Hpi: This is a 19 year old G3 P1 Ab1

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Sample L&D Admit Note: Don’t forget date and TIME
Chief Complaint: Contractions/ Ruptured membranes/ Elevated BP in clinic, ECT.
HPI: This is a 19 year old G3 P1 Ab1 at 39 weeks gestation by LMP / Sonogram who presents for contractions / ruptured membranes / elevated BP in clinic etc. Upon evaluation, she was noted to be 4 cm dilated / to have grossly ruptured membranes / to have BP of 140/90. She was then admitted to L&D for management. She reports (include all of the following whether positive or negative. You may also include other complaints if relative to chief complaint) +/- fetal movement, contractions, ruptured membranes, vaginal bleeding, headache, right upper abdominal pain, changes in vision.

She desires future fertility or She desires permanent sterilization. (Does she want a tubal ligation?)
Dating Criteria:

(This is based on supporting or disagreeing with LMP)

1. LMP (first day of LMP) 10/16/03 -- EDC+

2. First sonogram 1/16/04 @ 12 weeks – agrees (or redates)

3. First exam 12/16/03 @* weeks—agrees

4. Serial Exams @ 18-36 weeks; 2/04—5/04 -- agree

OB History: review each pregnancy

G1—1990 JPS SVD 36 wks 6 lbs PIH

G2-- 1995 JPS C/S 28 wks twins 2-3 lbs PPROM


GYN History:

Menarche-__Regular cyclic

Menses-__STD’s—Herpes, Gonorrhea, Chlamydia, Syphilis, HIV

GYN surgeries

Abnormal paps and treatment

Family Medical History:

Include parents and siblings; other pertinent

Social Hx: Tobacco, ETOH, IVDA

PMH: especially HTN, IDDM, Asthma


Alls: latex/iodine too

ROS: done in HPI


Vitals—use the most current; include Ht and Wt, (RR important for MG!)






Abd—gravid, soft, nontender



Pelvis-- Cervix—4/75/-2 Cephalic/Breech


Ext—describe Edema DTR’s

Current Labs: Ones ordered since admission

Other Diagnostic Tests: Include sono if done this admission
Prenatal Labs: Clinic labs—document all including HIV, GBS, GTT, Include prenatal sonos

19 yo G3 at 39 weeks gestation

Previous C/S x 1

Mild Gestatonal Hypertension/ Gestational diabetes etc.

Active Labor

Desire Repeat C/S or natural labor etc

Desires Future Fertility

Consents signed

Plan: “CPC” and “Expectant Management” mean nothing. What do you expect to happen?

Admit to L&D

MgSO4 for seizure prophylaxis

Fetal Monitoring

Anesthesia preop

Proceed with repeat C/S

Activity and nutrition as indicated

Ongoing labor notes:

S(ubjective): Pt reports…-increasing contractions / good pain relief/ no complications

  1. Vital signs

  2. Physical Exam

FHT’s—external or FSE


*Variability (when internal)—minimal / average / marked

*Accels—yes or no

*Decels—describe if present

* IUPC—4 ctx per 10 min 210 MIVU (or toco)

Cervix—8/90/-1 (not always done)

DTR’s—(+1--=4) /4 or absent

(If on MgSO)

Labs—If any new labs or test since H& P. Mg levels

A (ssesment) :

1. (39 week gestation in active labor)

2. Mild gestational hypertension

No evidence of Mg toxicity / Last Mg level

3. Progressing well

4. Good pain relief from ____

5. Reassuring FHT’s

6. Adequate contraction pattern


  1. Continue pitocin

  2. Continue MgSO4

  3. Check Mg level

  4. Anticipate vaginal delivery

  5. Change in activity

Sample Delivery Note

This is a 19 year old G2 now P2 who was admitted for active labor / post-term induction / preeclampsia etc. She progressed spontaneously / with pitocin augmentation to the second stage of labor. She pushed for ___hours/min. She delivered a viable / nonviable male / female infant, ROA / LOP etc. over an intact perineum / midline episiotomy. The mouth and nares were bulb suctioned on the perineum. A nuchal cord x 1 / 2 etc was / was not identified. The nuchal cord was reduced prior to deliver of the shoulders and body. Or- The infant was delivered throught the nuchal cord. Apgar scores were 9 and 9. the placenta delivered spontaneously / by manual extraction, intact / fragmented, with a 3 / 2 vessel cord. Inspection revealed no perineal, sidewall or cervical lacerations / (or describe laceration or extensions). The episiotomy / lacerations were repaired with 2-0 and 3-0 Chromic / Monocryl etc. The uterus was firm / atonic with no active bleeding / bleeding requiring 1 amp hemabate IM. The repair was done under epidural / local anesthesia. EBL was 500 mL (Use 500 mL unless obviously more. Placenta and umbilical artery blood gas were /were not sent. There were no complications during the procedure. Mom and baby cuddling/nursing/bonding following delivery.


Start with a brief summary of L & D:

This is a 18 yo G2 now P2 postpartum day #2 SVD with mild preeclampsia & pp hemorrhage EBL -1000mL s/p MgSO4. Hct36—28. BP’s WNL.

Review ALL PRENATAL LABS & OTHER LABS ORDERED THIS ADMISSION: Blood type & Rh, HBsAg, Rubella, Sickle, Pap (Does she need F/U), GC, Chlamydia, PIH labs and/or other if done this admit.

S: Patient reports…list relevant complaints. Be sure to ask about bleeding, ability to ambulate, pain control, breast/bottle feeding, birth control if desired. Flatus and BM for postop patients.
O: Vital signs—100.4 now 98.6 BP 100/64 HR 80 RR12

PE—Physical EXAM, Don’t forget:

  • Document Breast Exam—mass/engorgement/±erythema/tender?

  • Fundus—firm nontender/tender

  • C/S incision—clean/dry/ erythema

  • Perineum—normal / abnormal lochia. Episiotomy intact?

Current labs—1) AP—PP Hct if drop ≥10 OR PP Hct ≤ 25% ie. Pt not dizzy ambulating without difficulty, fl/u Hct to show it’s not still falling. 2) Blood Type and Rh. 3) HIV from this admit not prenatal..

Any other tests ordered document here.

A: 18 yo G2 now P2 ppd #2

Mild preeeclampsia s/p MgSO4

Aferbrile doing well


Desires depot

Breast feeding/problems/concerns

Normal postpartum exam

B: Plan: Education/discharge education (briefly state)

Discharge or plans for

Return for fever, pain, bleeding

Birth control plans

Follow up plans

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