Need help capturing correct sequence of diagnosis for a vaginal delivery, patient is 41 weeks pregnant with Group B streptococcus (GBS), normal live birth
OB H&P
33 yo G5P3013 at GA 41w3d (EDD by: LMP) presents for IOL or late term. Reports intermittent contractions.
Vaginal bleeding: Denies
Vaginal discharge: Denies
Loss of fluids: Denies
Contractions: Intermittent
Decreased Fetal movement: Denies
Last PO intake: Yesterday
Prenatal care with Dr. Bryan
Complications with this pregnancy: GBS Positive
ABO/Rh: A+
Rubella: Immune
HIV: Negative
Hep B: NR
GBS: Positive
RPR: NR
GC/CT: negative
PMH: Denies
PSxH: Denies
Meds: PNV
Ob Hx:
G1 - 2006 SVD, 8.6#
G2 - 2007 SAB
G3 - 2011 SVD, 7.2#
G4 - 2015 SAB, 6.12#
Gyn hx: Denies history of STD. Denies herpes. Denies abnormal pap Hx.
SH: Denies smoking, drinking and illicit drug use
All: NKDA
Review Of Systems:
Const: No weakness, fever, or chills.
Resp: No SOB or cough
Skin: No rash or itching
CV: No palpitations or edema
GI: No abd pain, nausea, vomiting, constipation, or diarrhea
GU: No dysuria, vaginal bleeding or vaginal discharge. +Pregnant.
Musc: No swelling or pain.
Neuro: No headache, neck pain, or neuro deficits.
Exam:
Gen: Well dressed, Well Nourished, alert and no acute distress
Head: Normocephalic/Atraumatic
Eyes: Normal inspection.
Neck: Supple.
Resp: Lungs clear to ausculation. No increased respiratory effort
CV: RRR. No m/r/g
ABD: Soft, no abnormal tenderness, obese, gravid
EXT: Non-tender. No swelling.
Skin: Intact.
Neuro: Awake and alert. No obvious motor or sensory deficits.
Psych: Normal mood.
Non-Stress Test:
Baseline 120, mod variablility, + accels, no decels
Toco: intermittent contractions
EFW: 6.5 by leopolds
Adequate pelvis
Membranes: intact
Presentation: cephalic
Assessment:
#Intrauterine pregnancy at GA:41w3d, induction of labor
- Expectant management, expect NSVD. Discussed possible reasons for c-section such as arrest of dilation, arrest of descent, or non-reassuring
fetal activity.
- Continuous EFM/TOCO monitoring
- Vitals: afebrile
- CAT I strip: baseline 120, moderate variability, +accels, - decels; TOCO intermittent contractions
- SVE: 2/70/-2, cephalic
- Membranes: intact
- Prenatal labs available and within normal limits
- Pain Management: Epidural desired
- Induction: Plan to start cytotec PV then pitocin when cervix is favorable
- Pitocin augmentation per protocol if needed
- Ambulate to restroom, place foley if epidural is placed
- Keep patient NPO, ice chips okay
#GBS Positive
- PCN allergy without sensitivities noted
- Vancomycin for ppx
#Postpartum Care
- Pediatrician:
- Breastfeeding
- Tdap: discuss in postpartum
- Contraception: discuss in postpartum
#Risk Assessment
- DVT risk: low. Will encourage early ambulation.
- PPH risk: low. Will monitor EBL at delivery and postpartum.Follow up postpartum hemoglobin and hematocrit
Full Code
DVT ppx: Ambulation
DIET: Regular
DISPO: Admit for IOL
OB Delivery
Pre-delivery
GBS status:
GBS status: positive
Baby A Information
Baby A information
Gender: male
APGAR 1 minute: 8
APGAR 5 minutes: 9
Nuchal cord Baby A
Nuchal cord: yes (tight,deliv.through)
Additional comments:
head was loa and there a nuchal cord that could not be reduced. nsvd viable male apgars 8,9. placenta delivered intact. there was bilateral
periurethal abrasions noted and not repaired.
ebl: 200
OB H&P
33 yo G5P3013 at GA 41w3d (EDD by: LMP) presents for IOL or late term. Reports intermittent contractions.
Vaginal bleeding: Denies
Vaginal discharge: Denies
Loss of fluids: Denies
Contractions: Intermittent
Decreased Fetal movement: Denies
Last PO intake: Yesterday
Prenatal care with Dr. Bryan
Complications with this pregnancy: GBS Positive
ABO/Rh: A+
Rubella: Immune
HIV: Negative
Hep B: NR
GBS: Positive
RPR: NR
GC/CT: negative
PMH: Denies
PSxH: Denies
Meds: PNV
Ob Hx:
G1 - 2006 SVD, 8.6#
G2 - 2007 SAB
G3 - 2011 SVD, 7.2#
G4 - 2015 SAB, 6.12#
Gyn hx: Denies history of STD. Denies herpes. Denies abnormal pap Hx.
SH: Denies smoking, drinking and illicit drug use
All: NKDA
Review Of Systems:
Const: No weakness, fever, or chills.
Resp: No SOB or cough
Skin: No rash or itching
CV: No palpitations or edema
GI: No abd pain, nausea, vomiting, constipation, or diarrhea
GU: No dysuria, vaginal bleeding or vaginal discharge. +Pregnant.
Musc: No swelling or pain.
Neuro: No headache, neck pain, or neuro deficits.
Exam:
Gen: Well dressed, Well Nourished, alert and no acute distress
Head: Normocephalic/Atraumatic
Eyes: Normal inspection.
Neck: Supple.
Resp: Lungs clear to ausculation. No increased respiratory effort
CV: RRR. No m/r/g
ABD: Soft, no abnormal tenderness, obese, gravid
EXT: Non-tender. No swelling.
Skin: Intact.
Neuro: Awake and alert. No obvious motor or sensory deficits.
Psych: Normal mood.
Non-Stress Test:
Baseline 120, mod variablility, + accels, no decels
Toco: intermittent contractions
EFW: 6.5 by leopolds
Adequate pelvis
Membranes: intact
Presentation: cephalic
Assessment:
#Intrauterine pregnancy at GA:41w3d, induction of labor
- Expectant management, expect NSVD. Discussed possible reasons for c-section such as arrest of dilation, arrest of descent, or non-reassuring
fetal activity.
- Continuous EFM/TOCO monitoring
- Vitals: afebrile
- CAT I strip: baseline 120, moderate variability, +accels, - decels; TOCO intermittent contractions
- SVE: 2/70/-2, cephalic
- Membranes: intact
- Prenatal labs available and within normal limits
- Pain Management: Epidural desired
- Induction: Plan to start cytotec PV then pitocin when cervix is favorable
- Pitocin augmentation per protocol if needed
- Ambulate to restroom, place foley if epidural is placed
- Keep patient NPO, ice chips okay
#GBS Positive
- PCN allergy without sensitivities noted
- Vancomycin for ppx
#Postpartum Care
- Pediatrician:
- Breastfeeding
- Tdap: discuss in postpartum
- Contraception: discuss in postpartum
#Risk Assessment
- DVT risk: low. Will encourage early ambulation.
- PPH risk: low. Will monitor EBL at delivery and postpartum.Follow up postpartum hemoglobin and hematocrit
Full Code
DVT ppx: Ambulation
DIET: Regular
DISPO: Admit for IOL
OB Delivery
Pre-delivery
GBS status:
GBS status: positive
Baby A Information
Baby A information
Gender: male
APGAR 1 minute: 8
APGAR 5 minutes: 9
Nuchal cord Baby A
Nuchal cord: yes (tight,deliv.through)
Additional comments:
head was loa and there a nuchal cord that could not be reduced. nsvd viable male apgars 8,9. placenta delivered intact. there was bilateral
periurethal abrasions noted and not repaired.
ebl: 200