Obs/Gyn: Postnatal Hx, Exam

1. Introduction
2. Past history, current pregnancy
3. Labour: onset/duration, analgesia, fetal signs, delivery/infant
4. Maternal postpartum history: lochia, pelvic pain, restored function
5. Maternal postpartum examination: affect, vitals, general, chest, legs, abdomen
6. Baby
7. Contraception/parenting/PT
8. Social support
Introduction
This is
<Mrs. || Miss || Ms.>
<O'Connor>,
a
<34 year old>
<secretary>,
from
<Dublin>,
who delivered her
<first>
baby
<two>
days ago at
<40>
weeks gestation, a
<boy || girl>
named
<Clair>
by
<spontaneous vaginal || assisted vaginal || breech || Cesarean section>
delivery,
<is || is planning>
<bottle || breast>
feeding, and
<both baby and mother are well>.
Past history
<She is a longterm diabetic, which is successfully managed with insulin>.
<She had a PDA repair in 1969>.
<In her Obstetric history, her prior child had congenital deafness>.
<Her mother and 3 sisters all had at least one post-partum hemorrhage>.
<She smoked one pack a day since she was 16, but since finding out she was pregnant, she has
limited herself to one or two cigarettes per week>.
<Before her pregnancy she consumed 3 units of alcohol per week, but she has not taken any
alcohol since finding out she was pregnant>.
<She is not on any medications, and she has no allergies>.
Current pregnancy
First day of her LMP was
<November 20th>
and she is
<certain || uncertain>
of her dates, because
<she wrote it in her diary || remembers the time of conception>.
By Nagele's rule, her estimated date of delivery is
<August 27th>.
An ultrasound scan at
<13 weeks>
<confirmed her dates>.
Her pregnancy was
<uneventful, except for a .... at 35 weeks gestation>.
She is Rhesus
<positive || negative>
and
<is || is not>
Rubella immune.
Labour: onset/duration
<Mrs. O'Connor's>
labour began with
<painful uterine contractions ... minutes apart, increasing in duration and frequency>
at
<1:00 am on Tuesday morning>
followed by
<a show and spontaneous rupture of membrane || a show but no spontaneous rupture of
membrane || a spontaneous rupture of membrane || neither show nor spontaneous rupture of
membrane>.
She was admitted to hospital at
<8:45 am>
by which time her cervix had dilated to
<3 cm>.
She was admitted to the antenatal ward. She was examined by the
<midwife>
and her cervix was found to be effaced and cervix dilated to
<7cm>.
A diagnosis of labour was made, and she was sent to delivery.
The first stage lasted for
<2 hours [some hospitals specify labour as time from admission to labor unit] || 9 hours>,
the second stage lasted for
<20 minutes>.
She was given
<10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.
Labour: analgesia
For anaglesia, she first tried
<Nitrous oxide by inhalation>,
but subsequently requested
<an epidural at 8:45am>
which
<gave adequate analgesic relief for the duration of labour>.
Labour: fetal signs
The liquor was
<clear throughout || green throughout || clear, then green>.
Optionally:
<a cardiotocograph was connected during the labour, and intermittent auscultation was
performed>.
Electronic fetal monitoring
<was not performed || <was performed due to:
<prolonged labor || suspected small for dates || prematurity || APH>>.
Fetal blood sampling
<was not done || was done to look for ...>
Labour: delivery/infant
The delivery was
<spontaneous vaginal || vaginal instrumental || breech || Cesarean section>
with
<a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches || no tears or
episiotomy required>
at
<2:45pm>.
<Claire's>
condition at birth was
<normal, crying immediately at birth || ...>,
and weighed
<3 kg>.
A pediatrician
<was || was not>
present at the time of delivery.
<Claire>
<was admitted to the neonatal unit || went with her mother to the postnatal ward>.
Maternal history: lochia
Her lochia is currently
<red || brown || white>,
<is odourless || has a pungent odour>,
<has no clots || has some clots>,
<is less || is more>
than a period,
and is
<getting less each day>.
Maternal history: pelvic pain
Mrs. O'Connor has
<no pelvic pain || is experiencing some pelvic pain which she describes as ...>
Maternal history: restored function
Since returning from delivery, she is
<now ambulatory || not yet ambulatory>,
<has passed her bowels || has not yet passed her bowels>,
<has no flatus || is experiencing some flatus>,
and
<has voided her bladder || has not yet voided her bladder>.
Maternal examination: affect
<Mrs. O'Connor>
looks
<clinically well>
and appears
<happy>
with her baby.
[This is a more polite way to descibe that she is not experiencing any postpartum
depression/psychosis.]
Maternal examination: vitals
Her temperature is
<36.9 Celcius>.
Her pulse is
<80 bpm, regular rhythm, and normal character and volume>.
Her blood pressure is
<124/80>.
Maternal examination: general
She has
<no signs of anemia || signs of anemia including...>.
Maternal examination: chest
Her chest is
<clear, with good air entry bilaterally, and no added sounds>.
Her respiratory rate is
<18>.
Maternal examination: legs
There
<are || are no>
signs of DVTs, such as asymmetric: size, color, or temperature. There
<are || are no>
signs of superficial thrombophebitis.
Maternal examination: abdomen
On inspection of the abdomen, it is distended
<below || above>.
the umbilicus. It
<moves || does not move>
with respiration, and
<no scars are visible || there is a visible cesarean and episotomy scar that is...>.
On palpation of the abdomen, the fundus is
<2>
fingerwidths below the umbilicus.
<It is less than the expected 1 cm/day, possibly due to a full bladder as she has not voided in the
last 8 hours>.
The fundus is
<normal size and shape || ...>,
<mobile || immobile>,
<regular || irregular>,
<firm || soft>,
and
<nontender || tender>.
If a Cesarean section was done:
The incision site appears to be
<healing well>.
The incision is
<red>,
the edges are
<well opposed>,
and there are
<stitches || stitches and steristrips>
in place.
There is
<no discharge or other signs of infection>.
There is
<no extreme abdominal distention>,
and bowels sounds are
<present and normal>.
Baby
<Clair>
appears
<well, moving all four limbs, ...> :
If bottle feeding:
<Clair>
is bottle feeding, taking
<SMA || Cow and Gate || ...>,
<50 mL>
per feed, feeding
<well>
every
<4>
hours, and is
<wetting her nappies [alternatively: if <3 days, can say "passing meconium and urine"]>.
If breast feeding:
<Clair>
is breast feeding
<8>
times a day
<and through the night>,
feeding
<on demand || by docking>,
with each feed lasting
<10 minutes, with 5 minutes per side>.
<Clair>
<is satisfied>
with her feed, and her nappies
<are wet>.
<Mrs. O'Connor>
<feels || does not feel>
her breasts empty and swell,
<has no nipple concerns, and>
<is comfortable taking Claire on and off, as she went to a class>.
If nation's protocol is for BCG vaccination and/or Guthrie tests:
<Clair>
<had || is scheduled for>
her BCG on
<Tuesday>,
and her metabolic screen is on
<Wednesday>.
Contraception / parenting / PT
After pregancy, she
<will || will not>
<start on || go back on>
<the combing oral contraceptive pill in 4 weeks time [alternatively: starting on the day of her next
period] || ...>,
<as it has offered good protection in the past>.
<She will not not use the pill because she doesn't like it>.
<She has had attended parenting sessions [esp. important if young with first baby]>.
<She has an appointment booked with the physiotherapist on ...>.
Social support
She
<has a partner at home who works as a ... || is self-supported socially>,
and is going home
<today>
to her
<1 bedroom house>.
Optionally:
She will be taking iron and has booked an appointment with her
<GP || hospital>
in 6 weeks time and
<will || will not>
have a smear at that time.