3/6/2021 Obstetric History Taking – OSCE Guide

Obstetric History Taking – OSCE Guide

geekymedics.com/obstetric-history-taking/

Dr Lewis Potter

An obstetric history involves asking questions relevant to a patient’s current and

previous pregnancies. Some of the questions are highly personal, therefore good
communication skills and a respectful manner are absolutely essential.

Taking an obstetric history requires asking a lot of questions that are not part of the
“standard” history taking format, therefore it’s important to understand what information
you are expected to gather.

It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely,
therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks
gestation could be an ectopic pregnancy).

Download the obstetric history taking PDF OSCE checklist, or use our interactive OSCE
checklist. You may also be interested in our gynaecological history taking guide.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

Key pregnancy details

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It is useful to confirm the gestational age, gravidity and parity early on in the
consultation, as this will assist you in determining which questions are most relevant and
what conditions are most likely.

Gestational age, gravidity and parity should also be included at the beginning of your
presentation of a patient’s history.

Gravidity (G) is the number of times a woman has been pregnant, regardless of the
outcome (e.g. G2).

Parity (P) is the total number of times a woman has given birth to a child with a gestational
age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth).

Example of gravidity and parity calculation

A patient is currently 26 weeks pregnant and already has two children of her own. She
reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks:

G5: The patient’s gravidity is 5 because she has had 5 pregnancies in total.
P3: The patient’s parity would be 3 because she has had 3 pregnancies which resulted
in the birth of a child with a gestational age of greater than 24 weeks (one of which was
a stillbirth).

How does parity work for twins?

A British Journal of Gynaecology study suggests that a mother who has carried twins to a
viable gestational age (greater than 24+0 weeks) should be defined as P1.

However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this
definition, with the remaining 80% referring to twin pregnancy as P2.

As a result, you should be aware that in clinical practice, a mother who has carried twins to a
viable gestational age will often be referred to as P2, but from an academic perspective, they
would be deemed P1.

General communication skills

It is important you do not forget the general communication skills which are relevant to
all patient encounters. Demonstrating these skills will ensure your consultation remains
patient-centred and not checklist-like (just because you’re running through a checklist in
your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

Demonstrating empathy in response to patient cues: both verbal and non-verbal.

Active listening: through body language and your verbal responses to what the patient
has said.

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An appropriate level of eye contact throughout the consultation.

Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning
slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and
what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint
Use open questioning to explore the patient’s presenting complaint:

“What’s brought you in to see me today?”

“Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

“Ok, can you tell me more about that?”

“Can you explain what that pain was like?”

Open vs closed questions

History taking typically involves a combination of open and closed questions. Open
questions are effective at the start of consultations, allowing the patient to tell you what has
happened in their own words. Closed questions can allow you to explore the symptoms
mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the differential
diagnosis.

History of presenting complaint

Once the patient has had time to communicate their presenting complaint, you should
explore the issue with further open and closed questions.

SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting
symptoms in more detail. It is most commonly used to explore pain, but it can be applied to
other symptoms, although some of the elements of SOCRATES may not be relevant to all
symptoms.

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Site

Ask about the location of the symptom:

“Where is the pain?”

“Can you point to where you experience the pain?”

Onset

Clarify how and when the symptom developed:

“Did the pain come on suddenly or gradually?”

“When did the pain first start?”
“How long have you been experiencing the pain?”

Character

Ask about the specific characteristics of the symptom:

“How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
“Is the pain constant or does it come and go?”

Radiation

Ask if the symptom moves anywhere else:

“Does the pain spread elsewhere?”

Associated symptoms

Ask if there are other symptoms which are associated with the primary symptom:

“Are there any other symptoms that seem associated with the pain?” (e.g. shortness of
breath in pulmonary embolism)

Time course

Clarify how the symptom has changed over time:

“How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better:

“Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction
may find going up or down the stairs makes things worse)

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“Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux
may find that antacid medication helps with their symptoms)

Severity

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain
you’ve ever experienced?”

Obstetric symptoms
Once you have completed exploring the patient’s history of presenting complaint, you need
to move on to more focused questioning relating to the symptoms that may be relevant
to pregnancy (if not already discussed). We have included a focused list of key symptoms to
ask about when taking an obstetric history, followed by some background information on
each, should you want to know a little more.

Summary of key obstetric symptoms

Key obstetric symptoms to ask about include:

Nausea and vomiting: common in pregnancy and mild in most cases. Hyperemesis
gravidarum represents a severe form of vomiting in pregnancy associated with
electrolyte disturbance, weight loss and ketonuria.
Reduced fetal movements: can be associated with fetal distress and absent fetal
movements may indicate early fetal demise.
Vaginal bleeding: causes include cervical bleeding (e.g. ectropium, cervical cancer),
placenta praevia and placental abruption (typically associated with abdominal pain).
Abdominal pain: causes may include urinary tract infection, constipation, pelvic
girdle pain and placental abruption.
Vaginal discharge or loss of fluid: abnormal vaginal discharge may be caused by
sexually transmitted infections such as gonorrhoea and the loss of fluid from the vagina
indicates rupture of the amniotic membranes.
Headache, visual disturbance, epigastric pain and oedema: these are typical
clinical features of pre-eclampsia. Mild oedema is common and normal in the later
stages of pregnancy.
Pruritis: associated with obstetric cholestasis (typically affecting the palms and soles
of the feet).
Unilateral leg swelling: consider and rule out deep vein thrombosis.
Chest pain and shortness of breath: pregnant women are at increased risk of
developing pulmonary emboli.
Systemic symptoms: fatigue (e.g. anaemia), fever (chorioamnionitis) and weight loss
(e.g. hyperemesis gravidarum).

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Nausea and vomiting

Nausea and vomiting are very common in pregnancy, but are typically mild, requiring only
reassurance and basic hydration advice.

Nausea and vomiting typically begin between the fourth and seventh week of gestation,
then peak between the ninth and sixteenth week and resolve by around the 20th week
of pregnancy.

Persistent vomiting and severe nausea can progress to hyperemesis gravidarum.

Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and
electrolyte disturbance, weight loss and ketonuria. ¹

Reduced fetal movements

Women typically start to feel fetal movements between 16 to 24 weeks gestation

(primigravida women will often not feel fetal movements until after 20 weeks gestation). A
mother will know what is the “usual” amount of fetal movements she experiences, therefore,
if a reduction in fetal movements is reported, it should be taken very seriously.

Reduced fetal movements are associated with adverse pregnancy outcomes, including
stillbirth, fetal growth restriction, placental insufficiency, and congenital
malformations. ²

You should always ask about fetal movements once the patient is of the appropriate
gestation to be able to feel them:

“Have you noticed any change in the amount of your baby’s movement?”

Vaginal bleeding

Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric
and gynaecological diseases.

It is important to ask about pain, associated trauma (including domestic violence),

fever/malaise, recent ultrasound scan results (e.g. position of the placenta), cervical
screening history, sexual history and past medical history to help narrow the
differential diagnosis.

You should also ask about fatigue if anaemia is suspected and symptoms of
hypovolaemic shock (e.g. pre-syncope/syncope).

Vaginal discharge

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All healthy women will have some degree of regular vaginal discharge, so it is important to
distinguish between normal and abnormal vaginal discharge when taking an obstetric
history.

You should ask the patient if they have noticed any changes to the following
characteristics of their vaginal discharge:

Volume
Colour (e.g. green, yellow or blood-stained would suggest infection)
Consistency (e.g. thickened or watery)
Smell (e.g. fish-like smell in bacterial vaginosis)

Urinary symptoms

Urinary tract infections are common in pregnancy and need to be treated promptly.
Untreated urinary tract infections in pregnancy have been associated with increased risk of
fetal death, developmental delay and cerebral palsy.

Common symptoms of urinary tract infections include:

Dysuria: pain whilst passing urine.

Frequency: increased frequency of passing urine.
Urgency: a sudden need to pass urine, with no earlier warning.
Fever

Headache, visual changes, epigastric pain, oedema

Pre-eclampsia is a relatively common condition in pregnancy which is characterised by

maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and
premature birth. The condition can be life-threatening for the mother and the fetus. As a
result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review
during pregnancy.

The key symptoms to ask about include:

Headache (typically severe and frontal)

Swelling of the hands, feet and face (oedema)
Pain in the upper part of the abdomen (epigastric tenderness)
Visual disturbance (blurring of vision or flashing lights)
Reduced fetal movements

Other symptoms

Fever is important to ask about when considering infectious pathology (e.g. urinary tract
infections, cervical infections, chorioamnionitis).

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Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic
pathology.

Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g.
malignancy, anorexia nervosa).

Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects
the palms and soles of the feet).

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and
expectations (often referred to as ICE) to gain insight into how a patient currently
perceives their situation, what they are worried about and what they expect from the
consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the
consultation in response to patient cues. This will help ensure your consultation is more
natural, patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your
consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

“What do you think the problem is?”

“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what
you think might be going on.”

Concerns

Explore the patient’s current concerns:

“Is there anything, in particular, that’s worrying you?”

“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

“What were you hoping I’d be able to do for you today?”

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“What would ideally need to happen for you to feel today’s consultation was a
success?”
“What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows
you to check your understanding of the patient’s history and provides an opportunity for
the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that
you’ve overlooked. Continue to periodically summarise as you move through the rest of
the history.

Signposting
Signposting, in a history taking context, involves explicitly stating what you have
discussed so far and what you plan to discuss next. Signposting can be a useful tool
when transitioning between different parts of the patient’s history and it provides the
patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms,
your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms
and then talk about your current pregnancy.”

Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body
systems which may or may not be relevant to the primary presenting complaint. A systemic
enquiry may also identify symptoms that the patient has forgotten to mention in the
presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your
level of experience.

Some examples of symptoms you could screen for in each system include:

Systemic: fatigue (e.g. anaemia), fever (e.g. chorioamnionitis, urinary tract infection),
weight loss (e.g. hyperemesis gravidarum)

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Respiratory: dyspnoea (e.g. pulmonary embolism, anaemia), chest pain (e.g.

pulmonary embolism)
Gastrointestinal: abdominal pain (e.g. placental abruption), vomiting (e.g.
hyperemesis gravidarum)
Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection),
abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
Neurological: visual changes, motor or sensory disturbances, headache (e.g. pre-
eclampsia)
Musculoskeletal: pelvic pain (e.g. symphysis pubis dysfunction)
Dermatological: rashes, skin lesions, linea nigra

Current pregnancy

Gestation
Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would
be written as “26+5”).

Accurate estimation of gestation and estimated date of delivery (EDD) is performed using
an ultrasound scan to measure the crown-rump length.

Scan results

Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and
20+6 weeks. You should ask about the results of the scan (or check the medical records if
the patient is unsure). The key findings to note include:

Growth of the fetus: clarify if it was within normal limits for the current gestation.
Placental position: if embedded in the lower third of the uterine cavity there is an
increased risk of placenta praevia.
Fetal anomalies: note any abnormalities identified.

Screening
There are several types of screening that women are offered during pregnancy:

Down’s syndrome screening

Rhesus status and the presence of any antibodies
Hepatitis B, HIV and syphilis.

You should clarify if the patient has opted for screening and if so, what the results were.

Other details of the pregnancy

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Check if this is a singleton or multiple gestation.

Clarify if the patient took folic acid prior to conception and during the first trimester.
Explore the planned mode of delivery (e.g. vaginal or Caesarian section).
Ask about any medical illness during pregnancy (clarify what type of illness and if
the patient is still receiving any treatment).

Immunisation history

Check the patient is currently up to date with their vaccinations including:

Flu vaccination
Whooping cough vaccination
Hepatitis B vaccination (if at risk)

Mental health history

Pregnancy can have a significant impact on maternal mental health, therefore it is
essential that patients are screened for symptoms suggestive of psychiatric illness (e.g.
depression, bipolar disorder, schizophrenia).

Ask about previous mental health diagnoses and any current thoughts of self-
harm and/or suicide if relevant.

Previous obstetric history

It is important to ask about a woman’s previous obstetric history, as this may help inform the
assessment of risk in the current pregnancy and have implications for the mode of delivery.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24
+ 0 weeks).

Term pregnancies (>24 weeks)

Gestation at delivery:

Previous pre-term labour increases the risk of pre-term labour in later pregnancies.

Birth weight:

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A high birth weight in previous pregnancies raises the possibility of previous

gestational diabetes.
A low birth weight (small for gestational age) in a previous pregnancy increases the risk
of a further small for gestational age baby.

Mode of delivery:

Spontaneous vaginal delivery

Assisted vaginal delivery (e.g. forceps)
Caesarian section (will have implications for the choice of future mode of delivery)

Complications:

Antenatal period: pre-eclampsia, gestational diabetes, gestational hypertension,

placenta praevia and shoulder dystocia.
Postnatal period: post-partum haemorrhage, perineal/rectal tears during delivery and
retained products of conception.

Assisted reproduction:

Clarify if IVF or other assisted reproductive techniques were used for any previous
pregnancies.

Stillbirth

As stated below, asking about stillbirths need to be done in a sensitive manner.

A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy.

Sensitivity clarify the gestation of the stillbirth if this is not already documented.

Other pregnancies (<24 weeks)

Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a
sensitive manner in a private setting. It can be very difficult for women to discuss these
topics. These questions should only be asked when relevant and by a person who is
competent to do so.

Miscarriage

A miscarriage is the loss of a pregnancy before 24 weeks gestation.

Gestation:

Clarify the trimester at which the miscarriage occurred (miscarriage is most common in
the first trimester).

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Other details:

Clarify if medical or surgical management was required for the miscarriage and if any
cause was identified for the miscarriage (e.g. genetic syndromes).

Termination of pregnancy

Termination of pregnancy is the medical process of ending a pregnancy so it doesn’t

result in the birth of a baby. The pregnancy is ended either by taking medications or having a
minor surgical procedure.

Clarify the gestation at which the termination of pregnancy was performed and the
method of management (e.g. medical or surgical).

Ectopic pregnancy

An ectopic pregnancy is when a fertilised egg implants itself outside of the uterus,
usually in one of the fallopian tubes.

Clarify the site of the ectopic pregnancy and how it was managed (e.g. expectant,
medical, surgical).

Gynaecological history
Cervical screening:

Confirm the date and result of the last cervical screening test.
Ask if the patient received any treatment if the cervical screening test was abnormal
and check that follow up is in place.

Previous gynaecological conditions and treatments:

Sexually transmitted infections

Endometriosis
Bartholin’s cyst
Cervical ectropion
Malignancy (e.g. cervical, endometrial, ovarian)

Past medical history
A patient’s past medical history is particularly relevant during pregnancy, as some medical
conditions may worsen during pregnancy and/or have implications for the developing fetus.

Ask if the patient has any medical conditions:

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“Do you have any medical conditions?”

“Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess
how well controlled the disease is and what treatment(s) the patient is receiving. It is
also important to ask about any complications associated with the condition
including hospital admissions.

Ask the patient if they’ve previously undergone any surgery or procedures in the past
such as:

Abdominal or pelvic surgery: may influence decisions regarding delivery due to the
presence of scar tissue and adhesions.
Previous Caesarian section: increased risk of uterine rupture in subsequent
pregnancies.
Loop excision of the transitional zone (LETZ): increased risk of cervical incompetence.

Allergies

It’s essential to clarify any allergies the patient may have and to document these clearly in
the notes, including the type of allergic reaction the patient experienced.

Medical conditions which are particularly important to be aware of during pregnancy

Diabetes (type 1 or 2): blood glucose control can deteriorate significantly during
pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia).

Hypothyroidism: untreated or undertreated hypothyroidism can result in congenital

hypothyroidism with significant neurodevelopmental impact.

Epilepsy: seizures during pregnancy pose a risk to both the mother and fetus (e.g.
miscarriage) and many anti-epileptic drugs are teratogenic.

Previous venous thromboembolism (VTE): pregnancy is a pro-thrombotic state,

therefore, women who have previously developed a venous thromboembolism are at
significantly increased risk of developing further VTEs without prophylactic treatment (e.g.
low molecular weight heparin).

Blood-borne viruses: HIV, hepatitis B, hepatitis C pose a risk to the fetus during
childbirth (vertical transmission).

Genetic disease: it is important to identify any genetic diseases (e.g. cystic fibrosis, sickle-
cell disease, thalassaemia) carried by both the mother and father as this may influence the
management of the patient and their pregnancy (e.g. arranging input from the paediatric
team immediately after delivery).

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Drug history
It is essential to gain an accurate overview of the medications the patient is currently and has
previously taken during the pregnancy. The first trimester is when the fetus is most at risk of
teratogenicity from drugs, as this is when organogenesis occurs.

Prescribed medications

Clarify the prescribed medications the patient has been taking since falling pregnant,
noting which they are still taking and which they have now stopped (including drug name,
dose and route).

“Are you currently taking any prescribed medications or over-the-counter

treatments?”
“Have you stopped taking any prescribed medication since you became pregnant?”

Ask if the patient was using contraception prior to becoming pregnant and if so, clarify
what method of contraception was being used. Check the patient has stopped their
contraception or had their contraceptive device removed (e.g. coil, implant).

If the patient is taking prescribed or over the counter medications, document the
medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

“Have you noticed any side effects from the medication you currently take?”

Teratogenic drugs
Some examples of drugs that are known to be teratogenic include:

ACE inhibitors
Sodium valproate
Methotrexate
Retinoids
Trimethoprim

Medications frequently used during pregnancy

Some medications are commonly used in pregnancy to both reduce the risk of fetal
malformations and treat the symptoms of pregnancy.

Some examples of medications commonly used in pregnancy include:

Folic acid (400μg): recommended daily for the first trimester of pregnancy to reduce
the risk of neural tube defects in the developing fetus.
Oral iron: frequently used in pregnancy to treat anaemia.

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Antiemetics: frequently used in pregnancy to manage nausea and vomiting (e.g.

hyperemesis gravidarum).
Antacids: frequently used to manage gastro-oesophageal reflux symptoms during
pregnancy.
Aspirin

Family history
Taking a brief family history can help to further assess the risk of adverse outcomes to the
mother and fetus during pregnancy. This can also help inform discussions with parents
about the risk of their child having a specific genetic disease (e.g. cystic fibrosis).

Some important medical conditions to ask about include:

Inherited genetic conditions: such as cystic fibrosis and sickle cell disease.
Type 2 diabetes: if first-degree relatives are affected there is an increased risk of
gestational diabetes.
Pre-eclampsia: most relevant if maternal mother or sister is affected as this is
associated with an increased risk of developing pre-eclampsia.

Social history
Understanding the social context of a patient is absolutely key to building a complete picture
of their health. Social factors have a significant influence on a patient’s pregnancy.

General social context

Explore the patient’s general social context including:

the type of accommodation they currently reside in (e.g. house, bungalow) and if there
are any adaptations to assist them (e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance
with (e.g. self-hygiene, housework, food shopping)

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Offer smoking cessation services (see our smoking cessation guide for more details).

Smoking increases the risk of a small for gestational age baby.

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Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis (see our
alcohol history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Excess alcohol use during pregnancy can result in conditions such as fetal alcohol
syndrome.

Recreational drug use

It is important to ask about recreational drug use, as these can have significant
consequences on the mother and developing fetus (e.g. cocaine use increases the risk of
placental abruption).

If recreational drug use is identified, patients can be offered input from drug cessation
services.

Diet and weight

Ask if the patient what their diet looks like on an average day.

Ask about the patient’s current weight (obesity significantly increases the risk of venous
thromboembolism, pre-eclampsia and gestational diabetes during pregnancy).

Occupation

Ask about the patient’s current occupation and if there are plans in place for maternity
leave.

Domestic abuse

It is important to privately ask all pregnant women if they are a victim of domestic abuse
to provide an opportunity for them to seek help.

Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

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Reviewer

Dr Venkatesh Subramanian

Obstetrics & Gynaecology Registrar in London

References
1. NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy. Published: June
2017. Available from: [LINK].
2. BMJ. Reduced fetal movements. 2018; 360. Published March 2018. Available from:
[LINK]
3. MBRRACE-UK. Saving Lives, Improving Mother’s Care. Surveillance of maternal
deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK
and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009.
Available from: [LINK].

https://www.printfriendly.com/p/g/5q8vnh 18/18