OBSTETRICS HISTORY
1. Biodata
 Name
 Age
 Occupation/ education level
 Residence
 Parity
 LMP
 EDD
 Date of admission
 IP number
2. Presenting complaint
 Single statement on why patient came to hospital; at what week of gestation
3. HPI
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If pain:
- Onset of pain (was it abrupt or gradual)
- Location of pain (which body part)
- Duration of pain (how long has pain persisted)
- Characteristic of pain (is it burning, aching, throbbing, sharp pains)
- Alleviating and aggravating factors (what worsens and improves pain)
- Radiating pain (is the pain spreading to another area)
- Timing (constant pain or it comes and goes)
- Severity of pain (scale of 1-10)
Any medications for the pain?
Have you experienced this before (previous pregnancy, trimester)
Is there history of trauma?
Does she experience fevers?
Does she experience any lower abdominal pains?
Is there bleeding per vaginum?
Is there discharge per vaginum?
Are there normal fetal movements? (Ask if above 16 weeks of gestation)
Any other problems/ pain that patient would like to be addressed?
4. Antenatal care profile
 How many antenatal clinics attended so far?
 Have you been regular and on time for your visits?
 What hospital?
 Hemoglobin levels
 HIV
 VDRL
 Blood group
 Any supplements (calcium, folate, vitamin D3)
5. Obstetric history
 Parity
 For all pregnancies:
- When was it?
- What mode of delivery? (SVD, C/S)
- If C/S, why?
- Gender of baby and weight of baby
- Where was baby delivered? (home or hospital)
- Which hospital?
- Were there any complications during pregnancy?
- Any symptoms during pregnancy and medications used? (Nausea,
diarrhea, hyperT, anaemia)
- Were there any complications during labour
- Were there any complications post-delivery?
- Were there any complications with the baby?
- Mention any miscarriages or abortions for any pregnancy, when it
was, at what week of gestation, the reason why, what hospital, what
procedure?
- Did she attend all antenatal clinics for that pregnancy?
- Was the baby exclusively breastfed for 6 months?
- Any form of immunization received during that pregnancy?
6. Past gynaecological history
 Menarche
 Regular or irregular periods?
 How long do they last?
 Heavy or light flow? How many pads a day? Were they fully soaked?
 Any cramps?
 Coitarche
 What form of contraception?
 If any, what symptoms due to the contraception?
 History of STIs
 Has she had HPV vaccine?
 Has she had pap smear screening?
 Does she experience pain after coitus?
7. Past medical history
 History of surgery – have you ever been admitted to hospital
- What surgery?
- When was it done?
- Where was it done?
- Outcome of surgery?
 History of diabetes
 History of hypertension
(when she was diagnosed, what medications)
 History of blood transfusion
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Any known drug and food allergy
Is there any medication you take every day?
8. Family and socioeconomic history
 Is she married?
 Does she smoke, drink, or take drugs?
 Any chronic illness in the family? (DM, cancer, cholesterol)
 Is she an NHIF beneficiary?
9. Systemic review
 CNS – any headaches, dizziness, visual disturbances, confusion
 CVS – chest pain, palpitations, peripheral oedema, any shortness of breath
 Respiratory – any cough, haemoptysis, wheezing, difficulty in breathing
 Musculoskeletal system – any joint pains, muscle pains, fatigue, trauma
 GIT – nausea, vomiting, diarrhoea, weight loss, change in appetite, abdominal
pain, jaundice
 GUT – change in output of urine, change in colour of urine, any pain when
going to the bathroom
 Dermatological – any rashes, skin lesions, ulcers, skin colour changes
10. Summary
 Include patient name, parity, presenting complaint, current week of gestation