Obstetrics post op history taking
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Obstetrics Post-OP HISTORY TAKINGPiyush Ranjan Sahoo
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• Chief Complaints
pain/fever/wound complication/urinary retention etc. headache, vomiting
if not having any, tell- __yr female P (no. of child) on __ day of
puerperium with no specific complain.
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History of Present Illness-Describe pain—onset, location, duration,
character, association, aggravating n relieving factors, radiation, with reln to time.
-Describe fever (puerperal pyrexia)—type, asso. with any other factor.
-Wound complication- Infection, stitch problem, pain at wound site, any bleeding/discharge, or swelling.
-Urinary retention- (look for catheterisation n accordingly present history) frequency of urination, urinary output.
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Hist. of past illness
medical hist. surgical hist.(obs/gynaec/general)
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Family History
Mention as routineIf Any relevant finding, mention.
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Menstrual historyMenarcheprev. cycleLMPGA on the day of surgery, EDD.Cycle- duration of flow, amount of flow,
association (e.g. pain), regular or not.
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Personal history
OccupationEducationSESwt gainDietAddictionsB/B habit
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Obs hist.-No. of pregnancy
Yr of pregnancy
Duration of Pregnancy(complications if any)
Duration oflabour
Mode Ofdelivery
NatureOf puerperium
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BabySex weight Health
of the child
If dead, cause ofDeath.
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HIST. OF PRESENT PREGNANCY
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Antenatal events-
1st trimester events-Morning sickness, fever (with rashes or not),
vomiting, bleeding PV, Abd pain (may be due to UTI/ectopic pregnancy)
Medication hist.- Folic acid(neural tube development)
USG done or not( for location of pregnancy & uterine anomaly)
ANC (booked case or not). Visits-
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Continued…2nd trimester events- Abd pain, bleeding PV, quickening,
PIH(blurring of vision, pedal oedema), Glucose challenge test ( to know GDM).
Medication hist.- Fe(not in 1st trimester, causes vomiting n GI prob.), Ca+2 (to prevent osteoporosis), TT( 1st dose at 16 wks, 2nd dose after 4-6wks).
USG done or not. – ANC
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Continued…3rd trimester events- Abd pain, PIH, GDM, Bleeding PV.Med history-Fe, Calcium ..contd or not. USG –ANC.
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Labour events-
Pain- durationBleeding Leaking
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Puerperal events-
Bleeding (for PPH)Any complications or illness
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Fetal outcome-
Wt-Crying, feeding, colour, CRTAny abnormalityImmunization
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General examn-Ht n wt, built, gait, pulse, BP, RR, temp.,
PICKLEBreast examn- Inspection- skin, nipple n areola, engorged
veins, any dischargePalpation-lax, tender or not, any massThyroid examn- (optional)Abdominal examn- ( same as medicine)
***No percussion is to be done.
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Thank u