On Exam After Birth

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Ob/Gyn: Postnatal History
Identifying Information
Gather the patient's general identifying data.

Gravidity and parity (e.g. G4T1P1A1L2)
Gravidity = total number of pregnancies, regardless of outcome (includes current
pregnancy, spontaneous & therapeutic abortions, ectopic pregnancy, hydatidiform moles,
stillbirths, live births)
Parity = number of various pregnancy outcomes
T = number of term deliveries (≥37 weeks)

P = number of premature deliveries (<37 weeks)
A = number of abortions (both spontaneous and therapeutic)(<20 weeks and/or 500g
fetal weight)
L = number of living children
Note: Twins count as 1 instead of 2 for gravidity (e.g. a female who is currently not
pregnant, but has 2 living twins carried to term would be considered G1T2P0A0L2)
Deﬁnitions
Nulligravida: a woman who is currently not pregnant and has never been pregnant
Nullipara: a woman who has never completed a pregnancy that lasted for more than
20 weeks
Primipara: a woman who has had 1 live birth or stillbirth (estimated gestation >20
weeks)
Note: Twins count as 1 live birth or stillbirth
Multipara: a woman who has had ≥2 live births or still births (estimated gestation >20
weeks)
Review Pregnancy and Delivery
# weeks postpartum
Delivery date, place of birth
Baby's sex
Gestational age (# of weeks)
Birth weight
Length of labour
Type of delivery - vaginal delivery, C section
Anesthesia used (e.g. epidural, spinal)
Complications
Problems during pregnancy (e.g. gestational diabetes, hyperemesis gravidarum)
Women who had gestational diabetes should be tested to ensure that they have not
advanced to frank diabetes
Problems during delivery (e.g. use of forceps, tears, post-partum hemorrhage, shoulder
dystocia)
Problems with the baby
Postpartum History
Review baby's health, any concerns

Breastfeeding vs bottle-feeding
Any concerns
Postpartum medical concerns
Bladder function
Bowel function
Perineal discomfort
Lochia/menses
Mood, emotional problems, postpartum depression
Sexual activity
Single or have a partner
Sexual activity and orientation
"Have you been sexually active since childbirth?"
Problems/concerns about sexual life
Pain during intercourse (dyspareunia)
Characterize patient's pain

Certain positions that cause pain vs all positions cause pain
FIFE
Alcohol
Experienced any unwelcome sexual advances, perhaps long ago in childhood
Bleeding during or after intercourse (postcoital bleeding)

Contraception
Current method of birth control
How often patient uses birth control

Satisfaction with current method
Planning to have any more children - when

If patient is certain that she does not want future children, counsel about tubal ligation
Questions/concerns about birth control methods
Counsel about options if applicable
Past Medical History (PMx)

Past and present medications
Prescriptions
Over the counter medication
Pain medications
Herbal medication
Pap
Last Pap test - when, results
Pap guidelines: every 3 years starting the age of 21 until the age of 70. If the pap
result is abnormal, the testing is done more frequently.
Any abnormal Pap tests in the past - when, investigations done
Social History (Sx)
Partner
Relationship status (single, relationship, common law, married)

Living arrangements
Is the partner supportive
Relationship problems
Intimate partner violence (IPV) (all women are at risk, most do not disclose IPV unless asked)
Do you feel unsafe or afraid at home
Are you afraid of your partner or anyone else
Have you ever been hit, kicked, punched, or hurt by someone (if yes, who)
HITS
H: How often does your partner hit you

I: How often does your partner insult or talk down to you
T: How often does your partner threaten you
S: How often does your partner scream or curse at you
Thank you for trusting me with this information and expressing your concern about safety.
Would you like for me to connect you with any legal assistance, counseling, shelter, or other
services?
Offer domestic violence hotline phone number
Social support
Coping with child care, parenting concerns
Substance Use
Smoking: during pregnancy, before pregnancy
Amount of cigarettes/packs per day (1 pack= 25 cigarettes), how many years has been
smoking for
Written in pack-years (# of pack years= # packs/day x # of years)
If ex-smoker: how long smoked for, amount/day, when quit, congratulate on quitting
If current smoker, counsel about smoking in future pregnancies, advise to quit, provide
resources
Alcohol consumption (see alcohol consumption screening tools)

Counsel about alcohol use in future pregnancies
Recreational drug history (see Recreational Drug History)
If currently takes recreational drugs, counsel about recreational drug use in future
pregnancies, advise to quit, provide resources
Caffeine - amount
Sources of stress
Medications
Gather complete list, including particularly relevant drugs such as:
Anticonvulsants (Valproic acid)

Pain meds (Gabapentin, opioids)
Psychiatric drugs
Vitamins
Allergies
Note allergies and ensure they concord with those listed in the EMR
Immunizations
Note immunization history as described in the immunization history section.
Follow-Up and Advice Regarding Future Pregnancies
Rubella immune - if patient is rubella susceptible, advise about rubella immunization before next
pregnancy
Preconceptual folate - advise to start 3 months before future pregnancy
References
1. Antenatal record. http://www.fammedref.org/wp-

content/uploads/2011/12/Ontarioantenatalrecord2005.pdf. Accessed November 4, 2013.
2. Bernstein HB, Weinstein M. Normal pregnancy & prenatal care. In: Decherney AH, Goodwin TM,
Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed.

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OnExam

Ob/Gyn: Postnatal History

Gather the patient's general identifying data.

T = number of term deliveries (≥37 weeks)

Review Pregnancy and Delivery

Review baby's health, any concerns

Characterize patient's pain

Bleeding during or after intercourse (postcoital bleeding)

How often patient uses birth control

Planning to have any more children - when

Past Medical History (PMx)

Social History (Sx)

Relationship status (single, relationship, common law, married)

H: How often does your partner hit you

Smoking: during pregnancy, before pregnancy

Alcohol consumption (see alcohol consumption screening tools)

Gather complete list, including particularly relevant drugs such as:

Anticonvulsants (Valproic acid)

Note immunization history as described in the immunization history section.

Follow-Up and Advice Regarding Future Pregnancies

1. Antenatal record. http://www.fammedref.org/wp-

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