Nursing Component Task
Nursing procedures & clinical learning

Midwifery (RM)

Taking the Past Obstetric History of a Pregnant Woman/Client

Past obstetric history reviews previous pregnancies, labour, births, puerperium, and outcomes. The information identifies recurrence risks, informs mode-of-delivery planning, and supports anticipatory management and referral.

Purpose

  • Identify previous obstetric risks and complications
  • Inform current pregnancy and delivery planning
  • Provide individualized counselling and referral

Indications

  • Antenatal booking or transfer of care
  • A history of previous pregnancy or birth complication
  • Review before labour or a planned intervention

Equipment

  • Private interview space
  • Antenatal and maternity records
  • Obstetric history or gravida/para aid
  • Interpreter if required
  • Documentation materials

Preparation

  • Review available records and prepare a chronological format.
  • Allow adequate time and offer support if the history is distressing.

Procedure steps

  • Explain confidentiality and ask the woman to describe previous pregnancies in her own words.
  • For each pregnancy, record year, gestation, antenatal complications, labour onset, duration, place, mode of birth, and birth attendant.
  • Record newborn sex, weight when known, condition at birth, admission, feeding, and survival.
  • Ask about miscarriage, stillbirth, neonatal death, caesarean birth, instrumental birth, tears, haemorrhage, hypertension, infection, and transfusion.
  • Explore previous postpartum recovery, lactation, contraception, emotional wellbeing, and any traumatic experience.
  • Verify records where available and clarify discrepancies without blame.
  • Identify recurrence risks and current implications with the woman.
  • Discuss the need for specialist review, birth plan, investigations, or additional surveillance.
  • Provide reassurance without false promises and answer questions within scope.
  • Document the obstetric history, risk factors, counselling, referrals, and plan.

Precautions

  • Use sensitive, non-judgmental language around pregnancy loss, infertility, trauma, and neonatal death.
  • Do not infer risk from parity alone; assess the details of each outcome.
  • Escalate significant previous complications or uncertainty to the appropriate clinician.
  • Protect privacy when family members are present.

Aftercare

  • Agree on current pregnancy surveillance and follow-up.
  • Offer referral for emotional or psychosocial support when indicated.

Nursing considerations

  • Use trauma-informed care and respect the woman’s narrative.
  • Share relevant information only with professionals involved in care.

Patient education

  • Explain how previous pregnancy outcomes can inform, but do not determine, current care.
  • Teach which symptoms should prompt urgent review.

Documentation

  • Record gravida/para, outcomes, complications, procedures, neonatal outcomes, and current implications.
  • Document counselling, referral, and the woman’s preferences.

References and further reading

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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