1. Dr J. Woodman Dr C.Gnanachandran
Taking a History in Obstetrics and Gynaecology
Dr J. Woodman
Dr C.Gnanachandran

2. History taking Taking a good history is an art form
An intelligent history is focused toward management and patient care

3. THE BASICS 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

4. History taking in Gynaecology
Presenting complaint:
e.g. IMB, PCB, menorrhagia
History of presenting complaint
Duration, Severity
Impact on quality of life?
Expectations?
Associated symptoms
Pelvic pain / dyspareunia
Gynaecological history
Menstrual diary / pattern, LMP
Subfertilty / PID / Infections
Contraception / menopause / HRT
Termination of pregnancy/ Miscarriages
Cervical smear
Bowel symptoms
Bladder symptoms
Obstetric history
Deliveries & complications 4

5. History in Gynaecology (cont)
Presenting complaint
History of presenting complaint
Gynaecological history
Obstetric history
Past medical history
Surgical history
Family history
Allergies
Drugs/ medications
Psychological well-being
Social

6. History taking in Obstetrics
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?

7. History taking in Obstetrics (cont)
Menstrual History including LMP
Cervical smear history
Was this a planned pregnancy?
Past Medical History
Current or past illnesses
Past surgical history
Especially any surgery in the abdomen, pelvis or vagina
Drug History
Prescribed medications
Non-prescribed medications / herbal remedies
Recreational drugs
Smoking and alcohol
Including if an ex-smoker
Any attempts at smoking cessation
Family History DVT/ DM/ HT/ congenital anomalies
Social History: Occupation, supportive partner / family

8. THE BASICS Presenting complaint General history
History of presenting complaint
Gynaecological history
Menstrual history
Sexual history
Contraception
Cervical smears
Obstetric history
Gravidity
Parity
Deliveries & complications
General history
Past medical history
Surgical history
Family history
Allergies
Drugs/ medications
Psychological well-being
Social

9. THE END