This is Obstetrics History Taking model of post-operative case of 25 years old, Parity3 Living3 Abortion1 second post-partum day following vaginal delivery with episiotomy.
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Obstetrics History Taking
Name: ************* ************
Age: 25 years
Sex: Female
Address: ********** *******************
Occupation: Home-maker
Education: No formal education
Religion: Hindu
Husband’s name: ************ **********
Husband’s occupation: Painter
Duration of marriage: 7 years
** name of patient, husband and address are hidden for privacy of the patient.
P3 L3 A1
LMP (Last menstrual period): 14 June 2021
EDD (Expected date of delivery): 21 March 2022
DOD (Date of delivery): 2 March 2022
POG (Period of gestation): 37 weeks
DOA (Date of Admission): 2 March 2022
DOE (Date of examination) 4 March 2022
Chief complaints
Today is second post-partum day following vaginal delivery with episiotomy. Today she complaints of pain at episiotomy site.
History of present illness:
According to the patient, she was apparently well 3 days back with at her 37th week of pregnancy. She developed discharge from vagina 2 days back which was sudden on onset, approximately 150 ml in amount, white in color, watery in consistency, with slightly blackish substances. It was non foul smelling and was not stained with blood. There was no history of fever, burning micturition and PV bleeding.
She was brought to the obstetric ward of ….. hospital. After 4 hours of admission, she developed labor pain, which was at lower abdomen, sudden on onset, gradually progressive, dull aching, radiating towards back and thigh. The pain lasted for 3 minutes with 10 minutes of pain free duration.
The labor was spontaneous, duration of labor was 3 hours, delivery was after 9 hours of admission at 9 PM with normal vaginal delivery with episiotomy. According to the patient, she perceived fetal movements during labor and she delivered live male baby weighing 2.9 kg, cried immediately after birth. There was passage of meconium and urine after 1 hour of delivery. Breast feeding was done after 2 hours.
Today is second post-partum day and she complains pain at episiotomy site, which is acute on onset, dull aching, not radiating, aggravated on movement and relieved on rest and taking medications. No history of fever, malaise, burning micturition.
History of present pregnancy:
Not planned pregnancy, spontaneous conception. Not counselled with doctor before conception.
Pre pregnancy weight: 53 kg (3 months before missed period).
There was missed period and pregnancy diagnosed by UPT kit at home at 4 weeks of due date.
1st trimester:
1 antenatal visit at 2rd month. Blood tests and USG done.
Taken folic acid.
No history of excessive vomiting, no history of fever, PV discharge and bleeding, no suprapubic pain, no history of rashes and burning micturition.
According to the patient, her vitals and investigations were at between normal range.
2nd trimester:
Amenorrhea continued.
Quickening perceived at 5th month and were more than 10 fetal movements per day.
3 antenatal visits. Iron, calcium taken. USG done at 5th month and shown no any fetal anomalies.
Taken two doses of Tetanus toxoid at 5th and 6th months.
According to the patient, her vitals and investigations were at between normal range.
No history of blurring of vision, headache, suprapubic pain, fever, burning micturition, PV discharge and bleeding.
3rd trimester:
Amenorrhea continued. Continued taking iron and calcium. Continued perceiving fetal movements.
3 antenatal visits. No history of PV bleeding, suprapubic pain, headache, swelling of limbs.
No history of raised BP, fainting attacks.
At term (37th week of gestation) she delivered live male baby weighing 2.9 kg, cried immediately after birth.
Obstetric History:
P3 L3 A1
| S.N. | Date and year | Pregnancy events | Labor events | Mode of delivery | Puerperium | Baby |
| 1. | 2016-09-11 | Well covered antenatally, uneventful. | Uneventful. | Spontaneous vaginal delivery. | Uneventful. | Healthy living, baby boy, weighing 2.7 kg, cried immediately after birth, breastfed till 6 months, well immunized, well and living. |
| 2. | 2018-05-16 | Miscarriage at 6th week | —— | Evacuation done. | —— | —— |
| 3. | 2020-04-23 | Well covered antenatally, uneventful. | Uneventful. | Spontaneous vaginal delivery. | Uneventful. | Healthy living, baby girl, weighing 2.3 kg, cried immediately after birth, breastfed till 6 months, well immunized, well and living. |
| 4. | 2022-03-02 | Well covered antenatally, uneventful. | Uneventful, Episiotomy done. | Spontaneous vaginal delivery. | Uneventful. | Healthy living, baby boy, weighing 2.9 kg, cried immediately after birth, breastfed till now, well immunized, well and living. |
Menstrual History:
Menarche at 12 years of age.
Cycle occurred at 28-30 days, regular, the period lasted for 4 days with 2 pads per day and no clots passed. There was no history of dysmenorrhea.
Past history:
No history of DM, TB, Hypertension, thyroiditis and asthma in past. No history of surgeries in past.
Drug and allergy history:
No known drug reactions and food allergy in past.
Family history:
Her mother died due to cardiovascular disease. Her father and elder brother have hypertension. No history of DM, TB, Hypertension, thyroiditis and asthma in other family member and siblings.
No history of multiple pregnancies, fetal anomalies in family. No history of blood dyscrasias in family.
Socioeconomic history:
There are 7 members in family, 2 of them are earning members. The house is pucca, 4 rooms with proper ventilation, separate kitchen and toilet. Use water from tap and cook food in gas.
Personal history:
Mixed diet, no history of alcohol intake and cigarette smoking. Normal sleep, appetite, bowel and bladder habits.
Contraceptive history:
No history of use of contraception.
