OBSETRICS HISTORY Flashcards
Describe the initial steps to take during an obstetric history consultation.
Opening the consultation
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the patient including your name and role
3 Confirm the patient’s name and date of birth
4 Explain that you’d like to take a history from the patient
5 Gain consent to proceed with taking a history
6 Confirm gestational age, gravidity and parity early on in the consultation
Explain Gravidity and Parity with examples.
Explain Gravidity and Parity
Gestational age, gravidity and parity should also be included at the beginning of your presentation of a patient’s history.
Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).
Parity (P) is the total number of times a woman has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth).
Example of gravidity and parity calculation
A patient is currently 26 weeks pregnant and already has two children of her own. She reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks:
G5: The patient’s gravidity is 5 because she has had 5 pregnancies in total.
P3: The patient’s parity would be 3 because she has had 3 pregnancies which resulted in the birth of a child with a gestational age of greater than 24 weeks (one of which was a stillbirth).
How does parity work for twins?
A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational age (greater than 24+0 weeks) should be defined as P1.
However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2.
As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable gestational age will often be referred to as P2, but from an academic perspective, they would be deemed P1.
How to explore the presenting complaint?
Presenting complaint
Use open questioning to explore the patient’s presenting complaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
How to assess for pain in presenting complaint
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Site
Ask about the location of the symptom:
“Where is the pain?”
“Can you point to where you experience the pain?”
Onset
Clarify how and when the symptom developed:
“Did the pain come on suddenly or gradually?”
“When did the pain first start?”
“How long have you been experiencing the pain?”
Character
Ask about the specific characteristics of the symptom:
“How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
“Is the pain constant or does it come and go?”
Radiation
Ask if the symptom moves anywhere else:
“Does the pain spread elsewhere?”
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom:
“Are there any other symptoms that seem associated with the pain?” (e.g. shortness of breath in pulmonary embolism)
Time course
Clarify how the symptom has changed over time:
“How has the pain changed over time?”
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
“Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction may find going up or down the stairs makes things worse)
“Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux may find that antacid medication helps with their symptoms)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
Key obstetric symptoms
Screen for other key obstetric symptoms (e.g. nausea, vomiting, reduced fetal movements,
vaginal bleeding, abdominal pain, vaginal discharge or fluid loss, headaches, visual
disturbance, epigastric pain, oedema, pruritis, unilateral leg swelling, chest pain, shortness of
breath, fatigue, fever, weight loss)
What conditions to think about with nausea and vomiting
Nausea and vomiting: common in pregnancy and mild in most cases. Hyperemesis gravidarum represents a severe form of vomiting in pregnancy associated with electrolyte disturbance, weight loss and ketonuria.
Nausea and vomiting
Nausea and vomiting are very common in pregnancy, but are typically mild, requiring only reassurance and basic hydration advice.
Nausea and vomiting typically begin between the fourth and seventh week of gestation, then peak between the ninth and sixteenth week and resolve by around the 20th week of pregnancy.
Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance, weight loss and ketonuria. ¹
What conditions to think about with reduced fetal movements
Reduced fetal movements: can be associated with fetal distress and absent fetal movements may indicate early fetal demise.
Reduced fetal movements
Women typically start to feel fetal movements between 16 to 24 weeks gestation (primigravida women will often not feel fetal movements until after 20 weeks gestation). A mother will know what is the “usual” amount of fetal movements she experiences, therefore, if a reduction in fetal movements is reported, it should be taken very seriously.
Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal growth restriction, placental insufficiency, and congenital malformations. ²
You should always ask about fetal movements once the patient is of the appropriate gestation to be able to feel them:
“Have you noticed any change in the amount of your baby’s movement?”
What conditions to think about with vaginal bleeding in pregnancy
Vaginal bleeding: causes include cervical bleeding (e.g. ectropium, cervical cancer), placenta praevia and placental abruption (typically associated with abdominal pain).
Vaginal bleeding
Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynaecological diseases.
It is important to ask about pain, associated trauma (including domestic violence), fever/malaise, recent ultrasound scan results (e.g. position of the placenta), cervical screening history, sexual history and past medical history to help narrow the differential diagnosis.
You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-syncope/syncope).
What conditions to think about with abdominal pain
Abdominal pain: causes may include urinary tract infection, constipation, pelvic girdle pain and placental abruption.
What conditions to think about with vaginal discharge or loss of fluid
Vaginal discharge or loss of fluid: abnormal vaginal discharge may be caused by sexually transmitted infections such as gonorrhoea and the loss of fluid from the vagina indicates rupture of the amniotic membranes.
Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking an obstetric history.
You should ask the patient if they have noticed any changes to the following characteristics of their vaginal discharge:
Volume
Colour (e.g. green, yellow or blood-stained would suggest infection)
Consistency (e.g. thickened or watery)
Smell (e.g. fish-like smell in bacterial vaginosis)
What conditions to think about for headache, visual disturbance, Epigastric pain and oedema
Headache, visual disturbance, epigastric pain and oedema: these are typical clinical features of pre-eclampsia. Mild oedema is common and normal in the later stages of pregnancy.
Headache, visual changes, epigastric pain, oedema
Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy.
The key symptoms to ask about include:
Headache (typically severe and frontal)
Swelling of the hands, feet and face (oedema)
Pain in the upper part of the abdomen (epigastric tenderness)
Visual disturbance (blurring of vision or flashing lights)
Reduced fetal movements
What conditions to think about with pruritus
Pruritis: associated with obstetric cholestasis (typically affecting the palms and soles of the feet).
What conditions to think about with unilateral leg swelling
Unilateral leg swelling: consider and rule out deep vein thrombosis.
Conditions to think about for Chest pain and shortness of breath
Chest pain and shortness of breath: pregnant women are at increased risk of developing pulmonary emboli.
