Obs/Gyn: Postnatal Hx, Exam
- Past history, current pregnancy
- Labour: onset/duration, analgesia, fetal signs, delivery/infant
- Maternal postpartum history: lochia, pelvic pain, restored function
- Maternal postpartum examination: affect, vitals, general, chest, legs, abdomen
- Social support
<Mrs. || Miss || Ms.>
<34 year old>
who delivered her
days ago at
weeks gestation, a
<boy || girl>
<spontaneous vaginal || assisted vaginal || breech || Cesarean section>
<is || is planning>
<bottle || breast>
<both baby and mother are well>.
<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>.
First day of her LMP was
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
An ultrasound scan at
<confirmed her dates>.
Her pregnancy was
<uneventful, except for a .... at 35 weeks gestation>.
She is Rhesus
<positive || negative>
<is || is not>
labour began with
<painful uterine contractions ... minutes apart, increasing in duration and frequency>
<1:00 am on Tuesday morning>
<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
by which time her cervix had dilated to
She was admitted to the antenatal ward. She was examined by the
and her cervix was found to be effaced and cervix dilated to
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
She was given
<10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.
For anaglesia, she first tried
<Nitrous oxide by inhalation>,
but subsequently requested
<an epidural at 8:45am>
<gave adequate analgesic relief for the duration of labour>.
The liquor was
<clear throughout || green throughout || clear, then green>.
<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 ...>
The delivery was
<spontaneous vaginal || vaginal instrumental || breech || Cesarean section>
<a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches || no tears or episiotomy required>
condition at birth was
<normal, crying immediately at birth || ...>,
<was || was not>
present at the time of delivery.
<was admitted to the neonatal unit || went with her mother to the postnatal ward>.
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,
<getting less each day>.
Mrs. O'Connor has
<no pelvic pain || is experiencing some pelvic pain which she describes as ...>
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>,
<has voided her bladder || has not yet voided her bladder>.
with her baby.
[This is a more polite way to descibe that she is not experiencing any postpartum depression/psychosis.]
Her temperature is
Her pulse is
<80 bpm, regular rhythm, and normal character and volume>.
Her blood pressure is
<no signs of anemia || signs of anemia including...>.
Her chest is
<clear, with good air entry bilaterally, and no added sounds>.
Her respiratory rate is
<are || are no>
signs of DVTs, such as asymmetric: size, color, or temperature. There
<are || are no>
signs of superficial thrombophebitis.
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
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>,
<nontender || tender>.
If a Cesarean section was done:
The incision site appears to be
The incision is
the edges are
and there are
<stitches || stitches and steristrips>
<no discharge or other signs of infection>.
<no extreme abdominal distention>,
and bowels sounds are
<present and normal>.
<well, moving all four limbs, ...> :
If bottle feeding:
is bottle feeding, taking
<SMA || Cow and Gate || ...>,
per feed, feeding
hours, and is
<wetting her nappies [alternatively: if <3 days, can say "passing meconium and urine"]>.
If breast feeding:
is breast feeding
times a day
<and through the night>,
<on demand || by docking>,
with each feed lasting
<10 minutes, with 5 minutes per side>.
with her feed, and her nappies
<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:
<had || is scheduled for>
her BCG on
and her metabolic screen is on
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 ...>.
<has a partner at home who works as a ... || is self-supported socially>,
and is going home
<1 bedroom house>.
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.