Obstetrics and Gynecology History

ID 

• Name
• Age
• Occupation
• Gravida/Parity
• Gestational Age
• Estimated Due Date
• Blood types
• GBS screen

CC or Reason for Referral

• Regular visit
• Gyne visit: Bleeding, Pain, Mass, Discharge, Infection
• Caseroom: Pain/?Labor, Bleeding, No baby movement, ?Ruptured membranes, Dysuria

HPI

• OLDSCARS: Onset, Location, Duration, Severity, Character, Alleviating/Aggravating factors, Radiation, Symptoms associated
• Associated symptoms
  • Gynecologic: bleeding, pain, mass, discharge, infection, dysuria
  • Caseroom: contractions (regular, painful, length, predictable, frequency, strength), bleeding, baby movement, ruptured membranes (with cough? How much flow?), dysuria
  • PIH: headache, visual changes, epigastric pain, N/V
  • Bleeding: how much, how long, from where, associated pain, contractions, previous imaging (previa)
• Last meal (if for surgery)

PREGNANCY HISTORY

• How did she find out she was pregnant
• LNMP, EDD
• Antenatal care?
• Any complications? bleeding, infection, hypertension, diabetes
• Investigations thus far and findings? ultrasound, amnio, NST, BPP, blood glucose, GBS, blood type
• Trimester
  • First: N/V, bleeding, ANC, EtOH/Rx use
  • Second: quickening, scan for dates, amniocentesis
  • Third: fetal movements, weight gain, edema, contractions

PAST PREGNANCY HISTORY

• Gravida, Term, Premature, Abortions, Live
• Other pregnancies’ dates, hospital, duration of labor, method of delivery, result (gender, apgars)
• Complications – antenatal, intrapartum, postnatal

GYNECOLOGIC HISTORY

• Menstrual history
  • Menarche, Cycle, Nature of periods, Regularity, LNMP, Dysmenorrhea, PMS, Postcoital and intermenstrual bleeding, Menopause, Postmenopausal bleeding
• Contraception
  • Current method, Adherence, Previous methods, Planned pregnancy
• Vaginal discharge
• Urinary history
  • Frequency, Dysuria, Urgency of micturition, Stress/Urge incontinence
• Pap smears
• Sexual history
  • Frequency, Dyspareunia, Number of partners
• Infectious history
  • Swabs, STIs, Yeast infections, Sexual activity
• Gyne surgeries or other interventions/investigations

Past Medical History – CVS, Respiratory, Neuro, Endocrine, MSK, GI, GU

Past Surgical History – C-sections, D&C, cervical surgery, biopsies?

Family History

SOCIAL HISTORY – smoking, EtOH, street drugs, current living situation, job, relationship, Hx/current abuse

MEDICATIONS – vitamins, any stopped during pregnancy or taken before knew of pregnancy

ALLERGIES – note reaction

ROS

INVESTIGATIONS

• Specialist consultations
• Ultrasounds – dates, place, findings
• Bloodwork – when, where, results
• Specific screens
  • 10-14 weeks
    • First trimester combined screening for Trisomy 21
    • Nuchal Translucency UltraSound (NTUS)
    • Serum β hCG
    • Pregnancy associated plasma protein A (PAPP-A)
  • 14-18 weeks 
    • Fetal movement (quickening)
  • 15 – term         
    • Amniocentesis
  • 16 weeks                   
    • Maternal Serum Screen for Trisomy 21 and oNTD
    • Maternal serum α-fetoprotein (MSAFP)
    • Serum β hCG
    • Unconjugated estrogen (estriol or uE3)

•  
  • 16-20 weeks
    • Ultrasound for dates, structural assessment
  • 24-28 weeks              
    • 50g Oral glucose challenge
  • 28 weeks                  
    • CBC, RhIG for all Rh negative women
  • 36 weeks                   
    • GBS screen, Rh antibody screen if indicated

 OBSTETRIC EXAMINATION

General and Vitals

            HEENT

CVS

Respiratory

Neurological – especially in PIH (CN, tone, reflexes, clonus)

Abdominal

• Inspection
  • Scars, Linea nigra, Distension, State of umbilicus, Striae, Fetal movement
• Palpation
  • FSH
  • Uterine tone and tenderness
  • Lie, presentation, position, attitude
• Auscultation
  • Fetal heart beat via doppler

Pelvic

• Cervical changes
  • Position
  • Consistency
  • Effacement
  • Dilatation
  • Station
• Speculum – nitrazine swab (blood, semen, urine, amniotic fluid)

GYNECOLOGIC EXAMINATION

General and Vitals

Pelvic

• Inspection
  • Hair distribution, Vulval inflammation/infection, Scars
  • Vaginal discharge, Odour
  • Incontinence of urine on coughing, Prolapse
• Bimanual
  • Cervix: consistency, regularity, excitation, pain, position
  • Uterus: size, shape, consistency, mobility, pain
  • Adnexae: palpable, size, pain, masses
• Speculum
  • Cervix:      inflammation, Nabothian follicles, eversion, polyps
  • Vagina :     estrogenization, urethral dislocation, bladder neck support, cystocele, rectocele, enterocele
  • Pap smear
  • Swabs for Chlamydia and Gonorrhea