Postnatal Physical Exam - Labour

Obstetrics and Gynecology

Labour: onset/duration
<Mrs. O'Connor's>
labour began with
<painful uterine contractions ... minutes apart, increasing in duration and frequency>
at
<1:00 am on Tuesday morning>
followed by
<a show and spontaneous rupture of membrane || a show but no spontaneous rupture of membrane || a spontaneous rupture of membrane || neither show nor spontaneous rupture of membrane>.
She was admitted to hospital at
<8:45 am>
by which time her cervix had dilated to
<3 cm>.

She was admitted to the antenatal ward. She was examined by the
<midwife>
and her cervix was found to be effaced and cervix dilated to
<7cm>.
A diagnosis of labour was made, and she was sent to delivery.

The first stage lasted for
<2 hours [some hospitals specify labour as time from admission to labor unit] || 9 hours>,
the second stage lasted for
<20 minutes>.

She was given
<10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.

Labour: analgesia
For anaglesia, she first tried
<Nitrous oxide by inhalation>,
but subsequently requested
<an epidural at 8:45am>
which
<gave adequate analgesic relief for the duration of labour>.

Labour: fetal signs
The liquor was
<clear throughout || green throughout || clear, then green>.

Optionally:
<a cardiotocograph was connected during the labour, and intermittent auscultation was performed>.

Electronic fetal monitoring
<was not performed || <was performed due to:
<prolonged labor || suspected small for dates || prematurity || APH>>.
Fetal blood sampling
<was not done || was done to look for ...>

Labour: delivery/infant
The delivery was
<spontaneous vaginal || vaginal instrumental || breech || Cesarean section>with
<a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches || no tears or episiotomy required>at
<2:45pm>.
<Claire's>
condition at birth was
<normal, crying immediately at birth || ...>,
and weighed
<3 kg>.
A pediatrician
<was || was not>present at the time of delivery.
<Claire>
<was admitted to the neonatal unit || went with her mother to the postnatal ward>.