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?
When?
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)
Dysuria?

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

Due Date

By last menstrual period or US or both (use your wheel to determine weeks)

TPAL may be used.
Texas Power And Light
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
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

Discharge instructions – patients (under instructions on triage sheet)

FKC stressed, labor precautions given
Keep next clinic appointment on (give date)

Sample delivery note

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

Pre-op diagnosis:
- Intrauterine pregnancy at term
- Arrest of descent/dilatation
- Chorioamnionitis
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)
Attending:
EBL (estimated blood loss): _______
Fluids in: _________
Urine output __________
Findings: _______gram female infant with Apgars of ____and _____. Normal uterus, tubes and ovaries
Complications: ______
Path

Standard questions to ask postpartum patients

Nausea/vomiting
Passing gas (flatus), BM
Urinating without difficulty
Lochia
Fever, chills
Pain under control with meds
Eating regular foods
Ambulating
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