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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



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


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

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.)