These are extra things I consider for complicated postpartum notes. For the basic uncomplicated postpartum note upon which I add these extras, click here.
Subjective:
If there is excessive vaginal bleeding, quantify. What kind of pads? How many pads at once? How often do you change it. Any heavy clots. How large are the clots, etc.
If preeclamptic: +/- HA, scotoma, and RUQ pain
If PPH: dizziness, dyspnea, and chest palpitation
Objective:
I/O’s on all preeclamptic, PPH, and C/S pts.
If murmur, describe. E.g. II/VI SEM
If C/S, describe dressing and incision. E.g. Incision clean, dry, intact. NB: Dressing usually off on POD#2.
Breast and perineum exams if indicated and a nurse present.
Assessment
34 y.o. G2, now P2002, S/P NSVD (or Vacuum or Forceps-assisted delivery) (with 4th-degree laceration, with pre-eclampsia s/p Magnesium Sulfate)–doing well. PPD or POD#_____
PIH – on magnesium sulfate, no toxicity, (+) diuresis, BP stable, no HELLP, asx
PPH – EBL __; H/H___; symptoms; not orthostatic
Anemia: symptoms; H/H
(+) substance abuse
Plan
Anemia: Ferrous sulfate 325 mg tid po (may also give Colace and vitamin C)
Rhogam, if Rh-negative
Disposition
SVD pts go home in 24hrs if no complications.
GBS + moms wait for 48hrs for baby observation. C/S stay for 48hrs as well.
Discharge Meds:
Progestin-only pills, Depo-Provera, NSAIDs, and Narcotics
If giving estrogen-containing OCPs, tell pt not to start the pills until 3 weeks after delivery.