OnExam

Identifying Information

Obstetrical History

Summary of Current Pregnancy

  • Confirmation of pregnancy
    • Home pregnancy test
    • B-HCG testing - serum, urine in office
  • Pregnancy dating
    • Estimated date of confinement (EDC)
      • Last menstrual period (LMP)
        • Is the patient certain of the date
      • Regular/irregular
      • Cycle length (e.g. 28 days)
    • Contraceptive - type, date last used
    • US - has ultrasound been done, when, results

Obstetrical History

  • Gravidity and parity (e.g. G4T1P1A1L2)
    • Gravidity = total number of pregnancies, regardless of outcome (includes current pregnancy, spontaneous & therapeutic abortions, ectopic pregnancy, hydatidiform moles, stillbirths, live births)
    • Parity = number of various pregnancy outcomes
      • T = number of term deliveries (≥37 weeks)
      • P = number of premature deliveries (<37 weeks)
      • A = number of abortions (both spontaneous and therapeutic)(<20 weeks and/or 500g fetal weight)
      • L = number of living children
    • Note: Twins count as 1 instead of 2 for gravidity (e.g. a female who is currently not pregnant, but has 2 living twins carried to term would be considered G1T2P0A0L2)
    • Definitions
      • Nulligravida: a woman who is currently not pregnant and has never been pregnant
      • Nullipara: a woman who has never completed a pregnancy that lasted for more than 20 weeks
      • Primipara: a woman who has had 1 live birth or stillbirth (estimated gestation >20 weeks)
        • Note: Twins count as 1 live birth or stillbirth
      • Multipara: a woman who has had ≥2 live births or still births (estimated gestation >20 weeks)
  • Past pregnancies
    • Year of delivery
    • Sex
    • Gestational age (# of weeks)
    • Birth weight
    • Length of labour
    • Place of birth
    • Type of delivery - vaginal delivery, C section
    • Anesthesia used (e.g. epidural, spinal)
    • Complications
      • Problems during pregnancy (e.g. gestational diabetes, hyperemesis gravidarum)
      • Problems during delivery (e.g. use of forceps, tears, post-partum hemorrhage, shoulder dystocia)
      • Problems post-partum (e.g. post-partum depression)

Current Pregnancy

  • Symptoms of pregnancy
    • Characterize patient's symptoms
    • Amenorrhea - absence of menses
    • Nausea, vomiting (often begins 2 weeks, resolves between 13-16 weeks)
    • Fatigue
    • Breasts: tenderness (mastodynia), fullness, colostrum secretion (> 16 weeks)
    • Skin changes - facial pigmentation (melasma), darkening of nipples and linea nigra
    • Vaginal discharge
    • Late symptoms (do not need to ask unless the patient presents for the first time late in pregnancy)
      • Quickening = Sensation of fetal movement (begins 18-20 weeks in primigravidas and 14-16 weeks in multigravidas)
      • Stretch marks (appear later in pregnancy)
      • Abdominal enlargement
      • Painless uterine contractions (Braxton Hick's contractions) (begin 28 weeks)
      • Urinary frequency
  • Problems during this pregnancy
    • Mood during this pregnancy (depression)
    • Bleeding
    • Excessive nausea and vomiting
  • Risks
    • Occupational, environmental risks
    • Dietary restrictions
    • Prenatal vitamins (Ca, Vitamin D, Fe) - when started
    • Folic acid (recommended 0.4-1.0mg) - when started

Past Medical History (PMx)

  • Past and present medications
    • Prescriptions
    • Over the counter medication
    • Pain medications
    • Herbal medication
    • Consider safety of medications
      • ResourceL Motherisk.org
  • Allergies
  • Medical conditions
    • Hypertension
    • Endocrine problems - diabetes, gestational diabetes, thyroid disease (hyperthyroidism, hypothyroidism)
    • Urinary tract problems - renal disease, UTI
    • Heart disease - congenital heart disease, rheumatic fever
    • Pulmonary problems - asthma
    • Liver disease - hepatitis
    • Gynaecological problems - fibroids, cervical dysplasia/cancer
    • Breast problems - breast cancer
    • Hematological problems - anemia, hypercoagulability
    • Autoimmune disease - lupus (SLE)
    • Psychiatric problems - depression, anxiety, substance abuse disorders, eating disorders
    • Neurological problems - epilepsy, seizures
    • Infectious diseases
      • STI - gonorrhea, chlamydia, syphilis, HIV, genital herpes (HSV)
      • Tuberculosis
      • Varicella (chicken pox) - chicken pox in the past, varicella immunizations
    • Exposure to diethylstilbestrol (DES) in utero
  • Pap
    • Last Pap test - when, results
      • Pap guidelines: every 3 years starting the age of 21 until the age of 70. If the pap result is abnormal, the testing is done more frequently.
    • Any abnormal Pap tests in the past - when, investigations done
  • Past gynecological procedures (e.g. colposcopy)
  • Surgeries - gynecological surgeries (e.g. LEEP- loop electrocautery excision procedure), problems with anesthetic
  • Hospitalizations
  • Immunizations
    • Influenza, tetanus, rubella

Family History (Fx)

  • Family history (FMHX)
    • Developmental delay
    • Congenital anomalies
    • Chromosomal disorders
    • Diabetes, gestational diabetes
    • DVT/PE (deep vein thrombosis/pulmonary embolism)
    • Hypertension, pregnancy induced hypertension, pre-eclampsia
    • Postpartum depression
    • Thyroid disease
  • Genetic history - genetic disorders
    • CF (cystic fibrosis)
    • Tay Sachs
    • Thalassemia
    • Sickle cell
    • Ashkenazi
  • Consanguinity in the family

Social History (Sx)

  • Feelings about pregnancy - any fears or concerns
    • Explore fears and concerns
  • Was the pregnancy planned or unplanned
  • Is the patient willing to continue pregnancy to term
    • If yes, patient's preference of obstetrical care - family physician, Obstetrician & Gynecologist, midwife
    • If no or unsure, provide information about abortion (e.g. timeline), ask the patient to think about her options at home, and have a further discussion at the next appointment
  • Partner
    • Name, age, occupation
    • Relationship status (single, relationship, common law, married)
    • Living arrangements
    • Is the partner supportive
    • Relationship problems
  • Intimate partner violence (IPV) (all women are at risk, most do not disclose IPV unless asked)
    • Do you feel unsafe or afraid at home
    • Are you afraid of your partner or anyone else
    • Have you ever been hit, kicked, punched, or hurt by someone (if yes, who)
    • HITS
      • H: How often does your partner hit you
      • I: How often does your partner insult or talk down to you
      • T: How often does your partner threaten you
      • S: How often does your partner scream or curse at you
    • Thank you for trusting me with this information and expressing your concern about safety. Would you like for me to connect you with any legal assistance, counseling, shelter, or other services?
    • Offer domestic violence hotline phone number
  • Social support
  • Parenting concerns
  • Religious or cultural issues

Substance Use

  • Smoking: during pregnancy, before pregnancy
    • Amount of cigarettes/packs per day (1 pack= 25 cigarettes), how many years has been smoking for
    • Written in pack-years (# of pack years= # packs/day x # of years)
    • If ex-smoker: how long smoked for, amount/day, when quit, congratulate on quitting
  • Alcohol consumption (see alcohol consumption screening tools)
    • During pregnancy, before pregnancy
    • There is no established "safe level" of alcohol durng pregnancy
  • Recreational drug history (see Recreational Drug History)
    • During pregnancy, before pregnancy
  • Caffeine - amount
  • Sources of stress
  • If smoking, alcohol, or recreational drugs during pregnancy
    • Inform patient of potential risks
    • Discuss possibility of reducing or eliminating use in a non-judgmental, supportive manner

Medications

Gather complete list, including particularly relevant drugs such as:

  • Anticonvulsants (Valproic acid)
  • Pain meds (Gabapentin, opioids)
  • Psychiatric drugs
  • Vitamins

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the immunization history section.

Prenatal Screening

  • All women should be offered screening
    • Provide information about prenatal screening. Different screening tests are available, depending on gestational age
    • If the patient is unsure whether she would like screening, ask the patient to think about her options at home, and have a further discussion at the next appointment
  • For women who present to the office <14 weeks, 0 days
    • FTS (First Trimester Screening)
      • Performed from 11 weeks, 0 days until 13 weeks, 6 days
      • Screens for trisomy 21, trisomy 18
      • Ultrasound screens for anencephaly
      • Does not detect spina bifida
    • IPS (Integrated Prenatal Screening)
      • Done before both first and second trimesters
      • Screens for trisomy 18, trisomy 21, and ONTD (open neural tube defects)
      • Highest detection rate and lowest false positive rate for Down syndrome
    • Serum Integrated Prenatal Screening
      • Done when nuchal translucency measurements are not available
      • Detection rate for Down syndrome is lower and false positive rate is higher than IPS
  • For women who present to the office ≥14 weeks 0 days
    • MSS (Maternal Serum Screening)
      • Performed from 15 weeks, 0 days until 20 weeks, 6 days
      • Screens for trisomy 18, trisomy 21, and ONTD (open neural tube defects)
  • For women who are >35yo on the estimated date of confinement (EDC)
    • May use the screening methods above
    • CVS (chorionic villus sampling) and amniocentesis- more invasive
  • If patient declines any screening, consider MSAFP screening (maternal serum α-fetoprotein) or US for ONTD (open neural tube defects)
  • Document that discussion has taken place, informed consent/refusal has been obtained.

Healthy Promotion and Counselling

  • Nutrition - patient’s eating patterns, attitudes towards weight gain
    • Total recommended weight gain based on pre-pregnancy BMI
      • BMI <19.8: Recommend 12.5-18kg gain (28-40lbs)
      • BMI 19.8-26.0: Recommend 11.5-16kg gain (25-35lbs)
      •                                    
      • BMI 26.0-29.0: Recommend 7.0-11.5kg gain (15-25lbs)
      • BMI >29.0: Recommend around 7.0kg gain (15lbs)
      • *These figures are based on singleton pregnancies in non-adolescents.
    • Recommend multivitamin with at least 0.4mg of folate (folic acid) per day
    • Caution against consumption of unpasteurized dairy products, undercooked meats, excessive vitamin A or mercury.
  • Exercise
    • Moderate exercise on most days recommended in absence of contraindications; should be based on pre-pregnancy fitness level
    • Avoid exercise in supine position (decreases blood flow)
    • Avoid overheating and dehydration
  • Plan for follow-up visits
    • Every 4 weeks up to 28 weeks, then every 2 weeks up to 36 weeks, then every week until delivery. The appointments may alternate between family physician and Obstetrician & Gynecologist. Postnatal visit with Obstetrician & Gynecologist is usually 6 weeks after delivery

References

  • Link to Ob/Gyn Reference page