How many days does the bleeding last?
Flow	Light / moderate / heavy? (Number of pads/tampons per day; does she pass clots?)
Dysmenorrhoea	Pain with periods? When does it occur — before, during, after?
Menarche	Age at first period
Intermenstrual bleeding (IMB)	Bleeding between periods?
Post-coital bleeding (PCB)	Bleeding after intercourse? (Red flag — think cervical pathology)
Post-menopausal bleeding (PMB)	Any bleeding after confirmed menopause? (Always a red flag)
Menopause	If applicable: age at menopause; any vasomotor/urogenital symptoms

Normal menstrual cycle: 21–35 day interval, lasting 2–7 days, flow ≤80 mL.

3. Abnormal Vaginal Discharge

Feature	Ask about
Volume	More or less than usual?
Colour	White, yellow, green, grey, blood-stained?
Consistency	Thin / thick / curdy?
Odour	Offensive / fishy?
Itch / Soreness	Vulval pruritus, soreness, dyspareunia?
Timing	Cyclical (mid-cycle physiological) or persistent?

Differentials: Bacterial vaginosis (fishy, grey), Candidiasis (thick, white, curdy), Trichomonas (frothy, yellow-green), cervical ectropion, cervical cancer.

4. Vaginal Bleeding (Abnormal)

Three main patterns to distinguish:

Menorrhagia — heavy regular periods
Metrorrhagia — irregular/intermenstrual bleeding
Post-coital bleeding — after intercourse (screen for cervical pathology/STI)

Always ask:

Volume, clots, colour (bright red / dark / old blood)
Associated pain
Any trauma (including intimate partner violence — ask sensitively and directly)
Recent smear history

5. Pelvic / Abdominal Pain

Use SOCRATES. Additionally ask:

Relation to menstrual cycle (cyclical = think endometriosis, dysmenorrhoea)
Relation to intercourse (dyspareunia: superficial vs. deep)
Relation to bowel/bladder function
Fever or systemic upset (think pelvic inflammatory disease)

6. Sexual History (ask sensitively, explain clinical relevance)

Are you currently sexually active?
Partners: male, female, or both? (avoid assuming)
Number of partners (recent)
Contraception method currently used
Unprotected intercourse? STI risk?
Dyspareunia (painful intercourse — superficial or deep?)
Any history of STIs? Treatment received?
Libido / sexual function concerns?

7. Cervical Screening (Smear) History

Date of last cervical smear
Results — any abnormalities (CIN, HPV)?
Any colposcopy / treatment for abnormal smear?
HPV vaccination received?

8. Urinary Symptoms (Urogynaecology)

Frequency / urgency
Stress incontinence (leaks with cough, sneeze, exercise)
Urge incontinence
Dysuria / haematuria
Nocturia
Prolapse symptoms (dragging sensation, "something coming down")

9. Bowel Symptoms

Constipation / diarrhoea
Rectal bleeding
Tenesmus (incomplete emptying)
Faecal incontinence (especially in obstetric tears)
Bloating (relevant in ovarian pathology)

🔹 PART 2: OBSTETRIC HISTORY

1. Key Pregnancy Details (confirm EARLY)

Term	Definition
Gravida (G)	Total number of pregnancies (including current)
Para (P)	Deliveries at ≥24 weeks (regardless of outcome — live/stillbirth)
Nulliparous	Never delivered
Primiparous	Delivered once
Multiparous	Delivered two or more times

Example: G3P2+1 = 3 pregnancies, 2 deliveries ≥24 weeks, 1 loss

Also confirm:

Gestational age (by LMP + USS dating — which takes precedence?)
EDD (estimated due date)
Type of pregnancy (singleton/twins/higher order)

2. Current Pregnancy History

Domain	Questions
Conception	Spontaneous or ART (IVF/IUI)?
Booking	When booked, where? Any blood tests / scans done?
Antenatal care	All appointments attended? Any concerns raised?
Anomaly scans	12-week nuchal, 20-week anomaly scan — results?
Screening	Combined test / NIPT / amniocentesis / CVS? Results?
Fetal movements	Present and normal? Reduced? (After 24 weeks)
Symptoms	Nausea/vomiting, heartburn, pelvic girdle pain, swelling, visual disturbance, headache (preeclampsia?), epigastric pain
Blood pressure readings	Any elevated readings noted?
Vaginal bleeding	When, how much, associated pain? (Early: miscarriage/ectopic; late: placenta praevia/abruption)
Vaginal discharge / SROM	Any amniotic fluid loss (rupture of membranes)?
PPROM / Preterm symptoms	Contractions before 37 weeks?

3. Previous Obstetric History (for each previous pregnancy)

Go through each pregnancy chronologically. For every pregnancy ask:

Question	Details
Year and outcome	Live birth / miscarriage / stillbirth / termination / ectopic?
Gestation at delivery/loss	Term / preterm / post-dates?
Mode of delivery	SVD / instrumental (forceps/ventouse) / LSCS (elective or emergency)?
If caesarean	Reason? Classical or lower segment?
Labour	Spontaneous / induced? If induced, reason?
Baby's weight	Growth restriction or macrosomia?
Baby's condition	APGAR, admitted to NICU?
Complications in pregnancy	Pre-eclampsia, GDM, APH, PPH, IUGR, infection?
Complications in labour	Prolonged labour, cord prolapse, shoulder dystocia?
Postpartum	PPH (how much blood loss?), infections, wound breakdown, perineal tears?
Neonatal outcome	Is the child alive and well?

4. Contraceptive & Fertility History

Current contraception?
Past methods and reasons for stopping?
Any difficulties conceiving (primary or secondary infertility)?
Any fertility investigations or treatments?

🔹 PART 3: COMMON TO BOTH (Systematic Background History)

5. Past Medical History (PMH)

Specifically relevant conditions:

Diabetes (type 1/2 — or GDM in previous pregnancy)
Hypertension / cardiac disease
Thyroid disease (hypo/hyperthyroidism)
Coagulation disorders / thrombophilias (VTE risk in pregnancy)
Autoimmune conditions (SLE, APS — antiphospholipid syndrome)
Mental health conditions (depression, anxiety, bipolar — especially relevant postpartum)
Previous abdominal/pelvic surgeries (adhesions, fibroid surgery, ectopic treatment)
Cervical smear abnormalities / gynaecological procedures (LLETZ, cone biopsy)
Sexually transmitted infections

6. Drug History (DH)

Ask about:

Prescribed medications — especially antiepileptics, antihypertensives, anticoagulants, steroids, immunosuppressants
Contraceptives (current and past — OCP, IUD, implant, injection, patch, ring)
Folic acid / prenatal vitamins (in pregnancy)
OTC medications and herbal supplements
Allergies — document drug and nature of reaction

7. Family History (FH)

Particularly relevant:

Ovarian cancer (BRCA1/BRCA2 mutations)
Breast cancer (hereditary syndromes)
Cervical cancer
Endometrial/colon cancer (Lynch syndrome)
Diabetes (GDM risk)
Hypertension / pre-eclampsia (familial risk)
Thrombophilias (DVT/PE family history)
Congenital anomalies (chromosomal or structural)
Twin pregnancies (zygosity — maternal side = dizygotic risk)

8. Social History (SH)

Domain	Key Questions
Occupation	Type of work; exposure to toxins, radiation, heavy lifting (esp. in pregnancy)
Living situation	Who does she live with? Support network?
Relationship status	Partner? Supportive?
Domestic violence	Ask directly and privately: "Do you feel safe at home?"
Smoking	Pack-years; current or ex-smoker
Alcohol	Units per week; binge drinking (teratogenesis)
Recreational drugs	Type, frequency; especially cocaine (placental abruption), opioids
Diet / nutrition	Folic acid intake, iron deficiency
Travel	Malaria risk, Zika virus exposure (in pregnancy)
Country of origin	FGM risk, haemoglobinopathy screening (sickle cell/thalassaemia)
Financial/social concerns	Housing instability, asylum status (impacts antenatal care access)

9. Systems Review (SR)

Complete a brief systemic enquiry:

CVS: Chest pain, palpitations, SOB, leg swelling (DVT/PE in pregnancy)
Respiratory: SOB, wheeze (asthma)
GI: Nausea, vomiting (hyperemesis gravidarum), constipation, change in bowel habit
Urological: UTI symptoms (frequency, dysuria), haematuria, incontinence
Neurological: Headache, visual disturbance, seizures (eclampsia)
Skin: Pruritis (obstetric cholestasis — severe itch in 3rd trimester, especially palms/soles)
Musculoskeletal: Pelvic girdle pain, symphysis pubis dysfunction

🔹 PART 4: Emergency / Focused Ob/Gyn History (SAMPLE)

When time is limited (e.g., A&E, labour ward):

Letter	Meaning
S – Signs & Symptoms	What is the presenting complaint?
A – Allergies	Any known allergies?
M – Medications	What medications is she on?
P – Past medical history	Relevant conditions; previous pregnancies
L – Last oral intake	When did she last eat/drink? (Pre-operative relevance)
E – Events	What led to this presentation?

🔹 Summary Table: What's Unique to Each History

Feature	Gynaecology Only	Obstetrics Only	Both
Key focus	Menstrual, discharge, sexual health, smear	Current pregnancy, previous pregnancies, fetal wellbeing	PMH, DH, FH, SH
Special questions	LMP, IMB, PCB, PMB, dyspareunia	G/P status, EDD, movements, antenatal care	Domestic violence, smoking, alcohol
Red flags	PMB, PCB, pelvic mass	Reduced fetal movements, bleeding in pregnancy, hypertension	New onset headache, visual changes

Sources: Berek & Novak's Gynecology (16th ed.), p. 54–55; Geekymedics.com Obstetric History Taking OSCE Guide; TeachMeObGyn Gynaecological History (updated Dec 2024)

In obstetrics

Asking for Preferences

In obstetrics: labour section, C section and then postnatal sections each separately what to ask in detail

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Obstetric History Taking: Labour, Caesarean Section & Postnatal — Each in Detail

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SECTION 1: LABOUR HISTORY

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This applies when a patient presents in labour, or when you are documenting a previous labour as part of her obstetric history.

📋 A. Background / Context First

Always establish these before exploring labour:

Question	Why it matters
Gravida / Parity (G_P_)	First labour vs. experienced; affects progress expectations
Gestational age at onset of labour	Term (37–42 wks), preterm (<37), post-dates (>42)
Was this pregnancy singleton or multiple?	Twins/higher order = higher risk labour
How was the pregnancy booked and where?	Community midwife, hospital, unbooked?
Any antenatal complications?	Pre-eclampsia, GDM, IUGR, placenta praevia, polyhydramnios

📋 B. Onset of Labour

Question	Details to probe
Was labour spontaneous or induced?	If induced — what was the indication? (post-dates, pre-eclampsia, IUGR, GDM, SROM, patient choice?)
Method of induction (if induced)	Prostaglandins (PGE2 gel/pessary), balloon catheter, ARM (artificial rupture of membranes), Syntocinon (oxytocin) infusion?
Date and time labour started	Duration of labour calculated from here
How did labour begin?	Show (bloody mucus plug)? Contractions? Spontaneous rupture of membranes (SROM)?

📋 C. Rupture of Membranes (ROM)

Question	Details
Spontaneous or artificial (ARM)?	ARM done by whom and when?
Time of membrane rupture	Duration from rupture to delivery = important (>18–24 hrs = infection risk)
Character of liquor (amniotic fluid)	Clear? Meconium-stained? Bloodstained? Foul-smelling?
Meconium grading	Thin/light meconium vs. thick/fresh meconium (fetal distress indicator)
Pre-term PROM (PPROM)?	Rupture before 37 weeks — management changes significantly

📋 D. The Stages of Labour

Stage 1 (Cervical dilation: 0 → 10 cm)

Question	Details
Latent phase duration	Up to 4 cm dilation; prolonged latent phase = >20 hrs (nullipara), >14 hrs (multipara)
Active phase progress	Expected ≥0.5 cm/hr (WHO); was progress normal?
CTG (Cardiotocograph)	Used? Any concerns (decelerations, reduced variability)?
Cervical assessments (VEs)	How many done? What was the cervical score (Bishop score on admission)?
Pain relief used	Entonox (gas and air), pethidine/diamorphine, epidural (regional analgesia), TENS?
Epidural	When sited? Any complications (hypotension, patchy block, dural tap)?
IV access / fluids	IV line in situ? Any IV antibiotics (e.g., Group B Strep prophylaxis, post-SROM)?
Maternal observations	BP, pulse, temperature monitored? Any pyrexia in labour? (Chorioamnionitis?)
Augmentation	Was Syntocinon (oxytocin) used? Dose and reason?
GBS status	Was Group B Streptococcus swab positive? Was prophylaxis given?

Stage 2 (Full dilation → Delivery of baby)

Question	Details
Duration of Stage 2	Normal: <2 hrs nullipara, <1 hr multipara (with pushing); with epidural, add 1 hr
Prolonged Stage 2?	Was it exceeded? What action was taken?
Position of baby	Cephalic (head first)? Occipito-anterior (OA), occipito-posterior (OP), occipito-transverse (OT)?
Rotation	Was manual rotation or Kielland's forceps needed for OP/OT?
Pushing	Directed pushing vs. passive descent (especially with epidural)?
Mode of delivery	Spontaneous vaginal delivery (SVD)? Instrumental? Caesarean?

If Instrumental Delivery:

Question	Details
Instrument used	Ventouse (vacuum) or forceps (Neville Barnes, Kielland's, Wrigley's)?
Indication	Fetal distress (CTG changes), maternal exhaustion, failure to progress, cord prolapse?
Grade of operator	Senior registrar / consultant?
Number of pulls / cup detachments	Failed instrument = proceed to LSCS
Complications	Scalp laceration (ventouse), facial bruising, facial nerve palsy (forceps)?

Stage 3 (Delivery of placenta)

Question	Details
Management	Active (Syntocinon/Syntometrine given IM) or physiological (expectant)?
Placenta delivery	Complete? Time taken?
Retained placenta	Needed manual removal under GA/spinal?
Cord traction complications	Cord avulsion? Uterine inversion?
Blood loss	Estimated blood loss (EBL) at delivery — PPH defined as >500 mL (vaginal) or >1000 mL (CS)
Primary PPH?	Uterine atony, trauma, retained products, coagulopathy (the 4 T's: Tone, Trauma, Tissue, Thrombin)?

📋 E. Perineum / Genital Tract

Question	Details
Perineal trauma	Intact perineum? Episiotomy? Tear?
Degree of tear	1st (skin only), 2nd (muscle), 3rd (anal sphincter involved), 4th (into rectum)
Episiotomy	Mediolateral (preferred in UK) or midline? Reason?
Repair	Who repaired? Continuous vs. interrupted sutures? Under what analgesia?

📋 F. Immediate Maternal Outcome

Question	Details
Total duration of labour	From onset of regular contractions to delivery
Blood transfusion needed?	How many units?
Transfer to HDU/ITU?	Why?
Any sepsis features?	Pyrexia >38°C in labour, tachycardia, offensive liquor?
Maternal satisfaction	How did the patient feel about her birth experience?

📋 G. Immediate Neonatal Outcome

Question	Details
Birth weight	In grams/kg — SGA (<10th centile), AGA, LGA (>90th centile)?
Sex of baby	Male / female / intersex?
APGAR scores	At 1 minute and 5 minutes (0–10 scale; <7 = concern)
Resuscitation needed?	Bag-mask ventilation? Intubation? Chest compressions?
Admission to NICU/SCBU?	Reason? Duration?
Cord pH	If taken — acidosis (pH <7.2) indicates perinatal asphyxia
Meconium aspiration?	If meconium in liquor, was baby's airway suctioned?
Skin-to-skin?	Was immediate skin-to-skin contact achieved?
Vitamin K given?	IM or oral (important for HDN prevention)

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SECTION 2: CAESAREAN SECTION HISTORY

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This applies when asking about a previous CS or when a patient presents for/after CS.

📋 A. Reason / Indication for CS

This is the most important single question. Always clarify whether:

Category	Examples
Elective (planned) CS	Previous CS (LSCS ×1 or ×2), placenta praevia, breech presentation at term, maternal request, HIV/HSV infection
Emergency CS	Fetal distress, failed induction, failure to progress, cord prolapse, abruption, uterine rupture, eclampsia, transverse lie in labour

Grades of Emergency CS (NICE classification):

Grade	Meaning
Grade 1	Immediate threat to life of mother or fetus — delivery within 30 minutes
Grade 2	Maternal/fetal compromise, not immediately life-threatening — within 75 minutes
Grade 3	Needing early delivery, no immediate compromise
Grade 4	Elective — at a time to suit mother and team

Ask: "Was it planned or was it an emergency? If emergency, was it urgent or did there seem to be time?"

📋 B. Type of Uterine Incision

Type	Details
Lower segment CS (LSCS)	Standard — transverse (Pfannenstiel) abdominal incision + transverse lower uterine incision
Classical CS	Vertical uterine incision — used for preterm, transverse lie, placenta praevia anterior — higher rupture risk in future
J/T incision	Extension of LSCS incision if inadequate space

Critical for future pregnancies: Always ask the type of uterine incision — a classical scar carries ~5–10% rupture risk in labour vs. <1% for LSCS.

Ask: "Do you know what type of cut was made on your womb?" / Check operative notes.

📋 C. Number of Previous CS

Number	Clinical significance
1 previous LSCS	May attempt VBAC (Vaginal Birth After Caesarean) — discuss with patient
2 previous LSCS	VBAC relatively contraindicated; elective repeat CS usually recommended
≥3 previous CS	High risk of placenta accreta spectrum; morbidly adherent placenta

Ask: "How many caesarean sections have you had in total?"

📋 D. Anaesthesia Used

Type	Details
Spinal anaesthesia	Most common for elective CS — rapid onset, good block
Epidural top-up	If epidural already in from labour — extended for CS
General anaesthesia (GA)	Emergency, failed spinal, patient refusal of regional — higher maternal risk

Ask: "Were you awake or asleep during the operation?" / "Did you have an injection in your back?"

Any complications?

Spinal: hypotension, post-dural puncture headache (PDPH), high block
GA: failed intubation, aspiration, awareness

📋 E. Intraoperative Details

Question	Details
Who performed the CS?	Consultant / registrar / trainee under supervision?
Difficulty of surgery	Easy / difficult — were there adhesions from previous surgery?
Estimated blood loss	>1000 mL = major haemorrhage
Blood transfusion required?	Units given?
Uterine incision extension?	Did the incision tear laterally (J or T extension)?
Bladder injury?	Particularly at repeat CS — bladder may be adherent
Bowel injury?	Rare but serious — especially with dense adhesions
Placenta accreta/increta/percreta?	If suspected preoperatively — was hysterectomy needed?
Concurrent procedures	Tubal ligation (sterilisation)? Myomectomy?
Sutures used	Single vs. double-layer uterine closure — affects future scar integrity
Skin closure	Suture / staples / clips?

📋 F. Postoperative Course After CS

Question	Details
Time in recovery	Any hypotension, excessive bleeding, pain?
Pain management	Morphine PCA / IV/IM opioids, NSAIDs, paracetamol — adequate analgesia?
Mobilisation	When did she first mobilise? (Early mobilisation reduces DVT risk)
Urinary catheter	How long in situ? (Usually removed at 12–24 hrs post-CS)
VTE prophylaxis	LMWH (e.g., enoxaparin) given? TED stockings?
Wound	Any signs of infection, breakdown, haematoma, seroma?
Ileus	Any delayed return of bowel function?
Fever	Endometritis? Wound infection? UTI? DVT?
Length of stay	Standard 2–3 days — any extended stay?
Discharge medications	Iron, analgesia, LMWH for how long?

📋 G. Implications for Future Pregnancies

Issue	Ask about
VBAC counselling received?	Was she told about risks/benefits of trial of labour vs. repeat CS?
Uterine rupture risk	Counselled on signs (sudden abdominal pain, fetal distress, haematuria)?
Placenta accreta spectrum	In subsequent pregnancy — USS for placental site — especially anterior low-lying?
Scar ectopic	Pregnancy implanted in CS scar — life-threatening
Interval between pregnancies	Recommended minimum 18–24 months before next pregnancy after CS

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SECTION 3: POSTNATAL HISTORY

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This covers the puerperium — conventionally the first 6 weeks after delivery. Subdivide into maternal and neonatal.

📋 A. Establish the Context

Question	Details
Date and mode of delivery	SVD / instrumental / CS?
Gestational age at delivery	Term / preterm?
Where delivered?	Hospital / home / en route?
Current day postpartum	Day 1 vs. week 4 — very different concerns

📋 B. MATERNAL POSTNATAL HISTORY

B1. Lochia (Postnatal Vaginal Loss)

Question	Details
Amount	Heavier than a normal period? Soaking pads?
Colour progression	Red (lochia rubra, days 1–4) → pink/brown (lochia serosa, days 5–9) → white/yellow (lochia alba, days 10–6 weeks) — is this occurring normally?
Offensive smell?	Suggests endometritis / retained products of conception (RPOC)
Clots?	Large clots may indicate retained products
Sudden heavy bleeding?	Secondary PPH (after 24 hrs, typically from RPOC or endometritis)

B2. Uterine Involution

Question	Details
Abdominal pain / afterpains	Expected for 2–3 days especially in multiparous women and breastfeeders
Uterine tenderness	Exquisite tenderness = endometritis (fever + offensive lochia + tender uterus)
Subinvolution	Uterus remaining large and boggy — suggests RPOC or infection

B3. Wound / Perineum

Question	Details
Perineal wound (if vaginal delivery)	Pain level, healing well? Haematoma? Wound breakdown?
Wound infection signs	Redness, swelling, discharge, dehiscence (breakdown)
Difficulty sitting / walking	Indicates significant perineal trauma or haematoma
CS wound (if applicable)	Pain, redness, discharge, breakdown?
CS scar	Numbness, keloid, scar ectopic risk in future

B4. Bladder & Bowel Function

Question	Details
Voiding urine	When first voided after delivery? Any retention (especially post-epidural, post-CS)?
Urinary incontinence	Stress incontinence (leaks with cough/laugh/exercise) — extremely common postnatal
Dysuria	UTI common postnatally
Bowels opened	When first opened post-delivery? Constipation?
Faecal incontinence	Especially relevant after 3rd/4th degree tears
Haemorrhoids	Very common postnatally

B5. Venous Thromboembolism (VTE) — DO NOT MISS

Postnatal period = highest VTE risk period of a woman's life.

Question	Details
Calf pain / swelling / redness?	DVT — especially after CS (highest risk)
Chest pain / shortness of breath?	PE — can be rapidly fatal
LMWH being taken?	Prescribed on discharge? Compliance?
TED stockings used?	Especially post-CS
Immobility	How mobile is she?

B6. Fever / Infection

Postnatal fever workup — think "5 Ws" (Wind, Water, Wound, Walking/DVT, Wonder drugs — though in modern practice use:)

Day	Common cause
Day 1–2	Atelectasis / physiological (breast engorgement)
Day 2–3	UTI, wound infection
Day 3–5	Endometritis, breast engorgement
Day 5+	Wound abscess, pelvic abscess, septic pelvic thrombophlebitis, mastitis

Ask:

Fever — temperature >38°C? When? How high?
Rigors?
Any wound / perineal pain / redness?
Offensive lochia?
Breast tenderness / hardness?
Urinary symptoms?

B7. Breastfeeding

Question	Details
Breastfeeding or formula feeding?	Patient's choice respected
If breastfeeding: latch?	Good latch established? Baby feeding well?
Nipple pain / cracks?	Common — poor latch usually the cause
Breast engorgement?	Painful engorgement peaks at 72–96 hours postpartum
Mastitis?	Unilateral breast pain + redness + fever = mastitis (Staph aureus) → needs antibiotics
Breast abscess?	Fluctuant mass — may need aspiration or I&D
Milk supply concerns?	Worried she's not producing enough?
Galactorrhoea / inhibition?	If not breastfeeding — has she been given cabergoline to suppress?

(Source: Creasy & Resnik, Issues in the Postpartum Period)

B8. Mental Health — CRITICAL, often under-asked

Condition	Timing	Questions
Baby blues	Days 3–5, self-limiting	Feeling tearful, emotional, overwhelmed — normal
Postnatal depression (PND)	Any time up to 1 year	Low mood >2 weeks, anhedonia, poor bonding, guilt, fatigue — Edinburgh Postnatal Depression Scale (EPDS ≥13 = screen positive)
Postpartum psychosis	Day 1–2 (acute onset)	Hallucinations, delusions, confusion, mania — psychiatric emergency
PTSD	Any time	After traumatic birth — flashbacks, nightmares, avoidance

Ask:

"How are you feeling in yourself emotionally?"
"Are you managing to bond with your baby?"
"Are you having any frightening thoughts?"
"Are you getting any support at home?"
"Have you had any thoughts of harming yourself or your baby?" (ask directly if concern)

B9. Resuming Normal Activities

Question	Details
Driving	After vaginal delivery: when ready; after CS: usually 6 weeks (UK DVLA guidance)
Return to intercourse	Usually advised to wait until lochia stopped and wound healed (~6 weeks)
Contraception	Has she been counselled? Ovulation can return from 3 weeks (sooner if not breastfeeding). Options: POP (safe while breastfeeding), COCP (not until 6 weeks post-delivery), IUD, implant
Return to work	Plans? Statutory maternity leave?

📋 C. NEONATAL POSTNATAL HISTORY

(Ask as part of the postnatal consultation)

Domain	Questions
Birth weight	Regained birthweight by day 10? (Expected 5–10% weight loss initially)
Feeding	Breast / formula / mixed? Feeding well?
Jaundice	Yellow skin/eyes? When started? (Physiological: days 2–5; pathological if <24 hrs = haemolytic)
Umbilical cord	Stump — clean and dry? Any discharge / redness (omphalitis)?
Bowels / urine	Passed meconium? First urine?
Vitamin K	Given IM (1 mg) at birth?
Newborn bloodspot screening	'Heel prick' test done (day 5)? Tests for: PKU, hypothyroidism, cystic fibrosis, sickle cell, MCADD
Newborn hearing screening	Passed? Referred?
Newborn physical examination	Done? Any concerns (heart murmur, hip instability, undescended testes)?
Any NICU admission?	Duration, reason, treatment?
Parental concerns	Any parental worries about the baby?

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QUICK REFERENCE SUMMARY

═══════════════════════════════════════

Section	Key Domains
Labour	Spontaneous vs. induced → onset → contractions → ROM → progress of stages → pain relief → CTG → mode of delivery → 3rd stage → perineum → neonatal outcome
Caesarean Section	Indication + grade (elective/emergency) → type of uterine incision → anaesthesia → intraoperative complications → postoperative recovery → implications for future pregnancies
Postnatal	Maternal: lochia, involution, wound, bladder/bowel, VTE, infection, breastfeeding, mental health, contraception; Neonatal: weight, jaundice, feeding, screening, parental concerns

Sources: Creasy & Resnik's Maternal-Fetal Medicine (8th ed.); Berek & Novak's Gynecology (16th ed.); Merck Manual Obstetric & Gynaecologic History (revised March 2024); TeachMeObGyn Obstetric History (updated Dec 2024)

Now write me example cases in each section from biodata to the end??

Here are three fully worked example cases — one for each section — written exactly as they would appear in clinical notes, from biodata through to the end.

CASE 1: LABOUR HISTORY

🪪 BIODATA


Name	Mrs. Amina Yusuf
Age	27 years
Occupation	Primary school teacher
Address	14 Greenfield Road, Manchester
Marital Status	Married
Religion	Muslim
Date of Admission	05/05/2026
Time	02:30 hrs
Referred by	Community midwife

PRESENTING COMPLAINT

"I have been having strong pains every 3–4 minutes for the last 5 hours and I think my waters have broken."

HISTORY OF PRESENTING COMPLAINT

Mrs. Yusuf is a 27-year-old woman, G2P1, currently at 39+2 weeks gestation by dating USS (confirmed at 12-week scan), who presents to the delivery suite with a 5-hour history of regular, painful uterine contractions occurring every 3–4 minutes, each lasting approximately 45–60 seconds.

She reports a sudden gush of clear fluid from the vagina approximately 2 hours ago, which she believes represents spontaneous rupture of membranes (SROM). The liquor is described as clear with no offensive odour and no meconium staining. There has been a small amount of fresh blood-stained mucus (show) but no heavy vaginal bleeding.

Contractions are described as cramping, suprapubic and lower back pain, radiating to the inner thighs. Pain scores 7/10 at peak contraction. She reports adequate fetal movements throughout the day — greater than 10 movements in 24 hours, with no subjective reduction.

She denies:

Headache, visual disturbance, or facial swelling (no features of pre-eclampsia)
Epigastric pain
Urinary symptoms (no dysuria, frequency, haematuria)
Fever, chills, or rigors
Diarrhoea

OBSTETRIC HISTORY

Gravida 2, Para 1 (+0)

Previous Pregnancy (2023):

Spontaneous vaginal delivery at 40+1 weeks
Spontaneous onset of labour
Membranes ruptured artificially (ARM) at 7 cm dilation
Clear liquor
Epidural analgesia used
Stage 2 lasted 45 minutes — OA position
Delivered SVD — baby girl, weight 3.2 kg
APGAR 9 at 1 min, 10 at 5 min
Active management of 3rd stage — Syntometrine IM
Estimated blood loss: 300 mL
2nd degree perineal tear — repaired with continuous absorbable sutures
No neonatal or maternal complications
Baby is alive and well

Current Pregnancy:

Booking appointment at 9 weeks at City Hospital
Combined first trimester screening (nuchal translucency + blood tests): low risk
20-week anomaly scan: normal, no structural anomalies identified
Blood group: O positive, antibody screen negative
Haemoglobin at booking: 12.4 g/dL; repeated at 28 weeks: 11.8 g/dL (started on oral ferrous sulphate)
GBS swab at 35 weeks: negative
No antepartum complications — no hypertension, no GDM, no IUGR on serial scans
Fetal presentation confirmed cephalic at 36 weeks clinic

MENSTRUAL HISTORY

LMP: 30/07/2025 (confirmed by 12-week USS dating: EDD 06/05/2026)
Regular cycles prior to pregnancy — 28-day cycle, 5 days duration
No history of dysmenorrhoea or menorrhagia

PAST MEDICAL HISTORY

Iron deficiency anaemia (currently on treatment)
No diabetes, hypertension, thyroid disease, epilepsy, or cardiac disease
No previous surgeries other than perineal repair (2023)

DRUG HISTORY

Ferrous sulphate 200 mg TDS (for anaemia)
Folic acid 400 mcg OD (taken first trimester, now stopped)
No known drug allergies (NKDA)

FAMILY HISTORY

Mother: type 2 diabetes mellitus
Father: hypertension
No family history of twins, congenital anomalies, haemoglobinopathies, or thromboembolic disorders

SOCIAL HISTORY

Married, lives with husband and one child
Non-smoker, no alcohol, no recreational drugs
Good support network — husband and mother both present
Maternity leave commencing from date of delivery
No domestic violence concerns — seen alone briefly and asked sensitively; denied

REVIEW OF SYSTEMS

CVS: No palpitations, chest pain, ankle oedema beyond normal pregnancy swelling
Respiratory: No SOB at rest; mild exertional SOB in 3rd trimester (normal for gestation)
GI: Mild heartburn, managed with Gaviscon; no vomiting; constipation managed with lactulose
Urological: No dysuria; no haematuria; no urinary incontinence
Neurological: No headache, no visual disturbance, no fitting
Skin: No pruritis (no obstetric cholestasis)

SUMMARY / CLINICAL IMPRESSION

Mrs. Amina Yusuf is a 27-year-old G2P1 woman at 39+2 weeks in spontaneous labour with SROM producing clear liquor. She has no antenatal complications in this pregnancy and has a favourable obstetric history. She requires: admission to delivery suite, CTG monitoring, VE to assess cervical dilation and confirm presentation, and her anaemia should be noted in anticipation of blood loss at delivery.

CASE 2: CAESAREAN SECTION HISTORY

🪪 BIODATA


Name	Mrs. Fatima Al-Hassan
Age	34 years
Occupation	Accountant
Address	8 Park Avenue, Birmingham
Marital Status	Married
Religion	Islam
Date of Attendance	05/05/2026
Clinic	Obstetric Day Assessment Unit

PRESENTING COMPLAINT

"I am 36 weeks pregnant. I had two previous caesareans and I've been told I need to come in to discuss my delivery options."

HISTORY OF PRESENTING COMPLAINT

Mrs. Al-Hassan is a 34-year-old G3P2, attending the obstetric day assessment unit at 36+0 weeks gestation (confirmed by 12-week dating scan, EDD 01/06/2026) for counselling and birth planning in light of her previous two lower segment caesarean sections (LSCS).

She reports the pregnancy has been uncomplicated. She denies contractions, vaginal bleeding, reduced fetal movements, headache, visual disturbance, or epigastric pain. She is anxious about delivery and has questions about her options.

PREVIOUS OBSTETRIC HISTORY

Gravida 3, Para 2 (+0)

Pregnancy 1 (2018) — Emergency LSCS:

Gestation at delivery: 40+4 weeks
Induced at 40+0 weeks (post-dates) with PGE2 gel
Progress of labour: latent phase adequate; active phase arrested at 7 cm after 14 hours despite Syntocinon augmentation
Indication for CS: failure to progress (grade 2 emergency)
Anaesthesia: spinal (uncomplicated)
Uterine incision: lower transverse (Pfannenstiel) — confirmed in operative notes
Estimated blood loss: 700 mL; no transfusion required
Baby: boy, 3.85 kg, APGAR 9/10 — no NICU admission
Postoperative: uncomplicated; discharged day 3
LMWH given for 10 days post-CS

Pregnancy 2 (2022) — Elective LSCS:

Gestation at delivery: 39+0 weeks
Indication: previous LSCS + patient declined VBAC after counselling
Grade 4 (elective, planned)
Anaesthesia: spinal (uneventful)
Uterine incision: lower transverse — documented in notes
Intraoperative findings: mild adhesions at bladder reflection — carefully dissected
No bladder or bowel injury
Estimated blood loss: 650 mL; no transfusion
Baby: girl, 3.4 kg, APGAR 10/10
Wound: healed well; no infection, no haematoma
Discharged day 3; LMWH for 10 days
No postoperative complications

Current Pregnancy (3rd — in progress):

Spontaneous conception
Booking at 8 weeks; all routine blood tests normal
Blood group: A positive, antibody screen negative
Haemoglobin: 12.9 g/dL at booking, 12.5 g/dL at 28 weeks
12-week scan: dichorionic appearance confirmed — singleton pregnancy confirmed
20-week anomaly scan: no fetal structural abnormality; placenta: posterior, upper segment — not praevia
GDM screen (OGTT at 28 weeks): normal
Serial growth scans from 32 weeks: fetal growth on 50th centile, no IUGR
No hypertension (BP consistently 118/72 mmHg)
Fetal movements: reported as normal throughout

KEY ISSUES IN THIS CASE

Issue	Detail
Two previous LSCS	VBAC is relatively contraindicated; repeat elective LSCS recommended
Uterine incision type	Both lower transverse — uterine rupture risk ~0.5–1% per labour (not planned)
Placenta location	Posterior upper segment — no accreta concern currently, but must be noted
Adhesions at previous CS	Documented; surgeon should be aware for 3rd CS
Anaesthetic risk	Third CS with adhesions — senior anaesthetist and surgeon required

MENSTRUAL HISTORY

LMP: 25/08/2025; regular 30-day cycles
EDD confirmed by 12-week USS: 01/06/2026

PAST MEDICAL HISTORY

No medical conditions
Two previous LSCS (as above)
No other surgeries

DRUG HISTORY

Pregnancy vitamins (folic acid + vitamin D)
No regular medications
NKDA

FAMILY HISTORY

Mother: hypertension, type 2 DM
Sister: had placenta praevia with previous CS — noted (↑ familial risk)
No inherited bleeding disorders, thrombophilias, or chromosomal conditions

SOCIAL HISTORY

Married, two children at home (ages 8 and 4)
Lives with husband; good family support
Non-smoker; no alcohol or recreational drug use
Financial: husband employed; patient on maternity leave
No domestic concerns
Patient is anxious about surgery — has been referred to obstetric anaesthetic pre-assessment clinic

REVIEW OF SYSTEMS

CVS: No chest pain, palpitations; mild pedal oedema (bilateral, normal for gestation)
Respiratory: No SOB at rest
GI: Reflux managed with omeprazole; no vomiting; normal bowels
Urological: Stress urinary incontinence (small leaks on sneezing) — ongoing since 2nd CS
Neurological: No headache, no visual symptoms
Haematological: No bruising, no petechiae; no prior VTE

SUMMARY / CLINICAL IMPRESSION

Mrs. Fatima Al-Hassan is a 34-year-old G3P2 woman at 36 weeks with two prior LSCS, both lower transverse incisions, and an uncomplicated current singleton pregnancy. Elective repeat LSCS at 39 weeks is the recommended delivery plan. Pre-operative preparation includes: consent for repeat LSCS with awareness of adhesion risk and possibility of extended operative time; group and save; senior surgeon/anaesthetist allocation; VTE prophylaxis plan; and discussion of sterilisation if desired.

CASE 3: POSTNATAL HISTORY

🪪 BIODATA


Name	Mrs. Grace Obi
Age	30 years
Occupation	Nurse
Address	22 Willow Lane, Leeds
Marital Status	Married
Religion	Christian
Date of Postnatal Visit	05/05/2026
Day Postpartum	Day 5
Mode of Delivery	Emergency LSCS (grade 2) at 39+5 weeks, 01/05/2026

PRESENTING COMPLAINT

"I have had a temperature since yesterday and my wound is quite sore. I'm also struggling with breastfeeding and I've been very tearful."

HISTORY OF PRESENTING COMPLAINT

Mrs. Grace Obi is a 30-year-old G1P1, presenting on day 5 postpartum for her community postnatal review. She delivered by emergency LSCS (grade 2 — fetal distress on CTG, category 2 decelerations with reduced variability at 7 cm dilation) on 01/05/2026 at 39+5 weeks. The CS was performed under spinal anaesthesia (uncomplicated). Uterine incision was lower transverse. Baby — boy — delivered in good condition.

She now presents with three days of a low-grade temperature (37.9–38.2°C), increasing wound pain, and breastfeeding difficulties. She has also been feeling very tearful and overwhelmed since day 3.

POSTNATAL HISTORY — MATERNAL

Lochia

Lochia was red (rubra) for the first 3 days, now transitioning to pink/brown (serosa) — normal progression
Volume: moderate — changing 3–4 pads per day
No clots, no sudden heavy bleeding
Mild offensive odour noted since day 3 ← important; suggests possible endometritis

Uterine Involution

Mild lower abdominal cramping (afterpains) for first 2 days — now resolved
Uterus mildly tender on palpation when asked about abdominal examination
No rebound tenderness

Wound (CS Scar)

Pfannenstiel incision — closed with subcuticular sutures
Wound: red, warm, and slightly swollen at the left end
Small amount of serous discharge from left edge — no frank pus yet
No wound dehiscence (breakdown)
Pain at wound: 6/10 at rest, 8/10 on mobilisation
Current analgesia: paracetamol 1 g QDS + ibuprofen 400 mg TDS — patient says "it's not enough"

Bladder and Bowel

Urinary catheter removed at 18 hours post-CS — voided well
Urinary frequency and dysuria for 2 days ← UTI needs to be excluded
No haematuria
Bowels not yet opened (day 5) — constipation; commenced on lactulose but not yet effective
No haemorrhoids
No faecal incontinence

VTE Assessment

LMWH (enoxaparin 40 mg SC OD) prescribed on discharge — has only taken 2 of 10 doses ("forgot and the needles hurt")
TED stockings given — currently wearing
No calf pain, redness, or swelling
No chest pain or dyspnoea
Reviewed VTE risk: CS + infection + limited mobility = HIGH RISK → reinforce LMWH compliance urgently

Fever / Infection Assessment

Temperature: 38.1°C on assessment today
Elevated since day 3
Offensive lochia + tender uterus + wound changes + urinary symptoms
Differentials: endometritis (most likely), wound infection, UTI, DVT
No respiratory symptoms, no breast engorgement on the affected side

Breastfeeding

Initiated breastfeeding within 2 hours of delivery (skin-to-skin achieved in theatre recovery)
Baby initially latching well
Bilateral breast engorgement since day 3 — breasts described as "rock hard and very painful"
Right nipple: cracked and bleeding — poor latch identified
Left nipple: sore but intact
No localised breast redness, hardness, or fever specifically from breast → mastitis not yet present
Baby weighed on day 4: birth weight 3.6 kg; lost 280 g (7.8%) — within acceptable range (<10%)
Referred to hospital lactation consultant; appointment arranged for today

Mental Health

Tearful since day 3 — describes crying "for no reason" at times
Feels overwhelmed, finding it difficult to sleep even when baby sleeps
Struggling to feel a connection with baby — reports: "I feel guilty because I don't feel what I expected to feel"
Denies hallucinations, delusions, confusion, or thoughts of harm to herself or baby
Husband supportive; mother visiting from day 7
Edinburgh Postnatal Depression Scale (EPDS) administered: score 11/30 — below threshold (≥13) for probable PND
Assessment: consistent with "baby blues" (day 3–5, self-limiting) — however close follow-up required; repeat EPDS at 6-week check

POSTNATAL HISTORY — NEONATAL

Domain	Detail
Baby name	Baby Obi (not yet named formally)
Sex	Male
Birth weight	3.6 kg
APGAR scores	8 at 1 minute, 10 at 5 minutes
Resuscitation	Brief facial O₂ given at delivery; no intubation
NICU admission	Not required
Feeding	Breastfed; taking 10–12 feeds per 24 hours; some feeds short (5 minutes each side) due to poor latch
Weight at day 4	3.32 kg (7.8% weight loss — acceptable; review at day 10 for regain of birthweight)
Jaundice	Mild yellowish tinge noted on day 4 — transcutaneous bilirubin measured: 145 μmol/L — below treatment threshold (177 μmol/L at this age); monitor
Umbilical cord	Drying and separating normally; no redness, discharge, or odour
Bowels/urine	Passed meconium day 1; yellow stools from day 3; adequate wet nappies (6+/day)
Vitamin K	1 mg IM given at birth ✓
Newborn bloodspot (heel prick)	Done day 5 today ✓
Newborn hearing screen	Passed bilateral ✓
Newborn physical exam (NIPE)	Completed by paediatrician day 1 — grade 1 hip click noted on left → referred for USS hips at 6 weeks
Parental concerns	Father worried about jaundice; counselled that mild physiological jaundice is expected; given advice on warning signs (deep yellow, not feeding, lethargic)

PAST MEDICAL HISTORY

No significant medical conditions
No previous surgeries prior to current CS

DRUG HISTORY

Ferrous sulphate 200 mg BD (postnatal — for blood loss at CS: EBL 900 mL)
Paracetamol 1 g QDS + ibuprofen 400 mg TDS (analgesia)
Enoxaparin 40 mg SC OD (VTE prophylaxis — 10-day course)
NKDA

FAMILY HISTORY

Mother: type 2 DM
No family history of neonatal jaundice, coagulation disorders, or thrombophilias

SOCIAL HISTORY

Married, husband present and supportive
Own home; ground floor bedroom temporarily as she struggles with stairs
Non-smoker; no alcohol; no recreational drugs
Plans to take full 12 months maternity leave
No financial concerns
No domestic concerns

SUMMARY / CLINICAL IMPRESSION

Mrs. Grace Obi is a 30-year-old G1P1 on day 5 following emergency LSCS presenting with:

Probable endometritis (fever + offensive lochia + tender uterus) → send high vaginal swab and endocervical swab, MSU; start co-amoxiclav or clindamycin + gentamicin per local protocol
CS wound cellulitis (early) → wound swab; augment oral antibiotics to cover wound; advise wound care; daily review
UTI query → MSU sent; start trimethoprim if uncomplicated pending culture
LMWH non-compliance → reinforce importance; provide sharps bin; consider community nurse to assist injections
Breastfeeding difficulties → lactation consultant referral today; cracked nipple care (nipple shields, lanolin); reassurance re: milk supply
Baby blues / early PND watch → supportive counselling; repeat EPDS at 6-week check; safety net given
Neonatal jaundice → monitor; repeat TcB in 24–48 hrs; advise on warning signs
Hip USS referral for baby → booked for 6 weeks

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