Obstetric and Gynecological History

last authored: July 2011, David LaPierre
last reviewed: Sept 2011, Joanna Tang

Introduction

A reproductive health assessment should endeavour to gather information as completely as possible at each visit. This should be placed within the context of a patient's education, social, cultural, and emotional state. Initial contact should be made with the woman fully clothed, to reduce anxiety about the exam. Seek any concerns the woman may have about the exam, including any distressing experiences she may have had in the past.

Patient Identification

Begin with the patient's age, work status, and educational background.

Obstetrical history may be recorded in a number of ways. GTPAL is helpful and represents:

Gestations
Term pregnancies
Preterm pregnancies
Abortions (spontaneous and induced)
Live births

For example: Ms. X is a 24 yo G1T0P0A0L0 at 28wks GA. Her LMP is May 23, 2011.

The beginning of the last menstrual period (LMP) is also a key aspect of a woman's reproductive status, whether or not she is pregnant, and should be determined early in the interview.

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Chief Complaint and History of Presenting Illness

Systematically evaluate each sign or symptom. Thoroughness is a key attribute to making the right diagnosis and determining investigation and treatment plans.

This will also allow an assessment of the change in health status.

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Obstetric History

If pregnant:

How far along is the pregnancy? Calculate gestational age and estimated date of delivery from:

LMP (using Naegle's rule: Date of LMP - 3 months + 7 days)
ultrasounds done, and results

Other important information needs to be obtained:

blood type
Rubella immunity
Serology (HepB, HIV, VDRL)
whether the patient has Gestational Diabetes or High Blood Pressure
GBS status - usually done at 36wks GA

Hisotry of Current Pregnancy:

activity of fetus
vaginal bleeding
contractions
leaking of fluid (ruptured membranes)
discharge

History of Previous Pregnancies:

Number of pregnancies and outcome (already explored above), including information regarding:

ectopic gestations
past hypertension or glucose intolerance/diabetes
complications during pregnancy e.g. Pre-term labour
complications during labour e.g. Post-partum hemorrhage

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Gynecological History

Gynecological history includes menstrual history, sexual history, and gynecological conditions.

Menstrual History

Identify the last menstrual period: "When was the first day of your last period?" Other important questions should be asked to explore how long the period lasts, how regular it is, how heavy it is ("how many pads do you need to use?"), and extent of pain and cramping.

Also define the age at menarche and time of menopause (if appropriate).

Sexual History

The sexual history should identify the number of partners a patient has, or has had. It is important to appear non judgemental during these questions. Ask if the patient has had sexual activity with both men and women, and if they have had multiple partners.

Contraception use is frequently defined under sexual history. Ask about the length of different methods used in past, the reasons for choosing them, and successes or failures the patient has experienced.