Obstetric and Gynaecological History Taking Sandy Gibson 1. Introduction Name, D.O.B.

, source of referral Menstrual flow - absent (associated symptoms), light, normal or heavy, (clots, flooding?, number of sanitary pads/towels used) 2. Presenting Complaint * Ideas, Concerns, Expectations * Effect of disease on pregnancy and effect of pregnancy on disease. 3. History of Presenting Complaint * Pain Uterine; colicky pain felt in sacrum and groins Ovarian; Iliac fossa with radiation down anterior aspect of the thigh to the knee * Try to normalise process and be clear why you are asking. Use simple pattern of questioning Site - Localised/general/symmetrical, abdominal or pelvic Onset (sudden or gradual), duration and evolution over time Character and Severity Relieving/Precipitating/Exacerbating factors external stimuli) Associated features e.g. bowel or urinary symptoms, peritonitis, nausea Timing Effects - Impact on life, functional capacity, disability, hygiene, sexuality, employment, relationships Spread - Radiation 4. Past Gynaecological History i. Menstrual history; Age at menarche Date of last menstrual period Menstrual cycle; Normality Regularity (current & past) Duration (x/y) Are you currently in a relationship? Is it a sexual relationship? Do you have a regular sexual partner at the moment? Is your partner a male or female? How long have you been with your partner? When did you last have sex? What sort? (With who?) When did you last have sex with anyone else? Can I ask if you have had any (other) sexual partners in the last 12 months? How many? Male/female? Nationality? Do you use barrier contraception - sometimes, always or never? What do you use for contraception/protection? Have you ever had a STI? Help to date (Exercise, posture, to make taking a sexual history straightforward and unambiguous. * Be confident and matter-of-fact/frank. * Pre-warning with PMH... as part of you medical history, I need to ask you some questions about your relationships. I hope that you dont mind this. * Open questions: Dysmenorrhoea Irregular bleeding (inter-menstrual, post-coital, pre- or post-menstrual) Age at menopause

ii. Sexual activity and contraception iii. Pregnancy history iv. Cervical screening v. Vaginal discharge (amount, colour, smell, itch) vi. Prolapse and incontinence 5. Sexual History

Obstetric and Gynaecological History Taking Sandy Gibson Dyspareunia - Where is the pain? Superficial (introital) e.g. infection so look for ulceration and discharge. Is she dry? Spasm? (= vaginismus, oestrogen deficiency/menopause or lack of stimulation?) Deep e.g. pelvic sepsis and endometriosis. Are there any sexual issues that you would like to discuss? Fertility * I.V. drug use or partner who uses I.V. drugs. * Smear test. * (Forced sex and abuse.) 8. Drugs History and Allergies 6. Past Obstetric History * Check on folate (400 g until week 12) * Nulliparous Never completed a pregnancy beyond 24 weeks; primipara (prim) First pregnancy; multiparous (multip) - A woman who has given birth two or more times. Nulligravida - A woman who has never been pregnant; primigravida - pregnant for the first time or has been pregnant one time; multigravida - pregnant more than one time. * Expected date of delivery - 40 weeks since LMP. Add one year and 7 days and remove three months, form first day of patients last menstrual period (assuming regular 28 day cycle - if longer add additional days [as always 14 days between ovulation and first day of menstruation]). Parity (x); Delivery beyond 28 weeks gestation Gravidity (y); Number of pregnancies to any stage (x + y) Menstrual history and contraception; Last period (normal/nature, length and interval since last) Gestation Expected date of delivery Antenatal scans and checks All previous pregnancies; including miscarriages (What stage? Why?), terminations (how) and ectopic pregnancy, gestation at delivery, spontaneous or induced method of delivery, birth weight and sex, any complications mother or baby suffered antenatally in labour or puerperium. Rhesus D status Ovarian, uterine and breast disease. Thromboembolism, pre-eclampsia, obstetric cholestasis Autosomal dominant; - Huntingtons chorea, myotonic dystrophy Autosomal recessive -Cystic fibrosis, sickle cell disease, thalassaemia X-linkled; Duchenne muscular dystrophy, haemophilia 9. Family history Prescribed including hormonal contraception and HRT, diuretics, anti-hypertensives, anti-epileptics contra-indicated in most cases. (Only prescribe if expected benefit to mother is thought to be greater than the risk to the foetus especially during first trimester. Caution should also be taken during lactation.) Dose and frequency Over-the counter Allergies * Check if on antibiotics or St. Johns Wort if on OCP Operations (particularly pelvic or abdominal) and psychiatric illnesses. Identify presence of diabetes, epilepsy, thromboembolism, UTIs, STIs and other chronic conditions (e.g. thyroid disease, cardiac disease, asthma, connective tissue disorders). 7. Past Medical History Date of last smear Breast fed?

Obstetric and Gynaecological History Taking Sandy Gibson 10. Social Socioeconomic status Cultural milieu Partner and stability of relationship. Who will give her support during and after pregnancy? Planed or not? If unplanned, how does she feel about it? Employment and its nature. Plans to return? Domestic violence Smoking Alcohol Illicit drugs

11. Systems Enquiry Particular reference to: i. General health and symptoms - Weight gain or loss, loss of appetite ii. GI Tract - Change in bowel habit (especially with menstruation) iii. GU system - Urinary frequency, nocturia, dysuria, incontinence 12. Summarise

* Summary:

Name and age Presenting complaint Gynaecological history Contraception Smears Obstetric history - Parity and gravidity Gestational age Scans and tests Past medical history