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Dr.Suresh Babu Chaduvula 
Professor 
College of Medicine 
King Khalid University 
Abha, KSA
Respect, confidentiality and privacy are 
important 
Information should be logical and also in 
chronological sequence 
History should guide a clinician to make a 
provisional diagnosis and perform proper and 
relevant investigations
To build a rapport with the patient 
To come to a provisional diagnosis 
To perform relevant investigations 
To give correct treatment 
To provide proper counseling
Seek permission from the patient, Greet the 
patient 
Dress code with Apron and identity badge 
Make sure a sister or a female attendant be 
with you. 
Be gentle and sensitive
Biodata [ personal and social hstory] 
Name : 
Age: 
Nationality: 
Occupation: 
Marital state: 
Relation: 
Wife/ Daughter of: 
Address: 
Obstetric Formula: Gravida, Parity, Abortions, 
Ectopic pregnancy 
LMP 
EDD
Gravidity – No. of pregnancies including this 
pregnancy 
Parity: No. of births beyond 24 weeks 
Abortion is termination before 24 weeks 
EDD can be calculated by ‘Naegele’s rule’ by 
adding 7 days and 9 months to 1st day of Last 
menstrual period. 
Hijri calendar - add 9 months and 15 days 
Formula will be G3P1+1+1 at 8th month for a 
woman who is pregnant third time, parity one 
with one abortion with one live child at 8th 
month of gestation.
Naegele’s rule needs to be adjusted or 
recalculated in following conditions for 
accuracy: 
1. Irregular periods 
2. Women on contraceptive pills 
3. Prolonged periods 
Early scan is important in estimating EDD
2. Complaints and Duration: [ chronological order ] 
Pain, Vomiting, Bleeding, Discharge, Fever etc. 
3. History of present illness: 
Elaborate or expand each complaint in chronological order. 
Explain the events happened in the hospital stay and what 
treatment she received. 
1st Trimester 
2nd Trimester 
3rd Trimester 
History of labor
Trimester wise History: 
1st Trimester – History of Pain lower abdomen, 
Bleeding per vagina, fever with chills and rigors, 
skin rash, intake of any drugs, radiation 
exposure, UTI symptoms 
Any investigations like ultrasound, urine 
pregnancy tests and any blood tests. 
History of any operations or any other trauma or 
interventions done. 
Drug and vaccination history 
Whether she is booked with any doctor, if so how 
many visits she has had
2nd Trimester: 
History of Pain lower abdomen, Bleeding per vagina, fetal movements, symptoms of 
anemia, Hypertension, APH and hyperemesis 
Time of Quickening: [ first perception of fetal movements ] – Primi – 18 – 20 weeks, 
Multi – 16-18 wk 
Weight gain – [ 5 kg ] 
H/O of headache, blurring of vision, edema of feet, change in the color and 
quantity of urine. 
Any investigations like ultrasound, urine pregnancy tests and any blood tests. 
Immunization history. 
History of any operations or any other trauma or interventions done. 
Whether she is booked with any doctor, if so how many visits she has had 
History of any drugs taken
3rd Trimester – 
History of Pain lower abdomen, Bleeding per vagina. 
Weight gain – [ 5 kg ] 
H/O of headache, blurring of vision, edema of feet, change in 
the color and quantity of urine. 
Any investigations like ultrasound, urine pregnancy tests and any 
blood tests. 
History of any operations or any other trauma or interventions 
done. 
Whether she is booked with any doctor, if so how many visits she 
has had 
History of drugs intake 
If it is Postnatal case: 
Labor and delivery details and postnatal period.
Gravida, parity and Abortions 
Elaborate each pregnancy like date and time 
of delivery 
Is it full term or preterm delivery 
Hospital or home delivery 
Normal or cesarean delivery 
Male or female baby 
Weight of the baby 
Any complications in the delivery 
Any problems for the newborn
Duration of cycle 
No. of days of flow 
Regularity 
LMP 
EDD
Usage of oral pills, IUCDs, Barriers, 
Duration and any side effects
Any history of medical illnesses like, 
Tuberculosis, Diabetes, hypertension, 
Epilepsy, SLE etc. 
Is she on treatment 
Is she following up with any physician 
What type of surgery she had undergone
Any history of medical illnesses like, 
Tuberculosis, Diabetes, hypertension, SLE, 
Congenital anomalies, Heart diseases, 
Multiple pregnancy 
Chromosomal diseases and metabolic 
diseases 
H/O Consanguinity.
To drugs 
To food 
Any others
Occupation 
Income or Living Status 
Level of education 
Total family members 
AND 
Smoking 
Alcohol intake 
Drug abuse 
Sleep, Bowel habits, Diet
Look for pallor, cyanosis, jaundice, hydration 
status, oral hygiene. 
Thyroid and any neck swellings 
Breast examination: 
Koilonychia, Clubbing 
Edema feet, varicose veins in legs 
Vital signs: 
BP – in semi-recumbent position at 45 degrees 
PR,RR,Temperature: 
Weight in Kg: 
Height in Cm: 
Calculate BMI = Wt[kg]/Ht[mt square]
CNS 
CVS 
Respiratory System 
GIT 
Genitalia 
Urinary system 
Locomotory system
INSPECTION: 
Size of abdominal distension 
Symmetrical or Asymmetrical 
Umbilicus – Inverted, flat or Everted 
Fetal movements 
Scars 
Engorged veins 
Hernia sites: Umbilical, Para-umbilical, 
Inguinal
LINEA NIGRA: a dark pigmented line from 
xiphi-sternum to symphysis pubis 
STRIAE GRAVIDARUM: recent stretch marks 
are purplish in color 
STRIAE ALBICANS: old stretch marks look 
silvery white
PALPATION: 
Symphysio-fundal height: measured in 
centimeters 
Measured from 20 weeks onwards 
Estimation of no. of fetuses 
If it is a single fetus –perform Leopold 
maneuvers: 
1. Fundal height and Grip 
2. Lateral or Umbilical grip 
3. Superficial or Pawlic’s grip 
4. Deep pelvic grip
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
History taking in obstetrics & Gynecology
Mrs.-------------- is a 21 year old Saudi house 
wife married for 2 years Primi or G4, P3, A0 
and living 3 at 33 weeks admitted with high 
blood pressure for admission and further 
management.
Bio-data is same 
Complaints and duration – 
Abnormal uterine bleeding 
Infertility 
Vaginal discharge 
Pelvic pain 
History of present illness:
Age of menarche 
Duration of cycle 
Amount of flow 
Pain with periods – Dysmenorrhea 
Premenstrual symptoms 
Inter menstrual spotting or bleeding 
Date of LMP
Obstetric History: 
Past & Surgical History: 
Family History: 
Treatment History: 
Allergy History: 
Sexual history: 
Husband 
Prevention of pregnancy 
Protection against STDs 
Practices 
Social and Personal History:
Past Gynecological history 
Any previous PID, Endometriosis, fibroids, etc 
Any operations 
HRT
General Examination 
Systemic Examination 
Abdominal examination 
Local or Genitalia examination 
Per speculum examination 
Per vaginal or Bimanual pelvic examination 
Vagino-rectal examination 
Provisional diagnosis 
Differential diagnosis
Mrs.----------- Saudi, 17 year old, complaining 
of vaginal discharge for evaluation and 
management
Thank You All

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History taking in obstetrics & Gynecology

  • 1. Dr.Suresh Babu Chaduvula Professor College of Medicine King Khalid University Abha, KSA
  • 2. Respect, confidentiality and privacy are important Information should be logical and also in chronological sequence History should guide a clinician to make a provisional diagnosis and perform proper and relevant investigations
  • 3. To build a rapport with the patient To come to a provisional diagnosis To perform relevant investigations To give correct treatment To provide proper counseling
  • 4. Seek permission from the patient, Greet the patient Dress code with Apron and identity badge Make sure a sister or a female attendant be with you. Be gentle and sensitive
  • 5. Biodata [ personal and social hstory] Name : Age: Nationality: Occupation: Marital state: Relation: Wife/ Daughter of: Address: Obstetric Formula: Gravida, Parity, Abortions, Ectopic pregnancy LMP EDD
  • 6. Gravidity – No. of pregnancies including this pregnancy Parity: No. of births beyond 24 weeks Abortion is termination before 24 weeks EDD can be calculated by ‘Naegele’s rule’ by adding 7 days and 9 months to 1st day of Last menstrual period. Hijri calendar - add 9 months and 15 days Formula will be G3P1+1+1 at 8th month for a woman who is pregnant third time, parity one with one abortion with one live child at 8th month of gestation.
  • 7. Naegele’s rule needs to be adjusted or recalculated in following conditions for accuracy: 1. Irregular periods 2. Women on contraceptive pills 3. Prolonged periods Early scan is important in estimating EDD
  • 8. 2. Complaints and Duration: [ chronological order ] Pain, Vomiting, Bleeding, Discharge, Fever etc. 3. History of present illness: Elaborate or expand each complaint in chronological order. Explain the events happened in the hospital stay and what treatment she received. 1st Trimester 2nd Trimester 3rd Trimester History of labor
  • 9. Trimester wise History: 1st Trimester – History of Pain lower abdomen, Bleeding per vagina, fever with chills and rigors, skin rash, intake of any drugs, radiation exposure, UTI symptoms Any investigations like ultrasound, urine pregnancy tests and any blood tests. History of any operations or any other trauma or interventions done. Drug and vaccination history Whether she is booked with any doctor, if so how many visits she has had
  • 10. 2nd Trimester: History of Pain lower abdomen, Bleeding per vagina, fetal movements, symptoms of anemia, Hypertension, APH and hyperemesis Time of Quickening: [ first perception of fetal movements ] – Primi – 18 – 20 weeks, Multi – 16-18 wk Weight gain – [ 5 kg ] H/O of headache, blurring of vision, edema of feet, change in the color and quantity of urine. Any investigations like ultrasound, urine pregnancy tests and any blood tests. Immunization history. History of any operations or any other trauma or interventions done. Whether she is booked with any doctor, if so how many visits she has had History of any drugs taken
  • 11. 3rd Trimester – History of Pain lower abdomen, Bleeding per vagina. Weight gain – [ 5 kg ] H/O of headache, blurring of vision, edema of feet, change in the color and quantity of urine. Any investigations like ultrasound, urine pregnancy tests and any blood tests. History of any operations or any other trauma or interventions done. Whether she is booked with any doctor, if so how many visits she has had History of drugs intake If it is Postnatal case: Labor and delivery details and postnatal period.
  • 12. Gravida, parity and Abortions Elaborate each pregnancy like date and time of delivery Is it full term or preterm delivery Hospital or home delivery Normal or cesarean delivery Male or female baby Weight of the baby Any complications in the delivery Any problems for the newborn
  • 13. Duration of cycle No. of days of flow Regularity LMP EDD
  • 14. Usage of oral pills, IUCDs, Barriers, Duration and any side effects
  • 15. Any history of medical illnesses like, Tuberculosis, Diabetes, hypertension, Epilepsy, SLE etc. Is she on treatment Is she following up with any physician What type of surgery she had undergone
  • 16. Any history of medical illnesses like, Tuberculosis, Diabetes, hypertension, SLE, Congenital anomalies, Heart diseases, Multiple pregnancy Chromosomal diseases and metabolic diseases H/O Consanguinity.
  • 17. To drugs To food Any others
  • 18. Occupation Income or Living Status Level of education Total family members AND Smoking Alcohol intake Drug abuse Sleep, Bowel habits, Diet
  • 19. Look for pallor, cyanosis, jaundice, hydration status, oral hygiene. Thyroid and any neck swellings Breast examination: Koilonychia, Clubbing Edema feet, varicose veins in legs Vital signs: BP – in semi-recumbent position at 45 degrees PR,RR,Temperature: Weight in Kg: Height in Cm: Calculate BMI = Wt[kg]/Ht[mt square]
  • 20. CNS CVS Respiratory System GIT Genitalia Urinary system Locomotory system
  • 21. INSPECTION: Size of abdominal distension Symmetrical or Asymmetrical Umbilicus – Inverted, flat or Everted Fetal movements Scars Engorged veins Hernia sites: Umbilical, Para-umbilical, Inguinal
  • 22. LINEA NIGRA: a dark pigmented line from xiphi-sternum to symphysis pubis STRIAE GRAVIDARUM: recent stretch marks are purplish in color STRIAE ALBICANS: old stretch marks look silvery white
  • 23. PALPATION: Symphysio-fundal height: measured in centimeters Measured from 20 weeks onwards Estimation of no. of fetuses If it is a single fetus –perform Leopold maneuvers: 1. Fundal height and Grip 2. Lateral or Umbilical grip 3. Superficial or Pawlic’s grip 4. Deep pelvic grip
  • 33. Mrs.-------------- is a 21 year old Saudi house wife married for 2 years Primi or G4, P3, A0 and living 3 at 33 weeks admitted with high blood pressure for admission and further management.
  • 34. Bio-data is same Complaints and duration – Abnormal uterine bleeding Infertility Vaginal discharge Pelvic pain History of present illness:
  • 35. Age of menarche Duration of cycle Amount of flow Pain with periods – Dysmenorrhea Premenstrual symptoms Inter menstrual spotting or bleeding Date of LMP
  • 36. Obstetric History: Past & Surgical History: Family History: Treatment History: Allergy History: Sexual history: Husband Prevention of pregnancy Protection against STDs Practices Social and Personal History:
  • 37. Past Gynecological history Any previous PID, Endometriosis, fibroids, etc Any operations HRT
  • 38. General Examination Systemic Examination Abdominal examination Local or Genitalia examination Per speculum examination Per vaginal or Bimanual pelvic examination Vagino-rectal examination Provisional diagnosis Differential diagnosis
  • 39. Mrs.----------- Saudi, 17 year old, complaining of vaginal discharge for evaluation and management