History Taking in ObstetricsKavya Liyanage

Main Topics

• Demographic history• About this pregnancy• Ultrasound scan• Past obstetric history• Gynecological history• Past medical and surgical history• Psychiatric history• Family history• Social history• Drug history• Allergies

Demographic history

⚫Name⚫Age⚫Occupation⚫Ethnic background⚫Presenting complaint or reason for attending

About this pregnancy

⚫Gestation

⚫Last menstrual period (LMP)

⚫Estimated date of delivery (EDD)

⚫Dates as calculated from ultrasound

⚫Single/multiple (chronicity)

⚫Details about presenting complaint

⚫What actions are taken?

⚫Is there any plan for the rest of the pregnancy?

⚫What are the patient’s main concerns?

⚫Have there been any other problem in this pregnancy?

⚫Has there been any bleeding, contractions or loss of fluids vaginally?

Ultrasound

⚫What scans have been performed?⚫Why?⚫Were any problems identified?

Past obstetric history

⚫Were there any previous pregnancies?⚫If were, their outcomes in order

Gynecological history

⚫Regularity of periods⚫Contraceptive history⚫Previous infections and their teatments⚫Previous cervical smear performed and their

results and if any, treatments⚫Previous gynecological surgery

Past medical and surgical history

⚫Relevant medical problems⚫Any previous operations; types of anaesthetic

used and any complications

Psychiatric history

⚫Postpartum blues or depression⚫Depression unrelated to pregnancy⚫Major psychiatric illnesses

Family history

⚫Diabetes⚫Hypertension⚫Genetic problems⚫Psychiatric problems

Social history

⚫Smoking/ alcohol/ drugs⚫Marital status⚫Occupation, partner’s occupation⚫Help at home⚫Housing problems

Drug history

⚫All medication including over-the-counter medication⚫Folate supplementation

Allergies ⚫Any allergies⚫What problems do they cause?

Thank you!