Essential etiquettes
Seek permission to enter the area where the patient is
Be very careful with the dress code
Make sure you are wearing your identity badge
Be courteous ,sensitive and gentle
Always have a chaperone present
Switch off your mobile
Template of an obstetric history
Personal history
Presenting complaints
History of presenting complaints
Course in the hospital
History of present pregnancy
Past obstetric history
Menstrual history
Contraceptive history
Past medical &surgical history
Drug history and allergies
Family history.
Social history
Systemic review
Summary
1-Personal and social history
Name ,age ,nationality ,occupation ,marital status and
adress.Hasband name ,age ,occupation ,consanguity.
Blood groups and Rh for both.
Gravida :is the number of times the woman has been
pregnant regardless of the out come of the pregnancy.
Parity is the total number of deliveries either live or still
birth after the viability (24 weeks)
LMP/EDD/Duration of gestation
LMP=First day of the last menstrual period .Establish
the patients certainty of date, the regularity of cycle
and the use of contraception.
EDD=expected date of delivery
Naegles rule
EDD=+7 days – 3monthes +1 to the year or
EDD=LMP+9months +7days or it calculated from
obstetric wheel
Chief complaint
Main complaint and duration of the symptoms that
make the patient seek medical help
Common obstetric symptoms are :bleeding per vagina ,
abdominal pain , urinary symptoms ,headache ,
reduced fetal movement , contractions , PROM
etcetera .
History of present illness
Onset , course , severity , duration .
What increase /decreases the symptoms .
Associated other symptoms .
Investigations done (date ,place &results)
Treatment received (details &response)
Any complications .
History of present pregnancy
Planned / unplanned pregnancy .
Antenatal care – number of visits ,any high risk factors
identified , results of investigations including early US
, any problems in each trimesters , what medication is
being taken
Adequate weight gain , BP , Protein urea .History of
vaccination.
Past obstetrical history
State the gravida and parity status and then give the
following details of all her pregnancies :Date , place ,
mode of delivery (normal or CS )
Maturity , fetal sex , weight .,onset of labor any
complications ,breast feeding .If long obstetrical
history one may summaries e.g. she had 8 children ,all
are normal vaginal deliveries ,breast feeding ,no
complications
Gynecological history
Menarche ,her cycle regular or not .dysmenorrhea ,
intermenstrual bleeding .
Any contraception used before ,type .
Any gynecological operation she had .
Any vaginal discharge .
Family history
Family history of chronic illness like HT , DM. Any
inherited disease ,family history of congenital
anomalies , multiple pregnancy .
Social history :occupation ,income ,level of educations
, smoking, drugs abuse .
Drugs history :any drugs used ,allergy
Past medical history :
Past surgical history :
Review of system
Examination :
Consent, privacy , female nurse present.
General examination :color , examination of pallor in
the palm and congectiva and mucous membrane of the
tongue .Cloasma of face .the presence of edema .
Vital sign (pulse ,BP ,Temp ,respiratory rate )
Systemic examination of head and neck
,cardiovascular ,respiratory system.
Obstetric examination
Inspection of the abdomen for distension ,symmetry ,
striae gravid arum ,lina nigra ,scars of previous
operation , edema ,fetal movement if present .
Palpation for any tenderness .
Examination for fundal height by ulner border of left
hand starting from xiphysternum downward till you
feel the fundus .
Symphysis fundal height measurement by tape measure in cm
,the measurement equal to gestational age in weeks .A large SFH
may be due to wrong date ,macrosomia ,multiple pregnancy
,polyhydramnios .A small SFH may be due to oligohydramnios .
Fundal grip palpate the fundal region by the two hand to feel
what occupy the fundal region .
Lateral examination to feel the back on which side ,estimate the
amount of liquor and determine the fetal lie .
Pelvic maneuver by using the two hand to feel the presenting
part ,the head is hard round while the breech is soft .
Pawlick grip try to hold the head between the thumb and index
to see is it fix to pelvis or free .
Auscultation : Try to listen to fetal heart by fetal
stethoscope or sonic aid usually on fetal back in one
of iliac fossa bellow the umbilicus while in breech F H
above umbilicus .
Vaginal examination :
Inspect the vulva for any abnormality
Vaginal examination for cervical dilatation ,cervical
consistency ,effacement ,position of cervix (bishop
score ) and station (level of presenting part to ischial
spine
