Labor and Delivery Admission History and Physical

Date/Time of Encounter: [Encounter date and time]

Date/Time of Note: [Note date and time]

Author/Role: [Author name and role]

Service: [Service or team]

Location: [L&D / triage / antepartum]

Sources of History: [patient / support person / prenatal records (source: [clinic/facility]) / outside records (source: [facility])]

History Limitations: [Limitations to obtaining complete history] (Only include if applicable; e.g., records unavailable, history limited by pain, interpreter used with language and modality specified.)

Chief Concern

[Immediate obstetric reason for admission in one sentence] (State clearly and concisely; may include brief patient quote.)

History of Present Illness

Pregnancy dating: [G/P], [gestational age today], EDD [date], dating by [LMP / ultrasound-adjusted with timing if known], [singleton / multiple]. (If dating unknown, state explicitly and document best available patient-reported estimate.)

Presenting symptoms with explicit times:

• Contractions: [onset time], [frequency], [intensity], [progression]
• Suspected ROM: [date/time of onset], [gush / trickle], [fluid color/odor], [fetal movement since] (Include only if ROM suspected.)
• Vaginal bleeding: [amount/character], [context/triggers]
• Fetal movement: [normal / decreased / absent], last perceived [time]
• Infection symptoms: [fever / uterine tenderness / foul discharge]
• Preeclampsia symptoms: [headache / visual changes / RUQ pain / epigastric pain / edema]
• Other urgent symptoms: [dyspnea / chest pain / syncope / other]

(Include only symptoms explicitly mentioned; omit categories that do not apply.)

Admission indication: [Labor: latent vs active suspected with rationale] OR [Induction: indication (medical/elective), urgency, prior cervical preparation] OR [ROM evaluation: term PROM / PPROM / uncertain, confirmation method, digital exams avoided yes/no]. (Document only the applicable indication type.)

Prenatal Course

[Prenatal care location and adequacy; key maternal conditions this pregnancy; obstetric complications; relevant hospitalizations; antenatal testing status and most recent results if high-risk.] (If records unavailable, state explicitly and provide patient-reported summary.)

Key Prenatal Labs

• ABO/Rh: [result], Antibody screen: [result] (date: [date], source: [source])
• GBS culture: [positive / negative / unknown] (collection date: [date], source: [source])
• HIV: [result / unknown] (date: [date], source: [source])
• Syphilis: [result / unknown] (date: [date], source: [source])
• Hepatitis B surface antigen: [result / unknown] (date: [date], source: [source])
• Rubella immunity: [immune / non-immune / unknown] (Include if available.)
• GC/CT: [results / unknown] (Include if available.)
• Hepatitis C: [result / unknown] (Include if available.)
• CBC: Hgb [value], Plt [value] (Include if anemia or thrombocytopenia relevant.)
• Glucose screening: [result and/or diagnostic testing] (Include if diabetes diagnosed with regimen.)

(For any unknown action-critical lab—type/screen, GBS, HIV, syphilis, Hep B—document as "Unknown" with plan to obtain records or order stat testing. If GBS positive with penicillin allergy, document reaction type in Allergies section.)

Obstetric History

Gravida/Para: G[#]P[T/P/A/L]

• [Prior pregnancy: year, gestational age, mode (SVD/operative vaginal/cesarean with indication), birth weight, complications (hemorrhage/transfusion, shoulder dystocia, laceration degree, hypertensive disorder, chorioamnionitis, uterine rupture, accreta)]
• (Repeat for each prior delivery.)

Uterine/cervical surgery affecting TOLAC eligibility: [details or none]

Medical and Surgical History

• Medical conditions: [hypertension / diabetes / cardiac disease / renal disease / seizure disorder / bleeding disorder / thrombophilia / OSA / mental health conditions / other]
• Prior anesthesia complications: [difficult airway / malignant hyperthermia / other / none known]
• Relevant surgeries: [uterine or cervical procedures, other significant surgeries]

Medications and Allergies

• Current medications: [prenatal vitamins / antihypertensives / insulin or diabetes medications / anticoagulants / HSV suppression / medication-assisted treatment / other] (Include doses if available.)
• Allergies: [drug: reaction type] (For penicillin allergy, specify: anaphylaxis / rash / GI intolerance / unknown reaction—this determines GBS prophylaxis choice.)

Social History

• Tobacco: [use status, quantity, last use]
• Alcohol: [use status, quantity, last use]
• Substances: [type, last use, treatment program if applicable]
• Support persons: [relationship if documented]
• Safety screening: [completed / declined / concerns identified]
• Discharge considerations: [housing/transportation barriers if relevant]

Review of Systems

• OB: [contractions / leakage of fluid / vaginal bleeding / fetal movement]
• Neurologic: [headache / visual changes]
• GI: [RUQ or epigastric pain / nausea / vomiting]
• Cardiopulmonary: [dyspnea / chest pain]
• GU: [dysuria]

Physical Examination

• Vitals: BP [value], HR [value], RR [value], Temp [value], SpO2 [value], pain [score]; weight [value] / BMI [value] (if available)
• General: [appearance, distress level]
• Cardiovascular/Pulmonary: [heart and lung exam]; edema [present/absent]; reflexes/clonus [if hypertensive concern]
• Abdomen: Gravid uterus, [fundal tenderness if present], [other findings]
• Fetal presentation: [cephalic / breech / transverse / unknown] by [Leopold maneuvers / bedside ultrasound]. (If ultrasound: presentation, placental location, AFI/MVP, FHR confirmed.)

Fetal Heart Rate Assessment

Strip reviewed [start time]–[end time]:

• Baseline: [rate] bpm
• Variability: [absent / minimal / moderate / marked]
• Accelerations: [present / absent]
• Decelerations: [none / early / variable / late / prolonged] (timing and severity if present)
• Contraction pattern: [frequency]
• Category: [I / II / III]
• Trends: [category changes or concerning trends, if any]

Uterine Activity

• Monitoring method: [tocodynamometry / IUPC]
• Contractions: every [frequency] minutes, [mild / moderate / strong] by palpation (MVUs [value] if IUPC)
• Tachysystole: [present / absent]

Cervical Examination

Date/Time: [date/time] | Examiner: [name/role] | Method: [SVE / SSE]

• SVE findings: [dilation] cm / [effacement] % / [station] / [position] / [consistency] / presenting part [type] / membranes [intact / ruptured / bulging] / [caput/molding if present]. Bishop score [value] (if induction).
• SSE findings (for ROM evaluation): Pooling [present / absent], ferning [positive / negative], nitrazine [positive / negative], leakage with Valsalva [present / absent], cervix visually [description], discharge [characteristics].

(Include only the exam type performed.)

Admission Labs and Studies

• CBC: WBC [value], Hgb [value], Plt [value] [results / pending]
• Type and screen: [results / pending]
• Condition-specific: [CMP, urine protein/creatinine ratio if hypertensive; glucose if diabetic; other] [results / pending]
• Unknown critical prenatal labs: [list]. Stat testing ordered: [yes/no]. Records requested: [yes/no].

Assessment

[G/P] at [gestational age] admitted for [indication]; [presentation] by [method]; FHR Category [I/II/III]; cervix [dilation/effacement/station]; membranes [intact / ruptured x duration]; GBS [status with date].

Problem list:

• [Problem 1]: [brief assessment]
• [Problem 2]: [brief assessment]
• (Add problems as needed, prioritizing maternal status, fetal status, labor status, key comorbidities.)

Plan

Labor/Induction Management

• Indication: [reason and goal]
• Method sequence: [cervical ripening agent] → [amniotomy] → [oxytocin] (as applicable)
• Reassessment triggers: [clinical criteria for reassessment and escalation]
• Cesarean criteria: [indications for operative delivery if documented]

Fetal Monitoring

• Strategy: [continuous / intermittent] ([justification])
• Category II/III response: [escalation plan and intrauterine resuscitation triggers]

GBS Prophylaxis

• Status: [positive / negative / unknown] ([date])
• Plan: [antibiotic agent/dose/frequency] OR [risk-factor based approach if unknown] OR [not indicated if negative]
• (If penicillin allergy: [alternative agent based on reaction type]. Note: Do not delay obstetric interventions solely to achieve 4 hours of prophylaxis.)

ROM Management

(Include only if membranes ruptured or ROM suspected.)

• Approach: [expectant / active] based on [term status, GBS status, clinical factors]
• Infection surveillance: [vital sign frequency, exam limitations, labs if indicated]
• Delivery timeline: [target timeframe or criteria]

Maternal Conditions

(Include subsections only for active conditions.)

• Hypertensive disorder: BP goal [target], monitoring [frequency], labs [schedule], seizure prophylaxis [threshold/agent], delivery timing [if applicable]
• Diabetes: Glucose monitoring [schedule], insulin/medication [plan]
• Anticoagulation: Hold [parameters], neuraxial timing [plan], VTE prophylaxis [plan]
• TOLAC: Eligibility [confirmed], monitoring [continuous], rupture contingency [plan]
• Other: [condition-specific intrapartum management]

Pain Management

• Patient preference: [non-pharmacologic / IV analgesia / neuraxial / undecided]
• Anesthesia: [consult requested / not indicated / contraindications present requiring consultation]

Hemorrhage Preparedness

• Risk level: [low / medium / high]
• Blood products: [type and screen / crossmatch for # units]
• Transfusion consent: [obtained / declined with alternatives discussed]

Communication

• Attending: [notified / will notify at threshold]
• Consults: [anesthesia / NICU / MFM / other] [placed / pending / not indicated]

Postpartum Planning

• Feeding intention: [breastfeeding / formula / combination / undecided]
• Contraception: [method planned / deferred to postpartum discussion]
• RhoGAM: [indicated / not indicated] (if Rh-negative)
• Newborn notifications: [pediatric concerns based on maternal conditions]

Consents and Patient Preferences

• Obstetric consent: [Vaginal delivery, possible assisted delivery, emergent cesarean discussed]
• Induction consent: [Indication, methods, risks, alternatives discussed] (if applicable)
• Transfusion consent: [consented / declined with alternatives discussed]
• Pain management preference: [stated preference documented]
• Shared decision-making: [Key points discussed, patient questions addressed] (Note interpreter use if applicable.)

(If emergent or time-limited, document reason for abbreviated consent process and information communicated.)