Obstetric history and the prenatal record

Assisting in obstetrics

Obstetrics

Pregnancy can be the most exciting and terrifying experience for a patient, especially the first time around. As a medical assistant working in obstetrics, it is important to be able to reassure the patient while remaining professional. The next section discusses the examinations and procedures related to prenatal and postpartum care.

Assisting with the prenatal examination

During the prenatal examination, the medical assistant is responsible for setting up the prenatal and obtaining the necessary health history information during the initial prenatal visit. There will also be lab work to be completed and ordered. For subsequent visits, a less extensive history will be taken, as well as the routine tests described later.

Prenatal record

At the first prenatal examination, an extensive health history will be taken. This history can help to identify any risk factors for the patient. Frequently, the first prenatal visit is the first comprehensive physical examination that the patient has had in a long time. The health history can point out pregnancy-related risk factors and overall health-related risk factors that can also be addressed. The following information should be collected when creating the prenatal record for a patient:

• Demographic information
• Menstrual history
• Obstetric history
• Medical and surgical history
• Family and social history

Menstrual history

The prenatal record should include the first day of the last menstrual period. This is used to determine the estimated date of delivery (EDD). It is also important to know the normal cycle length for the patient and if this last menstrual period was “normal.” The medical assistant should also ask if the patient was using contraception when she became pregnant. If she was, the method being used should be documented.

Obstetric history

The provider will need to have a complete history of previous pregnancies. This will help to determine any risk factors for the current pregnancy. The following information should be included in the obstetric history:

• Dates of deliveries
• Types of deliveries (vaginal or cesarean); if cesarean, the type of incision should be noted
• Birth weight and gestational age of previous infants
• Complications of previous pregnancies

There are some specific terms related to an obstetric history that you should be familiar with.

A prenatal record includes documenting the gravida, para, and abortion information. As a medical assistant, you should be able to determine those numbers after obtaining the obstetric history from a patient. It is important to remember that gravida and para refer to the number of pregnancies, not the number of babies. A twin pregnancy is considered just one pregnancy. If this was the first pregnancy for the patient and the pregnancy went to term (38 to 40 weeks), she would be gravida: 1 and para: 1.

Gravida is the number of pregnancies, regardless of the number of weeks the patient was pregnant. If a patient has three children and had a spontaneous abortion at 8 weeks, her gravida number would be 4.

Obstetric history terms

Term	Definition
Gravida	Number of pregnancies
Primigravida	A woman who is pregnant for the first time
Multigravida	A woman who has been pregnant two or more times
Nulligravida	A woman who has never been pregnant
Para	Number of pregnancies that have gone to the age of fetal viability (20 weeks’ gestation)
Primipara	A woman who has carried one pregnancy to the age of fetal viability
Multipara	A woman who has carried two or more pregnancies to the age of fetal viability
Nullipara	A woman who has not carried a pregnancy to the age of fetal viability
Abortion	Termination of a pregnancy before the fetal age of viability. Miscarriage, spontaneous, elective
Spontaneous abortion	Natural death of an embryo or fetus before the fetal age of viability; also called a miscarriage
Therapeutic or elective abortion	A procedure for the planned termination of a pregnancy
Stillbirth	Fetal death after 20 weeks’ gestation; also called intrauterine fetal death (IUFD)

Para is the number of pregnancies that have gone to the age of viability (20 weeks). In the above scenario, the patient’s para number would be 3, as the spontaneous abortion happened before 20 weeks.

The abortion information refers to the termination of a pregnancy before the age of viability (20 weeks). The abortion could be spontaneous, therapeutic, or elective. All would be included in this number. Some providers want this further defined as to which category of abortion. In our above scenario, the patient’s abortion number would be 1.

Medical and surgical history

There are medical and surgical conditions that could affect a patient’s current pregnancy. Common chronic conditions, such as diabetes, hypertension, asthma, and mitral valves prolapse, should be included in the prenatal record. The management of these conditions could change with pregnancy. Less common conditions, such as thyroid disorders, systemic lupus erythematosus, and bleeding disorders, can also affect the patient and the fetus. To help both, the provider needs to be aware of these conditions and the treatment being followed.

Certain infections can affect a pregnancy. A history of certain STIs can put the patient at risk for complications. Pelvic inflammatory disease (PID) can cause scarring of the fallopian tubes, which increases the risk of an ectopic pregnancy. Genital herpes and other infections can be transmitted to the newborn during delivery. If the provider is aware of those conditions, plans can be made to protect both the mother and the baby.

If the patient has had any type of abdominal surgical procedure, it could affect the pregnancy or delivery. If there is a history of a prior ectopic pregnancy, this would be a risk factor for another one. If there is a history of a uterine puncture or any uterine incision, the patient and provider will need to talk about a possible cesarean section.

Family and social history

Many conditions have a genetic component. Obtaining an accurate family history can help determine if the patient or the infant is at risk. With this knowledge, the patient and the provider can be prepared. Additional testing may be included during the prenatal period for a patient with certain factors in the family history. Conditions that could be of concern include the following:

• Diabetes
• Hypertension
• Heart disease
• Kidney disease
• Seizures
• Depression
• Thyroid disease
• Preeclampsia
• Autoimmune disorders (e.g. Lupus, rheumatoid arthritis)

A family history of genetic disorders should also be documented in the patient’s family history. These disorders can include the following:

• Down syndrome
• Neural tube defects ( spina bifida , meningocele , anencephaly )
• Hemophilia
• Sickle cell anemia
• Cystic fibrosis (CF)
• Phenylketonuria (PKU)

Other family history information that should be noted would include a history of twins in the family, food allergies, and a family history of recurrent miscarriages or stillbirths.

The social history includes tobacco, alcohol, and recreational drug use. This information can be used for patient education as it relates to pregnancy. Nutrition and exercise are an important part of pregnancy. Finding out if the pregnant patient follows a particular diet, such as vegan or vegetarian, will provide the opportunity for patient education regarding nutritional needs during pregnancy. Employment is also part of a social history. This can point out any occupational duties that could be affected by a pregnancy, such as working with certain chemicals or physical activities that should not be done when pregnant.

Collecting all of the components discussed previously is a great start to completing the patient’s prenatal record, in addition to supplying the provider with the information needed to provide excellent care during the patient’s pregnancy.

The prenatal record will continue to be updated throughout the pregnancy. Clinical data will be added at each prenatal visit. The medical assistant will also be checking with the patient to see if there have been any changes or additions to the initial demographic and historical information.