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Continuity Assignment for D.R.

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lynn earman

on 27 February 2018

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Transcript of Continuity Assignment for D.R.

Continuity Assignment for D.R.
Labor Triage 1/13/18
40 5/7 weeks gestation
No known allergies
Desires waterbirth - has certificate
Membranes intact
Pt states ctxns started 1/12 @ 0400 - irregular at this time, reports she was able to nap and rest
Reports ctxns every 5 minutes 1/13 @ 0030
Pt is visibly uncomfortable, breathing and rocking through ctxns @ 0100
SVE 0210 = 5/100/-1 with a bulging bag - admitted to inpatient in labor status
Labor Management 1/13/18
Walking in room, using tub intermittently
Intermittent fetal monitoring - FHR baseline 135bpm, moderate variability, +accels
Labs: A positive, H&H 12.4/32.5, platelets 228
Treated adequately with PCN x2
Transition phase began @ 0600 – at pt’s bedside at this time, pt vomiting and asking for pain medicine
One dose of Fentanyl given at 0700
continuously monitored at this time - FHR baseline 130bpm, moderate variability, +accels
pt was able to rest for approximately 30 minutes
SROM for clear fluid at 0730 - pt on hands and knees in bed
Felt pressure and desire to push at 0740
Birth 1/13/18
SVD @ 0803
Baby boy with APGARs 8&9
Spontaneous delivery of intact placenta 28 minutes after birth - preceptor assisted with delivery of placenta
EBL 250cc
1st degree laceration, no repair needed

Antepartum Visit 12/12/17
27yoa, African American, G2P0
36 1/7 weeks gestation
BP 114/53
Fundal height 35cm
FHR 148bpm
GBS collected - result was positive
Pt reports feeling a lot of fetal movement and occasional Braxton Hick's contractions
Discussed signs of labor and protocol for GBS prophylaxis in labor
Reports that she desires a waterbirth - took certification class
Reports pelvic and back pain - recommended belly band and chiropractic care
Suggested attending up-coming childbirth class
Postpartum Visit 2/22/18
Pt states she is tired, but adjusting well
Reports breastfeeding every 2 hours approximately in the day - baby will sleep for a 4-5 hour stretch at night
No pain with breastfeeding - infant is gaining weight appropriately and does not look jaundice
Reports that bleeding has stopped and she does not have perineal pain
Edinburgh postnatal depression scale score = 0
Pt states that she has a lot of support at home from friends and family - father present during visit
Both parents attentive and affectionate with infant during visit
No intercourse yet - discussed that intercourse is fine whenever mom is ready
Pt reports no desire for birth control - will use condoms
Reminded patient that she can get pregnant while breastfeeding - warned to be careful!
Discussed vaginal dryness with breastfeeding and gave UberLube sample
Encouraged pt to continue taking prenatal vitamins until she is done breastfeeding
Encouraged daily walks and told her that she could start exercising when she feels up to it
PE: no thyroid nodules or tenderness noted, unable to palpate fundus, abdominal muscles well approximated, no hernia noted
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