Obstetrics and Gynecology/Obstetric History Taking

Obstetric history taking involves a series of methodical questioning of an obstetric patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further investigative testing or treatment of a diagnosed condition.

There is a basic structure for all obstetric histories but this can differ slightly depending on the presenting complaint. Because of the nature of obstetrics there may not even be a presenting complaint. Expectant mothers receive antenatal check-ups and therefore may be referred because of the result of an examination or an investigation so the mother may be asymptomatic.

When taking any history in medicine it is essential to understand what the presenting complaint means (if any) and what the possible causes (differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning

Basic Structure of an Obstetric History
Ascertain Presenting Complaint History of Presenting Complaint Past Obstetric History Menstrual History Past Medical History Drug History Family History Social History Other
 * Name of patient
 * Age of patient
 * Consent for questioning
 * It is important to ask as open a question as possible in this part of the history and to ensure the complaint is understood as everything else follows on from here
 * This will differ slightly depending on the presenting complaint (see below) but follows a vague structure:
 * Onset
 * Periodicity
 * Duration
 * Recurrence?
 * Gravidity and Parity
 * Dates of deliveries
 * Length of pregnancies
 * Induction of labor/Spontaneous
 * Normal Delivery?
 * Weight of babies
 * Gender of babies
 * Complications before, during and after delivery
 * 1st day of last menstrual period
 * Regularity of normal cycle
 * Was this a planned pregnancy?
 * Previous contraception
 * Any antenatal problems thus far?
 * Current or past illnesses
 * Hospital admissions
 * Past surgeries
 * Prescribed medications
 * Non-prescribed medications/herbal remedies
 * Recreational drugs
 * Medical conditions
 * Obstetric complications
 * Occupation
 * Support network
 * Smoking
 * Alcohol
 * Blood group