OB GYN What you have covered Ok, so weve talked about your symptoms Previous pre-eclampsia higher risk
o weve talked about your symptoms Previous pre-eclampsia higher risk to develop it in the current
Introduction
Introduce yourself name / role
Confirm patient details name / DOB
Explain the need to take a history
Gain consent
Ensure the patient is comfortable
Presenting complaint
Its important to use open questioning to elicit the patients
presenting complaint
So whats brought you in today? or Tell me about your
symptoms
Allow the patient time to answer, trying not to interrupt or direct
the conversation
Facilitate the patient to expand on their presenting complaint if
required
Ok, so tell me more about that Can you explain what that pain was
like?
History of presenting complaint
Ask the following questions for each symptom the patient is
experiencing.
Onset when did the symptom start? / was the onset acute or
gradual?
Duration minutes / hours / days / weeks / months / years
Severity e.g. if symptom is vaginal bleeding how many sanitary
pads are they using?
Course is the symptom worsening, improving, or continuing to
fluctuate?
Intermittent or continuous? is the symptom always present or
does it come and go?
Precipitating factors are there any obvious triggers for the
symptom?
Relieving factors does anything appear to improve the symptoms
Associated features are there other symptoms that appear
associated e.g. fever / malaise?
Previous episodes has the patient experienced this symptoms
previously?
Key symptoms to ask about in a pregnant patient
Nausea / vomiting if severe may suggest hyperemesis gravidarum
Abdominal pain may suggest the need for imaging
Vaginal bleeding fresh red blood / clots / tissue
Dysuria / urinary frequency urinary tract infection
Fatigue may suggest anaemia
Headache / visual changes / swelling pre-eclampsia
Systemic symptoms fever / malaise
Ideas, Concerns and Expectations
Ideas what are the patients thoughts regarding their symptoms?
Concerns explore any worries the patient may have regarding their
symptoms
Expectations gain an understanding of what the patient is hoping
to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting
complaint.
This allows you to check your understanding regarding everything
the patient has told you.
It also allows the patient to correct any inaccurate
information and expand further on certain aspects.
Once you have summarised, ask the patient if theres anything else
that youve overlooked.
Continue to periodically summarise as you move through the rest of
the history.
Signposting
Signposting involves explaining to the patient;
What you plan to cover next Now Id like to discuss your past pregnancy
medical history Other medical conditions
History of the current pregnancy Any hospital admissions? when and why?
Is this the patients first pregnancy? Surgical history previous abdominal and gynaecological surgery of
How was the pregnancy confirmed? home testing kit / hCG blood relevance
test / ultrasound scan Immunisations up to date?
Last menstrual period (LMP) first day of the LMP Drug history
Was the patient using contraception? are they still? (e.g. COCP / Pregnancy medications: Folic acid, Iron, Antiemetics, Antacids
implant / coil) Teratogenic drugs: ACE inhibitors, Sodium valproate, Methotrexate,
Estimated date of delivery (EDD) estimated by scan or via dates Retinoids, Trimethoprim
(LMP + 9 months + 7 days) Document all regular medications
Over the counter drugs ensure nothing is unsafe / teratogenic
Did the patient take folic acid during the first trimester?
ALLERGIES
Family history
Any other scans or tests whilst being pregnant? dating scan /
Inherited genetic conditions cystic fibrosis
anomaly scan
Growth of fetus within normal limits? Pregnancy loss recurrent miscarriages in mother and sisters
o
o Placental location placenta praevia may alter delivery plans Pre-eclampsia in mother or sister increased risk
Fetal movements usually experienced at around 18-20 weeks Social history
gestation Smoking can cause intrauterine growth restriction
Labour pains more relevant in the third trimester Alcohol How many units a week? can cause fetal alcohol
Planned method of delivery vaginal / C-section syndrome
Medical illness during pregnancy if so are they taking any Recreational drug use cocaine use can cause placental abruption
medications? Living situation:
Previous obstetric history House / flat stairs / adaptations
Gravidity defined as the number of times a woman has been Who lives with the patient? important when considering discharging
pregnant regardless of the outcome home from hospital
Parity X = (any live or stillbirth after 24 weeks) | Y = (number lost Any carer input? what level of care do they receive?
before 24 weeks) Activities of daily living:
Details of each pregnancy: Is the patient independent and able to fully care for themselves?
o Date of delivery Can they manage self hygiene / housework / food shopping?
o Length of pregnancy Is the pregnancy interfering with these daily activities?
o Singleton / twins / or more? Occupation light duties / maternity leave
o Spontaneous labour or induced? Systemic enquiry
o Mode of delivery Systemic enquiry involves performing a brief screen for symptoms in
o Weight of babies other body systems.
o Current health of babies This may pick up on symptoms the patient failed to mention in the
Complications of previous pregnancies: presenting complaint.
o Antenatal IUGR / hyperemesis gravidarum / pre-eclampsia Some of these symptoms may be relevant to the diagnosis (e.g.
o Labour failure to progress / perineal tears / shoulder dystocia vomiting in hyperemesis gravidarum).
o Postnatal postpartum haemorrhage / retained products of Choosing which symptoms to ask about depends on the presenting
conception complaint and your level of experience.
o Miscarriages / terminations needs to be asked sensitively in an Cardiovascular Chest pain / Palpitations / Dyspnoea / Syncope
appropriate setting / Orthopnoea / Peripheral oedema
Gynaecological history Respiratory Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis
Previous cervical smears when? / results? / Chest pain
Previous gynecological problems and treatments STDs / PID / GI Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight
Ectopic pregnancy loss / Abdominal pain / Bowel habit
Current contraception COCP / POP / Depot / Implant / Implanted Urinary Volume of urine passed / Frequency / Dysuria / Urgency /
uterine device Incontinence
Gynaecological surgery: CNS Vision / Headache / Motor or sensory disturbance/ Loss
o Loop excision of transitional zone (LETZ) risk of cervical of consciousness / Confusion
incompetence Musculoskeletal Bone and joint pain / Muscular pain
o Previous C-sections risk of uterine rupture / Dermatological Rashes / Skin breaks / Ulcers / Lesions
placenta accreta /adhesions Closing the consultation
Past medical history Thank patient
Relevant medical conditions Summarise the history
Thromboembolic disease high risk for further events in following
pregnancy
Diabetes tight glycaemic control is essential risk of congenital
defects / macrosomia
Epilepsy some antiepileptics are teratogenic needs neurology
input
Hypothyroidism TFTs need close monitoring risk of congenital
hypothyroidism