ID
- Name
- Age
- Occupation
- Gravida/Parity
- Gestational Age
- Estimated Due Date
- Blood types
- GBS screen
CC or Reason for Referral
- Regular visit
- Gyne visit: Bleeding, Pain, Mass, Discharge, Infection
- Caseroom: Pain/?Labor, Bleeding, No baby movement, ?Ruptured membranes, Dysuria
HPI
- OLDSCARS: Onset, Location, Duration, Severity, Character, Alleviating/Aggravating factors, Radiation, Symptoms associated
- Associated symptoms
- Gynecologic: bleeding, pain, mass, discharge, infection, dysuria
- Caseroom: contractions (regular, painful, length, predictable, frequency, strength), bleeding, baby movement, ruptured membranes (with cough? How much flow?), dysuria
- PIH: headache, visual changes, epigastric pain, N/V
- Bleeding: how much, how long, from where, associated pain, contractions, previous imaging (previa)
- Last meal (if for surgery)
PREGNANCY HISTORY
- How did she find out she was pregnant
- LNMP, EDD
- Antenatal care?
- Any complications? bleeding, infection, hypertension, diabetes
- Investigations thus far and findings? ultrasound, amnio, NST, BPP, blood glucose, GBS, blood type
- Trimester
- First: N/V, bleeding, ANC, EtOH/Rx use
- Second: quickening, scan for dates, amniocentesis
- Third: fetal movements, weight gain, edema, contractions
PAST PREGNANCY HISTORY
- Gravida, Term, Premature, Abortions, Live
- Other pregnancies’ dates, hospital, duration of labor, method of delivery, result (gender, apgars)
- Complications – antenatal, intrapartum, postnatal
GYNECOLOGIC HISTORY
- Menstrual history
- Menarche, Cycle, Nature of periods, Regularity, LNMP, Dysmenorrhea, PMS, Postcoital and intermenstrual bleeding, Menopause, Postmenopausal bleeding
- Contraception
- Current method, Adherence, Previous methods, Planned pregnancy
- Vaginal discharge
- Urinary history
- Frequency, Dysuria, Urgency of micturition, Stress/Urge incontinence
- Pap smears
- Sexual history
- Frequency, Dyspareunia, Number of partners
- Infectious history
- Swabs, STIs, Yeast infections, Sexual activity
- Gyne surgeries or other interventions/investigations
Past Medical History – CVS, Respiratory, Neuro, Endocrine, MSK, GI, GU
Past Surgical History – C-sections, D&C, cervical surgery, biopsies?
Family History
SOCIAL HISTORY – smoking, EtOH, street drugs, current living situation, job, relationship, Hx/current abuse
MEDICATIONS – vitamins, any stopped during pregnancy or taken before knew of pregnancy
ALLERGIES – note reaction
ROS
INVESTIGATIONS
- Specialist consultations
- Ultrasounds – dates, place, findings
- Bloodwork – when, where, results
- Specific screens
- 10-14 weeks
- First trimester combined screening for Trisomy 21
- Nuchal Translucency UltraSound (NTUS)
- Serum β hCG
- Pregnancy associated plasma protein A (PAPP-A)
- 14-18 weeks
- Fetal movement (quickening)
- 15 – term
- Amniocentesis
- 16 weeks
- Maternal Serum Screen for Trisomy 21 and oNTD
- Maternal serum α-fetoprotein (MSAFP)
- Serum β hCG
- Unconjugated estrogen (estriol or uE3)
- 10-14 weeks
MSAFP | β hCG | uE3 | |
oNTD | ↑ | ||
Trisomy 21 | ↓ | ↑ | ↓ |
Trisomy 18 | ↓ | ↓ | ↓ |
-
- 16-20 weeks
- Ultrasound for dates, structural assessment
- 24-28 weeks
- 50g Oral glucose challenge
- 28 weeks
- CBC, RhIG for all Rh negative women
- 36 weeks
- GBS screen, Rh antibody screen if indicated
- 16-20 weeks
OBSTETRIC EXAMINATION
General and Vitals
HEENT
CVS
Respiratory
Neurological – especially in PIH (CN, tone, reflexes, clonus)
Abdominal
- Inspection
- Scars, Linea nigra, Distension, State of umbilicus, Striae, Fetal movement
- Palpation
- FSH
- Uterine tone and tenderness
- Lie, presentation, position, attitude
- Auscultation
- Fetal heart beat via doppler
Pelvic
- Cervical changes
- Position
- Consistency
- Effacement
- Dilatation
- Station
- Speculum – nitrazine swab (blood, semen, urine, amniotic fluid)
GYNECOLOGIC EXAMINATION
General and Vitals
Pelvic
- Inspection
- Hair distribution, Vulval inflammation/infection, Scars
- Vaginal discharge, Odour
- Incontinence of urine on coughing, Prolapse
- Bimanual
- Cervix: consistency, regularity, excitation, pain, position
- Uterus: size, shape, consistency, mobility, pain
- Adnexae: palpable, size, pain, masses
- Speculum
- Cervix: inflammation, Nabothian follicles, eversion, polyps
- Vagina : estrogenization, urethral dislocation, bladder neck support, cystocele, rectocele, enterocele
- Pap smear
- Swabs for Chlamydia and Gonorrhea