CS III Women's Health Documentation

What does G stand for in GPA?

Gravidity: the total number of pregnancies, regardless of outcome; include the current pregnancy.

What does P stand for in GPA?

Parity: the number of births delivered after 24 weeks, regardless of outcome. Twins count as one birth for parity.

What does A/Ab stand for in GPA?

Abortions: the number of pregnancy losses before 20 weeks.

What is a nulligravida?

Gravida 0: a patient who has had no pregnancies.

What is a primigravida?

Gravida 1 (G1): a patient with one pregnancy.

What is a multigravida?

A patient in a second or subsequent pregnancy.

What is a nullipara?

A patient with no viable offspring.

How is G2P2 interpreted?

Two pregnancies, both delivered after 24 weeks.

How is G2P0 interpreted?

Two pregnancies, neither survived to a gestational age of 24 weeks.

How is G2P1 interpreted?

Two pregnancies including the current pregnancy, with one delivery after 24 weeks.

How can G1P0 be interpreted?

One pregnancy that is still ongoing OR one pregnancy that did not survive to 24 weeks.

What does T stand for in TPAL?

Term pregnancies, defined in the study guide as ≥37 weeks. Twins count as one term pregnancy.

What does P stand for in TPAL?

Preterm pregnancies, defined as 20-37 weeks; may be alive or stillborn. Twins count as one preterm pregnancy.

What does A stand for in TPAL?

Abortions before 20 weeks.

What does L stand for in TPAL?

Living children. Multiples count individually.

TPAL example: 3 term pregnancies, 1 preterm pregnancy, 2 abortions, 4 living children = ?

TPAL 3-1-2-4.

GPA/TPAL example: 2 term pregnancies, 1 preterm pregnancy, 1 abortion at 11 weeks, 3 living children = ?

GPA G4P3A1; TPAL 2-1-1-3.

GPA/TPAL example: 0 term pregnancies, 1 preterm twin pregnancy, 2 living children = ?

GPA G1P1A0; TPAL 0-1-0-2.

What 5 factors make up the Bishop score?

Cervical dilation, cervical position, effacement, fetal station, and cervical consistency.

What does cervical dilation describe in the Bishop score?

How far the cervix has opened, from 0 to 10 cm.

What does effacement describe?

Shortening/thinning of the cervix, from 0% (normal) to 100% (paper-thin).

What does fetal station describe?

The fetal head's position relative to the maternal ischial spines.

What do negative station numbers mean?

The fetal head is above the ischial spines.

What do positive station numbers mean?

The fetal head is below the ischial spines.

What cervical position is most favorable in the Bishop score?

Anterior rather than posterior.

What cervical consistency is most favorable in the Bishop score?

Soft rather than firm.

Bishop score 0: what are the findings?

Closed dilation; posterior cervix; 0-30% effacement; station −3; firm consistency.

Bishop score 1: what are the findings?

1-2 cm dilation; mid-position cervix; 40-50% effacement; station −2; medium consistency.

Bishop score 2: what are the findings?

2-3 cm dilation; anterior cervix; 60-70% effacement; station −1 or 0; soft consistency.

Bishop score 3: what are the findings?

5-6 cm dilation; 80% effacement; station +1 or +2. No position or consistency value is listed for score 3.

What does APGAR stand for?

Activity, Pulse, Grimace, Appearance, Respiration.

At 1 minute, what does an Apgar score of 0-4 mean?

Severe depression; requires resuscitation.

At 1 minute, what does an Apgar score of 5-7 mean?

Some nervous system depression.

At 1 minute, what does an Apgar score of 8-10 mean?

Normal.

At 5 minutes, what does an Apgar score of 0-7 mean?

High risk for CNS or other organ dysfunction.

At 5 minutes, what does an Apgar score of 8-10 mean?

Normal.

Why are many neonates Apgar 9 rather than 10 at 1 or 5 minutes?

Acrocyanosis: distal body parts are blue while the rest of the body is pink; typically normal and lasts

APGAR Activity score 0/1/2?

0 = absent; 1 = flexed arms and legs; 2 = active.

APGAR Pulse score 0/1/2 according to the study guide table?

0 = absent; 1 =

APGAR Grimace score 0/1/2?

0 = floppy; 1 = minimal response to stimulation; 2 = prompt response to stimulation.

APGAR Appearance score 0/1/2?

0 = blue/pale; 1 = pink body with blue extremities; 2 = pink.

APGAR Respiration score 0/1/2?

0 = absent; 1 = slow and irregular; 2 = vigorous cry.

What should the first sentence of a gynecologic H&P include?

Age, parity, LMP, and the presenting problem.

What belongs in the menstrual history of a GYN H&P?

Menarche, duration of flow, cycle length, abnormal bleeding, and PMS.

What belongs in the gynecologic history of a GYN H&P?

Breast history, last mammogram, prior gynecologic surgery, infertility history, DES exposure, date of last Pap smear, and history of abnormal Pap smears.

What should be asked in the contraceptive/sexual history?

Current and past contraception, sexual activity, partner gender, lifetime partners, new partners in the last 3 months, condom use, and history of sexual abuse.

What family-history points are emphasized in a GYN H&P?

Usual family history plus mother's gynecologic history and family breast history.

What social-history points are emphasized in a GYN H&P?

Usual social history plus marital/partner status, age/health of children, support system, and IPV.

What GYN/GU ROS items are specifically listed?

Abnormal discharge/bleeding, dyspareunia, abdominal/pelvic pain, dysuria, hesitancy, urgency, incontinence, change in bowel habits, and rectal bleeding.

What extra physical-exam systems are emphasized in a GYN H&P?

Thyroid, breast, and pelvic examinations.

What should be inspected on breast exam?

Symmetry, skin dimpling, nipple discharge, and erythema.

What should be palpated on breast exam?

Tenderness; cysts/masses with location and size; and axillary nodes.

What should be inspected on external genital exam?

Hair distribution, edema, erythema, lesions, discharge, and cystocele.

What should be palpated on external genital exam?

Tenderness and the Skene and Bartholin glands.

What is inspected during the speculum portion of the internal genital exam?

Vaginal walls and cervix for color, discharge, lesions, bleeding, and atrophy; document the cervical os for size and shape.

What is assessed during the bimanual exam?

Cervical size/shape/mobility, cervical motion tenderness, uterine/ovarian enlargement, masses, tenderness, and adnexal masses/tenderness.

What should the prenatal H&P HPI focus on?

Present pregnancy, LMP, symptoms such as nausea/vomiting, weight gain, edema, vaginal bleeding, and medication use.

What belongs in the obstetric history of a prenatal H&P?

Gravidity/parity, previous prenatal care, details and complications of pregnancies/deliveries, and ectopic pregnancies.

What PMH items are emphasized in a prenatal H&P?

Immunizations; DM, HTN, CAD, autoimmune, psychiatric, thyroid disease; medications/allergies; gynecologic and other surgery/hospitalizations; abnormal Pap; DES exposure in utero.

What social-history exposures are emphasized in a prenatal H&P?

Tobacco, alcohol, illicit drugs, and IPV.

What maternal/prenatal genetic screening topics are specifically listed?

Thalassemia, Down syndrome/trisomy 21, Tay-Sachs, sickle cell disease, autism, recurrent pregnancy loss/stillbirth, and birth defects.

What is the routine prenatal visit schedule from 8-28 weeks?

Every 4 weeks.

What is the routine prenatal visit schedule from 28-36 weeks?

Every 2 weeks.

What is the routine prenatal visit schedule from 36 weeks until delivery?

Every week.

What routine vitals/tests are checked at prenatal visits?

Blood pressure, weight, and urine for protein/glucose.

What is the fundal-height rule after 24 weeks?

Fundal height should match the number of weeks pregnant.

What should be documented for fetal heart tones?

Location and rate.

What common concerns should be addressed at routine prenatal visits?

Nausea/vomiting, sleep difficulty, lower-extremity edema, dysuria, contractions, fetal movement, and bleeding.

What is an ongoing administrative task at every routine prenatal visit?

Check that labs and tests are up to date.

What should the HPI of an admission-to-L&D note include?

Age, G/P, gestational age, painful contractions and duration, ruptured membranes, vaginal bleeding, fetal movement, and pertinent headache/visual changes suggesting preeclampsia.

What dating criteria should be reviewed in an L&D admission note?

LMP, EDC, sonograms, and exams, noting whether they support or disagree with each other.

What prior history is reviewed in an L&D admission note?

Each pregnancy; menstrual/GYN surgery/abnormal Pap history and treatment; PMH especially HTN, DM, asthma; family history; social history; meds/allergies; ROS.

What is emphasized in the L&D admission physical exam?

Vitals, thyroid, lungs, CV; abdomen with FHT, Leopold maneuvers and tenderness; pelvic exam with cervix and membranes.

What diagnostic tests are reviewed in an L&D admission note?

Prenatal and current labs plus prenatal sonograms.

What is a standard assessment statement for active labor?

"__-year-old woman, G_P_, __ weeks in active labor."

What are the listed standard L&D admission plan orders?

Admit to L&D; NPO except ice chips; IV D5LR at 125 cc/hr; IV penicillin G if GBS positive; continuous fetal monitoring; CBC, T&C, RPR; anticipate NSVD.

What belongs in the Subjective part of an ongoing labor SOAP note?

Patient-reported intensity and frequency of contractions.

What belongs in the Objective part of an ongoing labor SOAP note?

Vitals; FHT baseline/variability/accelerations/decelerations/monitor readings; cervical dilation/effacement/station; DTR if on magnesium; new lab results.

What is a typical Assessment in an ongoing labor SOAP note?

Age, G/P, gestational age, active labor; progressing well; reassuring FHTs; adequate contraction pattern.

What is the typical Plan in an ongoing labor SOAP note?

Anticipate vaginal delivery.

How is the delivery note formatted according to the study guide?

Paragraph form; each listed bullet is written as one sentence.

What demographic opening belongs in a delivery note?

Age, gravida and now-parity, and that the patient was admitted for active labor.

What labor progression is stated in a standard delivery note?

Progressed spontaneously to the second stage of labor.

What delivery details are included in a standard delivery note?

Duration of pushing; viable male/female infant; ROA; delivery over intact perineum.

How should a nuchal cord be documented in the delivery note?

State it was not found, or that it was reduced before delivery of the shoulders.

What neonatal score must be included in a delivery note?

Apgar scores.

How is the placenta/cord documented after vaginal delivery?

Placenta delivered spontaneously and intact with a 3-vessel cord.

How are lacerations documented in a delivery note?

State no perineal, vaginal-wall, or cervical lacerations, or describe any episiotomy repair.

What uterine/bleeding statement belongs in the delivery note?

Uterus firm with no active vaginal bleeding.

What EBL is listed for an uncomplicated vaginal delivery note?

How does the delivery note close regarding maternal/neonatal status?

No complications; mother and baby nursing with skin-to-skin.

What maternal information belongs in a delivery report?

Name, G/P, gestational age, pertinent labs, and pertinent PMH.

What timing details belong in a delivery report?

Date/time contractions began; complete hours/minutes of first and second stages; time of delivery.

What neonatal information belongs in a delivery report?

Sex, weight, length, head circumference, chest circumference, pediatrician, presentation, position, amniotic fluid, Apgars, delivery-room care, airway/O2.

What placenta/cord/uterus details belong in a delivery report?

Method of delivery, intact status, number of cord vessels, abnormalities during birth, and uterine tone.

What additional delivery-report items are listed?

Delivery procedures, lacerations/repairs, and condition of the mother after delivery.

What are the key header elements of a C-section operative note?

Date/time; pre-op diagnosis; post-op diagnosis; procedure; surgeon and first assistant; anesthesia type and anesthesiologist.

What pre-op diagnosis example is given for a C-section operative note?

Pregnancy at term with failure to progress (FTP).

What should be added to the post-op diagnosis after C-section?

Same diagnosis plus anything newly diagnosed during surgery.

What intraoperative quantities are documented in a C-section op note?

Complications, EBL, fluids (example 1500 cc LR), and urine output with clear urine at end of procedure.