Postnatal Exam - Introduction

Obstetrics and Gynecology

Introduction
This is
<Mrs. || Miss || Ms.>
<O'Connor>,
a
<34 year old>
<secretary>,
from
<Dublin>,
who delivered her
<first>
baby
<two>
days ago at
<40>
weeks gestation, a
<boy || girl>
named
<Clair>
by
<spontaneous vaginal || assisted vaginal || breech || Cesarean section>
delivery,
<is || is planning>
<bottle || breast>
feeding, and
<both baby and mother are well>.

Past history
<She is a longterm diabetic, which is successfully managed with insulin>.
<She had a PDA repair in 1969>.
<In her Obstetric history, her prior child had congenital deafness>.
<Her mother and 3 sisters all had at least one post-partum hemorrhage>.

<She smoked one pack a day since she was 16, but since finding out she was pregnant, she has limited herself to one or two cigarettes per week>.
<Before her pregnancy she consumed 3 units of alcohol per week, but she has not taken any alcohol since finding out she was pregnant>.
<She is not on any medications, and she has no allergies>.

Current pregnancy
First day of her LMP was
<November 20th>
and she is
<certain || uncertain>
of her dates, because
<she wrote it in her diary || remembers the time of conception>.
By Nagele's rule, her estimated date of delivery is
<August 27th>.
An ultrasound scan at
<13 weeks>
<confirmed her dates>.

Her pregnancy was
<uneventful, except for a .... at 35 weeks gestation>.

She is Rhesus
<positive || negative>
and
<is || is not>
Rubella immune.