An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies. Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential. Show
Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history taking format, therefore it’s important to understand what information you are expected to gather. It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy). Download the obstetric history taking PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our gynaecological history taking guide. Opening the consultationWash your hands and don PPE if appropriate. Introduce yourself to the patient including your name and role. Confirm the patient’s name and date of birth. Explain that you’d like to take a history from the patient. Gain consent to proceed with history taking. Key pregnancy detailsIt is useful to confirm the gestational age, gravidity and parity early on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely. Gestational age, gravidity and parity should also be included at the beginning of your presentation of a patient’s history. Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2). Parity (P) is the total number of times a woman has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth). Example of gravidity and parity calculationA patient is currently 26 weeks pregnant and already has two children of her own. She reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks:
How does parity work for twins?A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational age (greater than 24+0 weeks) should be defined as P1. However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2. As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable gestational age will often be referred to as P2, but from an academic perspective, they would be deemed P1. General communication skillsIt is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient). Some general communication skills which apply to all patient consultations include:
You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation. Presenting complaintUse open questioning to explore the patient’s presenting complaint:
Provide the patient with enough time to answer and avoid interrupting them. Facilitate the patient to expand on their presenting complaint if required:
Open vs closed questionsHistory taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis. History of presenting complaintOnce the patient has had time to communicate their presenting complaint, you should explore the issue with further open and closed questions. SOCRATESThe SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms. SiteAsk about the location of the symptom:
OnsetClarify how and when the symptom developed:
CharacterAsk about the specific characteristics of the symptom:
RadiationAsk if the symptom moves anywhere else:
Associated symptomsAsk if there are other symptoms which are associated with the primary symptom:
Time courseClarify how the symptom has changed over time:
Exacerbating or relieving factorsAsk if anything makes the symptom worse or better:
SeverityAssess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
Obstetric symptomsOnce you have completed exploring the patient’s history of presenting complaint, you need to move on to more focused questioning relating to the symptoms that may be relevant to pregnancy (if not already discussed). We have included a focused list of key symptoms to ask about when taking an obstetric history, followed by some background information on each, should you want to know a little more. Summary of key obstetric symptomsKey obstetric symptoms to ask about include:
Nausea and vomitingNausea and vomiting are very common in pregnancy, but are typically mild, requiring only reassurance and basic hydration advice. Nausea and vomiting typically begin between the fourth and seventh week of gestation, then peak between the ninth and sixteenth week and resolve by around the 20th week of pregnancy. Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance, weight loss and ketonuria. ¹ Reduced fetal movementsWomen typically start to feel fetal movements between 16 to 24 weeks gestation (primigravida women will often not feel fetal movements until after 20 weeks gestation). A mother will know what is the “usual” amount of fetal movements she experiences, therefore, if a reduction in fetal movements is reported, it should be taken very seriously. Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal growth restriction, placental insufficiency, and congenital malformations. ² You should always ask about fetal movements once the patient is of the appropriate gestation to be able to feel them:
Vaginal bleedingVaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynaecological diseases. It is important to ask about pain, associated trauma (including domestic violence), fever/malaise, recent ultrasound scan results (e.g. position of the placenta), cervical screening history, sexual history and past medical history to help narrow the differential diagnosis. You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-syncope/syncope). Vaginal dischargeAll healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking an obstetric history. You should ask the patient if they have noticed any changes to the following characteristics of their vaginal discharge:
Urinary symptomsUrinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract infections in pregnancy have been associated with increased risk of fetal death, developmental delay and cerebral palsy. Common symptoms of urinary tract infections include:
Headache, visual changes, epigastric pain, oedemaPre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy. The key symptoms to ask about include:
Other symptomsFever is important to ask about when considering infectious pathology (e.g. urinary tract infections, cervical infections, chorioamnionitis). Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology. Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. malignancy, anorexia nervosa). Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects the palms and soles of the feet). Ideas, concerns and expectationsA key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic. It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below. IdeasExplore the patient’s ideas about the current issue:
ConcernsExplore the patient’s current concerns:
ExpectationsAsk what the patient hopes to gain from the consultation:
SummarisingSummarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history. SignpostingSignposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next. Signposting examplesExplain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.” What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your current pregnancy.” Systemic enquiryA systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint. Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience. Some examples of symptoms you could screen for in each system include:
Current pregnancyGestationClarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as “26+5”). Accurate estimation of gestation and estimated date of delivery (EDD) is performed using an ultrasound scan to measure the crown-rump length. Scan resultsWomen are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks. You should ask about the results of the scan (or check the medical records if the patient is unsure). The key findings to note include:
ScreeningThere are several types of screening that women are offered during pregnancy:
You should clarify if the patient has opted for screening and if so, what the results were. Other details of the pregnancy
Immunisation historyCheck the patient is currently up to date with their vaccinations including:
Mental health historyPregnancy can have a significant impact on maternal mental health, therefore it is essential that patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar disorder, schizophrenia). Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if relevant. Previous obstetric historyIt is important to ask about a woman’s previous obstetric history, as this may help inform the assessment of risk in the current pregnancy and have implications for the mode of delivery. Gravidity and parityGravidity is the number of times a woman has been pregnant, regardless of the outcome. Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks). Term pregnancies (>24 weeks)Gestation at delivery:
Birth weight:
Mode of delivery:
Complications:
Assisted reproduction:
StillbirthAs stated below, asking about stillbirths need to be done in a sensitive manner. A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy. Sensitivity clarify the gestation of the stillbirth if this is not already documented. Other pregnancies (<24 weeks)Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive manner in a private setting. It can be very difficult for women to discuss these topics. These questions should only be asked when relevant and by a person who is competent to do so. MiscarriageA miscarriage is the loss of a pregnancy before 24 weeks gestation. Gestation:
Other details:
Termination of pregnancyTermination of pregnancy is the medical process of ending a pregnancy so it doesn’t result in the birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical procedure. Clarify the gestation at which the termination of pregnancy was performed and the method of management (e.g. medical or surgical). Ectopic pregnancyAn ectopic pregnancy is when a fertilised egg implants itself outside of the uterus, usually in one of the fallopian tubes. Clarify the site of the ectopic pregnancy and how it was managed (e.g. expectant, medical, surgical). Gynaecological historyCervical screening:
Previous gynaecological conditions and treatments:
Past medical historyA patient’s past medical history is particularly relevant during pregnancy, as some medical conditions may worsen during pregnancy and/or have implications for the developing fetus. Ask if the patient has any medical conditions:
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions. Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:
AllergiesIt’s essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced. Medical conditions which are particularly important to be aware of during pregnancyDiabetes (type 1 or 2): blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia). Hypothyroidism: untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact. Epilepsy: seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage) and many anti-epileptic drugs are teratogenic. Previous venous thromboembolism (VTE): pregnancy is a pro-thrombotic state, therefore, women who have previously developed a venous thromboembolism are at significantly increased risk of developing further VTEs without prophylactic treatment (e.g. low molecular weight heparin). Blood-borne viruses: HIV, hepatitis B, hepatitis C pose a risk to the fetus during childbirth (vertical transmission). Genetic disease: it is important to identify any genetic diseases (e.g. cystic fibrosis, sickle-cell disease, thalassaemia) carried by both the mother and father as this may influence the management of the patient and their pregnancy (e.g. arranging input from the paediatric team immediately after delivery). Drug historyIt is essential to gain an accurate overview of the medications the patient is currently and has previously taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from drugs, as this is when organogenesis occurs. Prescribed medicationsClarify the prescribed medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped (including drug name, dose and route).
Ask if the patient was using contraception prior to becoming pregnant and if so, clarify what method of contraception was being used. Check the patient has stopped their contraception or had their contraceptive device removed (e.g. coil, implant). If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route. Ask the patient if they’re currently experiencing any side effects from their medication:
Teratogenic drugsSome examples of drugs that are known to be teratogenic include:
Medications frequently used during pregnancySome medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat the symptoms of pregnancy. Some examples of medications commonly used in pregnancy include:
Family historyTaking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus during pregnancy. This can also help inform discussions with parents about the risk of their child having a specific genetic disease (e.g. cystic fibrosis). Some important medical conditions to ask about include:
Social historyUnderstanding the social context of a patient is absolutely key to building a complete picture of their health. Social factors have a significant influence on a patient’s pregnancy. General social contextExplore the patient’s general social context including:
SmokingRecord the patient’s smoking history, including the type and amount of tobacco used. Offer smoking cessation services (see our smoking cessation guide for more details). Smoking increases the risk of a small for gestational age baby. AlcoholRecord the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information). Offer support services to assist the patient in reducing their alcohol intake. Excess alcohol use during pregnancy can result in conditions such as fetal alcohol syndrome. Recreational drug useIt is important to ask about recreational drug use, as these can have significant consequences on the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption). If recreational drug use is identified, patients can be offered input from drug cessation services. Diet and weightAsk if the patient what their diet looks like on an average day. Ask about the patient’s current weight (obesity significantly increases the risk of venous thromboembolism, pre-eclampsia and gestational diabetes during pregnancy). OccupationAsk about the patient’s current occupation and if there are plans in place for maternity leave. Domestic abuseIt is important to privately ask all pregnant women if they are a victim of domestic abuse to provide an opportunity for them to seek help. Closing the consultationSummarise the key points back to the patient. Ask the patient if they have any questions or concerns that have not been addressed. Thank the patient for their time. Dispose of PPE appropriately and wash your hands. ReviewerDr Venkatesh SubramanianObstetrics & Gynaecology Registrar in London References
What are the important questions to ask to the pregnant patient?15 Crucial Questions Every Woman Needs to Ask Her OB/GYN During Pregnancy. What over-the-counter medications are safe?. What about prescription meds that I might take?. Do I need to change my beauty routine?. How much weight should I gain?. What should I eat and avoid eating?. What exercise is okay during pregnancy?. What are the things you need to discuss to the pregnant woman on her first visit in the clinic?Ask about exercise, sex, dental care, vaccinations and travel during pregnancy, as well as other lifestyle issues. You might also talk about your work environment and the use of medications during pregnancy. If you smoke, ask your health care provider for suggestions to help you quit.
What information is important to include at every visit and at specific times during the pregnancy?Check your blood pressure, weight, and height. Calculate your due date based on your last menstrual cycle and ultrasound exam. Ask about your health, including previous conditions, surgeries, or pregnancies. Ask about your family health and genetic history.
What should you as a nurse assess during a pregnant woman's first prenatal visit?Assess her gastrointestinal system; ask about her pre-pregnancy weight, any discomforts such as vomiting, diarrhea or constipation, hemorrhoids, and changes in bowel habits. Assess her genitourinary system and ask about any urinary tract infections, STIs, PIDs, any difficulties in conceiving, and hematuria.
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