Case Author: Andrea Reimer, Class of 2021
Content Reviewer: Dr. Manpreet Sidhu, R2 Family Medicine, UHNBC
1. Familiarize yourself with the BC Antenatal form.
2. Propose an approach to conducting a consult for pregnant patients presenting to LDR
3. Perform a structured and concise consult presentation to an attending in OBGYN.
4. Identify the components of a delivery note.
5. Demonstrate an approach to writing SOAP notes for rounding on a patient in labour and post-partum
You are 3 weeks into your OBGYN rotation and are currently on the LDR portion of your rotation. It’s 3pm in the afternoon and so far it has been fairly quiet. Today’s date is April 17th. A couple people have come in for NST’s and you did one assessment earlier this morning for a patient that was subsequently sent home. You hear a patient and their partner approaching the front desk so you go out and meet them. The patient appears to be breathing fairly hard and has to stop and hold on to her partner as she appears to have what looks like a contraction. The patient tells you her name is Shannon Clark and she thinks she’s in labour. You quickly go and grab a LDR nurse to help you escort the patient into an assessment room.
While the nurse is doing her initial assessment, you look for the patients antenatal record and review her investigations on Powerchart. You find her antenatal records in the filing cabinet behind the nursing unit clerks (NUC) desk, which is alphabetically organized by last name.
1. Review the antenatal record and pull all the relevant information for your assessment before you go and talk to the patient.
The antenatal documents are something you may or may not have seen before in family practice. Basically, it is the document that GPs/ OBs fill out to track a patient's pregnancy. At one of their initial visits, they will complete a lot of the information on the first page, which includes a lot of demographics, PMHx, PSHx, and social history. There is also a section for the current pregnancy complications. The second page will include all of the prenatal lab results, info from each prenatal visit (including BP, urine sample, GA, fundal height, FM, presentation/position, and a narrative from the visit. At the bottom of the 2nd page, there is also a section to fill out the ultrasound results.
The antenatal that you have access to in LDR is not always the most recent or fully complete, so often you have to go onto PowerChart to find or confirm prenatal labs and ultrasounds. It is always a good idea to go and read the ultrasound reports for yourself on PowerChart and calculate your own gestational age from the dating scan.
Though ultrasound this is the recommended method for calculating GA, you should also know how to use the wheel (which can be found at the front desk at LDR), as this method may be used in exams/OSCEs and you may use it in your practice in the future.
After reviewing the antenatal, you feel like you have a fairly good overview of the patient's pregnancy. This is her first pregnancy to term and overall it has been quite uncomplicated. She has been having regular prenatal visits with her doctor and has gotten all of her prenatal lab work and ultrasounds. You note that the patient is O- blood type, but she received her first dose of Rhogam at the appropriate time. As well, the patient had a positive GBS swab.
The nurse is finished with their assessment so you go and chat with them. They tell you that it looks like this patient is definitely starting labour, but you should go and do an assessment for yourself. You go down the hall into assessment room 2 and introduce yourself to the patient and get the rest of the patient information. After chatting with Shannon and her husband, you have the following information
2. Propose an approach to conducting a consult for pregnant patients presenting to LDR
ID: 35 yo G3T0P0A2L0 woman at 39+6 GA by (US at 7+6) presenting with ?SROM and contractions.
HPI:
On and off cramping for last couple of days- “period cramps”
Increased pain this AM, then gush of fluid soaking underwear @ 1400- Clear w/ no blood or smell
Some episodes of urine leakage lately, but this is different
Since leaving house, pad has become soaked with more fluid
Regular contractions started early this AM @ 0500 and have been increasing every in intensity since then, now they are 5-6minutes lasting 30-40 sec, can’t talk through them.
Normal fetal movements
Some pink discharge, but no frank blood
Denies any symptoms of chest pain, shortness of breath, RUQ pain, or headaches. Some leg swelling, bit worse near end of pregnancy
Concerned about the pain of the contractions and would really like something for the pain.
History of Current Pregnancy: Some nausea during the first trimester, but she took Diclectin, which really helped.
Prenatal Labs
Blood type O+, received first dose of Rhogam on Jan 25th ( GA 28), antibody negative
Rubella 4.2, immune
Varicella immune
STI/HIV/syphilis negative
Hgb T1= 130 and T3=115
TSH = 2.0 (normal)
SIPS negative
GDM screen normal (6/5)
GBS positive
Ultrasounds
Sep 6/19 @ 7+6 GA which showed a single intrauterine pregnancy
Dec 14/19 @ 22+0 GA which showed an anterior placenta with no placenta previa, normal anatomy, normal growth and normal fluid levels.
OBHx
G3A2; Spontaneous abortion 2018 at 13 wks GA
Therapeutic surgical abortion in 2005
GyneHx: LMP on July 13/19. Previous paps normal, C&G negative
PMHx/PSHx: Has a history of depression treated on Celexa. Had an open appendectomy in 2000.
SocHx: Non-smoker, no EtOH or drug use during pregnancy. Works as a school teacher. Currently living with her husband Brent, her parents are planning on living with them for the first month after the baby is born.
FamHx: T2DM in maternal father
Medications: Celexa 10mg PO daily, PNV daily
Allergies: None
O/E
Vitals: BP: 130/82 HR: 83 RR: 12 O2: 99% on RA T: 36.9
Chest/Resp: Normal heart sounds, equal breath sounds bilaterally to bases with no adventitious sounds
Abdominal: Fundus measures 39cm. Leopold's maneuver shows the head is engaged in the pelvis with the back to the right side (this would usually just be drawn in the note) . Contractions are palpated as medium to strong strength and measured to last 45 seconds, with 3 in 10.
EFM: HR: 135 moderate variability, normal accels, no decels
Assessment: ?
Plan: ?
HPI: Purpose is to determine why did the patient come to LDR? For every patient, make sure to ask about:
Bleeding
Discharge/Fluid
Fetal Movements
Contractions
Pre-eclampsia Sx
HCP: Most of this will come from the antenatal, but confirm with patient; however, don’t ask excessive questions to labouring women (find a balance)
Prenatals: These will be on antenatal, but always check PowerChart because sometimes there will be labs that are not yet updated on the antenatal
Ultrasounds: Important information to include is:
Date and GA of each U/S
Dating scan to calculated estimated delivery date
Detailed scan: growth parameters, fluid, anatomy, placental location
Other scan- reason for them (eg: following fluid levels)
Rest of info (PMHx, PSHx…) can usually be found on antenatal, but confirm any pertinent info with patient
Physical Exam: When it comes to your role as a CC3 and the physical exam, you will only ever perform sensitive exams (eg: vaginal exam, sterile speculum) under the supervision of a nurse or physician. During your assessment, take note of:
Vital signs (mom and baby)
Listen to their heart and lungs
Feel of their abdomen (attempt Leopold's maneuver). If they are having contraction, be mindful not to poke and prod too much, but try and get a sense of the duration and strength of the contraction.
Now that you have finished doing the history and physical exam with the patient, you need to come up with an assessment and plan and phone the doctor to discuss it. Based on the patient’s presentation, it is likely that she has had spontaneous rupture of membranes and is now having fairly regular contractions. To really determine what stage of labour the patient is in, she needs to have a vaginal exam performed. The nurse goes into the room to perform the vaginal exam (VE), as well as collect a sample of the fluid to test it. The nurse comes back and tells you that the VE is as follows: The cervix was dilated 6cm, soft, mid-position, 75% effaced, and at 0 station. She has taken a nitrazine swab and it was positive. She has put some of the fluid on a slide to test for ferning, but while you are waiting for that, you decide to come up with a plan and phone the physician- Dr. Smith happens to be on-call for her group that day.
If the patient is in need of a vaginal exam and their water has not yet broke, you can ask the nurse if they can ask the patient if they are okay with you performing the exam, as well as the nurse to confirm. Once a patient’s water has broken, there is evidence to limit the number of vaginal exams to decrease rates of infection, so often you will not be given the opportunity to practice exams then.
3. Synthesize the information from your consult note and practice calling the physician to discuss your assessment and plan.
Example Call
“Hello Dr. Smith, this is X, the CC3 on Maternity. One of your patients, Shannon, a 35 yo G3A2 at 39+6 weeks by 7+6 week U/S and who is GBS (+) has shown up with query spontaneous rupture of membranes. She had a gush of fluid one hour ago that soaked her underwear, which she describes as clear and without blood. She’s having 3 in 10 contractions, lasting 30-40 seconds and palpated medium to strong. She has not had any frank bleeding, and has had normal fetal movements. The fetal strip shows a baseline of 135 bpm, moderate variability, accelerations present, and no decelerations. The nitrazine test was positive and ferning is pending. VE showed 6cm dilated. I believe she has had SROM and is in active 1st stage of labour. We will continue to monitor her progression, but we just wanted to make you aware that we will be admitting her, do you agree with that? Also, while we are waiting, the patient is having quite a bit of pain, so would we be able to give her something to help manage that? I think morphine 5mg IM would be appropriate.”
In Prince George, all patients will have a GP who is following their pregnancy. This information will either be on their antenatal, or they will tell you which “group” they are part of. The GPs work in call groups, so even if a patient sees a certain GP in office, they may not be the GP that delivers them, depending on who is on call. The call groups can be found on the white board in the nursing station (across from the med room). Always double check who is on call that day, and it doesn’t hurt when you call to start your call with “Hi Dr.___, this is _____, are you on call for Dr.____ patient’s today?”. That way, if you have the wrong person, you don’t go into your full assessment with the wrong person.
When it comes to presenting your assessment, you want to keep it short and to the point. Remember, this could be at 2am when you are calling someone and they may be half asleep, so keep it to the point. Touch on the main components of the HPI (bleeding, contractions, fetal movement, fluid) and any other pertinents (eg: GBS status, fetal anomalies). Then at the end of the call give your assessment in one short sentence and what you want to do about it. Why are you calling them- do they need to come in? If so why? Or do you just need a phone order confirmed?
Dr. Smith agrees that this is a pretty convincing story SROM and it sounds like the patient is fairly progressed along. She wants her to be moved into a labour room. She happens to already be in the hospital seeing a patient on the internal ward, so she will be down in 5 minutes. While you are waiting for her to arrive, she wants you to think about what order sets should be started for this patient. Given that the patient is GBS positive, she must be started in antibiotic prophylaxis. The typical prophylaxis for GBS is penicillin 5MU IV given (ideally) at least 4hrs prior to delivery, then 2.5MU IV q4h until delivery or labour stops. From reviewing the prenatal, you know that Shannon does not have any allergies, so you can use penicillin. You fill out this order set and have it ready for Dr. Smith to sign off on when she arrives.
LDR has A LOT of different order sets (Eg: GBS ABx prophylaxis, oxytocin protocol…) It is a good idea during your first couple days on LDR to familiarize yourself with some of these forms. They can be found in the shelves behind the NUC’s (nursing unit clerk) desk. A legend of the order of the forms can be found on the side of the shelf.
You are on call this evening, so you will be able to follow Shannon overnight. Around 7pm, you are alerted that Shannon reports feeling a lot more pressure. You call Dr. Smith and she says she will be in right away to come and assess Shannon. While you are awaiting, you go and talk to Shannon. She says that she is coping quite well with any pain with the help of her husband and LDR nurse, as well as using nitrous during the contractions. She has just noticed that there feels to be a lot more pressure now than there was previously. She hasn't had any frank bleeding and is still feeling baby move. IA shows FHR= 140, moderate variability and some accels, no decels. Her contractions are about 4 in 10, lasting 45-60 seconds, and palpate strong. Shannon’s vitals are as follows: BP: 130/80 HR: 95 RR: 16 O2: 100% on RA, T: 37.0 Dr. Smith arrives and performs a VE to assess Shannon’s progress. She reports that she is 8cm dilated, anterior, soft, fully effaced, and at 0 station. You write a labour progress note to document this new information.
When it comes to following your patients in LDR, it is vital that you are PRESENT. You are not likely to be called if you aren’t there. If you have a patient who is labouring, take ownership of them and make sure you are checking in on them every couple hours. This may even mean, if you are on call, waking up throughout the night to come down and check on your patients progress.
Every time you check on your patient, make sure you write a note to track their progress. Important things to comment on in your note include how the patient is coping, what they are using for analgesics (if any), any changes in the bleeding, fluid, fetal movement, pressure. For physical exam, common and mom and baby vitals. If EFM is going, you can include the appropriate values from there. If not, the nursing partogram will have vitals from intermittent auscultation (IA). If a VE is performed, document it, as well as the contraction pattern.
4. Write a progress note in SOAP format to document the patient's progression in labour
ID: 35 yo G3A2 woman at 39+6 GA admitted for SROM
S: Patient coping well, has epidural for pain management. No bleeding, normal fetal movement. Reports increasing pressure.
O/E
VS: BP: 130/80 HR: 95 RR: 16 O2: 100% on RA, T: 37.0
IA: FHR = 140, moderate variability, accelerations, no decels
Contractions: 4/10 lasting 45-60 sec, palpate strong.
VE: 8cm dilated, anterior, soft, fully effaced, and at 0 station
Assessment: 35 yo G3A2 woman at 39+6 GA in active labour and progressing well, fetal status is reassuring.
Plan: Re-assess in 1 hour to check progression, continue to monitor fetus with IA.
Shannon continues to labour with increasing pelvic pressure and when she is re-checked in 1 hour, she is still not fully dilated. However, about 2 hours later at 22:10, she again is feeling a lot of pressure and an urge to push, so Dr. Smith re-checks her. She is now fully dilated and ready to start pushing. With the support of her husband and LDR nurse, Shannon delivers a baby girl @ 23:38pm
5. Review the main components of a delivery note.
ID: 35 yo G3T0P0A2L0 woman at 39+6 GA by US at 7+6 admitted for SROM.
History of Current Pregnancy: (copied from assessment note- Prenatals, U/S, complications)
Stage I: Patient admitted on April 17th at 15:00 for SROM with clear fluid. She was dilated 6cm at this point. Her labour progressed and no augmentation was required. The patient used nitrous for pain control. She 7.5MU penicillin IV total for a positive GBS swab at 36 weeks. This stage lasted 7 hours and 10 minutes.
Stage II: The patient was fully dilated at 22:10 and pushed for 1 hour and 28 minutes with good maternal effort. FHR via IA was reassuring throughout. A newborn female was delivered at 23:38 in OA position. There was a nuchal cord present that was easily slipped over the head. The body was delivered without difficulty. Oxytocin 10 U IM given at delivery of shoulders. Cord clamping at 2 minutes. Baby weighed 3345g and had APGARs of 8,9.
Stage III: Placenta delivered at 23:45 with gentle cord traction.This stage lasted 8 minutes. It was intact, had central cord insertion and a 3-vessel cord. The perineum was intact with no lacerations. EBL was 400cc.
Baby: A healthy newborn F was born on April 17th at 23:38. She was delivered in an OA position with a nuchal cord, which was easily slipped over the head. There was no shoulder dystocia. APGARs were 8,9 and no resus was required. Baby weighed 3345g, was 46cm long and had a HC of 34cm. Newborn exam was normal (document full exam here- refer to peds). Vitamin K and erythromycin prophylaxis were given.
Summary: 35 yo G3A2 woman gave birth to a newborn female by SVD at 39+6 GA. There were no complications. Mom and baby are both doing well and will stay in LDR overnight for routine postpartum care.
When it comes to writing your delivery note, it is a good idea to have a template on your phone that you can use as you write it, as there is a lot of information to be included and it’s easy to miss something. Much of the information you will be able to add from:
The nursing labour partogram (which is a record of the patient's labour). It will have a lot of the times of significant events (eg: when fully dilated, time of baby delivery, placenta delivery).
The newborn record has a lot of information you need for the babies section of the delivery note, such as the APGARs, measurements, and newborn exam.
This is an example of how a delivery note can sound. It is a good idea to have the physician review your note after you have written it before dictating- they give a lot of good feedback.
It’s now 2am by the time you have finished all of the paperwork and dicated your delivery note, so you head up to the student lounge to get a bit of sleep. You’re able to sleep through the rest of the night and wake up at 7am and head back down to LDR to go and round on Shannon.
For rounding in LDR, it is a good idea to listen to the nursing hand over for your patient to pick up any details that happened overnight. They use a lot of terminology and go fairly quick, so it can take a couple weeks before you start getting more comfortable with their format of handover. Make sure to review the patient's vitals and nursing notes before you go and talk to them. If the patient is asleep, do not wake them up. Document that they were asleep and write in whatever information you can from the nursing notes (with “as per nursing notes” added). You won’t be faulted for not waking up a sleeping mom and baby, but you will if you don’t document that you at least tried to round on them. When it comes to rounding for OB, depending on the reason for your rounding, post C-section vs. post SVD, your focus is a bit different.
Post C-section: this is from the perspective of the OBGYN/surgeon, so you want to be looking for any complications from the surgery/pain management. The OBs do not follow the babies (the GPs do), so you do not need to write anything about them in your note, but it’s a good idea to at least ask how the baby is doing when you go in to round.
Post Vaginal Delivery: this is generally from the perspective of the GP, who is following mom and baby. Your note can still be focused more on mom, but if there are concerns about baby, definitely include them in/ short note about how they are doing. With your note, you want to think about the complications of delivery (prolonged bleeding, if they had significant tears- the impact of those, pain management), and comment on that
Generally, patients post vaginal delivery will typically stay 1 day postpartum, and patients post C-section will stay around 3 day.
6. Review a progress note in SOAP format to document your patient’s progress post-partum.
ID: PPD#1 from SVD with no complications.
(S): DAT, normal voiding/ flatus, no BM yet. Tylenol for pain, controlled. BF initiated. Tired. Normal lochia, no clots/ gushes.
(O): BP 128/76 HR: 69 RR: 14 O2:100% on RA T: 36.8.
Abdomen: soft, no peritonitic signs. Fundus is firm/ below umbilicus. Rubra lochia.
(A/P): PPD #1 doing well with no concerns. Likely discharged today with follow-up with Dr. Smith in one week.
Well done! You’ve assessed a patient, followed them through their labour and delivery and rounded on them.