OB Progress Note


S:   Pt c/o ______. Pt reports eating, ambulating, voiding, and stooling w/o difficulty. Lochia = period. Pain - good control. Euthymic.

O:  Vitals:
      CV:  
RRR no MGR
      Lungs: 
CTAB
      Abd: 
FF      Umb. Tenderness appropriate to procedure. BS+
      Wound:
C/D/I
      Ext:
No c/c/e, No Calf Tenderness
        
APHb | RI    | Bottle  |  MBT | UDS           
PPHb | GBS |  BC      |  IBT  | Placent path

        if HTN:     Plt  | BUN
                       LFT | Cr

A:
   1. TIUP @ 39 6/7 wks
        2. 28 yo G2 P2002 S/P (Primary/Repeat LTCS with BLT) for (NRFHT/Breech presentation) OR SVD by Dr. Spradlin / Steed on 12/05/12 @ 19:42 Hrs
        3. Anemia
        4. No PNC
        5. GDM
        6. Pre-eclampsia
        7.Tobacco Abuse 
        8. Methamphetamine abuse
        9. IUGR
       10. Depression
       11. Macrosomia
       12. Post-op Fever
       13. Endomyometritis
       14. FHx of Congenital Heart Disease
       15. Genital Condyloma
       16. Shoulder Dystosia
       17. Post-partum Hemorrhage.

P:     1. Routine Post-Op/Postpartum Care
        2. FeSO4 /  Transfusion
        3. PNV
        4. Patient Education: Maternal & NB care instructions

Consider When Appropriate:

Contraception Options:

  1. Breast Feeding: 3 Mo
  2. IUD : Can get it 6 wks postpartum
  3. Combined E/P: Can start 3 weeks Postpartum.
    • Ortho-Tricycline 1 po qd
  4. P - Only : Can start immediately after delivery.
    • Ortho-Micronor 1 po qd (must take at same time daily).
    • Depo-Provera 150mg IM q3mo
    • Nexplanon (good for 3 years)