Obstetrics History

Patients Profile

MR#: ________________________

Name:

Husbands/Fathers Name:

_____________________________________
_____________________________

Age:

_____________________________________

Husbands Age:

_____________________________

Education:

_____________________________________

Husbands Education:

Occupation:

_____________________________________

Husbands Occupation: _____________________________

Blood Group:

_____________________________________

Husbands Blood Group:

_____________________________

_____________________________
Married for (Yrs):

_____________________________________

Consanguinity: Yes/No

L.M.P:

_____________________________________

Parity:

_____________________________________

Phone:

_____________________________________

EDD:

_____________________________________

Residence:

_____________________________________

PRESENTING

COMPLAINT :

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Past Obstetrics History

Year
of
Birth

Place of
Birth

Duration

Complication

Mode of
Delivery

Se
x

Birth
Weigh
t

Breastf
ed

History of Present Pregnancy

1st Trimester
Pregnancy: planned/unplanned

Confirmed by:

_____________________________________
Booking:

done/not done, where: ____________________________Spontaneous/Induced (by what)

______________________
Investigations:
_________________________________________________________________________________________________
Fever, rash, spotting, bleeding, nausea,
_____________________________________________________________________________
Any treatment: _____________________________________________ Folic acid:

yes/no

2nd Trimester
Anomaly scan: ____________________________________________Quickening:
_______________________________________
Any complications: _________________________________________
______________________________

Urinary tract infection:

Current
Health
Status

Bleeding: ________________________________________________ Vaginal discharge:

__________________________________
Medical disorder (Diabetes/ Hypertension):
_________________________________________________________________________
_____________________________________________________________________________________________________________
_
Tetanus Prophylaxis: yes/no

1st Dose: _________________

2nd Dose:

__________________

Investigations:
_________________________________________________________________________________________________
Any treatment received: ____________________________________

Vitamin, folic and calcium supplements:

________________

3nd Trimester
Fetal movements approx. / day: _______________________________ Abdominal pain/ contractions:
________________________
Bleeding: _________________________________________________ Fever:
___________________________________________
Vaginal Discharge:

Color _____________ Amount ____________

itching (yes/no)

Consistency

_________________
Urinary complaints: _________________________________________

Bowel complaints:

_________________________________
Hypertension:

____________________________________________

Diabetes:

________________________________________
Investigations:
_________________________________________________________________________________________________
Any other medical or surgical complaints:
___________________________________________________________________________

Menstrual History
Menarche: ________ years

Cycle: _____/______

Flow and regularity: ____________________________________

Pap smear done: yes/no

Contraceptions used by husband/patient:

___________________________________________________________________________
Dysmenorrhea, postcoital bleeding, dyspareunia, intermenstrual bleeding,
_________________________________________________

History of Presenting Complaint

_____________________________________________________________________________________________________________
_
_____________________________________________________________________________________________________________
_
_____________________________________________________________________________________________________________
_
_____________________________________________________________________________________________________________
_
_____________________________________________________________________________________________________________
_
_____________________________________________________________________________________________________________
_

_____________________________________________________________________________________________________________
_

Review of System
G ENERAL : weakness, fatigue, fever
GIT: loss of appetite, nausea, dysphagia, regurgitation, flatulence, heartburn, vomiting, hematemasis,
abdominal pain, abdominal distention, abnormal bowel habit, constipation, diarrhea, abnormal stool,
rectal bleeding, incontinence
R ESP : hemoptysis, dyspnea, orthopnea, hoarseness, wheezing, chest pain
CVS: dyspnea, paroxysmal nocturnal dyspnea, chest pain, palpitations, dizziness, ankle swelling, limb pain
ENDOCRINE : acne, weight gain, hirsuitism, galactorrhea, hot flushes, night sweats, heat or cold intolerance
UGS: loin pain, poor stream, dribbling, hesitancy, dysuria, urgency, hematuria, polyuria, incontinence,
nocturia
CNS: behavioral changes, depression, memory loss, anxiety, tremor, syncopal attacks, loss of
consciousness, fits, muscle weakness, sensory disturbances, parasthesias, dizziness, change of smell,
vision or hearing, headaches
MSS: muscle aches, bone pain, joint swelling, limitation of joint movement, disturbance of gait, back pain,
muscle wasting

Past Medical History

Medical: DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, DVT, anemia
Surgical: trauma, transfusions, anesthesia complications, previous surgery: ____________________________
__________________________________________________________________________________________

Family History
DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, twins, congenital anomalies, infertility, prolapse

_________________________________________________________________________________________
_
Medication History
Current pregnancy: _________________________________________________________________________
Before pregnancy: __________________________________________________________________________

Allergies:

___________________________________________________________
_______________
Social History
Smoking, hukka, niswaar, alcohol

Housing: ___________________________________

Monthly income: _____________________________ Social class: _________________________________

_____________________________________________________________________________________________________________
_

Examination
GENERAL AND PHYSICAL EXAMINATION
Appearance:
___________________________________________________________________________________________________
Height:

________________________

Pulse:

________________________/min

Temperature:

________________________

Weight:

___________________kg

Blood pressure:

_______ / _______mmHg

Respiratory rate:

___________________/min

H ANDS: leukonychia, koilonychia, thenar or hypothenar atrophy, sweatiness, splinter hemorrhages, clubbing
S KIN : spider angiomata, pallor, rash, petechiae, bruises, capillary refill _________, skin turgor ________
EYES : both pupils round, regular and reactive, pallor, jaundice
FACE : chloasma, jaundice, periorbital edema, proptosis, oral hygiene ______________
N ECK : normal carotid pulses, tracheal deviation, goiter, engorged neck veins
LYMPH NODES:
__________________________________________________________________________________________________
LUNG :
________________________________________________________________________________________________________
H EART :
_______________________________________________________________________________________________________
GU: non-palpable kidneys, distended bladder, renal punch
EXTREMITIES : ankle edema, cyanosis, erythema, varicose veins, peripheral pulses normal, calf tenderness
CNS: cranial nerves _________, sensory or motor loss, tone _________, reflexes __________, neck rigidity

BREAST EXAMINATION
Inspection:
____________________________________________________________________________________________________
Palpation:
_____________________________________________________________________________________________________
Lymph nodes:
_________________________________________________________________________________________________
Any other:
____________________________________________________________________________________________________

ABDOMINAL EXAMINATION
Inspection
Shape of abdomen: _______________________________

Scars:

_______________________________________________
Umbilicus:

_______________________________

Striae gravidarum, linea nigra, visible veins, discoloration,

_______________________________________________________________
Palpation
Tenderness:

_______________________________

Scar tenderness (if previous LSCS):

_________________________
Fundal height: _______________________________

Lie of fetus:

___________________________________________
Presentation

_______________________________

__________________________________________

Engagement:

Liquor volume _______________________________

Estimated fetal birth weight:

______________________________
Auscultation
Fetal heart rate: ______________________________

Regular/ Irregular

OTHER EXAMINATION (_____________________________________________________________)

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___

PELVIC EXAMINATION
Vulva/ Perineum:
_______________________________________________________________________________________________
Bleeding:
Discharge:

Color _____________________
Color _____________________

Amount _____________________

Amount _____________________

Smell _____________________

SPECULUM EXAMINATION
Vagina:
_______________________________________________________________________________________________________
Cervix: Appearance_______________________

Dilatation ___________________

Discharge

Amount _____________________

: Color _____________________

Smell

_____________________
Bleeding:

Color _____________________

Amount _____________________

VAGINAL EXAMINATION
Cervical length:
Consistency:

_______________________
_______________________

Position:

_______________________

Liquor (clear/ meconium stained)

Cervical dilatation: _______________________

Station: ________________________________
Membranes: Intact/absent/ARM
Amount of liquor: _______________________

BISHOPS SCORE
Parameters

Score
0
0 cm
2 cm
Firm
-3
Posterior

Cervical Dilatation
Cervical Length
Cervical Consistency
Station
Position of Cervix

1
1-2 cm
2-1 cm
Medium
-2
Central

2
3-4 cm
1-0.5 cm
Soft
-1 or 0
Anterior

Total Bishops Score:

_________________________________________________________________________
PELVIC ASSESSMENT
Sacral promontory:

_______________________

Sacrotuberous ligaments:

______________________
Sacral curve:

_______________________

______________________

Inter-spinous distance:

3
5 cm
0.5cm
-

Sub-pubic arch:

_______________________

Inter-tuberous distance:

______________________

Result:
____________________________________________________________________________________________
Differential Diagnosis
_________________________

_________________________

_________________________

_________________________

Investigations
_____________________

_____________________

___________________

_____________________

_____________________

Plan/Treatment
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
____