Etiquette in taking a history

Patients expect doctors and students to be well presented and appearances do have an enormous impact on patients, so make sure that your appearance is suitable before you enter the room.

When meeting a patient for the first time, always introduce yourself; tell the patient who you are and say why you have come to see them. If you are a medical student, some patients will decide that they do not wish to talk to you. This may be for many reasons and, if your involvement in their care is declined, accept without questioning.

Some areas of the obstetric history cover subjects that are intensely private. In occasional cases there may be events recorded in the notes that are not known by other family members, such as previous terminations of pregnancy. It is vital that the history taker is sensitive to each individual situation and does not simply follow a formula to get all the facts right.

Some women will wish another person to be present if the doctor or student is male, even just to take a history, and this wish should be respected.

Where to begin

The amount of detail required must be tailored to the purpose of the visit. At a booking visit, the history must be thorough and meticulously recorded. Once

this baseline information is established, many women find it tedious to go over all this information again. Before starting, ask yourself what you need to achieve. In late pregnancy, women will be attending the antenatal clinic for a particular reason. It is certainly acceptable to ask why the patient has attended in the opening discussion. For some women it will be a routine visit (usually performed by the midwife or general practitioner), others are attending because there is or has been a problem.

Make sure that the patient is comfortable (usually seated but occasionally sitting on a bed).

It is important to establish some very general facts when taking a history. Asking for the patient’s age or date of birth and whether this is a first pregnancy are usually safe opening questions.

At this stage you can also establish whether a woman is working and, if so, what she does.

Dating the pregnancy

Pregnancy has been historically dated from the last menstrual period (LMP), not the date of conception. The median duration of pregnancy is 280 days (40 weeks) and this gives the estimated date of delivery (EDD). This assumes that:

•the cycle length is 28 days;

•ovulation occurs generally on the 14th day of the cycle;

2Obstetric history taking and examination

•the cycle was a normal cycle (i.e. not straight after stopping the oral contraceptive pill or soon after a

previous pregnancy).

The EDD is calculated by taking the date of the LMP, counting forward by nine months and adding 7 days. If the cycle is longer than 28 days, add the difference between the cycle length and 28 to compensate.

In most antenatal clinics, there are pregnancy calculators (wheels) that do this for you (Figure 1.1). It is worth noting that pregnancy-calculating wheels do differ a little and may give dates that are a day or two different from those previously calculated. While this should not make much difference, it is an area that often causes heated discussion in the antenatal clinic. Term is actually defined as 37–42 weeks and so the estimated time of delivery should ideally be defined as a range of dates rather than a fixed date, but women have been highly resistant to this idea and generally do want a specific date.

Almost all women who undergo antenatal care in the UK will have an ultrasound scan in the late first trimester or early second trimester. The purposes of this scan are to establish dates, to ensure that the pregnancy is ongoing and to determine the number of fetuses. If performed before 20 weeks, the ultrasound scan can be used for dating the pregnancy. After this time, the variability in growth rates of different fetuses makes it

Figure 1.1 Gestation calculator

unsuitable for use in defining dates. It has been shown that ultrasound-defined dates are more accurate than those based on a certain LMP and reduce the need for post-dates induction of labour. This may be because the actual time of ovulation in any cycle is much less fixed than was previously thought. Therefore, the UK National Screening Committee has recommended that pregnancy dates are set only by ultrasound. The crown–rump length is used up until 13 weeks 6 days, and the head circumference from 14 to 20 weeks. Regardless of the date of the LMP this EDD is used. It is important that an accurate EDD is established as a difference of a day or two can make a difference in the risk for conditions such as Down’s syndrome on serum screening. In addition, accurate dating reduces the need for post-dates induction of labour.

In late pregnancy, many women will have long forgotten their LMP date, but will know exactly when their EDD is, and it is therefore more straightforward to ask this.

Taking the history

Social history

Some aspects of history taking require considerable sensitivity, and the social history is one such area. There are important facts to establish, but in many cases these can come out at various different parts of the history and some can almost be part of normal conversation. It is important to have a list of things to establish in your mind. It is here more than anywhere that some local knowledge is helpful, as much can be gained from knowing where the patient lives. However, be careful not to jump to conclusions, as these can often be wrong.

The following facts demonstrate why a social history is important:

•Women whose partners were unemployed or working in an unclassifiable role had a maternal

mortality rate seven times higher than women whose partners were employed according to the Confidential Enquiry into Maternal and Child Health 2003–2005 (CEMACH).

•Social exclusion was seen in 18 out of 19 deaths

in women under 20 in the 1997–1999 Confidential Enquiries into Maternal Death (CEMD) (one

homeless teenager froze to death in a front garden).

•Married women are more likely to request amniocentesis after a high-risk Down’s syndrome

screening result than unmarried women. Husbands clearly have a strong voice in decision making.

•If a woman is unmarried, her partner cannot provide consent for a post-mortem after

stillbirth.

•Domestic violence was reported in 12 per cent of the 378 women whose deaths were reported in

1997–1999.

Enquiry about domestic violence is extremely difficult. It is recommended that all women are seen on their own at least once during pregnancy, so that they can discuss this, if needed, away from an abusive partner. This is not always easy to accomplish. If you happen to be the person with whom this information is shared, you must ensure that it is passed on to the relevant team, as this may be the only opportunity the woman has to disclose it. Sometimes younger women find medical students and young doctors much easier to talk to. Be aware of this.

Smoking, alcohol and illicit drug intake also form part of the social history. Smoking causes a reduction in birthweight in a dose-dependent way. It also increases the risk of miscarriage, stillbirth and neonatal death. There are interventions that can be offered to women who are still smoking in pregnancy (see Chapter 8, Antenatal obstetric complications).

Complete abstinence from alcohol is advised, as the safety of alcohol is not proven. However, alcohol is probably not harmful in small amounts (less than one drink per day). Binge drinking is particularly harmful and can lead to a constellation of features in the baby known as fetal alcohol syndrome (see Chapter 8, Antenatal obstetric complications).

Enquiry about illicit drug taking is more difficult. Approximately 0.5–1 per cent of women continue to take illicit drugs during pregnancy. Be careful not to make assumptions. During the booking visit, the midwife should directly enquire about drug taking. If it is seen as part of the long list of routine questions asked at this visit, it is perceived as less threatening. However, sometimes this information comes to light at other times. Cocaine and crack cocaine are the most harmful of the illicit drugs taken, but all

have some effects on the pregnancy, and all have financial implications (see Chapter 8, Antenatal obstetric complications).

By the time you have finished your history and examination you should know the following facts that are important in the social history:

•whether the patient is married or single and what sort of support she has at home (remember that

married women whose only support is a working husband may be very isolated after the birth of a baby);

•generally whether there is a stable income coming into the house;

•what sort of housing the patient occupies (e.g. a flat with lots of stairs and no lift may be

problematic);

•whether the woman works and for how long she is planning to work during the pregnancy;

•whether the woman smokes/drinks or uses drugs;

•if there are any other features that may be important.

Previous obstetric history

Past obstetric history is one of the most important areas for establishing risk in the current pregnancy. It is helpful to list the pregnancies in date order and to discover what the outcome was in each pregnancy.

The features that are likely to have impact on future pregnancies include:

•recurrent miscarriage (increased risk of miscarriage, fetal growth restriction (FGR));

•preterm delivery (increased risk of preterm delivery);

•early-onset pre-eclampsia (increased risk of pre-eclampsia/FGR);

•abruption (increased risk of recurrence);

•congenital abnormality (recurrence risk depends on type of abnormality);

•macrosomic baby (may be related to gestational diabetes);

•FGR (increased recurrence);

•unexplained stillbirth (increased risk of gestational diabetes).

4Obstetric history taking and examination

The method of delivery for any previous births must be recorded, as this can have implications for planning in the current pregnancy, particularly if there has been a previous Caesarean section, difficult vaginal delivery, postpartum haemorrhage or significant perineal trauma.

When you have noted all the pregnancies, you can convert this into the obstetric shorthand of parity. This is often confusing. Remember that:

•gravida is the total number of pregnancies regardless of how they ended;

•parity is the number of live births at any gestation or stillbirths after 24 weeks.

In terms of parity, therefore, twins count as two. Thus a woman at 12 weeks in this pregnancy who has never had a pregnancy before is gravida 1, parity 0. If she delivers twins and comes back next time at 12 weeks, she will be gravida 2, parity 2 (twins). A woman who has had six miscarriages and is pregnant again with only one live baby born at 25 weeks will be gravida 8, parity 1.

The other shorthand you may see is where parity is denoted with the number of pregnancies that did not result in live birth or stillbirth after 24 weeks as a superscript number. The above cases would thus be defined as: para 00, para 20 (twins), para 16.

However, when presenting a history, it is much easier to describe exactly what has happened, e.g. ‘Mrs Jones is in her eighth pregnancy. She has had six miscarriages at gestations of 8–12 weeks and one spontaneous delivery of a live baby boy at 25 weeks. Baby Tom is now 2 years old and healthy’.

Past gynaecological history

The regularity of periods used to be important in dating pregnancy (see Dating the pregnancy p. 1). Women with very long cycles may have a condition known as polycystic ovarian syndrome. This is a complex endocrine condition and its relevance here is that some women with this condition have increased insulin resistance and a higher risk for the development of gestational diabetes.

Contraceptive history can be relevant if conception has occurred soon after stopping the combined oral contraceptive pill or depot progesterone preparations, as again, this makes dating by LMP more difficult. Also, some women will conceive with an intrauterine device still in situ. This carries an increase in the risk of miscarriage.

Previous episodes of pelvic inflammatory disease increase the risk for ectopic pregnancy. This is only of relevance in early pregnancy. However, it is important to establish that any infections have been adequately treated and that the partner was also treated.

The date of the last cervical smear should be noted. Every year a small number of women are diagnosed as having cervical cancer in pregnancy, and it is recognized that late diagnosis is more common around the time of pregnancy because smears are deferred. If a smear is due, it can be taken in the first trimester. It is important to record that the woman is pregnant, as the cells can be difficult to assess without this knowledge. It is also important that smears are not deferred in women who are at increased risk of cervical disease (e.g. previous cervical smear abnormality or very overdue smear). Gently taking a smear in the first trimester does not cause miscarriage and women should be reassured about this. Remember that if it is deferred at this point, it may be nearly a year before the opportunity arises again. If there has been irregular bleeding, the cervix should at least be examined to ensure that there are no obvious lesions present.

If a woman has undergone treatment for cervical changes, this should be noted. Knife cone biopsy is associated with an increased risk for both cervical incompetence (weakness) and stenosis (leading to preterm delivery and dystocia in labour, respectively). There is probably a very small increase in the risk of preterm birth associated with large loop excision of the transformation zone (LLETZ); however, women who have needed more than one excision are likely to have a much shorter cervix, which does increase the risk for second and early third trimester delivery.

Previous ectopic pregnancy increases the risk of recurrence to 1 in 10. It is also important to know the site of the ectopic and how it was managed. The implications of a straightforward salpingectomy for an ampullary ectopic are much less than those after a complex operation for a cornual ectopic. Women who have had an ectopic pregnancy should be offered an early ultrasound scan to establish the site of any future pregnancies.

Recurrent miscarriage may be associated with a number of problems. Antiphospholipid syndrome increases the risk of further pregnancy loss, FGR and pre-eclampsia. Balanced translocations can occasionally lead to congenital abnormality, and cervical incompetence can predispose to late second and early third trimester delivery. Also, women need

a great deal of support during pregnancy if they have experienced recurrent pregnancy losses.

Multiple previous first trimester terminations of pregnancy potentially increase the risk of preterm delivery, possibly secondary to cervical weakness. Sometimes information regarding these must be sensitively recorded. Some women do not wish this to be recorded in their hand-held notes.

Previous gynaecological surgery is important, especially if it involved the uterus, as this can have potential sequelae for delivery. In addition, the presence of pelvic masses such as ovarian cysts and fibroids should be noted. These may impact on delivery and may also pose some problems during pregnancy. A previous history of sub-fertility is also important. Four deaths occurred in CEMACH 2003–2005 of women with ovarian hyperstimulation syndrome following IVF. Donor egg or sperm use is associated with an increased risk of pre-eclampsia. The rate of preterm delivery is higher in assisted conception pregnancies, even after the higher rate of multiple pregnancies has been taken into account. Women who have undergone fertility treatment are often older and generally need increased psychological support during pregnancy.

Legally, you should not write down in notes that a pregnancy is conceived by IVF or donor egg or sperm unless you have written permission from the patient. It is obviously a difficult area, as there is an increased risk of problems to the mother in these pregnancies and therefore the knowledge is important. Generally, if the patient has told you herself that the pregnancy was an assisted conception, it is reasonable to state that in your presentation.

Major pre-existing diseases that impact on

pregnancy

•Diabetes mellitus: macrosomia, FGR, congenital abnormality, pre-eclampsia, stillbirth, neonatal hypoglycaemia.

•Hypertension: pre-eclampsia.

•Renal disease: worsening renal disease, pre-eclampsia, FGR, preterm delivery.

•Epilepsy: increased fit frequency, congenital abnormality.

•Venous thromboembolic disease: increased risk during pregnancy; if associated thrombophilia, increased risk of thromboembolism and possible increased risk of pre-eclampsia, FGR.

•Human immunodeficiency virus (HIV) infection: risk of mother-to-child transfer if untreated.

•Connective tissue diseases, e.g. systemic lupus erythematosus: pre-eclampsia, FGR.

•Myasthenia gravis/myotonic dystrophy: fetal neurological effects and increased maternal muscular fatigue in labour.

care received and clinical presentation, and should be made in a systematic and sensitive way at the antenatal booking visit. A good question to lead into this is ‘Have you ever suffered with your nerves?’. If women have had children before, you can ask whether they had problems with depression or ‘the blues’ after the births of any of them. Women with significant psychiatric problems should be cared for by a multidisciplinary team, including the midwife, GP, hospital consultant and psychiatric team.

Medical and surgical history

All pre-existing medical disease should be carefully noted and any associated drug history also recorded. The major pre-existing diseases that impact on pregnancy and their potential effects are shown in the box (also see Chapter 12, Medical diseases complicating pregnancy).

Previous surgery should be noted. Occasionally surgery has been performed for conditions that may continue to be a problem during pregnancy, such as Crohn’s disease. Rarely, complications from previous surgery, such as adhesional obstruction, present in pregnancy.

Psychiatric history is important to record. These enquiries should include the severity of the illness,

Drug history

It is vital to establish what drugs women have been taking for their condition and for what duration. You should also ask about over-the-counter medication and homeopathic/herbal remedies. In some cases, medication needs to be changed in pregnancy. For some women it may be possible to stop their medication completely for some or all of the pregnancy (e.g. mild hypertension). Some women need to know that they must continue their medication (e.g. epilepsy, for which women often reduce their medication for fear of potential fetal effects, with detriment to their own health).

Very few drugs that women of childbearing age take are potentially seriously harmful, but a few are,