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

G3—current


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

Meds:

Alls: latex/iodine too

ROS: done in HPI

PE:


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

HEENT—


Neck—thyromegaly?

Heart/Lungs—

CV­—

Breast—


Abd—gravid, soft, nontender

FHT’s—140’s

EFW—8#

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



Intact/Ruptured

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
Assessment:

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
O(bjective):

  1. Vital signs

  2. Physical Exam

FHT’s—external or FSE

*baseline—130’s

*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


P(lan):

  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.



SAMPLE POSTPARTUM PROGRESS NOTE

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

Normotensive

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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