OBSTETRICS CLERKING NOTES

RN: During pregnancy, there is history of:

NAME: __ fever
AGE: G___ P_______ __ UTI
__ URTI/Cough
LMP: __Unsure of date __ GBS +ve
EDD/REDD: __ Irrecgular menses __ Vaginal candidiasis
POA/POG: __ on hormonal contraceptives __ Vaginal bleeding
__ breastfeeding __ Anemia
__ Hypertension
CHIEF COMPLAINT __ GDM: on diet // on medication // on insulin

__ Leaking liquor: Time_____ /Amount______/Color____ When: ___________ weeks of POA

__ Show Seek treatment: Yes // No
__ Contraction pain Medication given: _______________________
__ Reduce fetal movements Symptoms resolved: Yes // No
__ Anemia
__ Vaginal bleeding Other issues:
__ Maternal pyrexia

Others:

==========================================
LATEST CHECKUP: _________ weeks of POA
ANTENATAL HISTORY - Parameters: _____ weeks
__ equal/appropriate to date
Planned/unplanned pregnancy __ Small gestational age/small to date
First noticed pregnancy: __ Large gestational age/large to date
__ Vomitting Does she done: - Singleton // Multiple fetus
__ headache __ self UPT - Lie: Longitudinal // transverse // oblique
__ Lethargy __ confirmed at clinic - Presentation: Cephalic // breech
__ missed period: ______ days/weeks Head palpable at ______
- Amniotic Fluid Index: _________ cm
Booking history __ adequate/appropriate
When: _______________ Where: _________________ __ Inadequate
Dating scan: Antropometric: - Estimated fetal weight: ________ kg
__ done during booking - Weight _____kg - Placenta seen: upper // lower __________
__ at ____ POG/POA at ______ - Height ______ cm
Blood pressure: - BMI ________kg/m2
_______________ mmHg PAST OBSTETRIC HISTORY
Hb level: _________ g/dL Blood group: ________
Urine result: ___________________________________ YEAR M/F SVD/CS Wt Hx of?
1.
Screening:
__ VDRL (syphilis) __ HIV 2.
__ Hep B Tetanus injection:
__ Hep C ___ Done ___ Not done 3.
MOGTT: indicated/not indicated at booking 4.
Indication: _______________________________
Done at ________ weeks of POA - _______ mmol/L 5.
At ________ weeks of POA - _______ mmol/L
Any history of:
__ Preterm delivery
__ GDM
__ Pregnancy induced hypertension/Preeclampsia
Miscarriage history: PAST MEDICAL HISTORY
- At ______ weeks POA ___ DM
- Miscarriage confirmed by ultrasound ___ HTN
- Spontaneous delivery? YES // NO ___ IHD/CVS
- ERPOC? YES // NO ___ Asthma
- Others: ___ Renal disease
___ Thyroid disease

On medications: ______________________________
==============================================
Intrauterine death history: Dose:
- At _______ weeks POA
- Reasons: Compliance: Good // Poor
__ Loss of Fetal Heartbeat
__ Fetal anomaly Any complications history:
__ Trauma
Others: _____________________
- Methods of delivery:

GYNAECOLOGY HISTORY PAST SURGICAL HISTORY

Menarche at _________y/o What? When? Any complications?

Menses – Regular // irregular since then
____ days menses with _____ days heavy flow
_____ days per cycle
_____ Dysmenorrhea : Analgesia // not on any analgsia

Any history of:

___ Inter-menstrual bleeding
___ Heavy menstrual bleeding
___ Dyspareunia
Other history of menses problem:
FAMILY HISTORY
**family tree + any illness in family + any known
============================================== death
Contraception method used:
__ COCP: _______________________
__ Depot injection
__ Implanon
__ Intrauterine device

When? ___________ For ____________ months/years

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Pap-smear history
___ Done at _________________ when? ____________
___ Not done
SOCIAL HISTORY
Currently working _____________________________
Husband occupation ___________________________
Age of marriage: __________
Monthly income: RM _______________
Education level: __________________________
Distance to KK from home: _________ mins
High risk behaviour:
__ smoking __ premarital sex: have child? YES / NO
__ alcohol __ STD screening