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Taking a
History in
Obstetrics and
Gynaecology
Dr J. Woodman
Dr C.Gnanachandran
History taking
Taking a good history is an art form
An intelligent history is focused toward management and patient care
THE BASICS
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Presenting complaint
• History of presenting complaint
Gynaecological history
Obstetric history
Past medical history
Surgical history
Family history
Allergies
Drugs/ medications
Psychological well-being
Social circumstances
History taking in Gynaecology
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Presenting complaint:
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History of presenting complaint
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Duration, Severity
Impact on quality of life?
Expectations?
Associated symptoms
Pelvic pain / dyspareunia
Gynaecological history
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e.g. IMB, PCB, menorrhagia
Menstrual diary / pattern, LMP
Subfertilty / PID / Infections
Contraception / menopause / HRT
Termination of pregnancy/ Miscarriages
Cervical smear
Bowel symptoms
Bladder symptoms
Obstetric history
 Deliveries & complications
History in Gynaecology (cont)
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Presenting complaint
History of presenting complaint
Gynaecological history
Obstetric history
Past medical history
Surgical history
Family history
Allergies
Drugs/ medications
Psychological well-being
Social
History taking in Obstetrics
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Age
► Gravidity and Parity (e.g. G3 P1 +1)
► Current gestation
► Blood group
► Presenting Complaint
► History of Presenting Complaint
 Onset, Periodicity, Duration, Recurrence
► Past Obstetric History ►Length of pregnancies
►Mode of delivery
►Weight of babies
►Complications
► Any antenatal problems so far?
History taking in Obstetrics (cont)
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Menstrual History including LMP
Cervical smear history
Was this a planned pregnancy?
Past Medical History
 Current or past illnesses
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Past surgical history
 Especially any surgery in the abdomen, pelvis or vagina
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Drug History
 Prescribed medications
 Non-prescribed medications / herbal remedies
 Recreational drugs
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Smoking and alcohol
 Including if an ex-smoker
 Any attempts at smoking cessation
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Family History DVT/ DM/ HT/ congenital anomalies
Social History: Occupation, supportive partner / family
THE BASICS
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Presenting complaint
History of presenting complaint
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Gynaecological history
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Menstrual history
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Sexual history
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Contraception
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Cervical smears
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Obstetric
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history
Gravidity
Parity
Deliveries & complications
General history
• Past medical history
• Surgical history
• Family history
• Allergies
• Drugs/ medications
• Psychological well-being
• Social
THE END