Midwifery (RM)
Taking the Present Obstetric History of a Pregnant Woman/Client
Present obstetric history obtains accurate information about the current pregnancy, including dating, symptoms, fetal wellbeing, investigations, medicines, and care already received. It supports clinical decision-making and timely recognition of danger signs.
Purpose
- Establish current pregnancy status and gestational age
- Identify maternal or fetal risk and complications
- Guide investigations, treatment, education, and referral
Indications
- Antenatal booking or review
- New symptom or concern
- Transfer from another facility or unscheduled maternity contact
Equipment
- Antenatal record and referral documents
- Gestational-age calendar or calculator
- Vital-sign and fetal-assessment equipment as indicated
- Medication and investigation records
- Interpreter and documentation materials
Preparation
- Review previous antenatal records, results, and referral letters.
- Ensure urgent assessment equipment and referral contacts are available.
Procedure steps
- Confirm identity, privacy, gestational age if known, and the woman’s immediate concern.
- Ask about the last menstrual period, estimated due date, dating scan, and antenatal care received.
- Review current symptoms including bleeding, fluid loss, pain, contractions, fever, headache, visual symptoms, swelling, urinary symptoms, and fetal movements.
- Review medicines, supplements, allergies, immunizations, tests, results, treatments, and adherence.
- Ask about nutrition, psychosocial wellbeing, safety, support, and barriers to care.
- Assess maternal observations and fetal wellbeing using appropriate examination and investigations.
- Identify discrepancies in dates, abnormal results, danger signs, or risk factors.
- Explain the working plan, referrals, and warning signs.
- Confirm understanding and provide continuity information.
- Document the history, findings, advice, referral, and follow-up.
Precautions
- Treat vaginal bleeding, fluid loss, severe pain, severe headache, visual disturbance, fever, or reduced fetal movement as potential emergencies.
- Do not rely only on the woman’s estimated dates when records or scan information conflict.
- Review medicine safety and allergies carefully.
- Protect privacy for sexual, mental-health, and safeguarding questions.
Aftercare
- Give a clear plan, appointment, and emergency contact instructions.
- Arrange transport or referral support when delay could be harmful.
Nursing considerations
- Combine history with objective findings and trend information.
- Use shared decision-making and escalate beyond the scope of routine antenatal care.
Patient education
- Explain gestational age, fetal movement awareness, medication use, and danger signs.
- Encourage prompt return for bleeding, fluid loss, severe pain, fever, or reduced fetal movement.
Documentation
- Record dates, symptoms, fetal concerns, medicines, tests, findings, education, and plan.
- Document urgency, referrals, handover, and response.
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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