Labor History and Physical

Chief compliant: Contractions, rupture of membranes.

HPI: _year old Gravida (number of pregnancies) Para (number of deliveries).

Gestational age, last menstrual period, estimated date of confinement. Contractions (onset, frequency, intensity), rupture of membranes (time, color). Vaginal bleeding (consistency, quantity, bloody show); fetal movement.

Fetal Heart Rate Strip: Baseline rate, accelerations, reactivity, decelerations, contraction frequency.

Dates: First day of last menstrual period, estimated date of confinement. Ultrasound dating.

Prenatal Care: Date of first exam, number of visits; has size been equal to dates? infections, hypertension, diabetes.

Obstetrical History: Dates of prior pregnancies, gestational age, route (C-section with indications and type of uterine incision), weight, complications, length of labor, hypertension.

Gynecologic History: Menstrual history (menarche, interval, duration), herpes, gonorrhea, chlamydia, abortions; oral contraceptives.

Past Medical History: Illnesses, asthma, hypertension, diabetes, renal disease, surgeries.

Medications: Iron, prenatal vitamins.

Allergies: Penicillin, codeine?

Social History: Smoking, alcohol, drug use.

Family History: Hypertension, diabetes, bleeding disorders.

Review of Systems: Severe headaches, scotomas, blurred vision, hand and face edema, epigastric pain, pruritus, dysuria, fever.

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