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HISTORY TAKING INOBSTETRICS

• Dr. S.Salih MRCOG,MOG,DFFP/RHC/RCOG CERTIFICATION
  INMINIMAL ACCESS SURGERY,COLPOSCOPY/GYN.U/S
  ,cONsultant-subsp. Obgyn,wsh
• DR. AISHA MANSOOR
• RES. OB/GYN

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History taking inobstetric

• Essential step.
• Type of questions change with gestation.
• Synopsis of a womens background risk.
• Account of the progress of her index pregnancy.
• Clinical guide to follow examination.

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how to take history

• Care and sensitivity.
• Purpose of visit.
• Sound clinical knowledge.
• Logical sequence.
• Avoid inadvertent omission of important details.
• Identify risks.

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ETIQUETTE

• Appearance.
• A polite introduction.
• Respect.
• Confidentiality and privacy.
• Language.

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Where to begin ?

• Make sure that patient is comfortable.
• Safe opening question.
• Ask purpose of visit. (routine / problem)

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framework

• Self preparation.
• Introduction.
• Achieve patients comfort.
• Establish smooth communication.
• Chronological concise history.
• Identify risks.
• Final summary.

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STEPS
PERSONAL SOCIAL HISTORY
MENSTRUAL OBSTETRICAL HISTORY
CONTRACEPTIVE HISTORY
PAST MEDICAL SURGICAL HISTORY
FAMILY HISTORY
DRUG HISTORY
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PERSONAL HISTORY

• Special habits
• Smoking
• Drug abuse
• Alcohol intake
• Domestic pets

• Name
• Age
• Nationality
• Occupation
• Marital status
• Address

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SOCIAL HISTORY

• Husband and his medical history.
• Economic status
• Working hours.
• Planning to continue work during pregnancy?
• Education intellectual level
• Residence
• (WC aeration crowding sunlight)
• Domestic violence

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Previous obstetrical history

• Total no. of previous pregnancies GRAVIDA
• Order of current pregnancy.
• Outcome of each pregnancy.
• Delivery gt 20wks. PARITY
• Miscarraige lt 20 wks.

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Previous obstetrical history

• G. P.
• Para a b ( adelivery, bmiscarrage )
• Para a b c d
• a full term
• b preterm
• c Miscarraige
• d living

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Previous obstetrical history

• For each pregnancy ask
• Antenatal complication
• Place of delivery
• Onset of labour
• Mode of delivery
• Maturity
• Neonatal sex, birth weight, outcome.
• Postnatal complication.
• Breast feeding

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Previous obstetrical history

• Recurrent miscarraige (early / late?)
• IUGR
• Preterm delivery
• IUFD
• Early onset pre-eclampsia
• Abruption
• Congenital abnormalities
• Un-explained stillbirth

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Current pregnancy

• Validation of dates.
• L.M.P Regular cycles, Surety of date.
• If unavailable, dating by early scan.

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Past medical surgical history

• Diabetes mellitus
• Hypertension
• asthma
• Renal disorders
• Hepatic disorders.
• Hypothyroidism
• Epilepsy
• Autoimmune disorders
• Coagulation defects
• Psychiatric problems

• Previous surgery
• Gynecological surgeries
• Hospital admission
• Blood transfusion

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Weight gain obesity
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Drug history

• History of any known allergies
• Use / abuse of drugs.
• Need for dose adjustment

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Family history

• Hereditary illnesses
• Congenital defects
• Need for counseling
• Timely investigations.

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CONCLUSION

• Final summary include the silent details that
  will impact on investigations to be carried out
  and the proposed plan of management.

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