Antenatal History
Before taking a history introduce yourself to the patient and ask her permission.
1). Personal history: ask about the following
Name:……………………………………… Age:………………………..
Nationality: ……………………………….. Occupation:………………..
Gravida………….. Para………+………. Gestational age……………
Blood group:………….
2). Main complain:
Determine the patients complain and duration, date time and reason for admission.
This can start with any of the following phrases:
Presented complaining of.………………………………………………………………..
Referred with………………………………………………………………………………
Admitted for.……………………………………………………………………………….
How to present?
Example; Fatima Ahmed is a 28 year old Libyan, house wife, she is G3P1+1 at 32 weeks
gestation (twins pregnancy) with blood group O -ve, admitted on and Jan 2008 because of
lower abdominal pain for 2 days.
Note History of presenting complain:
Should be taken in full details and recorded in the patients own words
Examples of common obstetric complains:
1) Abdominal pain: ask about the site of pain and its radiation ,how & when it started, nature
of the pain, if colicky pain ask about its frequency and duration, associated factors
(urinary symptoms, vaginal bleeding, vaginal discharge, bowel symptoms).
How to present?
The pain started gradually in the lower abdomen radiating to the back, it is a colicky pain
increasing in frequency and severity, now it is coming and going every 5 min and lasting
45 seconds. Associated with bloody stained vaginal discharge, no urinary or bowel
symptoms. The most likely diagnosis is labour
pain.
2) Vaginal bleeding during pregnancy: ask about when and how it started, any precipitating
cause, amount, associated factors such as pain, previous attacks, and in late pregnancy ask
about fetal movement and previous ultrasound
, How to present?
The bleeding started early this morning with no precipitating factor, initially the loss was
moderate then started to decrease now she has mild spotting only, she has no abdominal
pain and fetal movements are normal. She had a similar attack 2 weeks ago but no
ultrasound was done.
Watery vaginal discharge: ask about the amount, color, smell and associated factors (urinary
symptoms, vaginal itching, abdominal pain)
Decrease fetal movement: since when? How many movements dose she feel in 12 hours,
associated factors (vaginal bleeding, abdominal pain, hypertension...etc)
Fitting and convulsion:
Referred with high blood pressure for assessment
Referred with DM for control of blood sugar
Referred for elective cesarean section due to
Referred with IUFD or prolonged pregnancy.
Discrepancy between gestational age and abdominal size.
3). Antenatal history:
Ask the patient the following about this pregnancy:
Is this pregnancy planned: if unplanned determine the cause eg. contraception failure,
breast feeding...etc
Any pre pregnancy counseling.
First day of the last normal menstrual period LNMP: ask about certainty, cycle length and
regularity, any prior contraception, lactation or any bleeding after (LNMP).
The expected date of delivery EDD is then calculated from the LNMP by adding 7 to the
days and adding 9 or subtracting 3 from the months.
Examples;
LINMP = 7/10/2007
BDD\ 7+7/10 - 3/2008 = 14/7/2008
§ LNMP = 1/1/2008
EDD = 1+7/1+9/ 2008 = 8/10/2008
> LNMP = 25/11/2007
EDD = 25+-3 /2008 because November has only 30 days add +1 to the months:
EDD = 2/9/2008
Note: in IVF patients the LNMP is calculated 2 weeks before the embryo transfer.
Calculate the gestational age in WEEKS from the LNMP or EDD.
Does the patient have an early ultrasound scan, if so calculate the gestational age from
this early scan. If there is a difference of more than 10 days between the period of
amenorrhea and the ultrasound scan then use the ultrasound dates.
Before taking a history introduce yourself to the patient and ask her permission.
1). Personal history: ask about the following
Name:……………………………………… Age:………………………..
Nationality: ……………………………….. Occupation:………………..
Gravida………….. Para………+………. Gestational age……………
Blood group:………….
2). Main complain:
Determine the patients complain and duration, date time and reason for admission.
This can start with any of the following phrases:
Presented complaining of.………………………………………………………………..
Referred with………………………………………………………………………………
Admitted for.……………………………………………………………………………….
How to present?
Example; Fatima Ahmed is a 28 year old Libyan, house wife, she is G3P1+1 at 32 weeks
gestation (twins pregnancy) with blood group O -ve, admitted on and Jan 2008 because of
lower abdominal pain for 2 days.
Note History of presenting complain:
Should be taken in full details and recorded in the patients own words
Examples of common obstetric complains:
1) Abdominal pain: ask about the site of pain and its radiation ,how & when it started, nature
of the pain, if colicky pain ask about its frequency and duration, associated factors
(urinary symptoms, vaginal bleeding, vaginal discharge, bowel symptoms).
How to present?
The pain started gradually in the lower abdomen radiating to the back, it is a colicky pain
increasing in frequency and severity, now it is coming and going every 5 min and lasting
45 seconds. Associated with bloody stained vaginal discharge, no urinary or bowel
symptoms. The most likely diagnosis is labour
pain.
2) Vaginal bleeding during pregnancy: ask about when and how it started, any precipitating
cause, amount, associated factors such as pain, previous attacks, and in late pregnancy ask
about fetal movement and previous ultrasound
, How to present?
The bleeding started early this morning with no precipitating factor, initially the loss was
moderate then started to decrease now she has mild spotting only, she has no abdominal
pain and fetal movements are normal. She had a similar attack 2 weeks ago but no
ultrasound was done.
Watery vaginal discharge: ask about the amount, color, smell and associated factors (urinary
symptoms, vaginal itching, abdominal pain)
Decrease fetal movement: since when? How many movements dose she feel in 12 hours,
associated factors (vaginal bleeding, abdominal pain, hypertension...etc)
Fitting and convulsion:
Referred with high blood pressure for assessment
Referred with DM for control of blood sugar
Referred for elective cesarean section due to
Referred with IUFD or prolonged pregnancy.
Discrepancy between gestational age and abdominal size.
3). Antenatal history:
Ask the patient the following about this pregnancy:
Is this pregnancy planned: if unplanned determine the cause eg. contraception failure,
breast feeding...etc
Any pre pregnancy counseling.
First day of the last normal menstrual period LNMP: ask about certainty, cycle length and
regularity, any prior contraception, lactation or any bleeding after (LNMP).
The expected date of delivery EDD is then calculated from the LNMP by adding 7 to the
days and adding 9 or subtracting 3 from the months.
Examples;
LINMP = 7/10/2007
BDD\ 7+7/10 - 3/2008 = 14/7/2008
§ LNMP = 1/1/2008
EDD = 1+7/1+9/ 2008 = 8/10/2008
> LNMP = 25/11/2007
EDD = 25+-3 /2008 because November has only 30 days add +1 to the months:
EDD = 2/9/2008
Note: in IVF patients the LNMP is calculated 2 weeks before the embryo transfer.
Calculate the gestational age in WEEKS from the LNMP or EDD.
Does the patient have an early ultrasound scan, if so calculate the gestational age from
this early scan. If there is a difference of more than 10 days between the period of
amenorrhea and the ultrasound scan then use the ultrasound dates.
