Demographics and History


The age of the mother is an example of a characteristic that is associated with both medical risk(because pregnancy at the extremes of the reproductive age span can have specific physiological consequences) and psycho-social risk. Marital status of the mother may provide a possible indicator of support if she is single, separated, divorced, or has no significant other to assist throughout her pregnancy and postpartum. It will indicate whether there is a need to plan for child care for the baby and some occasional respite care for the mother.

Assessment of income and financial resources for pregnancy will allow the provider to assess the need for financial assistance through Medicaid, or other funding. All clients should be assessed for Medicaid eligibility via the Medicaid Presumptive Eligibility process. Education assessment is useful for at least two reasons. The client may need assistance to either continue schooling if an adolescent, or in pursuit of a G.E.D. if she dropped out of school. Education assessment can also offer insight into possible ability to comprehend information supplied by the provider. It is important to ascertain from the patient what her housing situation is: homeless, evicted, living in a shelter, etc.

Gynecological History

Menstrual history includes premenstrual syndrome, dysmenorrhea, fibroid tumors, irregular bleeding, abnormal Pap smears, pelvic surgeries or interventions; last normal menstrual period (LNMP), and Diethylstilbestrol (DES) exposure. The number of weeks that have elapsed between the first day of the LNMP (not the presumed time of conception) and the date of delivery is the means to calculate gestational age, regardless of whether the gestation results in a live birth or a fetal death.

Contraceptive History

Information should include whether this pregnancy was planned and is wanted, what contraception method was used, the current sexual relationship, is it monogamous, and if not the number of partners involved.

Past Obstetric History

This topic covers prior pregnancies, previous intrauterine growth retardation (IUGR), infant/pre-term birth, high parity, birth interval of less than two years, previous hemorrhage, stillborn or neonate death, sudden infant death syndrome (SIDS). Any of these would indicate greater risk factors for the client.

Medical/Surgical History

Ascertain whether the client has experienced any chronic diseases such as diabetes, hypertension, anemia, and what prescription or over the counter medications were or are being used. Gather information on infections such as hepatitis, toxoplasmosis, group B streptococcus infections, allergies. Trauma, surgical procedures, blood transfusions. Learn whether satisfactory resolution was achieved on any of these topics.

Genetics History

Is there a record of repeated spontaneous abortions, chromosomal and other congenital abnormalities, hemoglobinopathies such as sickle cell anemia. Has the client, spouse or family been exposed to radiation or other toxic substance exposure? Have there been multiple births? Is there a family history of chronic diseases (diabetes, hypertension, anemia, etc.)?

Life Style Behaviors

This section should assess the client's use of tobacco products, alcohol, illicit drugs, over the counter medications, prescription drugs, rest and sleep patterns, extremes of exercise or physical exertion, and dental care.

Employment History

Work, in general, is not associated with adverse pregnancy outcomes. Women should be screened early in pregnancy regarding strenuous occupational activity and advised to modify as indicated. If the work environment would place the pregnancy in jeopardy, for example, if the business of the company is chemicals, questions should be raise regarding the teratogenic nature of the chemicals, what degree of exposure the client receives, and what safety measures are provided. Additionally, is there a need to request a change of duties to lessen exposure.