Obstetrics
Obstetric History (NB: HPC comes after obstetric + gynae history)
1. Introduce + Name/Age/Occupation/LMP (=gest age) + EDD
2. PC + HPC
3. Obstetric History:
a. Current Pregnancy:
i. How was pregnancy confirmed?
ii. Have the scans been normal?
iii. Have you felt the baby move (from 16-20wk)?
iv. Any issues/health problems prior to the current one?
1. Pains OR Bleeding/spotting?
2. Morning sickness?
3. Breast tenderness?
4. Urinary frequency?
b. Prior pregnancies (G P A already established):
i. GPA (G=total pregs inc <24wk; P=total viable pregs 24+wk not inc current)
1. Have you been pregnant in the past? How many times?
2. Were all pregnancies delivered?
3. Any abortions or miscarriages?
4. If had 3 pregs, 2 @ 24+ weeks (alive or dead), 1 miscarriage @ 20wk = G3P2+1
5. Miscarriages – suspect anti-phospholipid (multiple), Rho-D isoimmunisation,
TORCH prior to or during pregs, trauma, idiopathic (>50%)
ii. Pregnancies issues in past Preg issues for child + mother
1. Antenatal
2. Labour [inc induction]
3. Delivery [inc mode + gestational age]
4. Post-natal (mother – depression? Children – currently in good health?)
4. Gynae History: (brief)
a. Menstrual LMP? Regular periods? How long is cycle?
b. S Sexually active? Casual regular? Protected unprotected? Discharge? Prior STIs?
c. C Use any contraceptives? Any coils?
d. S Smears up to date? Any issues?
e. O
f. U Any bowel or bladder symptoms?
a. R
5. ICE
6. PMH Any clots or diagnosed with any clotting disorders? DM?
7. PSurgHx Prior surgeries inc C-section, cervical coning procedures?
8. FH
9. DH Anticoagulants?
10. SH Smoking, alcohol, illicit drugs
11. Request:
a. Examination, Obs, View previous scans/results
b. BP, Urine, CTG, USS, Blood (inc ABO + Rh)
,1st Trimester Bleed/Pain****
2. Introduction + Name/Age/Occupation/LMP + EDD (if known to be preg)
3. Which came first – bleed or pain? (pain 1st in ectopic; bleeding 1st in miscarriage)
4. Bleed
a. When did it start? Has it ever happened before? How many episodes of bleeding? Is it getting
worse?
b. How much blood?
c. What colour?
d. Any clots or tissue?
e. Does this feel like a period or is it different?
f. Dizzy? Chest pain? Shoulder tip pain?
5. Pain SOCRATES
6. Fever (R/O PID, septic abortion)
7. Ask:
a. Are you sexually active? Is it at all possible you could be pregnant?
8. Obs Hx: (If they do not know they are pregnant, just ask morning sickness + breast tenderness resolve)
a. Current Pregnancy
i. How was pregnancy confirmed? Was it natural or assisted (ectopic)?
ii. Have you had any scans?
iii. Any symptoms of pregnancy and are these resolving?
1. Pains or Bleeding/spotting?
2. Morning sickness?
3. Breast tenderness?
4. Urinary frequency?
b. Prior Pregnancies
i. GPA Pregnancies in total? Deliveries? Abortions or miscarriages?
ii. Complications in these past pregnancies
1. Antenatal (any issues with scans or any other issues during pregnancies)
2. Labour [inc induction]
3. Delivery [inc mode + gestational age]
4. Post-natal (mother – depression? Children – currently in good health?)
9. Gynae Hx:
a. Menstrual LMP? Regular periods? How long is cycle?
b. S Sexually active? Casual regular? Protected unprotected? Discharge? Prior STIs (ectopic)?
c. C Use any contraceptives? Any coils (ectopic)?
d. S Smears up to date? Any issues?
e. O
f. U Any bowel or bladder symptoms?
g. R
10. ICE
11. PMH DM? Clotting disorders or previous clots in blood? (miscarriage)
12. PSurgHx Previous pelvic surgery? (ectopic – Asherman’s)
13. FH
14. DH Anticoagulants?
15. SH Smoking, alcohol, illicit drugs (miscarriage)
, 16. DDx Ectopic, Miscarriage, Hydatidiform Mole, PID, Ovarian cyst/torsion
17. Request ABCDE, Full Ex in obs, Lying + Standing BP, Urine preg test, Blood (FBC, U+E, LFT, b-hCG,
Progesterone, G+S, X-match, ABO + Rh), TV-USS, inform seniors for potential need for
laparoscopy/laparotomy
18. Miscar Rx Observe, vaginal misoprostol, Suction D+C (esp if unwell or inevital/incomplete)
19. Risk:
a. PIPPA (ectopic Previous ectopic, IUD, pelvic surgery, previous STI, assisted repro
b. Miscarriage DM, Clotting disorders/clots (APLS), Illicit drugs (smoking, alcohol)
c. This will all come out in the general history
Obstetric History (NB: HPC comes after obstetric + gynae history)
1. Introduce + Name/Age/Occupation/LMP (=gest age) + EDD
2. PC + HPC
3. Obstetric History:
a. Current Pregnancy:
i. How was pregnancy confirmed?
ii. Have the scans been normal?
iii. Have you felt the baby move (from 16-20wk)?
iv. Any issues/health problems prior to the current one?
1. Pains OR Bleeding/spotting?
2. Morning sickness?
3. Breast tenderness?
4. Urinary frequency?
b. Prior pregnancies (G P A already established):
i. GPA (G=total pregs inc <24wk; P=total viable pregs 24+wk not inc current)
1. Have you been pregnant in the past? How many times?
2. Were all pregnancies delivered?
3. Any abortions or miscarriages?
4. If had 3 pregs, 2 @ 24+ weeks (alive or dead), 1 miscarriage @ 20wk = G3P2+1
5. Miscarriages – suspect anti-phospholipid (multiple), Rho-D isoimmunisation,
TORCH prior to or during pregs, trauma, idiopathic (>50%)
ii. Pregnancies issues in past Preg issues for child + mother
1. Antenatal
2. Labour [inc induction]
3. Delivery [inc mode + gestational age]
4. Post-natal (mother – depression? Children – currently in good health?)
4. Gynae History: (brief)
a. Menstrual LMP? Regular periods? How long is cycle?
b. S Sexually active? Casual regular? Protected unprotected? Discharge? Prior STIs?
c. C Use any contraceptives? Any coils?
d. S Smears up to date? Any issues?
e. O
f. U Any bowel or bladder symptoms?
a. R
5. ICE
6. PMH Any clots or diagnosed with any clotting disorders? DM?
7. PSurgHx Prior surgeries inc C-section, cervical coning procedures?
8. FH
9. DH Anticoagulants?
10. SH Smoking, alcohol, illicit drugs
11. Request:
a. Examination, Obs, View previous scans/results
b. BP, Urine, CTG, USS, Blood (inc ABO + Rh)
,1st Trimester Bleed/Pain****
2. Introduction + Name/Age/Occupation/LMP + EDD (if known to be preg)
3. Which came first – bleed or pain? (pain 1st in ectopic; bleeding 1st in miscarriage)
4. Bleed
a. When did it start? Has it ever happened before? How many episodes of bleeding? Is it getting
worse?
b. How much blood?
c. What colour?
d. Any clots or tissue?
e. Does this feel like a period or is it different?
f. Dizzy? Chest pain? Shoulder tip pain?
5. Pain SOCRATES
6. Fever (R/O PID, septic abortion)
7. Ask:
a. Are you sexually active? Is it at all possible you could be pregnant?
8. Obs Hx: (If they do not know they are pregnant, just ask morning sickness + breast tenderness resolve)
a. Current Pregnancy
i. How was pregnancy confirmed? Was it natural or assisted (ectopic)?
ii. Have you had any scans?
iii. Any symptoms of pregnancy and are these resolving?
1. Pains or Bleeding/spotting?
2. Morning sickness?
3. Breast tenderness?
4. Urinary frequency?
b. Prior Pregnancies
i. GPA Pregnancies in total? Deliveries? Abortions or miscarriages?
ii. Complications in these past pregnancies
1. Antenatal (any issues with scans or any other issues during pregnancies)
2. Labour [inc induction]
3. Delivery [inc mode + gestational age]
4. Post-natal (mother – depression? Children – currently in good health?)
9. Gynae Hx:
a. Menstrual LMP? Regular periods? How long is cycle?
b. S Sexually active? Casual regular? Protected unprotected? Discharge? Prior STIs (ectopic)?
c. C Use any contraceptives? Any coils (ectopic)?
d. S Smears up to date? Any issues?
e. O
f. U Any bowel or bladder symptoms?
g. R
10. ICE
11. PMH DM? Clotting disorders or previous clots in blood? (miscarriage)
12. PSurgHx Previous pelvic surgery? (ectopic – Asherman’s)
13. FH
14. DH Anticoagulants?
15. SH Smoking, alcohol, illicit drugs (miscarriage)
, 16. DDx Ectopic, Miscarriage, Hydatidiform Mole, PID, Ovarian cyst/torsion
17. Request ABCDE, Full Ex in obs, Lying + Standing BP, Urine preg test, Blood (FBC, U+E, LFT, b-hCG,
Progesterone, G+S, X-match, ABO + Rh), TV-USS, inform seniors for potential need for
laparoscopy/laparotomy
18. Miscar Rx Observe, vaginal misoprostol, Suction D+C (esp if unwell or inevital/incomplete)
19. Risk:
a. PIPPA (ectopic Previous ectopic, IUD, pelvic surgery, previous STI, assisted repro
b. Miscarriage DM, Clotting disorders/clots (APLS), Illicit drugs (smoking, alcohol)
c. This will all come out in the general history
