OSCE - Obstetric history

I find it helpful to have an idea of what I'm looking for when I'm taking a history, as it helps me remember what questions to ask and why I'm asking them. Here I've put down the things to ask in an obstetric history, followed by some of the things you're looking out for.

Obstetric History:

Introduction:

• wash hands
• introduce yourself (+shake hands with patient)
• explain why you're there
• check identity and parity
• name
• date of birth

Presenting Complaint

• in patient's own words, why they've come in 

History of Presenting Complaint

• how long
• onset - gradual or sudden
• associated symptoms
• pain?
• site
• onset
• character
• radiation
• associated symptoms
• timecourse
• exacerbating and relieving factors
• severity 1-10/10
• any blood or protein in the urine?
• any bleeding?
• any high blood pressure?
• have you noticed anything making it worse?
• better?
• was there anything you think triggered it?
• have you had anything like it before?
• any investigations?
• diagnosis?
• treatment?

Previous Reproductive History

• Have you been pregnant before?
• how many times
• what year
• how long was the gestation
• what was the outcome
• if live-birth, how are they now
• were/are they breast/bottle/mixed fed?
• How has this pregnancy been so far?
• any problems?
• have you noticed any bleeding in early pregnancy?
• how far along are you?
• when's the estimated date of delivery?
• was that confirmed on ultrasound?
• when was your last menstrual period?
• have you had scans?
• any prenatal diagnostic tests?
• have you felt the baby kicking?

Gynaecological History

• Any previous gynaecological problems?
• (have you had to see a gynaecologist before?)
• When was your last period?
• were your periods regular?
• how heavy was the bleeding?
• When was your last smear?
• what was the result?
• Were you using contraception prior to this pregnancy?
• what were you using?
• was it for contraception, or for problems with bleeding?

Previous Medical History

• Do you have any long-term health conditions?
• Do you see your GP for anything?
• Have you been admitted to hospital for any reason?
• Have you ever had any kind of surgery?

Previous Drug History

• Do you take any regular medications?
• Do you take any HRT (hormonal replacement therapy?)
• Any over-the-counter supplements? (St. John's Wort?)

Systems enquiry

• Neuro
• headaches
• changes in vision
• weakness
• tingling
• Resp
• shortness of breath
• cough
• sputum/blood
• Cardio
• palpatations
• chest pain
• faints
• feeling cold or clammy
• GI
• appetite
• bowel movements 
• abdo pain
• GU
• drinking enough
• waterwork problems
• frequency/urgency/retention
• change in colour
• pain
• smell
• MSK
• joint pain
• stiffness
• muscle pain
• General
• fever
• rash
• jaundice
• lethargy

Family History

• Does anything run in the family that you know of?
• heart disease
• diabetes
• thromboembolism
• hypertension
• Were there any complications with your mother during her pregnancy?
• Any sisters who've been pregnant?
• did they have any issues?

Social history

• How is everything at home?
• Who is at home with you?
• do you feel like you have enough help at home?
• do you receive any social support/do your other children have a social worker?
• Any financial trouble?
• Alcohol
• Smoking
• Drugs
• Allergies

ICE

• Are there any concerns that you have?
• Do you have any questions for me?

Summary

• So just to confirm... (1-2 sentence summary of what you've found out)

Conclusion

• Thank you very much for talking to me
• Wash hands
• Present

What you're looking out for:

Hypertension:

• Chronic hypertension
• present before 20 weeks
• 3-5% of pregnancies
• Pre-eclampsia
• hypertension
• proteinuria
• oedema
• HELLP syndrome
• Haemolysis
• Elevated liver enzymes
• low platelets
• Eclampsia
• pre-eclampsia + convulsions

Diabetes:

• Increased insulin requirements
• Nephropathy may worsen, especially if HTN
• Retinopathy may worsen
• Infection risk
• Pre eclampsia risk

Ectopic pregnancy:

• positive pregnancy but lower B-hCG than expected
• abdominopelvic pain
• bleeding

Epilepsy:

• 0.5% of pregnancies
• Highest risk in puerperium
• folate metabolism main concern

Sepsis:

• Pelvic inflammatory disease
• abdominopelvic pain
• fever
• discharge

Kidney Problems:

• Higher risk of UTI
• Hypertension
• CKD
• 1/30 pregnancies complicated by ckd
• largely due to increased maternal age 
• increased diabetes 
• RISKS:
• miscarriage
• IUGR
• preterm delivery
• Foetal death

Anaemia:

• defined as less than 10.5 g/dl
• haemodilution occurs in pregnancy as plasma volume increases by 50%
• 2-3x increased iron requirement
• 90% of pregnancy anaemia thought to be due to iron
• 10-20x increased folate requirement
• 5% of pregnancy anaemia thought to be due to folate
• Sickle cell disease increased risk, as is thalassaemia

Auto-immune:

• SLE - 1/1000
• Lupus nephritis carries poor prognosis
• high risk of miscarriage
• IUGR
• preterm delivery
• IUD
• transient neonatal lupus
• maternal hypertension
• symptoms may improve during pregnancy due to immunosuppression but often flare during pueperium

Asthma:

• 1-4% of women of childbearing age
• 1/3 have no change
• 1/3 improve
• 1/3 deteriorate
• asthma doesn't affect course of pregnancy unless poorly controlled:
• small for gestational age
• IUGR
• preterm delivery
• treatment is the same as in non-pregnant women

Hyperemesis gravidarum

• 0.1-1% have persistent nausea and vomiting
• weight loss
• tachycardia
• dehydration
• fluid and electrolyte imbalance
• postural hypotension
• think about vitamin B1 deficiency (Wernicke's encephalopathy)
• hyponatraemia
• malnutrition
• thrombosis
• psychological issues

IBD

• 50% risk of Ulcerative colitis exacerbation in 1st and 2nd trimester
• 75% of Crohn's remains quiescent
• improves in 1/3 of those with inactive disease at conception
• may have puerperial flare
• active disease at conception associated with
• miscarriage
• prematurity

Obesity

• 1/5 pregnant women obese
• risk of
• pre-eclampsia
• thromboembolism
• diabetes
• shoulder distocia (fat deposits on baby's shoulders)
• wound infection
• resp infection
• caesarean section
• miscarriage
• macrosomia
• stillbirth
• congenital abnormalities

Causes of death:

Direct

• sepsis
• pre-eclampsia
• thromoembolism
• amniotic embolism
• early pregnancy death
• haemorrhage
• anaesthesia

Indirect

• Cardiac disease
• Neurological disease
• Psychiatric causes
• suicide
• substance abuse
• violence
• Malignancy