Copyright 2023 © MedHubOnline, CAN Inc. All rights reserved.

MedHubOnline uses cookies to enhance your user experience. Please email us regarding our privacy, security, terms of use,  and adchoice or if you have any suggestions, questons or concerns.

2350 Health Sciences Mall, Vancouver, BC V6T 1Z3

 

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.)