Sunday, October 6, 2024

HISTORY TAKING OF A PREGNANT WOMAN

Table of Contents

REQUIREMENTS #

  1. Maternal and Child Health Record Book (Manual or Electronic)
  2. Ball pen
  3. Comfortable chairs
  4. Conducive room or an enclosed area

STEPS #

  1. Establish rapport (Refer steps)
  2. Explain procedure (Refer steps)
  3. Provide privacy and ensure client assume desired position
  4. Ask about client well-being
  5. Take personal history (name, age, town, house address)
  6. Take social history (occupation, marital status, next of kin etc.)
  7. Take medical/surgical history (past and present)
  8. Ask about family history of known diseases such as hypertension, diabetes. Mental disorders, etc.
  9. Take menstrual history: Age at menarche, cycle, duration of blood flow, LMP etc.
  10. Take contraceptive history (type used, duration and side effects)
  11. Take obstetric history (past and present)
  12. Take lactation history (exclusive breast feeding and duration)
  13. Explain to client the need to attend Antenatal Clinic and procedures involved
  14. Ask about the number of previous pregnancies and what happened in each case
  15. Ask for intervals between pregnancies and any ill health
  16. Ask about nutritional history (eating pattern, diet, food taboos and allergies)
  17. Enquire about number of tetanol injections received in lifetime
  18. Ask about family support
  19. Express appreciation to client for her cooperation
  20. Record and report findings to Officer in-charge