This article based on clinical medicine course because that course deals with the taking of history of patients during the hospital. Each history has its format and principle by simple meaning the difference of history is depend on department of the patient based. If the patient has obstetric cases the history that will be taken will be obstetric history and mostly different from other history like internal medicine and pediatric

In order to know to understand and learning how to writing a good perfect and best history some material and thing =s you need to be with that form examples, clerkship of specific history you want to know, and also thing like clinical area attending routine and also rating scale, but the things you need to be with like clinical attendance that will help to get experience

But this content wants to share with you a really, perfect and best history taking of obstetrics history. But also, you can download this that a best example of history taking of obstetrics history. Below after ending of this history taking.


Obstetric History

Demographic data

Name: Zukra Abdu

Age:21 years

Sex: Female

Tribe: Makua

Adress: Mlundelunde

Religion: Muslim




LNMP: Not remembered

Estimated Ga:8 weeks

DaC:22nd4 2018


Chief complain

Lower abdominal pain 1/7

Per vagina bleeding 1/7


History of presenting illness

Seen a patient came with a complain of lower abdominal pain for 1 day of gradual onset, cramping in nature with neither aggravating nor relieving factor not associated with painful urination, increased frequency of urination, loss of appetite, passage of loose stool, nausea, vomiting, constipation no fever.

Also, patient had per vaginal bleeding of gradual onset started with fresh blood increasing with time later contained clots with no foul smell not mixed with any abnormal vaginal discharge, no vaginal itching associated with dizziness and heart beat awareness not associated with difficulty in breathing, chest pain, cough, blurred vision, headache, no loss of consciousness.


Review of other system

Muscular skeletal system

No muscle pain

No joint pain


Past medical history

This is 2ndadmission

1stadmission was in 2014 due to labor

No history of BT

No any known drug/food allergy


Obstetric history

Index pregnancy

Tested urine pregnancy test was positive

Not booked for antenatal clinic


Previous pregnancy

Pre term delivery in 2014 by SVD at Mkomaindo hospital

A baby boy of 2 kg

No history of any disease during pregnancy

No history of post-partum complications


Gynecological history

Menarche at 15 years

Circle of 30 days

Period of 5 days

Changed pads 3 times in a day

Used Depo Provera stopped in 2017 due prolonged bleed

No history of dysmenorrhea

No history of STI


Family and social history

Did not get formal education



No history of inherited disease

No history of cigarette smoking and alcohol consumption


General examination

Conscious, oriented with people, time and place,

Good hair distribution, color and texture according to age and race,

No conjunctival pallor, no sclera jaundice

No eye, ear, nose discharge

No angular cheilitis, no stomatitis, no cyanosis, no oral thrush

No enlarged palpable lymph nodes

No palmar pallor, No finger clubbing, no koilonychia, capillary refill is < 3 sec

No lower limb oedema


Vital signs

BP 110/60 mmHg Normal

PR 75 b/min Normal

RR 20 c/min Normal

Temperature 36.6 C Normal


Systemic examination

Per abdomen


Normal abdominal contour

No surgical scar

No traditional marks

Moves with respiration

There is linear nigra


Superficial palpation

No tenderness

No superficial mass

Deep palpation

No tenderness

No organomegaly


Tympanic sound heard


Bowel sound heard


Pelvic examination

Per vaginal inspection

No ulceration

No swelling

There some blood clots

Digital vaginal examination

Cervix was thin and soft, dilated 4 cm, some clots seen


Cardiovascular system


No distended jugular vein

No pericardial bulging

No pericardial hyperreactivity


Pulse rate was strong and regular

Radial and femoral pulse were synchronized

No pericardial tenderness

Apex beat was located at 5th inter costal space


S1 and S2 heard with no added sound



Respiratory system


Chest is bilateral symmetrical

Moves with respiration

No surgical mark

No traditional mark


Trachea was centrally located

No chest tenderness

Normal tactile vocal fremitus


Resonance sound heard


Vesicular sound heard



Central nervous system

Higher center

Conscious, oriented with people time and place

Short- and long-term memory was intact

Cranial nerves examination

All cranial nerves except number X were tested and intact

Motor system examination

Normal muscle bulk

Normal muscle tone

Muscle power 5/5




Zukra Abdu 21 years from Mlundelunde, G2 P1 L1 but did not remember her LNMP, estimated gestation age 8 weeks. Came with complain of lower abdominal pain and per vaginal bleeding for 1 day blood contained clots with no foul smell associated with dizziness and heart beat awareness, no fever. Not pale, cervix was soft and thin dilated 4 cm. Vital sign wasBP 110/60 mmHg Normal, PR 75 b/min Normal, RR 20 c/min Normal, Temperature 36.6 C Normal.


Provisional diagnosis

Incomplete abortion

Differential diagnosis

Inevitable abortion



Hemoglobin level estimation, blood grouping and cross matching

Pelvic ultrasound



Intravenous fluid Ringer’s lactate 1 L

Capsule Amoxicillin 500mg 8 hourly 5/7

Tablets Metronidazole 400mg 8 hourly 5/7

Ferrous-sulphate Folic acid 205mg od 6/52

Manual vacuum aspiration


Post abortion care

Teach about the complications of abortion

Counsel and offer family planning options

Counsel for HIV

Discus about future sex fertility




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