MS3 H&P Date Time imated gestational age (EGA): 385/, weeks Last menstrual period (LMP): First day of LMP Estimated date of confinement: Duc 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, 38°, 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 fluid, vaginal bleeding, headaches, visual changes, or right upper quadrant pain, Pre~ natal care (PNC) at Montefiore Hospital (12 visits, frst visit at 7 wks GA), uterine size = to dates, prenatal BP range 100-126/64~83. 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 A good way to elicit 1) 02 NSVD @ term, girl, wt 3700 g, St. Joseph’s Hospital information about No complications during pregnancy, delivery, and puerperium ‘omplicaions in previous No developmental problems in childhood" preguances sf ack fhe 2) 04 NSVD @ term, boy, wt 3900 g, St. Joseph's Hospital baby went home fromthe Postpartum hemorthage, atonic uterus, syntomettine given and hemor- rhage resolved hospital with mom No developmental problems in childhood Past Gynecological History 13 yo/28 days/regular (age at first menstrual cycle/how often/regular or ir- regular) NO significant history of PID, intermenstrual bleeding, dyspareunia, post- coital bleed Last pap smear: 3/4/09—normal, 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: Ho asthma (asymptomatic x7 yrs), UTI x I @ 30 wks sip Macrobid 100 mg x7 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: Mother—DM I, father—HTN ROS: Bilateral low back pain. Denies chest pain, shortness of breath, nau- sea, vomiting, fever, chills PE General appearance: Alert and oriented (A&-O), no acute distress (NAD) Vital signs: T, BP, P, R HEENT: No scleral ieterus, pale conjunctiva Neck: Thyroid midline, no masses, no lymphadenopath (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 Leopold's Presentation: Vertex Extremities: Mild lower extremity edema, nonpitting, 2+ DTRs Pelvis: Adequate Sterile speculum exam (SSE)? (Nitraine?, Ferning?, Pooling?), mem. anes intact Sterile Vaginal Exam (SVE): 4 em/90%-2 (dilatation/effacementtstation) US (L&D): Vertex presentation confirmed, anterior placenta, AFI = 13.2 Fetal monitor: Bascline FHR = 150, accelerations present, no decelera- tions, moderate variability. Toco = UCs q 5 min Assessment 25 yo G3P2002 @ 38°/, weeks GA presented with regular painful contrae- tions - Early active labor. . Group B strep + 5: Ho + PPD with subsequent — CXR 5/06 | Hlo UTI @ 30 wks GA, s/p Rx—resolved . Hilo asthma—stable x 7 yrs, no meds vane Plan |. Admit to L&D . NPO except ice chips H&H, RPR, HIV, HBsAg and hold clot tube D5LR@ 125 ccfhr Penicillin 5 million units IV load, then 2.5 million units IV q 4 hr (for GBS) External fetal monitors (EFMs) Epidural when patient desires Always date, ime, and sign your notes 25 yo G3 now P3008 s/p spontaneous vaginal delivery (SVD) of viable male infant over a second-degree perineal laceration @ 12:35 4. Infant was bulb suctioned on the perineum. Nuchal cord x 1 was reduced. ‘The infant was de- livered with gentle downward traction. ‘The cord was doubly clamped and eut; the infant was handed to the awaiting nurse. Cord blood and arterial pH was obiained. The placenta was delivered spontaneously, intact, with 3.vessel cord. No vaginal or cervieal lacerations were noted. The second-degree lacer- ation was repaited with 3-0 vieryl in layers using local anesthesia. Rectal exam ‘was with in normal limits. EBL = 450 ec. Apgars 8 & 9, wt 3654 g, Mom and baby stable m = a ey FS = ey a5 Fs Ss s = = S: Pt ambulating, voiding, tolerating a regular dict. Denies preeclampsia mptoms Tot 99.1 Tae 98.6. BP.128(70 (117-130158-76) HR: 86 (76-100) RRB Heart: RRR, no murmurs/subsigallops Lungs: CTA bilaterally Breasts: Nonengorged, colostrum expressed bilateral Fundus: Firm, mildly tender to palpation, 1 fingerbreadth below umbilicus Lochia: Moderate amount, rubra Perineum: Intact, no edema Extremities: No edema, nontender Postpartum Hgh: 9.7 VDRL: NR, HIV neg, HBsAG neg Sip SVD, PP day # 1—progressing well, afebrile, stable Continue postpartum care 2 me PUM nee Le 1. Die pthome 2. Pelvic rest x 6 weeks 3. Postpartum check in 46 weeks 4. Dic meds a, FeSO, 325 mg, 1 tab PO TID, #90 (For Hgb < 10; opinions vary on. when to give [ron supplementation postpartum) . Colace 100 mg, 1 tab PO BID PRN no bowel movement, #60 (A side effect of Iron supplementation is constipation) ¢. Ibuprofen 600 mg, 1 tab PO q 4 hours, PRN pain, #60 Pee S: Pt clo abdominal pain, passing fiatus, minimal ambulation. Denies preeclampsia symptoms. Foley in place. O: Tyee 99.1 Tape 98.6 BP: 128/70 (117-130/58-76) HR: 86 (76-100) RRE18 IGO (urinary intake and output): Last 8 hr = 750/695 Heart: RRR without murmurs Lungs: CUA bilaterally Breasts: Nonengorged, no colostrum expressed Fundus: Firm, tender to palpation, | fingerbreadth above umbilicus; normal abdominal bowel sounds (NABS) Incision: Without erythema/edema; C/D/I (clean/dry/intact) Lochia: Scant, rubra