OnExam

Identifying Information

  • Gather the patient's general identifying data.
  • 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)

Review Pregnancy and Delivery

  • # weeks postpartum
  • Delivery date, place of birth
  • Baby's sex
  • Gestational age (# of weeks)
  • Birth weight
  • Length of labour
  • Type of delivery - vaginal delivery, C section
  • Anesthesia used (e.g. epidural, spinal)
  • Complications
    • Problems during pregnancy (e.g. gestational diabetes, hyperemesis gravidarum)
      • Women who had gestational diabetes should be tested to ensure that they have not advanced to frank diabetes
    • Problems during delivery (e.g. use of forceps, tears, post-partum hemorrhage, shoulder dystocia)
    • Problems with the baby

Postpartum History

  • Review baby's health, any concerns
  • Breastfeeding vs bottle-feeding
    • Any concerns
  • Postpartum medical concerns
    • Bladder function
    • Bowel function
    • Perineal discomfort
    • Lochia/menses
    • Mood, emotional problems, postpartum depression
  • Sexual activity
    • Single or have a partner
    • Sexual activity and orientation
      • "Have you been sexually active since childbirth?"
    • Problems/concerns about sexual life
    • Pain during intercourse (dyspareunia)
      • Characterize patient's pain
      • Certain positions that cause pain vs all positions cause pain
      • FIFE
      • Alcohol
      • Experienced any unwelcome sexual advances, perhaps long ago in childhood
    • Bleeding during or after intercourse (postcoital bleeding)
  • Contraception
    • Current method of birth control
      • How often patient uses birth control
      • Satisfaction with current method
    • Planning to have any more children - when
      • If patient is certain that she does not want future children, counsel about tubal ligation
    • Questions/concerns about birth control methods
      • Counsel about options if applicable

Past Medical History (PMx)

  • Past and present medications
    • Prescriptions
    • Over the counter medication
    • Pain medications
    • Herbal medication
  • 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

Social History (Sx)

  • Partner
    • 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
  • Coping with child care, parenting concerns

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
    • If current smoker, counsel about smoking in future pregnancies, advise to quit, provide resources
  • Alcohol consumption (see alcohol consumption screening tools)
    • Counsel about alcohol use in future pregnancies
  • Recreational drug history (see Recreational Drug History)
    • If currently takes recreational drugs, counsel about recreational drug use in future pregnancies, advise to quit, provide resources
  • Caffeine - amount
  • Sources of stress

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.

Follow-Up and Advice Regarding Future Pregnancies

  • Rubella immune - if patient is rubella susceptible, advise about rubella immunization before next pregnancy
  • Preconceptual folate - advise to start 3 months before future pregnancy

References

  1. Antenatal record. http://www.fammedref.org/wp-content/uploads/2011/12/Ontarioantenatalrecord2005.pdf. Accessed November 4, 2013.
  2. Bernstein HB, Weinstein M. Normal pregnancy & prenatal care. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:187-202.
  3. Bickley LS. Female genitalia. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 429-457.
  4. Bickley LS. Female genitalia. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009: 521-532.
  5. Bickley LS, Thompson, JE. The pregnant woman. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 817-838.
  6. Bickley LS, Thompson, JE. The pregnant woman. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009: 871-880.
  7. Cherniak D, Grant L, Mason R, Moore B, Pellizzari R. Intimate partner violence consensus statement. SOGC Clinical Practice Guidelines. No. 157. J Obstet Gynaecol Can. 2005; April: 365-388. http://www.sogc.org/guidelines/public/157E-CPG-April2005.pdf. Accessed February 17, 2011.
  8. Kawada C. Gynecologic history, examination, & diagnostic procedures. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:519-539.
  9. Lefebvre G, Pinsonneault O, Antao V, Black A, Burnett M, Feldman K, Lea R, Robert M. Primary dysmenorrhea consensus guideline. SOGC Clinical Practice Guidelines. No. 169. J Obstet Gynaecol Can. 2005; December: 1117-1146. http://sogc.org/wp-content/uploads/2013/01/169E-CPG-December2005.pdf. Accessed November 4, 2013.
  10. Leveno KJ, Hauth JC, Rouse DJ, Spong CY (2010). Chapter 8. Prenatal Care. In KJ Leveno, JC Hauth, DJ Rouse, CY Spong (Eds), Williams Obstetrics, 23e. Retrieved November 4, 2013 from http://www.accessmedicine.com.normedproxy.lakeheadu.ca/content.aspx?aID=6052072.
  11. Ontario's HPV Immunization Program - Human Papillomavirus Vaccine – MOHLTC. http://www.health.gov.on.ca/en/ms/hpv/about_program.aspx. Ontario Medical Association and Ontario Ministry of Health and Long-Term Care. Accessed January 17, 2015.
  12. Provincial and Territorial Guidelines. SOGC Clinical Practice Guidelines. http://sogc.org/wp-content/uploads/2013/10/PapTestProvTerr2013.pdf. Accessed January 17, 2015.
  13. Rowe T, Senikas V, Pothier M, Fairbanks J, Sams D, eds. Alcohol use and pregnancy consensus clinical guidelines. SOGC Clinical Practice Guidelines. No. 245. J Obstet Gynaecol Can. 2010; 32(8): S1-S32. http://sogc.org/guidelines/documents/gui245CPG1008E.pdf. Accessed February 17, 2011.