INITIAL VISIT:

Partner name: ***

Pregnancy complications: ***
Pregnancy test positive on ***
LMP: ***
EDD: ***
PMHx: ***
Family History: ***
Past Surgical History: ***
Social History: ***
Medications: ***
Allergies: ***
Domestic violence: ***
5 P’s screening tool: (1 yes requires further investigation)
- Did your parents have problem with alcohol or drug use? ***
- Do any of your friends have problem with alcohol or drug use? ***
- Does your partner have problem with alcohol or drug use? ***
- Before you were pregnant did you have any problem with alcohol or drug use? ***
- In the past month did you drink beer, wine or liquor or other drugs? ***
If high suspicion for drug use, assess for opioid use disorder
- Have you used any opioids, narcotics or pain medications in the last year? ***
- Were they prescribed or unprescribed? ***
- Have you used any other drugs or unprescribed medication in the last year? ***
If positive answers, pt will need referral protocol to link with services and MAT if indicated
Menstrual History:
- Menarche ***
- Period (duration) ***
- Regularity ***
- Tampons/Pads number per day ***
- PAP smear (last time result, Hx of past abnormal result) ***
OB History:
- Pregnancies: ***
- Full term: ***
- Preterm: ***
- Multiple gestations: ***
- Miscarriages: ***
- Terminations: ***
- Ectopic: ***
- Living: ***
OB outcomes:
 - **/***
- GA: ***
- Weight: ***
- Sex: ***
- Labor: spontaneous/induction ***
- Length of labor: ***
- Type of delivery: ***
o C-section indication: ***
- Analgesia: ***
- Feeding: ***
o Formula reason: ***
- Pregnancy complications: ***
- Delivery complications: ***

LABS
Blood type: ***
Rh Status: ***
- Rhogam ***
Rubella status: ***
Tetanus status: *** (Tdap @27 weeks)

- First trimester (0-13w):

o CBC: ***
o HIV: ***
o RPR: ***
o Hep B: ***
o Hep C ***
o Chlamydia ***
o Gonorrhea: ***
- Second trimester: (14-26w)
o QUAD screen: ***
- Third trimester (27-40w)
o 1h GTT: ***
o CBC: ***
o HIV: ***
o RPR: ***
o GBS: ***
US HISTORY:
- ***
- ***
- ***

PLAN

-1st visit: Type and screen, Rh, CBC, Rubella, varicella, UA & culture, PAP, HIV, RPR, Hep B, Hep C,
Chlamydia, Gonorrhea

-6-12w: US for dating (***), MFM referral if needed

- 15-18w: Quad screen (***), DM screening (***)

- 20w: Fetal survey (***), prenatal classes (***), breastfeeding education (***)

- 24 to 28w: 1h GTT (***), CBC (***), Rhogam (***), , Tdap (***), Education: Contraception
(***), anesthesia (***), OB procedures (***), symptoms of labor (***)

- 32w: NST/AFI/growth US (***) -Education: breastfeeding (***), circumcision (***), HIV (***),
RPR (***), Chlamydia (***), Gonorrhea (***)

-35-26w: GBS (***), fetal position (***), HSV prophylaxis (***)

OB Visit:
Patient is a ***YO G***P*** at ***/7 weeks EGA dated by LMP and confirmed by 1st trimester US with an
EDD of ***. She is here for a routine prenatal visit. Denies any complaints or concerns at this time.
Complications during this pregnancy: ***
Chronic problems: ***

ROS:
Denies nausea, vomiting, diarrhea, constipation.
Denies headache, visual disturbances, LE swelling.
Denies dysuria, urgency or increased frequency.
Denies LOF, vaginal discharge and vaginal bleeding or abdominal pain.
Fetal movement: Y/N.

PE:
Vitals: BP: HR: T: R:
CV: RRR, S1/S2 no murmurs.
CHEST: Lungs CTA B/L, vesicular breath sounds.
ABD: Gravid, non-tender, non-distended, BSx4 quadrants, no CVA tenderness, no RUQ
tenderness, No hepatomegaly, no epigastric tenderness. Uterine height: ***
 EXT: No edema.
BACK: no back pain.
Cervical exam: Deferred ( cm/ %/ station).
FHR: ***

Labs: Blood type: (+/-), Ab (+/-), RPR , rubella, GC/Chlamydia, GBS status, Hepatitis, HIV. CBC: Hgb -
UA: Protein, leukocytes, ketones, glucose, bacteria. QUAD screen:, CF screen:
Pain management plan: ***
Feeding plan:
- Formula reason: ***
Contraception plan: ***

Plan:
1) PNV, calcium supplementation for Hx of pre-eclampsia (1g/d)
Initial visit:

-Type and screen, Rh, CBC, Rubella, varicella, UA & culture, PAP, HIV, RPR, Hep B, Hep C, Chlamydia,
Gonorrhea

11-14 weeks

-dating US

-pelvic exam if fetal heart tones are not heard via ultrasound

-offer iron supplementation for patients with anemia

15-20 weeks

-anatomic survey ultrasound at 20 weeks

-offer screening test for aneuploidy

-evaluate signs of preterm labor

-offered prenatal classes

-breastfeeding education provided

24-28 weeks

-screening for gestational diabetes

-discuss normal fetal movement (kick count)

-discuss prenatal classes

-discuss postpartum contraception

-discuss anesthesia

-discuss OB procedures

-symptoms of preterm labor

27-36 weeks

-Tdap

-CBC, repeat type and screen, Rhogam if needed

32-34 weeks

-NST/AFI/growth US

-education about breastfeeding

-education about circumcision

-HIV, RPR, Chlamydia and gonorrhea

36 weeks

-determine fetal position

-group B streptococcus screen

-start herpes prophylaxis in women with a history of genital herpes

-education about labor

38 weeks

-review labor education

-discuss contraception postpartum

>41 weeks

-baseline unknown stress test, ultrasound, biophysical profile

-discuss labor induction after 41 weeks