The Obstetric History and Examination

and Paula Briggs2

(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
 

Obstetric History

When taking an obstetric history, commence with the gynaecological history, as described in Chap. 4. Then expand on the details of pregnancies and confinements.
For each pregnancy document whether it:
  • Ended in a live birth
  • Gestation at delivery
  • Duration of labour
  • Any complications
  • Normal delivery, assisted delivery (forceps or venteuse), or Caesarean Section (CS). If CS then what was the reason?
  • Any post natal problems e.g. post partum haemorrhage, infection, thrombosis
  • Breast fed and for how long
For this pregnancy:
  • Last Normal Menstrual Period (LNMP)
  • Whether the cycles prior to conception were regular
  • Any complications e.g. bleeding, nausea and vomiting, infection etc.
The woman’s history should be organised in the following way:
Age
Gravidity/parity
Gestation
The woman’s previous obstetric history: if this is simple, present as a summary/if it is complicated, present it chronologically
The history of this pregnancy: if simple summarise/if complicated list chronologically
Example of a simple history:
Mrs x, 28 years old
G 3 P2
32 weeks of gestation
Her two previous pregnancies resulted in normal deliveries near term
This pregnancy has been uneventful except for an episode of bleeding at 11 weeks
Example of a complicated history:
Mrs Y, 28 years old
G5 P2
32 weeks of gestation
Her first pregnancy, at the age of 21, ended in an early pregnancy loss at 8 weeks, requiring curettage.
Her second pregnancy, at the age of 23, resulted in an emergency CS for an antepartum haemorrhage at 34 weeks, resulting in a healthy baby.
Her third pregnancy, at the age of 25, resulted in a tubal ectopic pregnancy requiring surgery at 8 weeks.
Her fourth pregnancy, ended in an elective CS at 38 weeks with a healthy baby.
The current pregnancy has been complicated by bleeding between 6 and 9.

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Sep 23, 2016 | Posted by in OBSTETRICS | Comments Off on The Obstetric History and Examination

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