OBSTETRIC HISTORY

1-PERSONAL DATa
1. Name
8. LMP (First day of the last
2. Age
menstrual period)
3. Nationality
9. GA (Gestational age)
4. Occupation
10.
Any known illness
5. Marital Status (Since
(Duration + Medication)
when)
11.
-High risk pregnancy
6. Date of admission
(e.g. Twins - Previous
(ER/OPD)
caesarean etc)
7. -Grvida...... Para....+......
(Check the note)
2-main complaint +duration ( reason of admission)
3-HISTORY OF present illness (HPI)
1. Complaint analysis
3. -Associated symptoms
4. -Risk factor
2. -Previous episodes
4-History of current pregnancy
1. -LMP (Sure?? - Regular
7. Drug history during
menses?? - Contraceptive
pregnancy
8.
-Further investigations
pills?? - Lactating??)
(u/s - Screening for DM 2. GA (Gestational age)
3. -EDD (Expected date of
any other test not
delivery)
routinely done)
4. Planned?? (Use of
-Complications (HTN - DM
Assisted Reproductive
- Bleeding - Fluid leak Technology)
UTC - Heart disease 5. -How was she diagnosed
Other)
to be pregnant?
9. Fetal Movements (a.k.a.
6. Booking visit (When??
quickening)
Early or Late - Coming
10.
-Exaggerated
regularly?? - Results of
pregnancy symptoms
investigation
(Nausea A Vomiting)
5 ., past obstetric history For each pregnancy . .. Ask:
(Better to be organized in a table
1. -When (the delivery)
6. -Type of delivery (SVD -c/s
2. -Where
. . . why? - Instrumental . .
3. GA
. why?
4. -Duration of labor (long 7. ) -Gender
Short)
8. Birth weight
5. -Augmentation or
9. -Use of
induction??
anaesthesia/Analgesia?
any complications?

:maternal Complications
(HTN -DM - UTI ante/post
partum Haemorrhage.
10.
Fetal complications
(Prematurity - IUGR-lUFD'lCU admission -other
Gynaecological history
Menstrual
LPM
Regularity
Contraceptive
Type
Side effect
Sexual:
Superficial deep dyspareunia
Vaginal discharge

11.
Cry
12.
^ -Lactation
13.
-Left hospital with
mow? If not why? out)

Menarch
Duration amount and timing
Duration
Stop or not why
History of std
Post coital bleeding

Past history,
medical surgical- blood transfusion
Current MEDICATIONS:
Name duration dose side effect
Allergies
Penicillin other anesthesia
10-SOCIAL HISTORY:
-alcohol -Home -Smoking (Anybody smoking at home)
Drug abuse -Husband occupation
II-FAMLY history:
DM - 6DM - HTN - Pre-eclampsia ovarian breast uterine cancer
-History of twins or anomalies (Patient sister mother-mothers
sister-grandmother)
12-SVSTEMIC REVIEW
13-HOSPITAL COURSE
14-SUMMARY
1. -Name
2. -GA

3. Age

4. Known illness important

findings( depend on the
case)
5.
10.
11.

6. Important findings
7.
8. Gravida and para
9. Presenting ilness