OnExam

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)

Current Pregnancy

  • Estimated date of confinement (EDC)
  • Currently # of weeks
  • Screening, US, tests that have been done since last visit - results
  • Symptoms pregnancy
    • Characterize patient's symptoms
    • Fetal movements
      • Quickening = Sensation of fetal movement (begins 18-20 weeks in primigravidas and 14-16 weeks in multigravidas)
    • Nausea, vomiting
    • Lower abdominal pain, groin pain
    • Vaginal discharge - colour consistency (leucorrhea = physiologic mily white vaginal discharge)
    • Peripheral edema
    • Weight changes
    • Breast tenderness and tingling
    • Fatigue
    • Abdominal striae
    • Heartburn
    • Constipation
    • Backache
    • Urinary frequency
  • Red flags
    • Amniotic fluid leakage, loss of mucous plug
    • Painful regular contractions
    • Vaginal bleeding
    • Decreased or absent fetal movements
    • Fever
    • Hypertension
    • >1+ protein in urine (proteinuria)
    • Dysuria
    • Consistent weight loss
    • Excessive vomiting
  • Mood, how the patient is coping
  • Effect of pregnancy on daily activities (e.g. ability to work)
    • Does patient need time off work
    • Does patient need Diclectin (for nausea/vomiting)

Social History (Sx)

  • Fears or concerns about this pregnancy
  • Is the patient willing to continue pregnancy to term
    • If yes, patient's preference of obstetrical care - family physician, Obstetrician & Gynecologist, midwife
    • If no or unsure, provide information about abortion (e.g. timeline), ask the patient to think about her options at home, and have a further discussion at the next appointment
  • Partner
    • 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
  • Parenting concerns
  • Nutrition
  • Physical activity

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
  • Alcohol consumption (see alcohol consumption screening tools)
    • During pregnancy, before pregnancy
    • There is no established "safe level" of alcohol durng pregnancy
  • Recreational drug history (see Recreational Drug History)
    • During pregnancy, before pregnancy
  • Caffeine - amount
  • Sources of stress
  • If smoking, alcohol, or recreational drugs during pregnancy
    • Inform patient of potential risks
    • Discuss possibility of reducing or eliminating use in a non-judgmental, supportive manner

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.

Plan

  • Screening, US, tests to be done (depends on gestational age)
    • See Ontario antenatal record available at http://www.fammedref.org/wp-content/uploads/2011/12/Ontarioantenatalrecord2005.pdf
  • Discuss birth plan
  • Plan for maternity leave
  • Next follow-up visit
    • Every 4 weeks up to 28 weeks, then every 2 weeks up to 36 weeks, then every week until delivery. The appointments may alternate between family physician and Obstetrician & Gynecologist. Postnatal visit with Obstetrician & Gynecologist is usually 6 weeks after delivery

References

  • Link to Ob/Gyn Reference page