Documenting obstetrics and gynaecology care
Antenatal visit notes, letters to the GP, operation notes and postnatal discharge summaries.
A 28-week antenatal visit
Twenty-eight plus two, second pregnancy, previous normal vaginal birth.
BP 116/72, urine clear. Fundal height 28 centimetres, fetal heart 144, good movements.
GTT fasting 4.6, one hour 8.9, two hour 7.2, normal.
O negative, antibody screen negative. Anti-D 625 units today, again at 34 weeks.
Hb 108, ferritin 14. Start oral iron, 100 mg elemental daily, alternate days if it upsets her stomach.
Whooping cough vaccine given today. RSV vaccine offered, she'll have it at 32 weeks. Flu vaccine was given at booking. Next visit 32 weeks.
Gestation
28+2. G2P1, previous SVD.
Examination
BP 116/72. Urinalysis NAD. SFH 28 cm. FHR 144. Fetal movements normal.
Results
75 g OGTT: fasting 4.6, 1 h 8.9, 2 h 7.2 mmol/L. Normal. Group O Rh negative, antibody screen negative. Hb 108, ferritin 14.
Plan
- Anti-D 625 IU given today; repeat at 34 weeks
- Oral iron, 100 mg elemental daily (alternate days if GI upset)
- Pertussis (dTpa) vaccine given today
- RSV vaccine (Abrysvo) offered, to be given at 32 weeks
- Influenza vaccine given at booking
- Review at 32 weeks
Across the pregnancy and after
- Antenatal visit notes
- One per visit, so the 32-week note opens with the anti-D and iron already on it.
- Letter to the GP
- After the booking visit and at each change: results, vaccines given, anti-D dates and anything the practice is asked to do.
- Operation note
- For a caesarean or a gynaecological procedure, dictated in theatre.
- Discharge summary
- Mode of birth, blood loss, the baby's details, VTE prophylaxis, contraception discussed and the six-week review.
