Component Task: Taking the Present Obstetric History of a Pregnant Woman/Client

This is the process of obtaining accurate obstetric information on current pregnancy by the midwife through skillful communication.

Aims

·         Obtain baseline information

·         Identify the risk level of the client and foetus

·         Help with health promotion and management of the client

·         Inform the mode of delivery

·         Anticipate complications and manage

·         Ensure effective and accurate clinical decision making

Requirements

·         Maternal and Child Health Record Book (Manual or Electronic)

·         Ball pen

·         Comfortable chairs

·         Conducive room or an enclosed area

·         Gestational wheel (Manual or Digital)

Steps

1.        Establish rapport (refer steps)

2.      Explain procedure to client (refer steps)

3.      Provide privacy and ensure client assume desired position

4.      Obtain the Last Menstrual Period (LMP) and confirm pregnancy

5.      Involve client in calculating the Expected Date of Delivery (EDD)

6.      Explain to client the need to attend antenatal clinic and procedures involved

7.       Ask about the number of previous pregnancies and what happened

8.      Ask about present complaints

9.      Ask whether client has felt any foetal movement

10.    Ask about any known allergies

11.      Ask about any pre-existing conditions and medication

12.    Assist client and family to plan towards confinement

13.    Educate client on danger signs associated with pregnancy

14.    Ask about family support

15.    Express appreciation to client for her cooperation

16.    Record and report findings to officer in charge