By Dr. Catherine Friedman PGY2
ID: [age] [GTPAL] at [gestational age] (EDD ____ by [method of dating]) with [presenting issue]
e.g. 27yo G2T1L1 at 39+3 (EDD July 20, 2021 by T1US) with query labour
HPI: in addition to taking a general history, always ask the four golden questions –
Do you feel any contractions/regular cramping/abdominal or back pain?
Have you noticed any gush of fluid/increased fluid/think your water broke?
Have you noticed decreased or absent fetal movements?
Have you noticed any vaginal bleeding or spotting?
Pregnancy Hx:
Uncomplicated or Complicated by ____ e.g. Pregnancy complicated by cholestasis of pregnancy
EDD ____ by [method of dating - LMP, T1US, T2US, or T3US]
Rh status
GBS status
Seroprotected (i.e. HIV, VDRL, Hep B/C negative), & rubella status [immune, non-immune, or indeterminate]
Note if HTN or GDM e.g. no GDM & no HTN
Prenatal screening e.g. eFTS negative, or NIPT negative
Anatomy U/S results e.g. anatomy U/S normal & complete, placenta anterior & clear of cervix
Any recent U/S: [gestational age at time of U/S]: indication for U/S, BPP, EFW in grams & percentile, AFV normal/abnormal, Dopplers normal/abnormal, placenta location, presenting part
e.g. 38+2 – U/S to confirm presenting part, BPP 8/8, EFW 3706g (89th %le), vertex, AFV normal, Dopplers normal, placenta anterior & clear
OB Hx: