Professional Documents
Culture Documents
Introduction
Introduce yourself name / role
Confirm patient details name / DOB
Explain the need to take a history
Gain consent
Ensure the patient is comfortablePresenting complaint
Its important to use open questioning to elicit the patients presenting
complaint
So whats brought you in today? or Tell me about your symptoms
Allow the patient time to answer, trying not to interrupt or direct the
conversation
What you plan to cover next Now Id like to discuss your past medical
history History of the current pregnancy
Is this the patients first pregnancy?
How was the pregnancy confirmed? home testing kit / hCG blood test / USS
Last menstrual period (LMP) first day of the LMP
Was the patient using contraception? are they still (e.g. COCP / implant /
coil)
Estimated date of delivery (EDD) estimated by scan or via dates (LMP + 9
months + 7 days)
Did the patient take folic acid during the first trimester?
Any other scans or tests whilst been pregnant? dating scan / anomaly scan
Growth of fetus within normal limits?
Placental location placenta praevia may alter delivery plans
Fetal movements usually experienced at around 18-20 weeks gestation
Labour pains more relevant in the third trimester
Planned method of delivery vaginal / c-section
Medical illness during pregnancy if so are they taking any medications?
Previous obstetric history
Gravidity defined as the number of times a woman has been pregnant
regardless of the outcome
Parity X = (any live or still birth after 24 weeks) |
24 weeks)
Details of each pregnancy:
Date of delivery
Length of pregnancy
Singleton / twins / or more?
Spontaneous labour or induced?
Mode of delivery
Weight of babies
Current health of babies
Gynaecological surgery:
Loop excision of transitional zone (LETZ) risk of cervical incompetence
Previous C-sections risk of uterine rupture / placenta accreta /adhesions
Past medical history
Relevant medical conditions
PE / DVT high risk for further events in following pregnancy
Diabetes tight glycaemic control is essential risk of congenital defects /
macrosomia
Epilepsy some antiepileptics are teratogenic needs neurology input
Hypothyroidism TFTs need close monitoring risk of congenital
hypothyroidism
Previous pre-eclampsia higher risk to develop it in the current pregnancy
Other medical conditions
Any hospital admissions? when and why?
Surgical history previous abdominal and gynaecological surgery of
relevance
Immunisations up to date?
Drug history
Pregnancy medications:
Folic acid
Iron
Antiemetics
Antacids
Teratogenic drugs:
ACE inhibitors
Sodium valproate
Methotrexate
Retinoids
Trimethoprim
Document all regular medications
Over the counter drugs ensure nothing is unsafe / teratogenic
ALLERGIES
Family history
Inherited genetic conditions cystic fibrosis
Pregnancy loss recurrent miscarriages in mother & sisters
Pre-eclampsia in mother or sister increased risk
Social history
Smoking can cause intrauterine growth restriction
Alcohol How many units a week? can cause fetal alcohol syndrome
Recreational drug use cocaine use can cause placental abruption
Living situation:
House / flat stairs / adaptations
Who lives with the patient? important when considering discharging home
from hospital
Any carer input? what level of care do they receive?
Activities of daily living:
Is the patient independent / able to fully care for themselves?
Prenatal Checkup
The First Visit
Your first prenatal visit will probably be scheduled sometime after your
eighth week of pregnancy. Most health care providers wont schedule a visit
any earlier unless you have a medical condition, have had problems with a
pregnancy in the past, or have symptoms such as spotting or bleeding,
stomach pain, or severe nausea and vomiting.1
Because your first visit will be one of your longest, allow plenty of time.