Obstetrical Case History Management

Description

In order for the physician to insure the health and safety of mother and fetus, a comprehensive history of the mother's past pregnancies, gynecological history, sex and contraceptive history, and vaginal exam will be necessary.

Obstetrical case history

# During the initial prenatal examination, the physician will ask about and the woman should be prepared to discuss past delivery dates, delivery methods, term of pregnancy, labor duration, body weight at the time of delivery, and complications and diseases related to pregnancy. Complications-and the illnesses caused by such complications-that occurred in earlier pregnancies can return with subsequent pregnancies. If a woman has delivered a baby over 4 kg, a screening for gestational diabetes is conducted between the 24th and 28th week of pregnancy. Patients who had a cesarean section are candidates for vaginal deliveries, and this should be discussed at the prenatal examination.
# If the mother has delivered a baby with congenital deformation, or has experienced the death of a fetus or infant, genetic counseling and prenatal observation of the fetus are needed.


Gynecological case history

# It is essential to know exactly what day the last menstruation occurred. Based on a 28-day cycle, patients using oral contraceptives may need correction. Predicting the expected date of confinement from an accurate date of the last day of menstruation, along with vaginal examination findings from early in the pregnancy, is just as accurate as using ultrasound. A history of sexually transmitted diseases (STDs) increases the risk of extrauterine pregnancy, fetal infection, and premature birth.
# Contraceptive method: If pregnancy occurs while using an intrauterine device, that device must, of course, be removed, and patients using oral contraceptives need to correct their expected date of delivery.
# A case history of infertility increases the risk of extrauterine pregnancy, miscarriage, and other serious possibilities.
# Patients who have had uterine surgery have a greater chance of receiving a cesarean section, and patients who have had abdominal surgery have a higher chance of complications such as extrauterine pregnancy.


Vaginal examination findings

# External genitalia: the existence of STDs, vaginal secretion, observation of scars from past deliveries
# Cervix: whether it should be enlarged or reduced early, abnormal secretion, whether or not cyanosis exists
# Uterine body: size, hardness, pressure pain, whether the shape is abnormal (bicornate uterus), presence of fibroids and fetal heart sound, and size and position of fetus
# Uterine appendages: observe for abnormal mass and pressure pain


Case history related to sex life and contraception

# Sex life: current partner, method, and level of satisfaction are recorded.
# Contraception: questions are asked about the method of contraception and what kind of contraceptives will be used after delivery.
# The woman must be asked about any sexual assault or abuse in the past.