History Taking In Obstetrics

As a doctor I have found that history taking in Obstetrics is a task that requires your highest and the most skilled expertise. There are a number of ladies who aren't comfortable to talk about their pregnancy experience  in Asian setups specially if the doctor is male. So try to read it with concentration and if you have ANY QUERY then DO ASK ... !!!

                                      After all it's about SAFE MOTHERHOOD.

So here is the pattern of Obs History.


A) Personal Profile :-

Name ( wife and husband )
Age ( both )
Occupation ( both )
Education ( both )
Residence
Married for how long?
Consanguineous marriage
Blood Group
Gravidity
Parity
Last Menstrual Period
Calculate Expected Date of Delivery
Mode of Admission
Date of Admission

B) Presenting Complaints:- 
                                            Obviously that will be gestational ammenorhea for x weeks.(x is the no of weeks that you can calculate from LMP to EDD.

C) History of presenting complaints ( obviously for pregnancy )

Inquire that the pregnancy was spontaneous or assisted
Planned or Unplanned
Patient was booked/unbooked
How pregnancy was confirmed

1) 1st trimester
                         Inquire about Nausea, Vomiting, Hyperemesis Gravidarum, Easy fatigue Breast Tenderness, Dating Scan, Infections, PV Bleeding, Discharge, PV Leaking

2) 2nd trimester
                          Inquire about Quickening, Iron and Folic Acid Suppliments, High Blood Sugar, Raised Blood Pressure, Quickening, Anomaly Scan, Tetanus Vaccination, PV Bleeding, Discharge, PV Leaking

3) 3rd trimester
                           UTI, PV Bleeding, leaking, Discharge, Raised Blood Sugar, Raised Blood Pressure.

D) Previous Obs History:-
                                      Tell the examiner about alive issues, Abortions, Miscarriages and Premature babies, Then Draw a flow chart of all children in which note the details of the following points;
TERM pregnancy, Mode delivery, Place of Delivery, Complications in Individual Trimesters, Labor was Induced or patient went into labor spontaneous, duration of labor, Daee handling, Trauma during labor, Anti D injection if the patient is having O blood group, what was outcome, weight of baby, breast fed, any admission in NICU, Immunization.

E) Gynae History:-
                              Inquire the patient about her Age of Menarch, Menstrual Cycle Characteristics (Length, Duration, Regularity, Flow, Pain, Heaviness), Post Coital Bleed, Vaginal Discharge, Vaginal Pain, Contraception.

F) Past Medical History:-
                                        In her past medical history, one should always ask about Diabetes, Hypertension, Cardiac Issues, Recurrent Miscarriages, Thyroid Status, Twins.

G) Past Surgical History:-
                                          It can be important in the regard of planning Cesarean Section or in some infertility cases past surgical history may be helpful.

I) Family History:-
                             Diabetes, Hypertension, Cardiac Issues, Recurrent Miscarriages, Twins.
J) Drug History:-
                            Again you can write down here about Anti D, Iron and Folic Acid Supplementation or any any other chronic drug that she had been taking.

K) Socioeconomic history :- 
                                               Ask about how big their family is? Are they living in a joint family system or individuals? I mean this is the way to have some idea about a patient without making her embarrass.

L) Allergies :-
                        Ask about any allergy she has.

M) Substance Abuse:-
                                      Any history of Alcohol, Smoking or Drug Abuse.

O) systematic review:-

                                      Systemic review goes the same as in Medicine but fairly inclined to words Obstetrical point of view.

Add your knowledge to mine by correcting things if you feel i have written them wrong. I will appreciate it.