Examination checklist

    Obstetric history taking

    A 26-step mark sheet for the obstetric long-case history — biodata, dating, the current pregnancy trimester by trimester, past obstetric, gynaecological, medical and social history — with a model summary and the risk factors examiners expect you to pick out.

    OBGYN
    General
    All colleges

    Mark sheet

    26 steps · 26 marks

    #StepWellPartlyNot
    1. 1Greets the patient and examiner, introduces self, explains the purpose and obtains consent1½0
    2. 2Takes biodata: name, age, parity, marital status, occupation, education, religion, tribe and address1½0
    3. 3States parity correctly as para (births from the age of viability) plus losses before it, with the number of living children1½0
    4. 4Asks the husband's or partner's age, occupation and education1½0
    5. 5Records the presenting complaint and its duration in the patient's own words1½0
    6. 6Explores the presenting complaint fully, with relevant associated symptoms and negatives1½0
    7. 7Takes the first day of the last menstrual period, checks it was a normal, certain period on a regular cycle without hormonal contraception1½0
    8. 8Calculates the expected date of delivery and the current gestational age, and confirms with the earliest ultrasound1½0
    9. 9Asks whether the pregnancy was planned, spontaneous or assisted, and how it was confirmed1½0
    10. 10First trimester: nausea and vomiting, bleeding, abdominal pain, febrile illness, drugs and herbal remedies taken1½0
    11. 11Booking: gestational age at booking, where, booking blood pressure, weight and investigations (packed cell volume, blood group and rhesus, genotype, HIV, hepatitis B, syphilis, urinalysis, ultrasound)1½0
    12. 12Second and third trimesters: quickening and fetal movements, bleeding, leakage of liquor, headache, visual disturbance, epigastric pain, swelling, urinary symptoms, fever1½0
    13. 13Antenatal routine drugs and prophylaxis: haematinics, IPTp with sulfadoxine–pyrimethamine, insecticide-treated net, tetanus–diphtheria vaccine, calcium and aspirin where indicated1½0
    14. 14Number of antenatal visits, admissions and any complications in this pregnancy1½0
    15. 15Past obstetric history for each pregnancy in date order: year, gestation, onset and duration of labour, mode of delivery and indication, place, sex, birth weight, condition of the baby now1½0
    16. 16Complications in previous pregnancies, labours and puerperia: pre-eclampsia, haemorrhage, perineal tears, sepsis, retained placenta, stillbirth, neonatal death1½0
    17. 17Past miscarriages or terminations: gestation, how managed, complications1½0
    18. 18Gynaecological history: menarche, cycle, previous contraception, last cervical screening, sexually transmitted infections, gynaecological surgery, infertility1½0
    19. 19Past medical history: hypertension, diabetes, sickle cell disease, heart disease, asthma, epilepsy, thyroid disease, tuberculosis, HIV, blood transfusions1½0
    20. 20Past surgical history, particularly previous uterine surgery such as caesarean section or myomectomy1½0
    21. 21Drug history and allergies1½0
    22. 22Family history: hypertension, diabetes, twins, congenital anomalies, sickle cell disease1½0
    23. 23Social history: smoking, alcohol, support at home, occupation, domestic violence, finances and the plan for the delivery1½0
    24. 24Brief review of systems1½0
    25. 25Summarises the history and identifies the risk factors in this pregnancy1½0
    26. 26Thanks the patient and closes courteously1½0

    Summary of findings

    Summarise in one paragraph: who she is, dating, the problem, the relevant past history, and the risks to mother and baby that follow from them.

    Mrs A is a 32-year-old trader, gravida 4 para 2+1 with two living children, at 34 weeks and 2 days by a certain last menstrual period confirmed by an 11-week scan. She booked at 14 weeks with normal results; her genotype is AA, blood group O rhesus positive, and she is HIV, hepatitis B and syphilis negative. She presents with headache and blurred vision for two days. Her first baby was delivered by emergency caesarean section at term for obstructed labour in 2019, and her second delivered vaginally after that caesarean in 2022 with a postpartum haemorrhage treated with oxytocin. She had a first-trimester miscarriage in 2024, evacuated manually. Her mother has chronic hypertension. The key issues are possible pre-eclampsia with severe features at 34 weeks, one previous caesarean section, and a history of postpartum haemorrhage.

    Differential diagnoses

    Complaint in pregnancyCauses to consider
    Headache and visual disturbancePre-eclampsia, migraine, malaria, meningitis, cerebral venous thrombosis
    Bleeding after 28 weeksPlacenta praevia, abruption, vasa praevia, cervical or vaginal lesion, show
    Abdominal painLabour, abruption, uterine rupture, UTI or pyelonephritis, appendicitis, red degeneration of a fibroid, HELLP
    Leaking fluidRuptured membranes, urinary incontinence, vaginal discharge
    Reduced fetal movementsFetal growth restriction, fetal compromise, fetal death
    FeverMalaria, UTI, chorioamnionitis, respiratory infection

    Investigations

    • Booking set: packed cell volume or haemoglobin, blood group and rhesus, haemoglobin genotype, HIV, hepatitis B surface antigen, syphilis serology, urinalysis and culture, dating ultrasound
    • Targeted: chosen by the risks the history reveals — see Antenatal care schedule

    Treatment

    Management follows the risks identified. The history should close with a plan for the pregnancy, the place and mode of delivery, and the puerperium — see Obstetric abdominal examination for the examination that follows.

    Examiner questions

    References

    • Cunningham FG, Leveno KJ, Dashe JS, Hoffman BL, Spong CY, Casey BM, eds. Williams Obstetrics. 26th ed. New York: McGraw Hill; 2022.
    • World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO; 2016.

    Updated September 18, 2026