Department of Obstetrics & Gynecology
Helping Hand for Students on Obstetrics
Standard questions to ask patients seen on OB triage
- Are you having contractions?
When did they start?
How far apart are they?
- Did you break your bag of water?
Was the fluid clear?
- Is the baby moving? (>20weeks)
Are you doing kick counts? (Has the baby moved 8 times in 2 hours today? (>28 weeks)
- Any vaginal bleeding? (significant is like a period, more than a pad)
Pre-eclampsia questions (patients with elevated BP’s)
- Headaches? Before pregnancy? How often?
- Swelling of hands or face that does not go away?
- Pain in RUQ?
- Any changes in vision – spots, flashing lights?
Document on every triage sheet
- By last menstrual period or US or both (use your wheel to determine weeks)
may be used.
Term Premature And Live
Sample note: Triage Note
24yo G6P4 at 36 1/7 by LMP and an 6 week U/S c/o ctx q 5” since 2 am. No LOF (loss of fluid), no VB (vaginal bleeding), + FM (fetal movement), no dysuria,
[no non-dependent edema, no HA (headache), no visual changes].
FHT’s: 130’s, reactive, no decelerations
Discharge instructions – patients
TOCO’s: q 2-4”
SVE (sterile vaginal exam): 3(dilation)/50% (effacement)/high (station)
and or SSE (sterile speculum exam): +pooling, +nitrazine, +fern, +valsalva
(under instructions on triage sheet)
Sample delivery note
- FKC stressed, labor precautions given
- Keep next clinic appointment on (give date)
Stage I: ______yo G_ P_ at _______weeks admitted for (active labor, SROM, R/O pre-eclampsia, etc). Brief synopsis of labor course. She progressed to complete in ______hours. (Comment on antibiotics, GBS status if relevant, use of pitocin or MgSO4, whether labor was induced, augmented and if patient AROM (artificial rupture of membranes)
Stage II: Pt pushed for _______hrs or minutes to deliver a (viable, nonviable, vigorous) male/female infant (wt______g, Agars ___________ 1 __________ 5 over (intact perineum, second degree laceration). Nose and mouth (bulb, wall) suctioned on perineum. Shoulders delivered easily (if dystocia, list maneuvers). Nuchal cord? Cord clamped and cut and baby handed to RN or peds. (if forceps or vacuum delivery, resident should write the delivery note).
Stage III: Placenta delivered spontaneously and intact or w/gentle manual traction. Inspection revealed no lacerations of perineum, vagina or cervix (describe lacs/extension of episiotomy if present; describe repair and suture type, e.g. “in sterile fashion with 3-0 vicryl”). Good hemostasis with fundal massage and 20U pitocin IV (other meds if needed). EBL ________cc. Mother stable to RR, infant stable to NBN.
Sample operative note for cesarean section
Standard questions to ask postpartum patients
- Pre-op diagnosis:
- Intrauterine pregnancy at term
- Arrest of descent/dilatation
- Post-op diagnosis: same
- Procedure: Low transverse cesarean section (and bilateral tubal ligation)
- Anesthesia : Spinal
- Surgeons: Primary surgeon (usually the second year resident), 1st assist (usually the Chief Resident), any medical students in attendance ( last names only for all of these)
- EBL (estimated blood loss): _______
- Fluids in: _________
- Urine output __________
- Findings: _______gram female infant with Apgars of ____and _____. Normal uterus, tubes and ovaries
- Complications: ______
- Passing gas (flatus), BM
- Urinating without difficulty
- Fever, chills
- Pain under control with meds
- Eating regular foods
- Breast or bottle feeding
- Type of Birth Control
- OCP or Depo-Provera available at hospital
- PPTL or IUD at Postpartum Check
LTCS (low transverse cesarean section ) on POD #1
- D/C Foley
- Remove bandage