Obstetric history

Comprehensive Obstetric History
             Comprehensive obstetric history is the process of gathering detailed information from the woman during pregnancy, labour and puerperium.

Creating Rapport
>When attending the patient it is important to build a comfortable connection so that information can be shared.
> It is important to create a relationship based on trust and respect created through both verbal and non verbal actions
>It is essential in order to gain acceptability and cooperation from the patient

o Rapport may include the following aspects:
~Greeting by shaking hands
~ Welcoming
~Introduce yourself using same language as client
~ Offering a seat
~Have time for client
~Do not interrupt
~ Say ‘yes’, ‘um-hum’ or use non verbal gestures showing that you care
~Make eye contact
~Do not attend other clients while busy with another
~Determination of Expected Date of Delivery (EDD), Gestation Age{GA}

Expected Date of Delivery (EDD): This can be determined using several methods.

1.Naegele’s Rule and Ultrasound are the most accurate methods.

Naegele’s Rule:
>The EDD is calculated by taking the Last Normal Menstrual Period (LNMP),
counting forward by nine months; OR
> Adding one year and subtracting three months, and then adding seven days to.

2.Last Normal Menstrual Period (LNMP):
      The first day of the last normal
menstruation.

3.Extrapolation from the fundal height at booking (should not be more than 20 weeks)
4. Ultrasound – 1st trimester Ultrasound Scan (USS)

5.Extrapolation from quickening (primigravida 18-20 weeks, multigravida 16-18 weeks)
>Quickening: The foetal movement felt by the mother.

Gestation Age: Is calculated from the LNMP or EDD and recorded in weeks. >Gestation age is the period of pregnancy from the LNMP reported in weeks.

Documentation of Obstetrical History Chronologically

Introduction
>Name, age in years,
>place of residence,
>marital status,
>gravidity, parity, living (G, P, L)
>LNMP, EDD, GA.

Gravida: The number of total pregnancies regardless of the outcome.
Parity: The number of live births at any gestation age or stillbirths after 28 weeks. In terms of parity, twin counts as two.
Grand multiparity: Refers to a woman who has had 5 or more deliveries.

Chief Complaints and Duration
>These are main problems that brought the patient to hospital. They should be recorded chronologically.
>Use the complaints to grade the severity of the problem
> Make sure that you correlate all the complaints so as you have a comprehensive outcome which will lead you to diagnosis
>Make sure the complaints lead you to the relevant differential diagnosis

History of Presenting Illness(HPI)
>In this section each main complaint of the patient is expanded by determining its duration, mode of onset, aggravating and relieving factors, progression and possible aetiological factors.
> Review of other systems{ROS}:
        Ask questions to rule out involvement of other systems
>Past medical history{PMHx}:
      Ask questions with regards to medical, drugs and surgical history which could have influence on the current condition.
>Obstetric history: Ask and record the previous pregnancies and their outcomes
        Index Pregnancy: The pregnancy that a client is having (i.e., current pregnancy).
        Inquire when the client reported to the clinic for the first time during the index pregnancy (booking).
>Ask about the number of visits that the client has made to the clinic, parameters
(weight, blood pressure, haemoglobin levels), screening tests (HIV, syphilis) ,
Iron and folic acid supplements given, IPTp and TT

Gynaecological History π
>Gynaecology: Previous diseases of the female genital tract, as well as endocrinology and reproductive physiology of a female.
      Outline menarche, menstrual cycle and its regularity, periods/ amount of blood loss, previous infections and their treatment, gynaecological surgery, contraception history.
      Menarche: Establishment of‘menstrual function’ the time of the first of menstrual
period. men = means month and arche = means beginning.

Medical, Family and Social History
>Ask about familial diseases (e.g. Diabetes Mellitus, hypertension), history of twins
pregnancy in the family, occupation of woman and her husband
>Ask about cigarette smoking and excessive drinking of alcohol during this pregnancy
>History of hereditary illnesses or congenital defects is important and may be of concern to the couple.
> Appropriate counselling and investigations should be organised. This is a good opportunity to counsel patient about smoking/tobacco use cessation and/or reducing alcohol intake, if applicable.
> Relevant social aspects such as childcare arrangements and plans for breastfeeding and contraception can be discussed at this point.

Summary of the Obstetric History - Important Positives and Negatives
>Make sure the complaints assist you in performing physical examinations
>Make sure you are able to identify the urgency of treatment and take action
>Depending on the responses of the patient, identify key findings revealed during history.
>Remember to document both positive and negative findings
>Make sure you are able to interpret moods and body language of the patient during history taking so that you can probe for more responses as need

By: Welfare Jambo

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