(a) Last menstrual period (LMP) and menstrual history (for example,
last regular cycle and spotting).
(b) Contraceptive history (Were birth control pills used? Did the patient
become pregnant immediately after cessation of pills? How long after cessation of
(c) Reproductive history (for example, number of previous pregnancies
and their outcomes, complications).
Exposure or treatment for any sexually transmitted diseases
(e) Problems with the current pregnancy (for example, bleeding,
nausea, and headaches).
(4) Present medical condition of the patient (for example, hypertension,
diabetes, medications presently taking, and any drug allergies).
e. Physical examination. After a complete history is obtained, the patient is
prepared for a through physical examination.
Vital signs are taken to include:
(a) Temperature, pulse, respiration, and blood pressure.
(b) Fetal heart tones. Document if obtained with a doppler or
Evaluate height, normal weight, and present weight.
(3) Obtain urine specimen. This should be obtained before the patient
undresses for the pelvic examination.
(a) On the initial visit, a complete urinalysis is done.
(b) On subsequent visits, a urine specimen will be dipsticked for
albumin and glucose.
(c) Additional testing will be done only if there are indications of
toxemia of pregnancy or diabetes mellitus.
Prepare patient for a pelvic examination, if performed.