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! Taking a history and performing an obstetric
examination are quite different from their
medical and surgical equivalents.
! Not only will the type of questions change
with gestation but also will the purpose of the
! àlways introduce yourself; tell the patient who
you are and say why you have come to see
! Sensitive to intensely private data.
! Some women will wish another person
(chaperon) to be present if the doctor or
students is male, even just to take a history,
and this wish should be respected.
! "#" $
%  P to build rapport and reflects good
bedside manner.
%  P as a general rule, the very young (<18
years) and the elderly (>35 years) are more likely
to be associated with problems.
%   - this would give us an idea of the
social class of the patient.
ñ! |  '
a) Gravida - total number of pregnancy regardless
of how they ended.
b) Parity - is the number of live births at any
gestation or stillbirths after 24 (?) weeks.
c) EDD:
! Naegele͛s rule [EDD = (LMP + 1yr + 7dys) P (3
mths). àpplied for: 28 day cycle, regular, no
recent use of OCP.
! Ultrasound P PD, àC*, FL, HC
! Gestation Calculator (Wheel)
d) Singleton/Multiple fetus
¬!  (| 
a) Menarche
b) Cycle Regularity (28-30 day)
c) Duration of Menses P e.g. 7 day with 3 heavy
d) Pads used
e) Planned / Unplanned pregnancy
f) ooking P date of booking started
! Test results: Ht, Wt, P, VDRL, TPHà, HIV,
Hep , à O, Rh, F C, Hgb, etc.
! Numbers of check-up attended P where?
Eventful? CTG?
! Earlier & Latest USS P when? What finding?
!'  (
a) Reason admitted
b) Test done

! Problem must be listed in priority if there are

multiple problems and explained concisely
and adequately.
! Common problems: UTI, HPT, GDM,
àntpartum hge., twins, leaking liquor, etc.
Ã!'   | 
a) Previous Pregnancy (first to latest)
b) Mode of delivery P SVD, CS
c) àlive or Well?
d) Term of pregnancy P pre, term, post
e) Termination P abortion, miscarriage
f) Weight range
g) Place of delivery
h) Complication P mother? Child?
i) Singleton? Twins?
(( | 
a) Procedure undergone
b) Gynecological problem
c) Contraception
d) Dyspareunia (e.g. vaginasmus)
e) Cervical examination: e.g. Pap Smear
×!' )&(*(| 
a) History of: HD, Epilepsy, à, HPT, DM, Thyroid
disorder, TIà.
b) Surgery P anaesthetic, complication
c) Immunization
d) àllergic
e) Medication
a) Complicated pregnancy and delivery
b) Twins
c) Health condition P HPT, à, DM etc.
a) Marital status* - single, divorced, married,
partnership, medicolegal.
b) Occupation
c) Vices P alcohol, smoking, illicit drugs.