Postpartum Note:
** Special progress note for postpartum patients:
ID: Age, GTPAL, Post-delivery day #, route of delivery and any complications during delivery, GBS?, GDM?, baby(s) status
Subjective:
Ask every patient about:
Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on?
Contraceptive plan – with relevant sexual history
Lochia – vaginal bleeding, if so hoy much/how many pads/hr? Symptoms of anemia? is there clots?
Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds?
Mood & Social Support
Objective:
Vital signs (Note maximum 24 hr and current temperature)
Focused physical exam including
o Heart
o Lungs
o Breasts: engorged? Nipples – skin intact?
o Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
o Perineum: Assess lochia (blood on pad, how old is pad?) Visually inspect perineum – Hematoma? Edema? Sutures intact?
o Extremities: Edema? Cords? Tender?
Postpartum labs: Hemoglobin and hematocrit
Assessment/Plan:
Patient Summary: PPD#_ S/P NSVD or Vacuum or Forceps (with 4th-degree laceration, with pre-eclampsia s/p Magnesium Sulfate). Include:
• General assessment – Afebrile, doing well, tolerating diet
• Contraception plans (must discuss before patient goes home)
• Vaccines – does pt need rubella vaccine prior to discharge?
• Breastfeeding? Problems? Encourage.
• Rhogam, if Rh-negative
Discharge and follow-up plan: (Pt usually go home if uncomplicated 24-48 hours postpartum, Follow-up appointment scheduled in 2-6 weeks postpartum with fam dr.)