 |
Antenatal History and Examination
Introduce yourself, opening statement re: presenting complaint:
- Include name, age, parity and reason for consultation or presentation
- Details of presenting complaint (if other than routine antenatal visit)
History of this pregnancy
Last menstrual period dates – calculate Expected Day of Delivery (EDD)
Establish reliability of LMP by
- cycle regularity
- history of recent oral contraceptive pill use
- early ultrasound assessement of gestational age
Model of antenatal care – GP, specialist obstetrician, midwifery care,
independent midwifery or shared care
Booking visit – gestational age, first trimester blood pressure measurements,
screening serology (blood group, Rh and RBC antibodies, rubella immunity, hepatitis
B, syphilis, and HIV status), MSU.
Antenatal care to date – regular visits, blood pressure, clinical assessment
of fetal growth (satisfactory or not)
Later screening tests: maternal serum screening for Down syndrome,
18 week morphology scan, 28 week glucose challenge test
- Previous obstetric history
- Ask for details, date of pregnancy, outcome, gestation, weight and sex of
baby, well being now, problems in labour or pregnancy, delivery mode
- Previous gynaecological problems – STIs, endometriosis, infertility, surgery,
polycystic ovarian disease
- Papanicolaou smear history, date and results of last smear
- Previous medical/surgical/psychiatric history
- Medications
- Doses and times of administration
- Allergies
- Social history
- Marital status and supports/Employment
- Smoking/Alcohol/Other drugs
- Family history
- Systems enquiry
BACK |
NEXT
|
