T E R M I N O LO G Y

G (gravidity) 3 = total number of pregnancies, including normal and abnormal intrauterine pregnancies, abortions, ectopic pregnancies, and hydatidiform moles. (Remember, if patient was pregnant with twins, G = 1.)
P (parity) 3 = number of deliveries > 500 g or > 20 weeks gestation, stillborn
(dead) or alive. (Remember, if patient was pregnant with twins, P = 1.)
Ab (abortus) 0 = number of pregnancies that were lost before the 20th
gestational week or in which the fetus weighs < 500 g.
LC (living children) 3 = number of successful pregnancy outcomes. (Remember, if patient was pregnant with twins, LC = 2.)
Or use the TPAL system if it is used at your medical school:
T = number of Term deliveries (3)
P = number of Preterm deliveries (0)
A = number of Abortions (0)
L = number of Living children (3)

MS3 H&P
Date
Time
Estimated gestational age (EGA): 385/7 weeks
Last menstrual period (LMP): First day of LMP
Estimated date of connement: Due date (specify how it was determined)
by LMP or by ____ wk US
Chief complaint (CC): Uterine contractions (UCs) q 7 min since 0100
History of present illness (HPI): 25 yo Hispanic female, G3P2002, 385/7
weeks GA, dated by LMP (10/13/09) and consistent with US at 10 weeks
GA, who presented to L&D with CC of uterine contractions q 7 min. She
reports that fetal movement is present, denies leakage of uid, vaginal
bleeding, headaches, visual changes, or right upper quadrant pain. Prenatal care (PNC) at Monteore Hospital (12 visits, rst visit at 7 wks GA),
uterine size = to dates, prenatal BP range 100126/6483. Problem list
includes h/o + group B Streptococcus (GBS) and a +PPD with subsequent
negative chest x-ray in 5/06. Pt admitted in early active labor with a vaginal
exam (VE) 4/90/2.
Past Obstetric History
1) 02 NSVD @ term, girl, wt 3700 g, St. Josephs Hospital
No complications during pregnancy, delivery, and puerperium
No developmental problems in childhood
2) 04 NSVD @ term, boy, wt 3900 g, St. Josephs Hospital
Postpartum hemorrhage, atonic uterus, syntometrine given and hemorrhage resolved
No developmental problems in childhood
Past Gynecological History
13 yo/28 days/regular (age at rst menstrual cycle/how often/regular or irregular)
No signicant history of PID, intermenstrual bleeding, dyspareunia, postcoital bleed
Last pap smear: 3/4/09normal, no h/o abnormal Pap smear
Last mammogram:
Contraception: None
Blood group: O, anti D prophylaxis given at 30 weeks GA
Allergies: NKDA
Medications: PNV, Fe
Past Medical Hx: H/o asthma (asymptomatic 7 yrs), UTI 1 @ 30 wks s/p
Macrobid 100 mg 7 d, neg PPD with subsequent neg CXR (5/06)
Surgical Hx: Negative
Social Hx: Denies h/o alcohol, smoking, drug abuse. Feels safe at home
Family Hx: MotherDM II, fatherHTN
ROS: Bilateral low back pain. Denies chest pain, shortness of breath, nausea, vomiting, fever, chills
PE
General appearance: Alert and oriented (A&O), no acute distress (NAD)
Vital signs: T, BP, P, R
HEENT: No scleral icterus, pale conjunctiva
Neck: Thyroid midline, no masses, no lymphadenopathy (LAD)

Lungs: CTA bilaterally

Back: No CVA tenderness
Heart: II/VI SEM
Breasts: No masses, symmetric
Abdomen: Gravid, nontender
Fundal height: 36 cm
Estimated fetal weight (EFW): 3500 g by Leopolds
Presentation: Vertex
Extremities: Mild lower extremity edema, nonpitting, 2+ DTRs
Pelvis: Adequate
Sterile speculum exam (SSE)? (Nitrazine?, Ferning?, Pooling?); membranes intact
Sterile Vaginal Exam (SVE): 4 cm/90%/2 (dilatation/effacement/station)
US (L&D): Vertex presentation conrmed, anterior placenta, AFI = 13.2
Fetal monitor: Baseline FHR = 150, accelerations present, no decelerations, moderate variability. Toco = UCs q 5 min
Assessment
25 yo G3P2002 @ 385/7 weeks GA presented with regular painful contractions.
1. Early active labor.
2. Group B strep +
3. H/o + PPD with subsequent CXR 5/06
4. H/o UTI @ 30 wks GA, s/p Rxresolved
5. H/o asthmastable 7 yrs, no meds
Plan
1.
2.
3.
4.
5.

Admit to L&D
NPO except ice chips
H&H, RPR, HIV, HBsAg and hold clot tube
D5 LR @ 125 cc/hr
Penicillin 5 million units IV load, then 2.5 million units IV q 4 hr (for
GBS)
6. External fetal monitors (EFMs)
7. Epidural when patient desires

SA M P L E D E L I V E RY N OT E

Always date, time, and sign your notes.

25 yo G3 now P3003 s/p spontaneous vaginal delivery (SVD) of viable male
infant over a second-degree perineal laceration @ 12:35 P.M. Infant was bulb
suctioned on the perineum. Nuchal cord 1 was reduced. The infant was delivered with gentle downward traction. The cord was doubly clamped and cut;
the infant was handed to the awaiting nurse. Cord blood and arterial pH was
obtained. The placenta was delivered spontaneously, intact, with 3-vessel
cord. No vaginal or cervical lacerations were noted. The second-degree laceration was repaired with 3-0 vicryl in layers using local anesthesia. Rectal exam
was with in normal limits. EBL = 450 cc. Apgars 8 & 9, wt 3654 g. Mom and
baby stable.

SA M P L E P O ST PA RT U M N OT E

S:
O:

A:
P:

Pt ambulating, voiding, tolerating a regular diet. Denies preeclampsia

symptoms
Tmax: 99.1 Tcurrent: 98.6 BP:128/70 (117130/5876) HR: 86 (76100)
RR: 18
Heart: RRR, no murmurs/rubs/gallops
Lungs: CTA bilaterally
Breasts: Nonengorged, colostrum expressed bilaterally
Fundus: Firm, mildly tender to palpation, 1 ngerbreadth below umbilicus
Lochia: Moderate amount, rubra
Perineum: Intact, no edema
Extremities: No edema, nontender
Postpartum Hgb: 9.7
VDRL: NR, HIV neg, HBsAG neg
S/p SVD, PP day # 1progressing well, afebrile, stable
Continue postpartum care

SA M P L E P O ST-N S VD D I S C HAR G E O R D E R S

1.
2.
3.
4.

D/c pt home
Pelvic rest 6 weeks
Postpartum check in 46 weeks
D/c meds:
a. FeSO4 325 mg, 1 tab PO TID, #90 (For Hgb < 10; opinions vary on
when to give Iron supplementation postpartum)
b. Colace 100 mg, 1 tab PO BID PRN no bowel movement, #60 (A side
effect of Iron supplementation is constipation)
c. Ibuprofen 600 mg, 1 tab PO q 4 hours, PRN pain, #60

SA M P L E P O ST C E SAR E AN S E C T I O N N OT E

S:
O:

10

Pt c/o abdominal pain, passing atus, minimal ambulation. Denies

preeclampsia symptoms. Foley in place.
Tmax: 99.1 Tcurrent: 98.6 BP: 128/70 (117130/5876) HR: 86 (76100)
RR: 18
I&O (urinary intake and output): Last 8 hr = 750/695
Heart: RRR without murmurs
Lungs: CTA bilaterally
Breasts: Nonengorged, no colostrum expressed
Fundus: Firm, tender to palpation, 1 ngerbreadth above umbilicus;
normal abdominal bowel sounds (NABS)
Incision: Without erythema/edema; C/D/I (clean/dry/intact)
Lochia: Scant, rubra

A:
P:

Extremities: 1 + pitting edema bilateral LEs, nontender

Postpartum Hgb: 11
VDRL: NR, HIV neg, HBsAG neg
S/p primary low-transverse c/s for arrest of descent, POD # 1 afebrile,
+ atus, stable
1. D/c Foley
2. Strict I&OCall HO if UO < 120 cc/4 hr
3. Clear liquid diet
4. Heplock IV once patient tolerates clears
5. Ambulate qid
6. Incentive spirometry 10 hr
7. Tylenol #3, 2 tabs PO q 4 hr PRN pain

SA M P L E D I S C H A R G E O R D E R S P O ST C E SA R E AN S E C T I O N

1.
2.
3.
4.

D/c patient home

Pelvic rest 4 weeks
Incision check in 1 week
Discharge meds:
a. Tylenol #3, 2 tabs PO q 4 hr PRN pain, #30
b. Ibuprofen 600 mg, 1 tab PO q 4 hr, PRN pain, #60
c. Colace 100 mg, 1 tab PO bid, #60

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N OT E S

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