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Postnatal

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

Neurology: Sensory and motor disturbance of LL due to Obstetric palsy? Postpartum


eclampsia fits?
Cardiology: SOB, orthopnea, PND in the case of postpartum cardiomyopathy
Respi: SOB or chest pain due to PE, productive cough + fever due to Pneumonia (GA
leads to poor repi muscle and atelectasis-foci of infection) or mandleson syndrome
Infection: Peuperial pyrexia, ssx of sepsis?
(ii) Fetal
- Baby boy/ girl, weight Kg?
-Apgar score, baby cries
-Pass urine? Bowel?
-Sent to NICU? Reason?
*Hep B immunization and vit K will be given. Umbilical cord blood was taken to test
G6PD, thyroid function test and Coombs test if indicated

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

Past medical history


Drug and Allergy
Family history (DM/HPT)
Social history
-Family planning..completed family?
-Discuss abt contraception. Permanent or reversible?

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

(b) Neonatal examination


1. Equipment required for this station:
-Neonatal stethoscope
-Opthalmoscope
-Oxygen saturation monitor/pulse oximeter
2. Introduce yourself to mum and clarify her, and babys identity. Explain what you would like to
do, i.e. full examination of her new baby(s) and gain her consent. Congratulate her on the birth as
this will put her at ease and help gain your trust. New mums are protective of their babies so trust
and rapport is essential.
3. Whilst washing your hands you could ask mum to strip her baby down to its nappy. Ensure you
have a changing mat to do the examination on.
4. Start by asking mum a few questions:
How was the birth?
Good to know as forcep deliveries can cause facial bruising, c-sections can occasionally cut the
babys skin. Babys born by c-section are usually more mucusy too.
Did your baby need any help after birth with breathing?
i.e. did the midwives or paediatric doctors have to give oxygen/rescue breaths.
How are you feeding your baby? Breast or bottle?
If breast feeding ask her
How is it going/baby latching ok, etc?
If bottle feeding ask
Which milk are you giving your baby/is baby taking bottles ok, etc?
Dont criticise if mum has not opted to breast feed, this is an individual decision.
Are there any conditions that run in you or dads family e.g. congenital heart problems?
Has anyone in your family (especially females) had problems with their hips at birth?
Female babies are more likely to have clicky or dislocated hips due to the hormones that are in
mums body during pregnancy, these are the hormones which help to open up mums pelvis prior to
and during birth.
Has your baby passed its sticky black stool yet?
Parents often dont know the term meconium

*Measurement of baby weight, head circumference and chest circumference*


5. Start by observing the baby. Does it look and behave normally, i.e. colour e.g. jaundice,
activity and posture. Is there any obvious bruising or marks from birth. Are there any other marks
such as strawberry naevus, stork marks or Mongolian blue spot (congenital dermal melanocytosis).
Remember to turn the baby over and inspect its back too.
6. With the baby lying on its back feel the fontanelle gently with your hand. It should be nice and
soft, a tense/bulging or sunken fontanelle can suggest the baby is unwell.
7. Using both your hands gently feel the babys bones checking they are symmetrical on both sides.
Face, around ears, clavicles (these can be injured during birth if shoulder dystocia occurs), both
arms (e.g. Erbs palsy) down to legs and feet. Open up the babys hand and look at the palm for
normal palmar creases, count the fingers on each hand. Look at the feet, is there any signs of a
sandal gap or talipes and count the toes on each foot.
8. If the baby has its eyes open at this point check for the red reflex using your opthalmoscope. An
absent reflex could suggest congenital cataracts.
9. Auscultate the babys heart using a neonatal/paediatric stethoscope. The normal rate is 120-150
so you will have to listen much more carefully for any murmurs as there is less time between
heartbeats to hear them. If you do pick up any murmurs assess whether it radiates anywhere.
10. Ausculate the lung fields. The normal respiratory rate is 30-60 in newborns. Are there any extra
sounds e.g. grunting or stridor.
11. Palpate the abdomen and check the umbilical stump/clamp to ensure no signs of infection.
12. Turn the baby over and check down its spine and between buttock cheeks for the sacral dimple.
13. At this point undo the babys nappy. Look for any obvious genital abnormalities. If its a male
infant you should check the scrotum to see if the testicles have descended. If not you may be able to
palpate them in the spermatic cord and gently bring them down yourself. Check the patency of the
anus at this point too.
14. Test the babys hips. This is done by two techniques, Ortolani and Barlow tests. Essentially cup
the babys hips in the palm of your hand and gently abduct the hips, this should be smooth with no
clicks. Next move your hands to the front of the baby and with their knees flexed push gently
downwards into the bed, again this should be smooth with no clunks.
15. At this point redo the nappy and again wash your hands. With your hands freshly washed you
now want to assess inside the babys mouth. Use your little finger to feel the palate of the mouth.
Look to see if there is a tongue tie.
16. Again wash your hands. Attach the pulse/oxygen monitor to the babys foot. Remember if a
baby is sleeping or crying the heartrate may be higher or lower than the normal range.
17. There are a number of primitive reflexes present in newborns which you should elicit. Moro,
grasp and sucking.
Thank mum, offer to dress the baby, although she will usually wish to do this herself. Answer any

questions she may have.


Again wash your hands and report your findings, if any, to the examiner, or doctor if on a ward.
Should you notice any abnormalities you may wish to suggest how to investigate these further.
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