IOL Admit

SUBJECTIVE CHIEF COMPLAINT: Induction of labor

HPI:

Ms. [] is a [] yo G[]P[] at [] []/7 wga by [] wk US (EDD []) here for [elective/indication] IOL.

Reports []contractions and good fetal movement. Denies vaginal bleeding or leakage of fluid[change as necessary].

Pregnancy complicated by []. Prenatal care with [].

OB HISTORY:

G1 []date []SVD vs C/S ([] indications for C/S) [] term vs preterm []complications [] sex []largest baby weight [] baby complications (ex. NICU)

G2 []date []SVD vs C/S ([] indications for C/S) [] term vs preterm []complications [] sex []largest baby weight [] baby complications (ex. NICU)

G3 []date []SVD vs C/S ([] indications for C/S) [] term vs preterm []complications [] sex []largest baby weight [] baby complications (ex. NICU)

GYN HISTORY:

[]/[regular/irregular]/[]; denies hx of STIs and abnormal Pap smears

PMHx: []

PSHx: []

FAMILY Hx: No bleeding, clotting or genetic disorders. No birth defects. No colon, breast, or GYN cancers.

SOCIAL Hx: denies tobacco, alcohol or illicit drug use this pregnancy

MEDS: PNV

ALLERGIES: NKDA

ROS: all systems obtained and negative except as stated in above HPI

OBJECTIVE Vitals: []

GEN: NAD

HEENT: NCAT

CV: extremities warm and well perfused

PULM: normal work of breathing

ABD: soft, mild suprapubic tenderness, no CVA tenderness, no rebound/guarding []

PELVIC: Cervix 1/th/hi[***], adequate pelvis, EFW #[]

SKIN: normal turgor, no rash

EXT: no edema or calf tenderness

PSYCH: appropriate mood and affect

NEURO: AAOx3, CN2-12 grossly intact

Prenatal Lab Data: [] blood type [](Rh antibody) +/-, RI, RPRNR, HIV-, HBV-, GC/CT-, 1hr [], GBS- [edit as needed]

MDM: FHT: 145/mod/+acc/-dec [edit as needed] Toco: contracting q[] minutes (range) Limited bedside US: []presentation, [] (location of) placenta

ASSESSMENT [] yo G[]P[] at [] []7 wga by [] wk US here for elective IOL - clinically stable, FHT reactive and reassuring. 2. []

PLAN -Admit to L&D for delivery -R/B/A of delivery and blood transfusion discussed and consents signed -Routine labs, IVF and intrapartum monitoring -NPO except ice chips -[] as inductive agent -Will augment with Pitocin as needed ******delete if Pitocin is primary agent -Dispo: pending milestones postpartum