Obstetrics & Gynecology
MSC 10 5580
1 University of New Mexico
Albuquerque NM 87131-0001
Phone - (505) 272-4051
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2011-2012 Annual Report
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
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
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.