Obstetric History Taking

1. Max Brinsmead PhD FRANZCOG March 2010 Obstetric History Taking

2. Objectives: • To date the pregnancy • But ultrasound is more accurate • To identify problems requiring pro active care • Antenatal care is an exercise in screening • To establish rapport • In order to prepare patients for childbirth and parenthood • Is difficult unless there is continuity of care

3. Components of an Obstetric History • Pregnancy dating • Past obstetric history • Past medical history • Social and Psychological Profile • Drug history • Family History

4. Pregnancy dating: • Is important because… • Both pre term and post term pregnancies are at risk • As is being small or large for dates • Many tests require dates for accurate interpretation • Begin with LNMP and cycle length • Inaccurate indicator of conception in 1:3 women • Date when fetal movements are first felt • 16 – 22w in Primigravida & 14 – 20w for Multipara • The EDD is calculated by Naegele’s rule • Add 9 months and 7 – 10 days to LMP • Or use an obstetric wheel

5. The obstetric detective: • A few women keep a menstrual calendar • Go back over important events • Coital history sometimes helps • “When did you first think you might be pregnant” • Assisted conceptions • Date of the 1st missed period • Date of the 1st positive pregnancy test • Fetal movements • Date of the first scan – and its EDD • Date of EDD from the 1st examination

6. Past Obstetric History • Let the woman tell her own story • This tells you about “where she’s coming from” • But the essential information is… • Date and outcome of all pregnancies • Gestation and birthweight • Complications of pregnancy • Onset and length of labour • Mode of delivery • Complications of the labour, birth or puerperium • The baby • Facilitated by a form or aide memoire

7. Medical History • “Serious illnesses or operations” • But especially those that may impact pregnancy • Trigger phrases that I use… • Heart problems or rheumatic fever • Asthma, bronchitis or other lung problems • Kidney disease or bladder infections • High blood pressure • Blood clots or thromboses • Nerves or depression • Back or spine problems • Serious accidents or blood transfusions • Sexually transmitted infections • Pap smears and gynaecological operations

8. Social and Psychological Profile • “Is this a planned pregnancy” • Age, education, occupation & religion • All about the partner (or father of the baby) • The relationship – how long and how good • His age, health, occupation and family • Domestic violence • The in-laws and outlaws • Especially relationship with the patient’s mother • Do you have all your previous children with you? • Pregnancy and birth plans • “Do you wish to meet with a counselor”

9. Drug History • Smoking, Alcohol, Prescribed and Other Drugs • Trigger phrases that I use… • Do you smoke, how many, do you have to, have you ever stopped • What is your favourite alcoholic drink, how often, how many • Are you taking any other vitamins, minerals or supplements • Have you ever injected yourself with drugs • Do you use pot, marijuana or any other recreational drugs • How about your partner

10. Family History • Usually Hypertension, Diabetes & Twins • But routine screening makes the latter 2 superfluous • Trigger phrases that I use… • Do you know of any inherited conditions that run in the family like anaemia, birth defects, stillborn babies or babies that did not survive • Have there been any early deaths from heart disease or strokes, blood clots or thromboses • Anyone in the family who suffers from depression or nerves • Epilepsy or any other handicaps • Anyone in your family require Caesarean section

11. Antenatal care is designed to: • Single out pregnancies that are abnormal, disordered or high risk… • In order to provide interventions that will optimise an outcome • So this is an exercise in screening • That starts with the history

12. The objective of screening:

13. The objective of screening:

14. A typical screening scenario:

15. Characteristics of a Test • Sensitivity = the chance that the disease will be detected • Positive predictive value = the chance that a screen positive individual will have the disease

16. 7 Criteria to test a screening program • Is there a good screening test available • Is there an intervention available • Is the disease worth detecting • Will screen positive patients comply • Will the test reach those applicable • Has the program been tested by RCT • Can the health system cope with the program

17. So never ask a question… • Unless the answer that you get will help you in the care of your patient • And never do an examination or a test • Unless the result is going to influence what you do next • This is especially true for the physiological event that is Pregnancy and Childbirth