Obstetric

History Taking
- Ankit Suniyal


1. Patient Details
Name –
Husband name, occupation -
Age –
Place –
Occupation-
Education –
Family’s Monthly income –
Nearest health facility –

2. Obstetric Index & POG
Obstetric index – Gravida, Para, Live birth, Abortion
POG
LMP
EDD
Booked & Immunization –

3. Chief complain
Referred case –
Complains – pain/ BPV / Leaking , etc.

4. HOPI
Elaborate symptoms -
Etiology/ cause –
Complication-
Fetal wellbeing –

OG HISTORY TAKING | Ankit Suniyal

 DM/HTN -

5. History of present pregnancy
• 1st trimester
- type of conception – spontaneous /Artificial
- Pregnancy detected by –
- Preg. Confirmed by –
- No. of antenatal visit –
- H/O – excessive vomiting, Fever with Rash, Radiation , BPV, UTI , discharge , Drugs
• 2nd Trimester
- no. of antenatal visits –
- Weight gain -
- Investigations –
- Quickening –
- H/o OGTT , high BP recording , symptoms of Gest. HTN , Pedal odema
- H/o BPV, Drugs
• 3rd Trimester
- No. of antenatal visits
- Weight gain-
- H/O – GDM , gest. HTN
- H/O – BPV, LPV , Drugs , Labor pain , Pruritus

6. Menstrual History
Menarche
Cycles – regular, frequency, days of flow, volume , clot , intermenstrual bleed ,
LMP, any abnormality,
any use of OCP
7. Marital History
No. of years of marriage –
Consanguinity degree –
Infertility

OG HISTORY TAKING | Ankit Suniyal

 8. Previous obstetric history

• Conception – after how many years of marriage , type ,
• H/O – APH , pre-eclampsia , IUGR, gest DM
• Labor – induction , prolonged labor
• Type of delivery – Normal /Assisted/ LSCS
• Episiotomy
• Blood transfusion , PPH
• BABY
- live/still birth
- Weight , anomaly
- Admitted to NICU
- Breastfeeding started after birth ___time , exclusive till__
- Present health
• Puerperium sepsis
• removal of catheter
• Anti- D prophylaxis (ask Blood group)
• Contraception used
• Spacing between children
9a) Previous LSCS
• Emergency / elective
• Labor pain
• Blood transfusion
• Suture removal , catheter removal
• Puerperium fever , sepsis (endomyometritis)
• Baby kept in NICU
• Breast feeding started
9 b) Still birth
• Time/ Week of delivery
• Weight of baby
• H/O labor pain

OG HISTORY TAKING | Ankit Suniyal

 • Reason - prematurity, anomaly, IUGR, cord compression, Pre-eclampsia, gest. DM
9c) abortion
• Cause
• Period of gestation
• H/O of D& C , procedure
• MTP done where, complications

10.Past history
Surgery – bowel Sx, Myomectomy, Prolapse
Epilepsy –Blood transfusion
Jaundice
TB / STD
Cardiac / DM /Endocrine /Thyroid disorder
Drug allergy

11. Personal History

• On any medications
• Psychiatric disorder
• Sleep
• Appetite & weight
• Bowel & bladder
• Addictions

12. Diet History

• Before admission to hospital
• Now as IPD patient
• Normal intake

13. Family history

• Family H/O -DM, HTN, Multiple preg, Anomaly,
• TB/Bleeding disorders

OG HISTORY TAKING | Ankit Suniyal

 Summary of history
• ____ year old, obstetric index of _____ & POG ____
• came with C/C___ for __ / or referred as a case of __ from __
• With comorbidities – HTN/DM/asthma/ cardiac, etc
• Admitted for evaluation /workup / safe confinement

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OG HISTORY TAKING | Ankit Suniyal