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Inpatient Obstetrics Rounds & Charts

Description of Wards/Clinics
General Guidelines for Post-Partum Notes
Subjective Data
Objective Data
Assessment and Plan
Abbreviations

 

Medical Student Responsibilities and Expectations:

  • Know your patients and their obstetric and/or medical problems.

  • Obtain and review all prenatal and postpartum labs: Know the significance for checking certain tests and management of abnormalities.

  • Round daily on your patients and write the daily progress notes.

  • Be able to present your patients in a concise but thorough fashion

  • Keep the chart up-to-date - follow up on any pending studies/tests

  • Complete all discharge forms and prescriptions for the patients that you are following.


General Guidelines for Post-Partum Notes

 

Post-partum notes should be concise but thorough,  and always legible. Since a large number of issues (e.g. Rhogam, family planning, breastfeeding, rubella status, etc.) must be systematically addressed in a short time (typical postpartum hospital stay is 48 hours or less), the guidelines below will assist students with documentation:

  • Begin all post-partum notes with date/time and the heading: 

    POD# s/p LTCS (primary or repeat, reason for C/S) or

    PPD #  SVD or Forceps or Vacuum

    Additional Diagnosis /Abx Day # or Meds/ Prenatal Labs/ Breast or Bottle/ Birth Control. / HD (Health Department)

Example: PPD#1 s/p ILV/Metritis/Gent & Clinda day#2/Rh neg/Rubella immune/Breast/Depo

  • From OBAR summary first sheet (clinic labs), obtain prenatal Rh Status,  RPR, GC, Chlamydia, Group B Strep status, PAP, Rubella, HBSAg.  Notify the resident if any are abnormal.

Vaginal Delivery Patients: Guidelines

  • Patients with endometritis must be afebrile for 48 hrs before discharge

  • Magnesium sulfate for preeclampsia/PIH is continued 24 hrs PP, and then the patient is monitored closely for an additional 24 hrs before discharge is considered.

  • Rose's Law Early Discharge waiver must be signed by the patient and MD if the patient is discharged < 48 hours after a vaginal delivery.

C-Section Patients: Guidelines

  • The cesarean incision bandage should be left on 24-36 hours postop. When this bandage is removed, it should be covered with telfa pads or 4x4 gauze sponges - change after patient showers. 

  • All physicians and students should wash their hands before and after changing the wound. 

  • Staples should not be routinely removed before postoperative days 4-7.

  • Any suspicious-appearing wound should be examined by a third or fourth year resident or an attending.  Infected wounds should be opened promptly, cultured, and debrided.

  • Rose's Law Early Discharge waiver must be signed by the patient and MD if the patient is discharged < 96 hours after cesarean delivery.

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Subjective Data

  • Lochia [bleeding)

  • Ambulating especially post-operative patients

  • Tolerating diet (clears, fulls, regular)

  • Voiding

  • BM and Flatus if C/S

  • Orthostatic symptoms (dizziness upon sitting up or standing)

  • Breasts engorgement, nipple soreness, problems breastfeeding

  • Pain / Pain control

  • Pre-eclamptics visual changes, edema, epigastric pain, severe HA

  • Episiotomy site (pain)


Objective Data

  • Vital signs - BP range, pulse range, RR, T current and Tmax including time, repeat BP if abnormal, AF x - hrs if on abx, I/O's (especially in preeclampsia).

  • Lungs

  • Heart

  • Abdomen - bowel sounds, tenderness, distention

  • Uterus - fundus firm, tender, relation to the umbilicus

  • Abdominal Incision - clean, dry, intact, signs of infection (erythema, induration, drainage, inappropriate tenderness)

  • Perineum/ pelvic - no exam necessary unless fever, maladoorous discharge, pain, etc. (always perform this component of exam with resident or faculty).

  • Extremities - pulses, edema, cords, tenderness

  • Neuro - pts on MgSO4, check DTRs

  • Lab - PCV on PPD# 1/POD# 1 Include all other routine labs in your note, pattern blood sugars, etc, if ordered should also be included here

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Assessment and Plan

  • Summarize

Include # of days on antibiotics and # hours afebrile when appropriate
Always note if there is something that needs to be followed up on.

  • Routine POD # 1 orders:

    • DC Foley, notify M.D. if no void in 6 hrs

    • DC MSO4 IM/IV

    • Change to oral pain meds (Scheduled Ibuprofen 600 mg po q 6 hrs and Tylox 1-2 po q4-6 hrs prn)

    • Clear liquid diet, advance as tolerated to regular. This is done differently by many residents - ask how they like to manage diet postop.

    • Ambulate tid

    • Heplock IV when taking po well

  • Routine Discharge orders:

  • Common Discharge medications:

    • Motrin 600 mg 1 po q6h prn pain #30

    • Tylox 1-2 po q4-6h prn pain (C/S and BTL pts only)

    • FeSO4 325 mg 1 po (q day X 30 days if pp PCV > 35%, bid 30-35, tid < 30)

    • Colace 100 mg 1 po bid prn constipation (especially if on higher dose FeSO4 or with 30 or 40 laceration)

  • Routine Postpartum Follow-up: 1 week for staple removal, 4 weeks after Cesarean, 4-6 weeks after vaginal delivery.

  • Rubella immunization if prenatal Rubella non-immune.

  • Rhogam if mother is Rh negative and neonate is Rh+.

  • Review all lab work-notify MD if any abnormality.

  • Contraceptive Counseling - choice may be documented in OBAR and may be affected by breastfeeding status. In order to counsel patient, students should read about the contraceptive options and indications/contraindications.

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Abbreviations

  • DOD Day of delivery

  • POD Postoperative day

  • PPD Postpartum day

  • PP Postpartum

  • SVD Spontaneous vaginal delivery

  • EOF/ILF Elective outlet forceps/Indicated low forceps

  • ILV Indicated low vacuum

  • LTCS Low transverse cesarean section

  • OBCC Obstetric complications clinic (1500 6th Avenue South)

  • BTL Bilateral tubal ligation

  • OCPs Oral contraceptive pills

  • IUD Intrauterine device

  • OBAR Obstetric Automated Record

  • Depo Depo Provera

  • A/G/C Ampicillin/Gentamicin/Clindamycin

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