Professional Documents
Culture Documents
HISTORY TAKING
Madam_______, a ___ y/o Para_ lady who had delivered a baby boy/girl via _ (SVD/
Assisted vaginal delivery/ ELLSCS in the view of _/ EMLSCS in the view of _) 12 hours
ago, was initially admitted to the hospital on_ due to_
HOPI:
(a) Pre-delivery
1. Spontaneous onset of labor?
2. Induced onset of labor?
3. Asymptomatic. Admitted for elective LSCS
4. Symptoms of obstetrics emergency such as severe PV bleeding, conditions that can
lead to fetal distress...
(b) Labor
-Mode of labor and its detail.
-When? Regional or GA given? What was done? Intraops finding if C-Sec? Estimated
blood loss?
(c) Postnatal
(i) maternal:
General
-Tolerate orally?
-Ability to ambulate? (risk of postpartum VTE/ patients with symphysis pubis diastasis
have difficulty in walking/ Obstetric palsy lead to LL weakness/ severe pain after
operation leads to immobility)
-TEDS given?
GI
-constipation due to dehydration of fear of defecation due to 3 rd or 4th degree perineal
tear, hemorrhoids, anal fissure
- risk of anal incontinence - hard stool can disrupt the repaired 3 rd or 4th degree
perineal tear repair)
-Able to pass flatus if post-ops? Paralytic ileus
Renal
-Urination (urinary retention due to postpartum increase in diuresis, spinal or epidural
analgesia-took 8 hours for bladder to regain its sensation, neuropraxia of lumbosacral
trunk during descend of fetal presenting part, fear of urination due to vulvovaginal
laceration, hematoma or periurethral edema) *urinary retention can lead to UTI,
hypocontractile bladder, hydroureter and hydronephrosis*
Repro
-Lochia (Rubra, alba, serous) *normally lochia resolves within 14 days postpartum.
Persistent lochia rubra is caused by delayed uterine involution due to retained product
of conception or infection.
-secondary PPH (think of retained product of conception & infection like endometritis)
-Breast feeding? Breast tenderness, engorgement, cracked nipple or nipple fissure
Antenatal hx
-
LMP?
How the patient found out to be pregnant? Planned pregnancy?
Any confirmatory test? EDD?
Signs and symptoms? Morning sickness? Miss period?
Booking visit where and with whom?
Checkup? Blood test result, ABO and Rhesus Factor, VDRL, HIV, Hep B, MGTT
GDM/PIH/anemia?
1st trimester
2nd trimester: prenatal diagnosis? Quickening? Ultrasound scan? Findings at the
clinic
- 3rd trimester: findings at the antenatal clinic? Assessment of the fetal well being?
Gynaecological history
Madam ______ had her menarche at the age of __ y/o, regular with ____ days between
cycles. Each cycle last for ____ days. She uses _____ pads per day, with the pad
(halfly/fully) soaked each time. Blood clots? Dysmenorrhoea?
Obstetrics history
1. This is the _____ th time Madam _______ being pregnant. Delivered how many
children? Any miscarriage? She delivered her first child in (year), who is a baby
(boy/girl) via (SVD/C-sec), weighing ______kg without any antenatal, internatal and
postnatal problems. He/she is nw ____ y/o and healthy. GDM/PIH during that
pregnancy? Breastfeeding?
- if deliver via C-sec, hav to take note whether there was any complication (PPH)
2. Contraception- method (IUCD? Injectable contraception which is assumed to be
depot Provera? OCP?) Suitability? Reasons if not suitable?
3. PAP Smear done? Results? (Recommended schedule: after the first sexual
intercourse, 2 years consecutively, then if results ok, once in 3 years until 65y/o)
Systemic review
PHYSICAL EXAMINATION
(a) Maternal
Madam ____ is comfortable and lying on the couch. Vital signs: BP, PP, RR, T. There was
no pallor, jaundice, cyanosis, clubbing, pedal edema and varicose veins.
1. Hands: palmar erythema, pulse
2. Eyes: pallor, jaundice
3. Mouth: angular stomatitis, glossitis?
4. Neck: mass felt? Lymphadenopathy? JVP if indicated
5. Breasts: swollen and redness? Tenderness? Blood discharge? Cracked nipple
showing wrong technique of breastfeeding?
6. CVS
7. Respi
8. Abdomen
- inspection: upon inspection of the abdomen, the abdomen is mildly distended with
evidence of recent pregnancy such as linea nigra? Striae gravidarum? Striae
albicans? Fetal movement visible? There is a dry/ blood stained/ pus stained
dressing over the surgical scar.
* if the scar can be examined, comment: the surgical scar at the suprapubic region
measured _____ cm, well healed with no keloid formation.
- Palpation:
- a) SFH: ____ cm - to check for proper uterine involution. Postpartum uterus is abt 18
week size, 4cm below the umbilicus and 12cm above the upper border of pubic
symphysis. Minimal 1cm of uterine involutio per day.Uterus should not be palpable
after 10-14 days postpartum
b) palpation: the abdomen is soft and non tender with no uterine irritability.
Consistency of uterus is firm or soft (soft - uterine atony). Uterine scar tenderness
present?
C) Auscultation: fbowel sound - paralytic ileus