OnExam

Identifying Information

Gather the patient's general identifying data. As part of the complete obstetrics history, you should also gather:

  • Partner's name and relationship, if present
  • Gravidity and parity (e.g. G4T1P1A1L2). Remember:
      G = Gravidity - number of previous pregnancies, regardless of outcome (including current)
      P = Parity - can be broken down as:
        T = Term deliveries
        P = Premature deliveries
        A = Abortions (both spontaneous and therapeutic)
        L = Living children
  • Nulligravida: a woman who is currently not pregnant, nor has she ever been pregnant
  • Nullipara: a woman who has never completed a pregnancy past 20 weeks’ gestation
  • Primipara: a woman who has delivered only once of a fetus or fetuses born alive or dead with an estimated gestation of at least 20 weeks
  • Multipara: a woman who has completed two or more pregnancies to 20 weeks or more

Chief Complaint

Elicit the patient's chief complaint or reason for visit.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Gynecological History

  • Age at menarche
  • Last menstrual period (LMP)
  • Menstrual cycle characteristics (length, regularity, duration, heaviness, pain)
    • Menorrhagia - heavy or prolonged flow, ask about frequency of having to change hygiene products
    • Metrorrhagia - bleeding between periods, "spotting"
    • Oligomenorrhea - infrequent, irregular periods
    • Primary amenorrhea - absence of periods, has never had one
    • Secondary amenorrhea - absence of periods, cessation of periods
    • Dysmenorrhea - pain/discomfort with menstruation
    • Associated symptoms including diarrhea, nausea and vomiting, fatigue, dizziness
    • Does patient ever miss school/ work due to menstrual discomfort?
    • PMS symptoms (tension, nervousness, irritability, depression, mood swings, weight gain, abdominal bloating, edema, breast tenderness, headaches)
  • Postcoital bleeding
  • Vaginal discharge (amount, colour, consistency, odour, change from normal)
  • Hx of bacterial vaginosis or yeast infections
  • Genital pain, discomfort, and pruritis
  • Vaginal dryness, dyspareunia
  • Genital lumps, sores, lesions
  • Sexually transmitted infections (STIs)
    • Hx of STIs, including treatment
    • Last STI testing
  • Last Pap test, history of abnormal paps, and any further investigations
  • Past surgical history including cryotherapy, loop electrocautery excision procedure (LEEP)
  • Contraception (current method, satisfaction with current method, concerns, preferences, past methods)
  • Menopausal history, if applicable
    • Age at menopause (absence of periods for 12 consecutive months)
    • Associated symptoms (hot flashes, flushing, sweating, sleep disturbances)
    • Feelings towards menopause and effects on life?
    • Postmenopausal bleeding (endometrial cancer until proven otherwise)

Obstetric History

  • GTPAL and details of each pregnancy chronologically
    • Date of birth
    • Sex and weight
    • Gestational age at delivery
    • Length of labour
    • Type of delivery (vaginal, operative)
    • Anesthesia (epidural, spinal, etc.)
    • Complications
  • Amenorrhea suggesting current pregnancy? Common early symptoms:
    • Breasts: tender, tingling, increased size
    • Urinary frequency
    • Nausea, vomiting
    • Easy fatigability
  • LMP? How sure of the date? Regularity of periods prior to this?

Prenatal/Postnatal History

Initial/Routine Prenatals
  • Ontario antenatal record available online.
  • Symptoms of pregnancy
    • Amenorrhea
    • Breasts: tender, tingling, increased size
    • Urinary frequency
    • Nausea, vomiting
    • Easy fatigability
    • Quickening = sensation of fetal movements (beings 18-20 weeks in primigravidas and 14-16 weeks in multigravidas)
  • Symptoms in followup prenatals
    • Headache
    • Abdominal/groin pain
    • Vaginal bleeding/discharge
    • Dysuria
    • Edema
    • Constipation
    • Low back ache
    • Heartburn
  • Confirmation of pregnancy
    • Beta hCG testing-urine or serum
  • Pregnancy dating
    • LMP
      • How sure of dates?
      • Were cycles previously regular or irregular?
    • Ultrasound dating
  • Past obstetrical history
    • GTPAL and details of each pregnancy chronologically
      • Date of birth
      • Sex and weight
      • Gestational age at delivery
      • Length of labour
      • Type of delivery (vaginal, operative)
      • Anesthesia (epidural, spinal, etc.)
      • Complications (including post-partum depression)
  • Past medical history
  • Family history
  • Social history
    • Concerns and attitudes towards pregnancy
      • How does she feel about pregnancy? Was it planned/desired?
      • Does she plan to continue with pregnancy?
      • Support from partner/family
      • Broader support network
        • Occupation and education
        • Relationship with partner
        • Living arrangements
        • Intimate partner violence (IPV): all women can be at risk of IPV and IPV has a significant impact on women’s health and safety
  • Medications
    • Prenatal vitamins(PNV including calcium folate, iron, vitamin D)
    • When did patient start PNV?
  • Health promotion and counselling
    • Nutrition
        Total recommended weight gain based on pre-pregnancy BMI
        • BMI < 19.8: Recommend 12.5-18kg gain (28-40lbs)
        • BMI 19.8-26.0: Recommend 11.5-16kg gain (25-35lbs)
        • BMI 26.0-29.0: Recommend 7.0-11.5kg gain (15-25lbs)
        • BMI >29.0: Recommend around 7.0kg gain (15lbs)
      • Recommend multivitamin with at least 400 mg of folic acid/day
      • Caution against consumption of raw foods, unpasteurized dairy products, excessive vitamin A or mercury
  • Exercise
    • Moderate exercise on most days recommended in absence of contraindications; should be based on pre-pregnancy fitness level
    • Avoid exercise in supine position (decreases blood flow)
    • Avoid overheating and dehydration
  • Smoking, alcohol, and recreational drugs
    • Inform patient of potential risks
    • Discuss possibility of reducing or eliminating use in a non-judgmental, supportive manner
    • Refer to appropriate community and other resources
  • Discuss prental screening options
  • Discuss birth plan
Postnatal visit
  • Ontario postnatal record available online.
  • Review of birth
  • Baby's health and any concerns
  • Infant feeding choices
  • Bladder function
  • Bowel function
  • Menses, lochia, discharge
  • Perineal discomfort
  • Psychosocial:
    • Emotional problems, coping, depression
    • Contraception and family planning
    • Sexual/relationship concerns
    • Social support
    • Family violence

Sexual History

  • Sexual orientation ("Do you have sex with men, women, or both?")
  • Number of sexual partners (ie. in past 6 months)
  • Types of sexual activity (oral, vaginal, anal)
  • Satisfaction with sex life and/or problems with sex
  • Partner's satisfaction
  • Concerns
  • Ability to reach climax
  • Dyspareunia = pain during sexual intercourse. Can be superficial or deep
  • Vaginismus = involuntary spasm of muscles surrounding vaginal orifice; makes penetration during intercourse painful or impossible

Past Medical History (PMHx)

Specifically ask about:

  • Diabetes mellitus (DM)
  • Hypertension (HTN)
  • Bleeding diasthesis
  • Anemia
  • Epilepsy
  • Asthma
  • Cardiovascular disease (CVD)
  • Thyroid disease
  • Renal disease
  • Psychiatric problems (depression, bipolar, schizophrenia)
  • Cancer

Family History (FmHx)

Specifically ask about:

  • DM (including gestational DM)
  • HTN
  • Psychiatric problems such as depression (including post-partum depression)
  • Congenital malformations
  • Developmental delay
  • Known hereditary disorders
  • Malignancies (breast, endometrial, ovarian, colon, etc.)
  • Endometriosis

Social History (SocHx)

Specifically ask about:

  • Occupation and education
  • Relationship with partner
  • Living arrangements
  • Intimate partner violence (IPV): all women can be at risk of IPV and IPV has a significant impact on women’s health and safety
    • Most women do not disclose spontaneously; but may do so if asked
  • Social/family supports
  • Nutrition
  • Physical activity

Substance Use History (SubHx)

  • Smoking: historical and ongoing
  • Alcohol consumption
  • Recreational drug use

Medications

  • All prescriptions and non-prescription
  • Contraceptives
  • Prenatal vitamins (PNV; including calcium, folate, iron, vitamin D)
  • Hormone replacement therapy (HRT); previous and/or current HRT
  • If pregnant pt, consider effect of all drugs on pregnancy

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the immunization history section. Especially relevant to the Obstetric and Gynecological history is the human papilloma virus (HPV) vaccine.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  1. Rowe T, Senikas V, Pothier M, Fairbanks J, Sams D, eds. Alcohol use and pregnancy consensus clinical guidelines. SOGC Clinical Practice Guidelines. No. 245. J Obstet Gynaecol Can. 2010; 32(8): S1-S32. http://sogc.org/guidelines/documents/gui245CPG1008E.pdf. Accessed February 17, 2011.
  2. Bernstein HB, Weinstein M. Normal pregnancy & prenatal care. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:187-202.
  3. Bickley LS. Female genitalia. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 521-532.
  4. Bickley LS, Thompson, JE. The pregnant woman. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 871-880.
  5. Cherniak D, Grant L, Mason R, Moore B, Pellizzari R. Intimate partner violence consensus statement. SOGC Clinical Practice Guidelines. No. 157. J Obstet Gynaecol Can. 2005; April: 365-388. http://www.sogc.org/guidelines/public/157E-CPG-April2005.pdf. Accessed February 17, 2011.
  6. Kawada C. Gynecologic history, examination, & diagnostic procedures. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:519-539.
  7. Lefebvre G, Pinsonneault O, Antao V, Black A, Burnett M, Feldman K, Lea R, Robert M. Primary dysmenorrhea consensus guideline. SOGC Clinical Practice Guidelines. No. 169. J Obstet
  8. Gynaecol Can. 2005; December: 1117-1146. http://sogc.org/wp-content/uploads/2013/01/169E-CPG-December2005.pdf. Accessed November 4, 2013.
  9. Leveno KJ, Hauth JC, Rouse DJ, Spong CY (2010). Chapter 8. Prenatal Care. In KJ Leveno, JC Hauth, DJ Rouse, CY Spong (Eds), Williams Obstetrics, 23e. Retrieved November 4, 2013 from http://www.accessmedicine.com.normedproxy.lakeheadu.ca/content.aspx?aID=6052072.
  10. Ontario Medical Association and Ontario Ministry of Health and Long-Term Care. Antenatal record. http://www.fammedref.org/wp-content/uploads/2011/12/Ontarioantenatalrecord2005.pdf. Accessed November 4, 2013.
  11. ?