Obstetric and Gynecological History
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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.
Patients increasingly are using the internet for health information.
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
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.
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.
Obstetric History
How far along is the pregnancy? Calculate gestational age and estimated date of delivery from:
- LMP
- ultrasounds done, and results
Number of pregnancies and outcome
- Gravida: number of pregnancies
- Parity: number of pregnancies over 20 weeks
- Abortion: number of pregnancies lasting less than 20 weeks
If the women is pregnant, inquire into:
- activity of fetus
- bleeding
- contractions
- discharge
Regarding previous pregnancies, establish:
- Ectopic gestations
- past hypertension or glucose intolerance
- complications during pregnancy
- complications during labour
Menstrual History
Last menstrual period: "When was the first day of your last period?"
"How long does your period last?"
"how many pads do you need to use?"
Age at menarche
duaration of menstrual cycle
menstrual pain
menopause (if appropriate)
Past Medical History
blood type
GBS status
STDs
regularity and normality of paps
Ask especially about:
- hypertension
- diabetes
- other chronic health conditions
- coagulopathy
- depression/anxiety
- thyroid
- surgeries
Current Medications and Allergies
Family History
Ask especially about:
- cancer
- diabetes
- hypertension
- chromosomal abnormalities
Social History
smoking
drinking
drug use
Sexual History
- men and/or women
- multiple partners
contraception use
- length of OCP
- different methods used in past
- reasons for choosing
Resources and References
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