OBSTETRIC HISTORY & WRITE-UP

By

Associate Professor Dr Hanifullah Khan

Importance of History Taking

• Obtaining an accurate history

• The critical first step in determining the

aetiology of a patient's problem.

• A large percentage of the time, a diagnosis can

be made based on the history alone.

The obstetric history

• 2 purposes

– Provide a synopsis of background risk

– An account of the progress of the pregnancy

• A carefully taken history – provides a clinical

guide for the P/E to follow

• History should be taken & presented in a logical

sequence

Complete History Taking

• Chief complaint

• History of present illness

• History of current pregnancy

• Past medical /surgical history

• Family history

• Drug /blood transfusion history

• Social history

• Gyn/ob history.

Order of histories

• Mandatorily, the initial sequence must include

– CC, HOPI, HOCP & HOPP

– in that order,

– although HOPI and HOCP may be combined if required.

• Other histories such as

– medical, surgical, family, social, drug and menstrual or gynae

history then follow

– but these may be rearranged

– in order of relevance to the HOPI or HOCP.

CHIEF COMPLAINT

What is the “Chief Complaint”

• This is the main reason the pt presented

• Usually a single symptom,

– occasionally more than one complaint eg: chest pain, palpitation, shortness of breath

• The patient describes the problem in their own words It should be recorded as such

• Short/specific in one clear sentence

• Must have duration of problem

– “per Vaginal bleeding for 3 days prior to admission”.

HISTORY OF PRESENT ILLNESS

Details & progression, regression of the CC:

History of Present Illness - overview

• Elaborate on the chief complaint in detail

• Ask relevant associated symptoms

• Have differential diagnosis in mind

Components of HOCI

1. Demographic info

2. Primary history –

- Onset, course, severity,

duration

3. Associated symptoms

4. Symptoms of any

complications P

rop

er H

OC

I

Analysis of the complaint

+

symptoms

Important points

• Always relay story in days before admission e.g.

• “the patient was apparently well until 1 day prior to

admission…”

• If patient has > 1 symptom,

• take each symptom individually and

• follow it through fully

• mentioning significant negatives as well

• Avoid medical terminology

Demographic information

• Appropriate to begin with a summary of the

details

• Name, age , gravidity, parity, LMP, EDD

(Naegele’s rule)

Gravidity no. of pregnancies including current

pregnancy (regardless of the outcome)

Parity no. of births beyond 24 wk gestation

Primary history

• Describes the onset,

course, severity and

duration of the chief

complaint

– elaborates on the main

complaint

– deals with the chronology

& the characteristics of the

chief complaint.

• Chronology &

characteristics of the

current symptom:

– -Anatomic location

– -Quality

– -Quantity or severity

– -Timing

– -Setting in which the

symptoms occur

– -Aggravating or relieving

factors

– -Associated symptoms

Primary Hx cont..

• If > 1 chief complaint, repeat this series of

questions for each complaint

• Not all questions may be relevant for a symptom

– For example, a location cannot be determined for “difficulty in

breathing”.

Associated symptoms

• A general review of systems

• Requires more experience on the part of the

interviewer than before

• Information gathered here serves to

– support the diagnosis

– as well as to gauge the severity of the disorder

• Examples

– abdominal pain - presence or absence of nausea and vomiting

– vaginal bleeding - per vaginal discharge, pruritis or smell.

Symptoms of complications

• Again - help to confirm the diagnosis and assess

the severity of the problem

– thus establishing an idea of the management that is to follow

• Examples

– For complaint of symptoms of dysuria & increased frequency

of micturition - loin to groin pain, backache & fever

– might suggest ascending infection complicating the UTI

HISTORY OF CURRENT

PREGNANCY

Components of HOCP

• Chronological & concise account

– 1st, 2nd & 3rd trimesters

• How was pregnancy confirmed?

• First trimester symptoms

• Results of routine tests

• Ultrasound scans

• Subsequent antenatal check-ups

• MOGTT, H/T

Confirm dates

• LNMP

– Sure of date

– Regular menstrual cycle

• UPT

– Brand?(Clearview®most sensitive UPT), detect β-hCG

• Early pregnancy symptoms?when? (vomiting

started at 6-7 week)

• Quickening

– Primigravida: 22-23 weeeks

– Multigravida: 16-18 weeks

Investigations

• Routine tests – just mention if normal

• Of particular importance

– Hb & early BP reading

– ABO and Rhesus blood grouping

• Early u/s scanning

– Document the number of fetuses, the viability & gestational

age

• Subsequent ANC – just mention if normal

– 2nd trimester u/s scanning - to assess for fetal anomalies

– This should be specifically mentioned even if not done.

DM

• Nowadays, routine

screening for DM

– At first booking

– At 24-28 weeks of

gestation if suspicion of

DM arises or persists

• Previously, this was done

based on the presence of

risk factors

– Pts were being missed out

• 75g OGTT, HbA1c

• Document if DM

screening was done, when

& the results

• Must still list the risk

factors of DM

• If results abnormal, ?

subsequent action

– regular serial sugar

monitoring

– diet modification

– oral or insulin therapy

Fetal growth

• Fetal growth is an

important indicator of

diabetic control and any

development of

macrosomia &

polyhydramnios must be

mentioned

Prepregnancy disorders

• Medical disorders in pregnancy - presence of the

disorder prepregnancy

– Must actively determine this

– Important implications on the classification of the condition,

the risks involved & the management of the pregnancy.

• DM & HT - the most common medical disorders

encountered

– Epilepsy, thalassemia, anaemia and heart disease.

HISTORY OF PAST PREGNANCY

Past Obs History

• This section details the events & outcomes in the

patient’s past pregnancies

– May have important implications on current pregnancy

– May also give clues on the current problem the patient is facing

• Enough to summarize significant points rather than

listing them out

– Any significant antenatal, intrapartum or postpartum events

– Any abortions & ectopic pregnancies &their outcomes have to be

mentioned

– Previous maternal complications

• Mode of delivery

• B Wt

• Life & health of the baby

• Contraception –

– Type, when begun, why stopped, any side effects

• Did the current complaint occur in past

pregnancy?

OTHER HISTORIES

The order of appearance

• Usually presented as separate individual sections

• There should be flexibility in the order of listing

them

– depending on their importance with regards to the current

complaint

• Examples

– Pt referred for management of DM - family, dietary & social

history more important than menstrual history.

– Problem of wrong dates - a detailed menstrual history

becomes very important

MENSTRUAL & GYNAE HISTORY

Important points

• LMP details ( does it conform to the usual in

terms of timing, volume, and appearance)

• Regular or irregular cycles

• Length of the cycle

• OCP

• Surgical procedures

• Hx of infertility

• Sexually transmitted diseases

• Uterine anomalies

PAST MEDICAL/SURGICAL HX

Importance

• Important to know because

– Current complaint may be part of past illness

– Past illness may affect pregnancy , e.g. hypothyroidism

– Pregnancy might impact past illness, e.g. heart disease

• Any known pre-existing illness

– time of diagnosis/current medication/clinic check up

• Surgery – indications, type

– Any blood transfusions

Other past illnesses

• Include past trauma & accidents

– time/place/ and what type of accident

• Minor procedures such as endoscopies, biopsies,

dental procedures

– e.g. tooth extraction & cavity filling may be a source of

infective endocarditis in patients with valvular heart disease

• Childhood diseases

• Vaccinations if relevant

– In the case of suspected fetal anomaly, past history of Rubella

vaccination is important

DRUG/MEDICATION HX

Relevance

• Drug taken may be relevant to the pregnancy

• Although most drugs are safe during pregnancy,

some are not

– Teratogenic

– e.g. - sodium valproate (epilepsy) is prone to congenital

anomaly , relevant in a patient referred for a uterus that is

smaller than dates

Medications

• With regards to medicines

– Purpose

– Dose

– Route

– Frequency

– Side effects

• Immunizations

Protein binding

• Medications also affected by ↑amounts of

proteins produced by the pregnant women

– →increased drug protein binding

– → decreased bioavailability and efficacy of the drug

● for example in the case of replacement thyroid hormone for

hypothyroidism

• Some drugs have side effects that may be

exacerbated during pregnancy

– Patients on aspirin for heart disease, hypertension or recurrent

abortion may have gum and other bleeding.

Important points

• Always use generic name

– May put trade name in brackets

– with dosage, timing & how long.

• Do not forget

– OCT/Vitamins/Traditional /Herbal medicine & alternative

medicine as cupping or acupuncture.

• Blood transfusion

Designer drugs

• Smoking history - amount, duration & type.

– A strong risk factor for IHD

– Not so prevalent in Malaysian society

• Consumption of alcohol

– Is the pt really alcoholic or just a social drinker.

FAMILY HISTORY

Major illnesses in the immediate family (parents,

grandparents, siblings)

Determine the presence of any heritable or communicable

disorders that may impact the pregnancy

Most common

• DM & hypertension most important

– These & other disorders may occur during pregnancy and be

the cause of the current complaint

• Also good to know as a means of determining &

documenting the risks

• Communicable diseases

– e.g. dengue & avian flu common

– should be asked for especially if the chief complaint is fever

Family History

• Any familial disease/running in families

– e.g. breast cancer, IHD, DM, schizophrenia,

• Infections running in families

– such as TB, Leprosy

– Cholera, typhoid in case of epidemics.

• Endemic conditions

– such as AGE, Dengue

Pregnancy related

• Congenital defects

– Neural tube defects, Down’s syndrome

• Multiple pregnancy

– Spontaneous or fertility treatment -related

• Haematological / Genetic

– Thalassemia , sickle cell disease, haemophilia

• Psychiatric diseases

– Heritable

– Affect patient’s psychosocial environment

SOCIAL HISTORY

The aim is to detect a preventable cause of illness

Occupational & Home

• Occupation, social & education background,

– family social support& financial situation.

– Social class.

• Home conditions as:

– Water supply.

– Sanitation status in his home & surrounding.

– Animals / birds in his/her house.