Maternity Dismissal Summary

Complete Note, Obstetrics
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[textarea rows=50 columns=80 default="***#1 Spontaneous Onset of Labor/#1 Induction of labor for ***
Significant Issues During Pregnancy: ***Hyperemesis Gravidarum/Preterm Labor/Gestational Diebetes, diet controlled/Gestational Diebetes, medically controlled/Pregnancy Induced Hypertension/Social Issues/Suspected Substance Abuse/Late Prenatal Care***
Patient presented to L&D in active labor.
Patient presented to L&D for induction of labor.
She had Premature Rupture of Membranes.
Her cervix was ripened with Cytotec per vagina until an adequate bishop score was obtained.
Pitocin was used to augment her labor pattern.
She progressed to completely effaced and completely dilated and delivered a liveborn infant vaginally.
Vacuum was applied for assistance.
Forceps were applied for assistance.
Patient and infant were doing well immediately post-partum.
Laceration repaired using standard sterile technique with 3-0 Vicryl.
Laceration not present or sufficient to require primary closure. After criteria were met, she was transferred to the post-partum unit where she had an uneventful recovery. By the time of dismissal, she was able to ambulate and had normal bowel and bladder function.
Dismissal medications ***none/Tylenol 500 mg by mouth every 4 hours as needed for pain, not to exceed 4 grams in 24 hours/Ibuprofen 600 mg by mouth every 6 hours as needed for pain, not to exceed 3200 mg in 24 hours/Oxycodone 5 mg by mouth every 4 hours as needed for breakthrough pain/Colace 100 mg by mouth twice daily as needed for constipation/Prenatal vitamin one by mouth once daily***
You should refrain from placing anything into the vagina for six weeks. This includes but is not limited to tampons, intercourse and douching. If you should develop fever greater than 100.4 degrees Fahrenheit, abdominal tenderness or pain, or foul smelling vaginal discharge, these are signs of serious infection and you should call your doctor right away. Be aware for excessive breast tenderness, red streaks on the skin of the breast, or warmth or painful swelling of the breast. These are signs of an infection and you should call your doctor. For a short period after pregnancy, you are at increased risk for developing blood clots. If you should notice painful swelling of the leg, one leg warmer than the other, or if you notice shortness of breath at rest, you should contact your doctor. During the first few months after giving birth you are also at risk for postpartum depression. You should have received a handout with information about this condition. If you have not, ask your nurse or doctor. If you should notice any of the signs of depression listed in the handout, contact your doctor. Contact your doctor if you have any other concerns or questions. You should see your physician in 6 weeks for routine post-partum exam. You will need to schedule a follow up appointment with your primary doctor at six weeks after delivery. Call the appointment desk of your doctor's clinic to make this appointment as soon as possible."]
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