prenatal history taking

Health problems facing other blood relatives may also be pertinent. my-obn.ca ontariobreastfeedingnetwork@gmail.com Fax: (519) 512-0051. Name:_____ Date of Birth:_____ Appointment Date:_____ Prenatal History Questionnaire PART 1 pre-syncope/syncope). The tests isolate and analyze fragments of placental and fetal DNA circulating in pregnant woman’s blood to assess fetal sex and the likelihood of Trisomy 13, 18 or 21. Some claim that taking prenatal vitamins makes hair grow thicker or faster, and that nails could grow faster or … Demonstrating empathy in response to patient cues: both verbal and non-verbal. Ask the patient if they’ve previously undergone any surgery or procedures in the past such as: 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. History taking in newborn and neonates is different from those in elder children because, most of the things are related to when bay was in the maternal womb. Facilitate the patient to expand on their presenting complaint if required: History taking typically involves a combination of open and closed questions. It is important to ask about recreational drug use, as these can have significant consequences on the mother and developing fetus (e.g. 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). Confirm the patient’s name and date of birth. 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. Once the patient has had time to communicate their presenting complaint, you should explore the issue with further open and closed questions. Ask if the patient received any treatment if the cervical screening test was abnormal and check that follow up is in place. house, bungalow) and if there are any adaptations to assist them (e.g. You will also need to take prenatal vitamins, maintain a healthy lifestyle, prepare for childbirth and delivery, and more. First and Last are required. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Published: June 2017. Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential. Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal growth restriction, placental insufficiency, and congenital malformations. Making sure not to interrupt the patient throughout the consultation. 2011: Cell free DNA screening tests (also known as “non-invasive prenatal testing or sequencing”) first clinically available, performed between 8-12 weeks. Nutritional 9. Prenatal History. medical or surgical). Clarify how and when the symptom developed: Ask about the specific characteristics of the symptom: Ask if there are other symptoms which are associated with the primary symptom: Clarify how the symptom has changed over time: Ask if anything makes the symptom worse or better: Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10: 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). Gravidity is the number of times a woman has been pregnant, regardless of the outcome. Blood-borne viruses: HIV, hepatitis B, hepatitis C pose a risk to the fetus during childbirth (vertical transmission). A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. Folic acid (400μg): recommended daily for the first trimester of pregnancy to reduce the risk of neural tube defects in the developing fetus. Prenatal care in the United States is a health care preventive care protocol recommended to women with the goal to provide regular check-ups that allow obstetricians-gynecologists or midwives to detect, treat and prevent potential health problems throughout the course of pregnancy while promoting healthy lifestyles that benefit both mother and child. A high birth weight in previous pregnancies raises the possibility of previous gestational diabetes. You should always ask about fetal movements once the patient is of the appropriate gestation to be able to feel them: Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynaecological diseases. Prenatal vitamins consist of a variety of vitamins and minerals that help your baby get the nutrients that are essential for healthy development. A miscarriage is the loss of a pregnancy before 24 weeks gestation. While many of these tests are routine, some can be a much more personal decision. Before taking prenatal multivitamins, tell your doctor about all your medical conditions and all medicines you use. Taking a relevant and comprehensive history. So maternal history becomes an integral part of Neonatal history. Prenatal vitamins cause few side effects. Fetal anomalies: note any abnormalities identified. History taking during pregnancy •The medical history is a structured assessment to get a comprehensive picture of a participants’ health and health problems before and during her pregnancy. A. Prenatal and birth history B. Developmental history C. Social history of family - environmental risks D. Immunization history II. This allows us to get in touch for more details if required. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. Loop excision of the transitional zone (LETZ): increased risk of cervical incompetence. 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. Colour (e.g. OBSTETRICS History Taking December 9, 2015 Prenatal check-up is usually done in the clinic History 1. Some important medical conditions to ask about include: Understanding the social context of a patient is absolutely key to building a complete picture of their health. The key findings to note include: There are several types of screening that women are offered during pregnancy: You should clarify if the patient has opted for screening and if so, what the results were. miscarriage) and many anti-epileptic drugs are teratogenic. A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy. Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if relevant. . 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: Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next. arranging input from the paediatric team immediately after delivery). G2). Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects the palms and soles of the feet). Gynaecological instruments Juby Raju. cervical, endometrial, ovarian). Clarify the trimester at which the miscarriage occurred (miscarriage is most common in the first trimester).          Allergies         Illnesses suffered as a child         Previous medical conditions         Chronic illnesses         Hospital stays,          Minor surgical operations         Major surgical operations         Anesthesia history         Accidents requiring hospitalization,          Current prescription medications         Current over the counter medications         Previous prescription medications         Medication based creams and lotions both prescription and non-prescription,          Smoking         Drinking         Eating habits         Weight loss         Weight gain,          Previous full-term pregnancies         Previous aborted pregnancies         Miscarriages         Multiple pregnancies,          Cycle- normal or abnormal         Blood flow – normal or abnormal         Endometriosis         Pelvic inflammatory disease         Other gynecological problems,          History of all infectious diseases both cures and ongoing,          Date of last period         Date of positive pregnancy test         Cramping         Bleeding         Vaginal discharge,          Chronic illnesses         Pregnancy complications         Multiple births         Ethnic background, Read More:High-Risk Pregnancy Complications GuidePregnancy and HIVPregnancy and Sexually Transmitted Diseases (STD), Dr. Amos Grunebaum, MD, FACOG is a Professor of Obstetrics and Gynecology, and among the world's leading authorities on fertility and pregnancy. Read Dr. Amos' full bio, the book about him "Lessons in Survival: All About Amos," and a fictionalized account of his father's life in the novel, "Through Walter's Lens.". In that way it is very unique, as when assessing these patients, your actually also assessing another the child.Consequently, the approach to history taking in Obstetrics whilst similar to other fields of medicine, includes a number of additional components. Confirm the date and result of the last cervical screening test. Gain consent to proceed with history taking. Ask about your stress level. abdominal pain at 8 weeks gestation could be an ectopic pregnancy). As stated below, asking about stillbirths need to be done in a sensitive manner. Rhesus status and the presence of any antibodies. Ask about the patient’s current occupation and if there are plans in place for maternity leave. the type of accommodation they currently reside in (e.g. Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience. Postnatal period: post-partum haemorrhage, perineal/rectal tears during delivery and retained products of conception. Antenatal period: pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia and shoulder dystocia. self-hygiene, housework, food shopping), NICE. Socio-demographic risks 2. Perform prenatal blood tests to do the following: Determine your blood type and Rh (Rhesus) factor. Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks). Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. 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). This will help ensure your consultation is more natural, patient-centred and not overly formulaic. 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. “Prenatal” comes from the same roots as “pregnant.” “Pre” means before or prior to. You should ask about the results of the scan (or check the medical records if the patient is unsure). However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. But, prenatal health care involves more than just going to appointments. Obie takes a holistic approach to improving your fertility, tracking your cycle and ovulation, and helping you get pregnant. 1. 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. Mother's Name required, First and Last are required. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. We've also just launched an OSCE Flashcard Collection which contains over 800 cards. Obstetrics & Gynaecology Registrar in London, You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. 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. During the first prenatal visit, a prenatal health history is taken to give the doctor insight into any potential problems that may be faced during the pregnancy. Social factors have a significant influence on a patient’s pregnancy. ². Accurate estimation of gestation and estimated date of delivery (EDD) is performed using an ultrasound scan to measure the crown-rump length. Health problems facing other blood relatives may also be pertinent. As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy. The basic components of a pediatric history are as follows: history of presenting illness, past history including prenatal, birth, and postnatal history, past medical history, surgical history, growth and developmental, medications, allergies, immunizations, family history, social history and review of systems. Hypothyroidism: untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact. Prenatal care is necessary to maximize the health of both the mother-to-be and the developing fetus. depression, bipolar disorder, schizophrenia). Active listening: through body language and your verbal responses to what the patient has said. The condition can be life-threatening for the mother and the fetus. Many women claim that prenatal vitamins affect hair and nail growth. A patient is currently 26 weeks pregnant and already has two children of her own. 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). Menstrual 4. It is essential to appreciate that taking a comprehensive history in obstetrics and gynaecology involves eliciting confidential and often very ‘personal’ information. Ultrasound in Gynecology meducationdotnet. cocaine use increases the risk of placental abruption). Malignancy (e.g. You may need to continue taking prenatal multivitamins if you breast-feed your baby. Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. 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. Perinatal history, normal newborn 1. Antiemetics: frequently used in pregnancy to manage nausea and vomiting (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. This is particularly true where most paediatric histories are taken - that is, in general practice and in accident and emergency departments. Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies. The developing embryo and fetus need extra vitamins for healthy development. She reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks: 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. In addition to his current work, Dr. Amos is using his vast experience to launch Obie, a science-based app that offers personalized fertility advice. Prenatal tests can provide valuable information about your baby's health. 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. Abdominal or pelvic surgery: may influence decisions regarding delivery due to the presence of scar tissue and adhesions. Your health care provider will typically offer a variety of prenatal genetic screening tests, which may include ultrasound or blood tests to screen for certain fetal genetic abnormalities, such as Down syndrome. Epilepsy: seizures during pregnancy pose a risk to both the mother and fetus (e.g. Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology. 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. Gestational age, gravidity and parity would also usually be included at the beginning of any documentat… Ask if the patient has any medical conditions: 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. Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis. Check out our brand new medical MCQ quiz platform at https://geekyquiz.com. Infection 10. Ask if the patient was using contraception prior to becoming pregnant and if so, clarify what method of contraception was being used. Medical 8. It is also important to ask about any complications associated with the condition including hospital admissions. Oral iron: frequently used in pregnancy to treat anaemia. Family Health History Checklist: Planning a Pregnancy Gather family history information before seeing the doctor. Previous pre-term labour increases the risk of pre-term labour in later pregnancies. Ask about your lifestyle, including whether you smoke, drink, or take drugs, and whether you exercise regularly. Ontario Breastfeeding Network. Clarify the site of the ectopic pregnancy and how it was managed (e.g. Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information). Termination of pregnancy is the medical process of ending a pregnancy so it doesn’t result in the birth of a baby. A lot of people wonder about about prenatal vitamins side effects. Ask if the patient what their diet looks like on an average day. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Available from: [. Saving Lives, Improving Mother’s Care. Some people get nauseated or constipated from taking prenatal vitamins. Ask the patient if they’re currently experiencing any side effects from their medication: Some examples of drugs that are known to be teratogenic include: Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat the symptoms of pregnancy. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. The pregnancy is ended either by taking medications or having a minor surgical procedure. Started in 1995, this collection now contains 6907 interlinked topic pages divided into a tree of 31 specialty books and 737 chapters. Family Health History Checklist: During Pregnancy Gather family history information before seeing the doctor. Obs and gyn instruments Aman Shaik. If recreational drug use is identified, patients can be offered input from drug cessation services. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint. Outcomes of prior pregnancies are Children above the age of 4 may be able to provide some of their own history 2. Ultrasound diagnostics fin MUBOSScz. Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive manner in a private setting. 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. Open, relaxed, yet professional body language (e.g. WebMD provides common contraindications for Prenatal Vitamin oral. Gestational age, gravidity and parity should also be included at the beginning of your presentation of a patient’s history. PRENATAL HISTORY Format of History – same as a regular history including Review of Symptoms Add the following additional information regarding the OB/Gyn History Student’s name Date of History Patient’s Name Preceptor’s Name General Information (make sure these are included in the history) Patient’s age Occupation Medications Allergies

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