This is <Mrs. || Miss || Ms.> <O'Connor> a <34 year old> <secretary> from <Dublin> who delivered her <first> baby <two> days ago at <40> weeks gestationa <boy || girl> named <Clair> by <spontaneous vaginal || assisted vaginal || breech || Cesarean section> delivery <is || is planning> <bottle || breast> feedingand <both baby and mother are well>.
<She is a longterm diabeticwhich is successfully managed with insulin>. <She had a PDA repair in 1969>. <In her Obstetric historyher prior child had congenital deafness>. <Her mother and 3 sisters all had at least one post-partum hemorrhage>.
<She smoked one pack a day since she was 16but since finding out she waspregnantshe has limited herself to one or two cigarettes per week>. <Before her pregnancy she consumed 3 units of alcohol per weekbut she has not takenany alcohol since finding out she was pregnant>. <She is not on any medicationsand she has no allergies>.
First day of her LMP was <November 20th> and she is <certain || uncertain> of her datesbecause <she wrote it in her diary || remembers the time of conception>. By Nagele's ruleher estimated date of delivery is <August 27th>. An ultrasound scan at <13 weeks> <confirmed her dates>.
Her pregnancy was <uneventfulexcept for a .... at 35 weeks gestation>.
She is Rhesus <positive || negative> and <is || is not> Rubella immune.
<Mrs. O'Connor's> labour began with <painful uterine contractions ... minutes apartincreasing in duration andfrequency> at <1:00 am on Tuesday morning> followed by <a show and spontaneous rupture of membrane || a show but no spontaneous rupture ofmembrane || a spontaneous rupture of membrane || neither show nor spontaneous rupture ofmembrane>. She was admitted to hospital at <8:45 am> by which time her cervix had dilated to <3 cm>.
She was admitted to the antenatal ward. She was examined by the <midwife> and her cervix was found to be effaced and cervix dilated to <7cm>. A diagnosis of labour was madeand she was sent to delivery.
The first stage lasted for <2 hours [some hospitals specify labour as time from admission to labor unit] || 9hours> the second stage lasted for <20 minutes>.
She was given <10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.
For anaglesiashe first tried <Nitrous oxide by inhalation> but subsequently requested <an epidural at 8:45am> which <gave adequate analgesic relief for the duration of labour>.
The liquor was <clear throughout || green throughout || clearthen green>.
Optionally: <a cardiotocograph was connected during the labourand intermittent auscultation wasperformed>.
Electronic fetal monitoring <was not performed || <was performed due to: <prolonged labor || suspected small for dates || prematurity || APH>>. Fetal blood sampling <was not done || was done to look for ...>
The delivery was <spontaneous vaginal || vaginal instrumental || breech || Cesarean section> with <a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches|| no tears or episiotomy required> at <2:45pm>. <Claire's> condition at birth was <normalcrying immediately at birth || ...> and weighed <3 kg>. A pediatrician <was || was not> present at the time of delivery. <Claire> <was admitted to the neonatal unit || went with her mother to the postnatal ward>.
Her lochia is currently <red || brown || white> <is odourless || has a pungent odour> <has no clots || has some clots> <is less || is more> than a period and is <getting less each day>.
Since returning from deliveryshe is <now ambulatory || not yet ambulatory> <has passed her bowels || has not yet passed her bowels> <has no flatus || is experiencing some flatus> and <has voided her bladder || has not yet voided her bladder>.
<Mrs. O'Connor> looks <clinically well> and appears <happy> with her baby. [This is a more polite way to descibe that she is not experiencing any postpartumdepression/psychosis.]
On inspection of the abdomenit is distended <below || above>. the umbilicus. It <moves || does not move> with respirationand <no scars are visible || there is a visible cesarean and episotomy scar thatis...>.
On palpation of the abdomenthe fundus is <2> fingerwidths below the umbilicus. <It is less than the expected 1 cm/daypossibly due to a full bladder as she hasnot voided in the last 8 hours>. The fundus is <normal size and shape || ...> <mobile || immobile> <regular || irregular> <firm || soft> and <nontender || tender>.
If a Cesarean section was done: The incision site appears to be <healing well>. The incision is <red> the edges are <well opposed> and there are <stitches || stitches and steristrips> in place. There is <no discharge or other signs of infection>. There is <no extreme abdominal distention> and bowels sounds are <present and normal>.
If bottle feeding: <Clair> is bottle feedingtaking <SMA || Cow and Gate || ...> <50 mL> per feedfeeding <well> every <4> hoursand is <wetting her nappies [alternatively: if <3 dayscan say "passing meconiumand urine"]>.
If breast feeding: <Clair> is breast feeding <8> times a day <and through the night> feeding <on demand || by docking> with each feed lasting <10 minuteswith 5 minutes per side>. <Clair> <is satisfied> with her feedand her nappies <are wet>. <Mrs. O'Connor> <feels || does not feel> her breasts empty and swell <has no nipple concernsand> <is comfortable taking Claire on and offas she went to a class>.
If nation's protocol is for BCG vaccination and/or Guthrie tests: <Clair> <had || is scheduled for> her BCG on <Tuesday> and her metabolic screen is on <Wednesday>.
After pregancyshe <will || will not> <start on || go back on> <the combing oral contraceptive pill in 4 weeks time [alternatively: starting onthe day of her next period] || ...> <as it has offered good protection in the past>. <She will not not use the pill because she doesn't like it>. <She has had attended parenting sessions [esp. important if young with firstbaby]>. <She has an appointment booked with the physiotherapist on ...>.
She <has a partner at home who works as a ... || is self-supported socially> and is going home <today> to her <1 bedroom house>.
Optionally: She will be taking iron and has booked an appointment with her <GP || hospital> in 6 weeks time and <will || will not> have a smear at that time.
