Examples of other Notes for OB/Gyn
MS H&P
S: Pt is a 20 y.o G4P1112 (Grava 1, Para 1 (term), 1 (preterm), 1 (abortions), 2 (living)) at 39+1 weeks by 10 week
ultrasound c/w LMP (consistent with last menstrual period) who presents to L&D (labor and delivery) in labor.
Pregnancy has been uncomplicated. + FM (Fetal movement), denies LOF (loss of fluid), VB (vaginal bleeding). Ctx
(contractions) q 4 minutes
ROS: Among other things, be sure to ask about headaches, visual changes, abdominal pain (especially RUQ pain),
worsening non dependent edema, change in urinary habits
PMH: asthma, does not take meds now
PSH: Tonsillectomy as a child
Meds: PNV (prenatal vitamin)
Allergies: Penicillin -> anaphylaxis
POBHX: G1 - 35 week SVD (spontaneous vaginal delivery) of VMI (viable male infant) 5 lbs, 2 oz
G2 - 8 week, SpAB (spontaneous abortion)
G3 - 40 week, LTCS (low transverse Cesarean section) for breech
G4 - Current
PGYNHx: No hx of STDs,
+ hx of abnormal PAP with LEEP, but all PAPs normal since then
Menarche at 13 years of age w regular periods q 28 dys lasting 4-5 days, no menorrhagia
SH: tobacco (1.5 PPD), denies use of alcohol or illicit drugs
FH: No history of birth defects
No history of bleeding or clotting disorders
No history of multiple gestations
DM - grandmother
Emphysema - paternal grandfather
PE Temp, BP, HR, RR
Labs: A+ (blood type), antibody -, rubella immune, RPR NR (non reactive), HBSag negative, HIV negative, GBS (group
B strep) positive, 1 hour glucola 63, GC and Chlamydia negative; CBC (complete blood count)...
A/P: 20 yo G4P1112 at 39+1 weeks who presents in labor currently 4 cm dilated, 90% effaced and -1 station
1) Admit to L&D
2) Epidural when desired
3) Clindamycin for +GBS and penicillin allergy
4) AROM (artificial rupture of membranes) after 4 hours of antibiotics
MS Triage Note
S: pt is a 20 y.o. G2P1 at 37+1 weeks by 8 week ultrasound that is consistent w LMP, presents to L&D with complaints of
ctxs. No LOF, VB. + FM
O: Temp, BP, HR, RR, T
Abd: soft, gravid, NT (non tender)
Ext: 1+ edema bilaterally, NT
FHT (fetal heart tones): 140, moderate variability
TOCO (tocometer): ctxs q 9 minutes
Cervix: 1/40/-3 (dilation/effacement/station) (per RN)
A/P: Pt is a 20 y.o G2P1 at 37+1 weeks who presents for rule out labor
1) Will have patient walk for 1 hour after getting reactive FHT, then recheck cervix
MS Delivery Note
SVD (spontaneous vaginal delivery) of VMI (viable male infant) with APGARs 8, 9 over 2nd degree midline laceration.
Head delivered atraumatically, mouth and nose bulb suctioned at perineum, loose nuchal cord x 1 easily reduced,
shoulders and body delivered without delay or force. Cord clamped and cut and infant handed to awaiting RN. Cord
gases obtained. Spontaneous delivery of placenta with 3 VC (vessel cord) intact. No cervical, vaginal vault
or periurethral lacerations. 2nd degree midline laceration repaired with 3.0 vicryl suture.
EBL (estimated blood loss): 300 cc
Anesthesia: Epidural
Dr. (attending) present
MS Operative Note
Pre-operative diagnosis: IUP (intrauterine pregnancy) at term, breech presentation
Post-operative diagnosis: same
Procedure: primary LTCS via Pfannensteil incision
Surgeon:
Assistant:
Anesthesia: spinal with duramorph
Findings: VFI (viable female infant), frank breech, APGARs 8,9, 3VC, intact placenta, normal ovaries
EBL (estimated blood loss): 800 cc
Fluids: 1800 cc crystalloid
UOP (urine output): 200 cc, clear
Packs/Drains: foley
Complications: none
Disposition: Patient and infant stable to PACU (post anesthesia care unit)
MS Post-op Check
S: Pt resting comfortably. Pain well-controlled. Minimal nausea. No vomiting.
O: Temp, BP, HR, RR
Gen: NAD, A&O x3
Abd: soft, appropriately tender, ND, absent BS
Inc: Dressing clean and intact
Ext: No edema, non-tender, SCDs in place
A/P: 47 y.o. WF POD #0 TAH/BSO
1) Hemodynamically stable, CBC in am
2) continue routine post-op care
MS HROB (High risk obstetrics/Maternal fetal medicine)
S: No complaints. Denies VB, LOF, ctx. +FM
O: Temp, BP, HR, RR
Gen: NAD, A&O x3
Abd: soft, gravid, non tender
Ext: No edema, non-tender, DTRs (deep tendon reflexes) 2+ bilaterally, SCDs in place
TOCO: No contractions
FHT: 135, moderate variability, reactive
A/P: 32 y.o. G1P0 at 30+1 weeks with PTL (preterm labor)
1) s/p BMZ (status post betamethasone)
2) Continue bed rest with BRP (bathroom privileges)
3) GBS negative
MS PPD (post partum day) #1
S: Pain?
Lochia?
Ambulating?
Breast/bottle feeding?
Pain meds used?.
Diet?.
Voiding?
Plan for contraception?
O: Temp
BP
HR
RR
Gen:
Lungs:
C/V:
Abd: soft? NT/ND? Fundus? (Should be firm, 2 finger breadths below umbilicus)
Ext: edema? Palpable cords?
DTRs:
Labs?
A/P: 19 y.o. PPD # __ SVD
1) MWB (maternal well being) - doing well, Rh + or - , RI (rubella immune)? Hgb?
2) FWB (fetal well being) – male/female infant, well?, breast/bottle feeding?, desires circumcision?
3) PPBC (post partum birth control)
4) D/C (discharge) planning
MS POD (post operative day) #1 from C/S (can be used for other Gyn surgeries, omitting lochia/fundus)
S:
Pain
Pain meds used?
Lochia?
nausea or vomiting?
Flatus?
Diet?
Ambulating?
Contraception?
O: Temp
BP
HR
RR
Gen:
Lungs:
C/V:
Abd: soft?
Appropriately tender?
Fundus?
BS?
Inc (incision): C/D/I (clean/dry/intact)?
Staples/sutures?
Ext: tenderness?
Edema?
SCDs (serial compression devices) in place?
Labs?
A/P: 55 y.o. WF POD #1 C/S
1) Hemodynamically stable, CBC?
2) advance diet to clears, await flatus for regular diet
3) ambulate with assistance, continue incentive spirometry
HELLP syndrome
Hemolysis
Elevated LFTs
Low Platelets
Risk factors for Preterm Labor - MAPPS
Multiple gestations
Abdominal surgery during pregnancy
Previous Preterm labor
Previous Preterm delivery
Surgery of the cervix
Contraindications to tocolytics –
CHAMPS
Chorioamnionitis
Hemorrhage
Abruption
Maturity of fetus
Preeclampsia/eclampsia
Severe IUGR
Risk factors for shoulder dystocia –
MOMS on L&D
Maternal
Obesity
Macrosomia
Second stage prolonged
Late (post-date pregnancy)
Diabetes
Causes of fetal baseline tachycardia
FFAASTT Heart
Fetal infection
Fever
Arrhythia of fetus
Anemia of fetus
Sympathomimetics
Tacycardia of mother
Thyrotoxicosis of mother
Hypoxia
Causes of postpartum hemorrhage - 4T's
Tone diminished
- Uterine Atony represents 70% Postpartum hemorrhage
Tissue
- Retained Placenta
- Placenta accreta
Trauma
- Uterine Inversion
- Uterine Rupture
- Cervical Laceration
- Vaginal hematoma
Thrombin
- Coagulopathy