OBSTETRICS
L&D Triage/Admission Note
Labour Progress Note
Delivery Note
Postpartum Rounding Note
NOTE TEMPLATES
Available for Download
Friendly Reminders...
Always add date and time for your notes
Indicate your level of training ("CC3")
Indicate who you have reviewed with and their level of training ("reviewed with Dr. Bob, PGY2")
TRIAGE AND ADMISSION
*Patients often come with a folder of their prenatal history or their information can often be found on the electronic medical record system. For example, information about previous deliveries, PMHx, etc. can be filled out according to antenatal records and clarified/confirmed by the patient on assessment. It is important to review some history before seeing the patient, as current pregnancy complications or previous pregnancy outcomes may be important to know.
*Review the case with the resident/fellow. Clarify what exams are ok to do independently (likely cardiac, respiratory, and abdominal exams if indicated). Do not perform speculum, bimanual exams, or cervical checks without your resident or staff.
ID: age, GTPAL, gestational age, GBS status, Rh status, obstetrician
CC: ?labour, ?SROM, bleeding, pain, N/V, fall, IOL
HPI:
4 Cardinal questions:
Contractions: since when, last how long, how often, how painful
“Are you experiencing consistent cramping or contractions?”
Vaginal Bleeding: quantify (soaking a pad, with wiping, just spotting etc.), since when, how long, associated with pain, placenta previa?, associated with intercourse/trauma?
“Are you experiencing any vaginal bleeding or spotting?”
Rupture of Membranes: gush vs. leaking vs. trickle of fluid, soaked through underwear/pants?, any colour?, still leaking in triage?
“Are you experiencing any leaking from the vagina, where you feel you’ve broken your waters?”
Fetal Movement (guideline: 6 FM in 2 hours): how often? last FM? kick counts? tried lying still, movement, cold juice?
“Are you experiencing fetal movements today?”
IOL: Confirm the reason for induction. Examples include: post-dates (41+ weeks), IUGR, oligohydramnios, GDM, preeclampsia, etc.
Elevated BP: how long and how many readings, any previous history, associated symptoms (headache, visual changes, shortness of breath, epigastric pain, swelling or erythema of the peripheries), any medications etc.
Pain: OPQRST
Differential includes, but not limited to:
Pregnancy related: round ligament pain (usually ≥ 20wks GA, may be bilateral, radiating to groins, resolves with rest), placental abruption, labor
Non-pregnancy related: MSK-related, UTI (can be asymptomatic), trauma, appendicitis, gallstones, renal colic etc.
Trauma: when did it occur, mechanism, injury to abdomen, MVC (speed, type of car, seatbelt use), any loss of consciousness
Pearl: safety screens should be conducted routinely in pregnancy. This may be better performed together with your resident, if applicable.
Last meal: if patient may need OR for CS, what time, what was eaten
Current OB Hx: HTN? GDM (controlled on what?)? Most recent U/S (note estimated fetal weight, BPP score, growth percentile, vertex/breech/transverse, distance of placenta from cervix, amniotic fluid index)? Prenatal screening results? Any infections? Any bleeding? Serology status? Last VE/ dilation in a clinic?
Past OB Hx: Year, gestation, type of delivery (vaginal/CS, vacuum/forceps assisted, including SA and TA and if D&C was required), complications during pregnancy/delivery/postpartum (previous GDM, PIH, tears, PPH, etc.), length of labour, health of baby (size, resus., NICU stay)
PMHx: any medical conditions, note asthma and vaccination status
PSHx: Note abdo/pelvic surgeries, previous procedures to the cervix (i.e. LEEP)
Meds: PNVs?
Allergies: medications? shellfish (applicable to iodine based surgical prep)? latex?
SHx: Support system (who is present with them?), how far they live (helpful when trying to decide whether to send them home for monitoring)
Substance Hx: smoking, alcohol use, drug use (including marijuana)
P/E:
General appearance: Note if in any distress
Vital signs: Temperature, BP, HR, RR, O2Sat
Abdominal exam: Full exam if complaint of abdo discomfort/pain, Leopold’s maneuvers
For patients presenting with elevated BP or signs or symptoms of preeclampsia, add on the following exams: reflexes, clonus
Investigations:
FHR tracing: baseline heart rate, note variability (minimal, moderate, marked), presence of accels, presence and type of decels (variable, early, late)
Toco: Q_min, duration
Sterile speculum exam (*to be done with resident/staff):
If suspecting SROM:
Check for pooling of fluid, Nitrazine test for pH, ferning on microscopy (only swab the ‘watery’ looking discharge to place on slide)
Valsalva cough, pad check, walking/ gravity
Helpful for assessing dilation when digital exam may not be appropriate (e.g. placenta previa)
Assessment of vaginal bleeding: check cervix, polyps, vaginal trauma etc.
Cervical exam for labour assessment (*to be done with resident/staff):
Dilation, effacement, station, position
Urine dip: depending on symptoms (pain, elevated BP)
Bloodwork: if applicable
Ultrasound: if applicable
Assessment:
In summary, Age/G_P_/ at __ gestational age, in active labour, SROM, PVB etc.
Plan:
Admit, ARM, Pitocin
*Ask if they have a plan for pain management.
LABOUR PROGRESS
Subjective:
Analgesia: epidural?
Pitocin? Dose?
Coping?
Objective:
FHR assessment – baseline, note variability, accels, deccels
Contractions – frequency, strength
Exam: cervical dilation, effacement, station, position, fluid (meconium? blood tinged? clear?)
If ARM – head well applied before and after ARM? FHR after ARM?
Impression: progress or not, reassuring fetal status or not
Plan: continue current management or change, reassess in __ hours
DELIVERY
*Note: Depending on the site, this is frequently done by the resident/fellow/staff.
Brief history: __year old G_P_ at ___weeks GA. Presented for IOL/spontaneous labor/ SROM etc. Uncomplicated/ complicated pregnancy by _____. GBS pos/neg. Otherwise healthy patient. Progressed well in labour with oxytocin for augmentation.
Type of delivery: SVD, vacuum, forceps, C/S
Obstetrician: staff name
Assistants: fellow, resident, medical student
Anesthesia: epidural, spinal, combined spinal/epidural, local, nitrous oxide, none
Delivery: vertex/breech, shoulder dystocia, complications
Infant: liveborn male/female child, birthweight, APGAR score
Placenta: spontaneous or gentle cord traction or manual removal, intact, 3 vessels cord
Laceration/Episiotomy: degree of laceration, repaired with ____ suture, DRE performed?
Blood loss: ___ cc
Complications: Shoulder dystocia (maneuvers used), PPH (medications given)
POSTPARTUM ROUNDING
*Postpartum rounding typically occurs first thing in the morning of a L&D shift.
*On the paper list of postpartum patients (often can be printed, depending on the site), you can write the patients' initials and room numbers as identifiers. If there are names or other identifying information, please make sure you discard the paper in a secure shredding box (often in Med Ed student centres or around the nursing stations).
ID: age, GTPAL, PPD_, type of delivery (CS, SVD, forceps, vacuum), complications (3rd/4th degree laceration, PPH)
S: (head to toe screening)
Most important questions for meeting discharge criteria:
Pain well controlled? Analgesia use?
Tolerating PO intake?
Voiding well?
Passing flatus/BM?
Ambulating? Calf swelling?
Lochia within normal limits? (bleeding - minimal, moderate, heavy?)
Nausea/vomiting?
Headache, visual changes
Chest pain/SOB?
Breastfeeding?
O:
General appearance, vital signs
Cardiorespiratory exam: if applicable
Abdominal exam: Uterine fundus (feel uterus around umbilicus, 1-2cm below/above), incision if applicable (look at dressing and see if soaked, dry blood, fresh blood etc.)
Perineum: typically not required but sometimes indicated; *only perform with resident/staff
Calves: edema, erythema, tenderness
Investigations: POD#1 Hb level in C/S patients, PPD_ Hb in PPH patients
Assessment: Well, recovering OR not well, complicated recovery - differential diagnosis if applicable
Plan: encourage ambulation, encourage PO intake, DAT, advance diet. Investigations. Outstanding goals required to meet for discharge.