DISCLAIMER: THIS IS ONLY AS A GUIDE YA!!
Include the relevant/important info according to the case @Zainab Abang 2022
POA-based on last menstrual (1St day of Lmp)
Example for Obstetrics Clerking POG-based on Scan
Mdm Aya, 40yo, G7P5+1 at 32w POA PROBLEM LIST: -
any issues !
LMP: 1) AMA
EDD: 2) maternal obesity
REDD (if any): 3) GDM on DC
4) Poor social support
HOPI:
p/w leaking liquor 2 hours prior to presentation to
PAC.
Sudden onset, soaked pad, clear, non foul smelling,
persistent until now.
Otherwise good FM, no show/contraction/fever.
ANC:
1st trim (1 -
12 wks] MOTHER BABY
SF SOD, Reg menses
-
UPT + at ??w Dating scan
ate - Nuchal translucency
-
-
* Booking at (when), (where): test .
1st booking ↓ Hx • - Sx of early pregnancy
I
V
usually
• BP, PR
1-12 wKs
PES - -
• Ht, wt → BMI ?? kg/m2 = interpret
S
Blood
• Bloods (3 – Hb, BG, infective amore
-
IX
screening)
• Urine (2 – prot/glyc)
• MGTT glucose I
2nd trim (12-24 WKs)
-
Detailed scan
/
Check for fethl anomaly (Nuchal translucency)
NIPT (Noninvasive prenatal testing) test
• MGTT – indication, result, interpret
- .
• Follow up how often
3rd trim (24-birth (37-40) wks)
• Total weight gain – interpret (approp/exc)
-
Serial growth scan -
check for A A
LAC LAF1
• Latest Hb LHC Placenta
·
Fetal movement count
① Past Obs Hx: ② Past Medical Hx:
Year/Gestation/MOD/BW/Gender/ANC/Intra/post
Vacuum – ask indication, cx
CS – indication, cx, whether allowed VBAC
① Gynae Hx: ② Past Surg Hx
Menarc/cycle/duration,HMB/Dysmenorrhea/IMB/PCB
Pap smear
Contraception
⑫
③ Fam hx Drugs:
③ Social Hx Allergies:
DISCLAIMER: THIS IS ONLY AS A GUIDE YA!! Include the relevant/important info according to the case @Zainab Abang 2022
Intro
I
Mdm Aya, 40yo, G7P5+1 at 32w POA
With underlying:
1) Advanced maternal age
I for
2) Maternal obesity leakingin howlong days
3) GDM on DC
g
Currently presents with leaking liquor. (presenting complaint ya – whatever the pt say, so do NOT put
diagnosis/technical term here)
Summary:
Mdm Aya, 40yo, G7P5+1 at 32w POA
With underlying:
1) Advanced maternal age
2) Maternal obesity
3) GDM on DC
Currently presents with leaking liquor, with no other labour sx, blablabla.
a w HMB
syntomatic anaemia
Examinations:
for 3 months etc
DDx:
Eye Nongyse
DISCLAIMER: THIS IS ONLY AS A GUIDE YA!! Include the relevant/important info according to the case @Zainab Abang 2022
Management: *FOR EACH PART OF MX – LOOK
Now (for current presentation): BACK AT YOUR PROBLEM LIST AND
Admit
Do Ix: CTG, urine (if suspect UTI), insert branula, MX EACH ISSUE*
take FBC, CRP, GSH, Do ultrasound for …..
EES
Dexa look at problem list
CTG
Pad charting
Monitor sx/sg of chorio which includes ….
FBC, CRP – if normal repeat twice a week NEW Mode of delivery
Time of
Monitor DXT
CTG OD/BD abdopain delivery
Weekly AFI
2weekly fetal growth
Delivery: Postnatal:
If stops leaking, monitor as outpatient ST (in ward)
Deliver at term Enquire: ambulation, tolerating orally, establish BF
Admit for IOL Ex: pallor, VS, abdo, pad, perineal inspection, LL
Branula, FBC, GSH Ix: if any (?rpt FBC)
CTG Mx: pad/VS charting, medication
Bishop score – if favorable: ARM, Pitocin
If not favourable, IOL with prostin
CTG repeat 1h and 5h post prostin.
Review 6hrs post insertion, maximum of 2 doses/d
Intrapartum: LT (discharge):
Monitor labour progress using partogram Perineal hygiene
Continuous CTG with hourly tracing Discharge advise & medication
If HVS C&S noted GBS positive, cover with IV Contraception
antibiotics. Pap smear
Mx of GDM in labour Breastfeeding
Active 3rd stage mx (grandmultip) Repeat MGTT
Optimise health
Future pregnancy (if planning to do so)
- Pre-pregnancy counselling (if have U/L
medical problem)
- Early booking next pregnancy
- Folic acid 3m prior to conception
Post menopausal for 10 etc
yrs
