History Taking in Obstetrics

This should be a brief sentence explaining why the patient has come to the hospital. There may be multiple presenting complaints, which should be mentioned in chronological order with their duration.

For example:

• 8 months amenorrhea (LMP, EDD, EGA)
• Bleeding per vaginam of 2-hour duration

Check here for common obstetric symptoms and how to clerk them.

In some cases, there may be no presenting complaints. The patient may have come for antenatal clinic (ANC) booking or a routine antenatal follow-up visit.

If there is more than one complaint, explore each individually. Also, inquire about other problems that have occurred since the onset of pregnancy and any treatment received.

The 5Cs Approach

The 5Cs can be used to explore the presenting complaints:

• Characterize each symptom.
• Course – Describe the progression of symptoms.
• Cause – Ask questions to rule out differentials and identify likely causes.
• Complications – Consider complications of the suspected disease process and their impact on the patient’s quality of life.
• Care received so far – Include care at home, at a referral center, and since admission.

Keep relevant differential diagnoses in mind and mention significant negatives. For example, stating that a reproductive-age woman with acute abdomen is not sexually active can help rule out certain conditions.

The SOCRATES Acronym

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in detail. While it is most commonly used for pain assessment, it can also be applied to other symptoms (though some elements may not be relevant to all symptoms).

• Site – Where is the symptom located?
• Onset – When did it start, and was it sudden or gradual?
• Character – What is the nature of the symptom (e.g., sharp, dull, burning)?
• Radiation – Does it spread to other areas?
• Associated symptoms – Any other symptoms present?
• Time course – How has it changed over time?
• Exacerbating and alleviating factors – What makes it worse or better?
• Severity – How bad is it on a scale of 1 to 10?

General

• Was the pregnancy desired/planned? Was it spontaneously conceived or through ARTs?
• How was the pregnancy suspected and what method was used for confirmation?
• Gestational age (GA) at confirmation.
• Is it a singleton or multiple pregnancy?
• Is the patient booked? If yes, where, when, and GA at booking? If not, why?
• Indication at booking.
• Total ANC visits.
• Tetanus toxoid – GA at which it was received and number of doses.
• Intermittent preventive treatment (IPT) – GA at which it was received, number of doses, and drug used.
• Hematinics use – folic acid, fersolate.

Rule Out Possible Problems From Each Trimester

History Of First Trimester

Possible Problems:

• Bleeding, pain (ectopic pregnancy, miscarriage).
• Vaginal discharge.
• Hyperemesis.
• Urinary problems.

Investigations Done:

• Any tests conducted to confirm or rule out conditions.

Medications Used For Treatment:

• Any drugs taken to manage symptoms or conditions.

History Of Second And Third Trimesters

• Fetal movement.
• GA at first fetal movement.
• General health – sleep, diet, bowel movements.
• Symptoms of anemia, miscarriage, ectopic pregnancy, vaginal discharge, UTI, hyperemesis gravidarum.
• Symptoms of APH, PIH, DM, preterm labor.

Results Of Antenatal Investigations

• Blood pressure.
• Urinalysis.
• Blood group.
• Genotype.
• PCV, FBC.
• Viral markers – HBsAg, Anti-HBC, LVS, VDRL.
• Ultrasound scans – latest done.

The patient may not know all the details, so ask if results were normal.

If She Is Postnatal

• Intrapartum and postpartum complications.

Details Of All Previous Pregnancies

• Miscarriages and terminations.
• Live births.
• Date (month/year).
• Mode of delivery – spontaneous vaginal, assisted vaginal, or caesarean.
• Gender of the baby.
• Birth weight.
• Any significant antenatal, intrapartum, or postpartum events/complications – pre-eclampsia, pregnancy-induced hypertension, gestational diabetes, postpartum hemorrhage.
• If the mother is not aware of previous perinatal complications, ask how soon she went home with the baby after delivery.
• Quality of care provided and type of health center.
• Assisted reproductive therapies (ART) – e.g., induction of ovulation with clomiphene. ARTs can increase the risk of pre-eclampsia during pregnancy.
• Life and health of the child(ren).

Abortions/Miscarriages/Terminations

• Outcome – spontaneous, medical management, surgical management (evacuation of retained products of conception).
• Identified causes of miscarriage or intrauterine fetal loss (stillbirth).

For Ectopic Pregnancies, Ask About:

• Site of the ectopic pregnancy.
• Management approach:
• Expectant – monitoring of serum hCG levels.
• Medical – methotrexate injection.
• Surgical – laparoscopy or laparotomy (salpingectomy or salpingotomy).

• Age at menarche.
• Length of menstrual cycle – regular or irregular.
• Days of flow.
• Menorrhagia – number of pads used per day.
• Dysmenorrhea.
• Contraceptive use before conception – type and duration.
• Cervical smear history – date and result.
• History of sexually transmitted diseases (STDs).

• Any medical illness requiring treatment and/or hospitalization.
• Personal history of:
  • Diabetes
  • Hypertension
  • Hemoglobinopathies – SCD, thalassemias
  • Cardiac disease
  • Chronic renal disease
  • Tuberculosis (TB)
  • Asthma
  • Epilepsy
  • Hypothyroidism
  • Blood-borne viruses
  • Systemic autoimmune diseases – SLE, rheumatoid arthritis
  • Previous venous thromboembolic events
  • Any other history suggestive of RTI/STI, HIV/AIDS
• Previous surgeries or procedures:
  • Abdominal or pelvic surgery – may influence delivery decisions due to scar tissue and adhesions.
  • Previous Caesarean section – increased risk of uterine rupture in subsequent pregnancies.
  • Loop excision of the transitional zone (LETZ) – increased risk of cervical incompetence.
• Any history of blood transfusions.

• Medications taken since pregnancy – prescribed or over-the-counter.
• Current and discontinued medications – document:
  • Medication name
  • Dosage
  • Frequency
  • Form and route of administration
  • Any significant side effects
• Use of herbal or complementary therapies.
• History of hormone replacement therapy (HRT).
• Allergies – environmental, food, drug-related.
  • Type and severity of allergic reactions
• Medication adherence – assess if the patient takes medications correctly or inconsistently (too often or too little).

• History of similar illnesses in the family – if relevant.
• Cancers of the reproductive system – including:
  • Breast cancer
  • Cervical cancer
  • Endometrial cancer
  • Ovarian cancer
• Family history of chronic illnesses – such as:
  • Diabetes
  • Hypertension
• Family history of twinning – may be relevant.

• Accommodation – type of housing, ventilation, number of people per room, and any adaptations for assistance.
• Living arrangements – who the patient lives with and their personal support network.
• Level of independence – tasks they can perform independently and those requiring assistance (e.g., self-hygiene, housework, food shopping).
• Smoking – type and amount.
• Alcohol use – type and weekly volume consumed.
• Recreational drug use.
• Diet and weight.
• Source of water.
• Refuse and sewage disposal method.
• Marital setting – polygamous or monogamous.
• Husband’s details:
  • Age
  • Occupation
  • Educational status
• Domestic violence screening.

• General – weight loss, fever.
• Central Nervous System (CNS)
  • Headache
  • Fits, faints, dizziness
  • Trauma
  • Vertigo
  • Sleep habits
  • Vision changes
  • Incoordination
• Cardiovascular System (CVS)
  • Chest pain
  • Dyspnea
  • Dyspnea on exertion
  • Orthopnea
  • Paroxysmal nocturnal dyspnea (PND)
  • Palpitations
  • Angina
• Respiratory System (RS)
  • Cough
  • Sputum/hemoptysis
  • Sore throat/earache
  • Weight loss/night sweats/fever
  • History of tuberculosis contact
• Gastrointestinal System (GIT)
  • Abdominal pain
  • Dyspepsia/indigestion
  • Appetite changes
  • Dysphagia
  • Nausea, vomiting, hematemesis
  • Change in bowel habits
  • Constipation/diarrhea
  • Nature of stool
• Urinary System
  • Frequency/nocturia
  • Dysuria
  • Hematuria
  • Incontinence (stress, urge, overflow)
  • Urine color, odor, and amount
• Skin – rash, sores, itching.
• Locomotor System
  • Muscle weakness, cramps, stiffness
  • Joint pain, swelling, stiffness, deformity

Two or three sentences

Patient’s name

Age

EGA

Current problem/situation

Actions taken- investigations and plan

I have presented [Patient's Name], a [Age]-year-old [Gravidity and Parity] [Occupation] at an estimated gestational age (EGA) of [X] weeks. She presented with [Current problem/situation]. [Actions taken – investigations, treatments, and plan].

Example:

I have presented Mrs. AK, a 32-year-old booked G3P2+0[2A] primary school teacher at an EGA of 20 weeks. She presented for a routine antenatal clinic visit with no complaints. She has commenced hematinics.