Receiving an Antenatal Patient

Front page

• Height, weight, BMI –> pre pregnancy
• Weight gained during pregnancy
• VT score

• Date & time of receiving
• Demographic details –>

  History

• Chief Complaints –>
  • Admitted for safe confinement
  • if freshly received today –> Referred from ……….. I/V/O(In view of) …………… at …..GA
  • if it is a old patient –> Booked case of ……
• Married life –>
  • Primi or G..P..L..A.. prev CS or FTVD/PTVD
  • if >3 years –> ask spontaneous ? or after infertility treatment?
  • Consanguineous or NCM

  • Mention about previous pregnancy’s –> Sex

    Birth weight

    age

    CS/ND

    Any complications

    • Previous LSCS? -> indication & at what week?
    • FTVD/PTVD @…Month
    • Abortions @…Month –> Medically managed/ D&C done or not done
  • Menstrual history –>
    • regular cycles?
      • …/…… days, h/o clots, dysmenorrhea
    • LMP of present pregnancy
    • EDD by LMP ==>
    • LMP-GA as of today
      • Check for EDD with Dating scan –> Corresponding(<1wk disparity) -> good
      • if not mention T1 EDD & T1-GA
• HOPI –> start describing
  • Presenting illness
    • Pain
      • Intermittent abdominal pain
        • Radiating to back
        • since __ hours or __ days
      • Lower abdominal pain
        • Continuous type
        • ddx -> dysuria/white discharge
    • Bleeding PV
    • Leaking PV
    • Appreciating good FM/ decreased FM
    • Fever/ vomiting/ etc….
  • T1
    • Preconceptionally FolicAcid?
    • When was the UPT done,
      • if with in 2wks of missed period –> suggest regular cycles
    • Inj TT ? 2 doses
    • Any h/o fever with rash
    • h/o Teratogenic drug intake
    • h/o Radiation exposure
    • h/o spotting p/v? or Abdominal pain?
    • Dating scan –>
      • when was it done?
      • Corresponding dates?
    • NT scan –>
      • NT thickness
      • NB -
    • Aneuploidy Screening –> when? T1/T2
      • Low risk / moderate risk/ high risk
    • any Past history
  • T2
    • When was the Quickening?
    • 75gm GGT
    • Anomaly scan –> when?
      • mention any details
  • T3
    • Regular ANC?
    • Scan to assess interval growth are normal
• Include Referred from ____ at __wk+__D of GA i.v.o ………….
• Medical History –>
  • Anemia
    • Treated with Fe BD/ orofer/ PRBC
    • Deworming done?
    • PS, Ferritin, LDH –> reports
    • Last Hb
  • GDM
    • GTT or F/PPBS values
    • When was it detected? FBS/PPBS at that time
      • if it is >126/200 –> Suspect Overt diabetes –> Enquire about HbA1c value
    • Treated with MNT/OHA/Insulin
    • Overt DM –> End organ evaluation
  • HTN
    • When was it detected?
    • h/o Impending signs
    • if <20 wk –> c/c HTN
    • Check urine P/C >0.3 or Urine Albumin + ==> Preeclampsia
    • c/c HTn –> End Organ evaluation %% - check Doppler scan –>
      • Uterine artery PI
      • Whether started on Tab. Ecosprine 150mg HS ?%%
  • Seizure
    • When was detected
    • last seizure episode
    • if any occurred during pregnancy
    • on which drug, dose and last neurology follow-up report
    • any drug changed in pregnancy
  • Thyroid disorder
    • Since How many years
    • on Tab. Thyronorm __ mcg OD
    • Last TSH
  • Heart disease
    • NYHA grading
    • since how many years
    • symptoms if any, Rx if any, regular follow up, last cardiac consultation date & Advice
  • Asthma/COPD/ TB
• Drug history
  • h/o blood transfusion
  • Any h/o Drug allergy –> allergy chart
  • Teratogenic drug intake
• Past surgical history
  • for what, when, what Sx
• Family history –> Gynecology patients & Genetic disease patients
  • Any history breast/endometrial/ovarian cancer in the family
• If not covered previously
  • Personal history
    • sleep regular
    • decreased appetite
    • normal bladder & bowel movement
    • no addiction
    • SES - low income
  • Menstrual history
  • Past obstetrics history

  • any reference’s from medicine/cardiology/nephrology/ophthalmology

    Examination

• General Physical examination
  • Conscious, oriented
  • Pallor, icterus, cyanosis,
  • pedal edema, lymphadenopathy
  • Febrile?
  • PR -
  • BP -
    • Impending signs
  • Spo2
• CVS - S1 S2 heard
• RS - clear AEBE, no added sound
• P/A -
  • Inspection findings
    • Longitudinally stretched –> pregnant
    • linea nigra/alba
    • striae gravidarum
    • prev cs scar
  • Palpation findings
    • soft, non tense, non tender, obesity +/-
    • uterus ~……wks
    • Cephalic
      • (M)
      • fixed - (4/5, 3/5, 2/5, 1/5, 0/5)
    • any other presentation
    • FM +
    • FHS –> …..bpm,
    • no scar tenderness if prev cs
• if r/o Abruption -> no clinical evidence of abruption
  • Also do BT/CT and write
• if PPROM –> no s/o Chorioamnionitis
• P/Speculum -
  • OS closed, cervical length ~…….
  • Any discharge/ leaking/ bleeding
    • curdy white or purulent
• P/Vaginal -
• if relevant Don’t forget to mention, often decisions are made based on evidence
  • NST details
  • Scan details

  • Investigation details

    Impression

• Married life x ..yrs

  G..P..L..A..

  previous FTNVD/CS

• POG - ….wk + …days
• Risk factors / co-morbidities
  • GDM
  • Placenta previa
  • anemia

• Enter Investigation/scan impression

  Advice

• Monitor Vitals
• DFMC –> Daily Fetal Movement Count
• NST
• 6x GRBS –> BF/AF—BL/AL—BD/AD
• MNT(Maternal Nutritional therapy)
• Tab. Iron 200mg OD/BD/TID
• Tab. Folic Acid 5mg 1-0-0
• Tab. Calcium 500mg 0-2-0
• Tab. Albendazole 400mg stat (if not dewormed)
• [ ]
• Arrange Blood
• Collect investigation
• Prepare parts
• Tab. Dulcolax 2 HS
• Tab. Flucanzole 150mg stat
• Cansoft CL Vaginal tablet (1/3)