Obs/Gyn: Postnatal Hx, Exam

Introduction
This is <Mrs. || Miss || Ms.> <O'Connor>, a <34 year old> <secretary>, from <Dublin>, who delivered her <first> baby <two> days ago at <40> weeks gestation, a <boy || girl> named <Clair> by <spontaneous vaginal || assisted vaginal || breech || Cesarean section> delivery, <is || is planning> <bottle || breast> feeding, and <both baby and mother are well>.

Current pregnancy
First day of her LMP was <November 20th> 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 <August 27th>. An ultrasound scan at <13 weeks> <confirmed her dates>. Her pregnancy was <uneventful, except for a .... at 35 weeks gestation>. She is Rhesus <positive || negative> and <is || is not> Rubella immune.

Labour: onset/duration
<Mrs. O'Connor's> labour began with <painful uterine contractions ... minutes apart, increasing in duration and frequency> at <1:00 am on Tuesday morning> followed by <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 <8:45 am> by which time her cervix had dilated to <3 cm>. She was admitted to the antenatal ward. She was examined by the <midwife> and her cervix was found to be effaced and cervix dilated to <7cm>. A diagnosis of labour was made, and she was sent to delivery.

Past history
<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>.

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 <20 minutes>. She was given <10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.

Labour: analgesia
For anaglesia, she first tried <Nitrous oxide by inhalation>, but subsequently requested <an epidural at 8:45am> which <gave adequate analgesic relief for the duration of labour>.

condition at birth was <normal, crying immediately at birth || ...>, and weighed <3 kg>. A pediatrician <was || was not> present at the time of delivery. <Claire> <was admitted to the neonatal unit || went with her mother to the postnatal ward>.

Maternal history: lochia

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, and is <getting less each day>.

Labour: fetal signs

The liquor was <clear throughout || green throughout || clear, then green>. Optionally: <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 ...>

Maternal history: pelvic pain

Mrs. O'Connor has <no pelvic pain || is experiencing some pelvic pain which she describes as ...>

Maternal history: restored function

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>, and <has voided her bladder || has not yet voided her bladder>.

Labour: delivery/infant
The delivery was <spontaneous vaginal || vaginal instrumental || breech || Cesarean section> with <a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches || no tears or episiotomy required> at <2:45pm>. <Claire's>

Maternal examination: affect

<Mrs. O'Connor> looks <clinically well> and appears <happy>

with her baby. [This is a more polite way to descibe that she is not experiencing any postpartum depression/psychosis.]

Maternal examination: vitals

Her temperature is <36.9 Celcius>. Her pulse is <80 bpm, regular rhythm, and normal character and volume>. Her blood pressure is <124/80>.

On palpation of the abdomen, the fundus is <2> 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>, and <nontender || tender>. If a Cesarean section was done: The incision site appears to be <healing well>. The incision is <red>, the edges are <well opposed>, and there are <stitches || stitches and steristrips> in place. There is <no discharge or other signs of infection>. There is <no extreme abdominal distention>, and bowels sounds are <present and normal>.

Maternal examination: general

She has <no signs of anemia || signs of anemia including...>.

Maternal examination: chest

Her chest is <clear, with good air entry bilaterally, and no added sounds>. Her respiratory rate is <18>.

Maternal examination: legs

There <are || are no> signs of DVTs, such as asymmetric: size, color, or temperature. There <are || are no> signs of superficial thrombophebitis.

Baby
<Clair> appears <well, moving all four limbs, ...> : If bottle feeding: <Clair> is bottle feeding, taking <SMA || Cow and Gate || ...>, <50 mL> per feed, feeding <well> every <4> hours, and is

Maternal examination: abdomen

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...>.

<wetting her nappies [alternatively: if <3 days, can say "passing meconium and urine"]>. If breast feeding: <Clair> is breast feeding <8> times a day <and through the night>, feeding <on demand || by docking>, with each feed lasting <10 minutes, with 5 minutes per side>. <Clair> <is satisfied> with her feed, and her nappies <are wet>. <Mrs. O'Connor> <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: <Clair> <had || is scheduled for> her BCG on <Tuesday>, and her metabolic screen is on <Wednesday>.

Social support
She <has a partner at home who works as a ... || is self-supported socially>, and is going home <today> to her <1 bedroom house>. Optionally: 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.

Contraception / parenting / PT
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 ...>.