Obstetrics Board Presentations
One-liner, initial cervical exam, intrapartum course and interventions
(pitocin/FSE/IUPC/dilaudid/Ampicillin), GBS status, current cervical exam.
"Sally Jones is a 32-year-old G3P1102 at 32weeks 5days who presented with painful contractions. Her
initial cervical exam was 3/70/-3. She received an epidural and was started on pitocin. She's GBS
positive, on ampicillin. She is now 8/90/-2."
Obstetrics H&P:
CC: A few words on why the patient presents, usually a symptom such as my water broke. You may
quote the patient, or simply write painful ctx, leakage of fluid etc
HPI: Start with age and G_P_ _ _ _ @ ## of weeks, admitted for: __________.
Describe the reason for coming to the hospital as you would for other rotations. Be sure to ask about pain,
vaginal bleeding, contractions (frequency, intensity, when they started), loss of fluid (what color, what
time), and fetal movement.
Prenatal Course: Complications (diabetes, hypertension, hyperemesis gravidum, any antepartum
hospitalizations and treatments, if Rh neg did the pt receive Rhogam at 28wks)
Ultrasound: Most uncomplicated patients will have a growth ultrasound (Level I) at 20wks
Look through prenatal chart and document most recent ultrasound.
Ex. 30w1d: 1488g, 64%, AFI 26.4cm, anterior placenta grade 1, cephalic
Prenatal Labs: Look through prenatal chart and document Blood type /Rh status /antibody status/Rubella
/RPR /HepB/HIV/Gonorrhea/Chlamydia/GBS status
PMH: As per usual (asthma, hypertension, thyroid issues, diabetes, heart disease, cancer etc)
PSH: Particularly any abdominal surgeries (include D&Cs), include year of surgery
OBHx: # of pregnancies; # of births; Ask about date, route of delivery, duration of labor, birth weight,
gender, anesthesia requirement and any complications (including postpartum hemorrhage, preeclampsia,
gestational diabetes, etc)
Ex. G1 - 2003, FTNSVD (full-term normal spontaneous vaginal delivery), 12hour labor, 7lb 6oz,
Male, epidural no complications 4.GBS: neg/pos; if pos, document antibiotics given
G2 - 2007, C-section, 5hour labor, 7lb 4oz, Female, epidural - FITL (fetal intolerance to labor),
postpartum hemorrhage
G3 - 2010, Missed abortion @ 12weeks
G4 - Current
GynHx: Abnormal pap smears? STDs?
Meds: As per usual, including prenatal vitamins
Allergies: As per usual
Social Hx: EtOH, tobacco, illicits. Specify if used during pregnancy. Patient communicates comfortably
in [language]. Domestic violence?
Family Hx: History of birthing complications or birth defects, mental retardation, bleeding diatheses,
clotting disorders, HTN, DM, CAD, gyne cancers, genetic/chromosomal abnormalities
Physical Exam:
Vitals
General: NAD, A&Ox3 etc
CV: normal rate, rhythm, no murmur, pulses present etc
Lungs: clear to auscultation in all four quadrants
ABD: Gravid uterus, nontender, fundal height, estimated fetal size by Leopolds maneuver
EXT: Note if edema is present (1+? 2+?) or absent, reflexes/DTRs (including clonus)
FHT: (fetal heart tones)
4 components:
- Baseline HR (normal 110-160)
- Variability [absent (0), minimal (1-5), moderate (normal, 6-25), marked (>25)]
- Accelerations (generally a 15x15 increase from baseline)
- Decelerations (early, late, variable)
TOCO: (tocometer measures uterine contractions) q*** min
SVE (sterile vaginal exam): Dilation/Effacement/Station (done by the resident or attending; students write
deferred or per [examiner]).
SSE (sterile speculum exam): nitrazine/pooling/ferning (often done in triage by resident/attending).
EFW (estimated fetal weight): bag of flour roughly equals 7lb baby; or estimate how many bags of saline,
1bag equals 1000g
Presentation: cephalic/vertex? Transverse? Breech? by leopolds or BSUS (bedside ultrasound)?
Membranes: intact? ruptured? pooling/nitrizine/ferning? amnisure? AFI?
A/P: Age, G_P_ _ _ _ at ## weeks admitted for _____________.
1.Maternal issues (e.g gestational diabetes, HTN, PreE, etc.)
2.Fetal Well Being (FWB): Reassuring? Reactive? Category of FHT tracing?
3.Labor: Expectant management? Induce/Augment with Pitocin? AROM?
5.Pain: Plan for CLE when uncomfortable? No pain control desired?
6.CEFM/Toco
Attending: Dr._________
Resident: Dr.__________
Student: ______________ MS3