PUERPERIUM HISTORY

1-PERSONAL DATA: -Name -Age -Nationality -Occupation

-Marital Status (Since when)
-Date of admission (ER/OPD)
-Para……+……
-Any known illness (Duration + Medication)

2-SHE IS NOW . . . . . . DAYS (HOURS) POST DELIVERY (SVD – C/S) OF A BOY/GIRL AT . . . . . . WEEKS GA

3-ADMITTED . . . . . . DAYS (HOURS) AGO:

-For elective c/s
OR
-Complaining of abdominal pain (labor-like / menstrual cramp-like) & . . .

4-HISTORY OF PRESENTING ILLNESS:

-Pain analysis

-Associated symptoms

-Show (Blood stained mucus plug):

-When -Nature
-Amount -Color -Odor

-Ruptured membranes (large amount of watery fluid):

-When -Nature -Amount
-Color -Odor -Time between rupture & delivery

-When she came to the hospital:

-What Happened? -Given what?
-Examination & Vitals -Cervical dilatation?

5-LABOR & DELIVERY:

-Type (SVD - c/s - Instrumental)
-Episiotomy
-Duration
-Anesthesia / Analgesia
-Augmentation or induction
-Maternal complications (Shoulder dystocia – Bleeding – Other)
-Delivery of placenta (time - Mode [Spontaneous / Manual]
-Blood transfusion
-Baby: -Cry -Sex -Birth weight
-Complications -Anomalies
6-PEURPERIUM & HOSPITAL COURSE:
a- How is she today?
-Bleeding -Pain
-Fever & chills -Moving & walking (a.k.a. Up & about)
-Constipation (passed stool or flatus)
-Urine retention (Passed urine)

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 b-Lochia: -Color -Odor -Getting more or less
-Pruritis -Discharge -Clots
-Number of pads used -Symptoms of anemia

c-Episiotomy: -Pain -Bleeding -Discharge

-Redness -Swelling

d-Breast: -Pain -Enlargement -Tenderness

-Redness -Lactation -Lump -Fever
-Abdominal pain during lactation (a.k.a. After pain)
e-Abdominal pain

f-Lower limb pain or swelling

g-Urinary: -Loin pain -Dysuria -Urine color

-Supra pubic pain -Incontinence

h-CVS & Resp: -Sore throat -Dysponea -Cough -Chest pain

i-GIT – CNS – Heam – Musculoskeletal systems

7-HISTORY OF THIS PREGNANCY

8-PAST OBSTETRIC HISTORY

9-GYNECOLOGICAL HISTORY

10-PAST MEDICAL & SURGICAL HISTORY

11-MEDICATION HISTORY & ALLERGIES

12-SOCIAL & FAMILY HISTORY

13-SUMMARY
-Name -Age -Para…… + ……
-Presenting illness
-…… days (Hours) post delivery of boy/girl at GA …… weeks
-Important findings (Depend on the case)
-Known illness

Note: Regarding the incomplete titles (e.g. Past obstetric history . . .),
Please check my Medicine & Obstetric History sheets.

DONE BY:
Mohammed Gogandy
House Officer – 2007 / 2008
がんばって ください 。。。
Version - 2

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