General Obstetric Intake

Subjective:
Chief Complaint:
Delivery options and family planning

History of Present Illness:
The patient presents for a discussion regarding delivery options and family planning. She is currently 13 weeks pregnant with an estimated due date of February 18th. This is her fourth pregnancy, with a history of one prior cesarean section performed on March 16th, 2023, due to concerns about the placenta. She reports a good recovery from the surgery. Her menarche occurred at age 12, and her menstrual cycles were regular prior to pregnancy. She has a history of using an intrauterine device for contraception for approximately 12 years, which was removed prior to her last pregnancy. She denies smoking or alcohol use currently, though she smoked prior to her last pregnancy but quit due to illness. She has no known medication allergies and is currently taking prenatal vitamins and a combination of vitamin B6 and doxylamine for nausea. She denies any significant past medical history, including asthma, diabetes, or hypertension. Her family history is notable for diabetes and hypertension. She is married and currently not employed, having stopped work due to severe nausea during this pregnancy. The patient expresses interest in discussing delivery options, including the possibility of a trial of labor after cesarean section versus an elective repeat cesarean section, as well as family planning options such as tubal ligation.

Obstetric History:
The patient is currently in her fourth pregnancy at 13 weeks gestation, with an estimated due date of February 18th. She has a history of one prior cesarean section performed on March 16th, 2023, due to concerns regarding the placenta, which was posterior and required intervention for bleeding. Recovery from the previous cesarean section was reported as good. No miscarriages, infertility, or use of assisted reproductive technology were mentioned. No VTE risk assessment, immunizations, or Rh-status were discussed.

Gynaecological History:
Menarche occurred at age 12. Menstrual cycles were regular prior to pregnancy. The patient used an intrauterine device for approximately 12 years, which was removed prior to her last pregnancy. No further intrauterine device was inserted after removal. No history of sexually transmitted infections or other gynecological conditions was reported. Pap smear was performed a few months after the birth of her last child, with normal results. No additional gynecological history provided.

Past Medical History:
No asthma, diabetes, or hypertension in personal medical history. No other significant medical conditions were reported.

Past Surgical History:
History of one cesarean section performed on March 16th, 2023. No other surgeries apart from the C-section.

Family History:
Family history is notable for diabetes and hypertension.

Social History:
The patient is married and currently not employed, having stopped work due to severe nausea during this pregnancy. No smoking currently. No alcohol intake. No illicit drug use, domestic violence, or other social concerns were reported.

The Review of Systems:
Constitutional – no Fever, Chills, Weight Loss, Weight Gain, Night sweats, Fatigue, or Weakness

Eyes – no double vision, no blurry vision, wears glasses

ENT – no Hearing loss, dizziness, runny nose, nose bleeds, nasal septum deviation, or sore throat

Integumentary – no rashes, lesions, dry skin, or eczema

Cardiovascular – no chest pain, heart palpitations, dizziness

Respiratory – no shortness of breath, no cough, no wheezing

Endocrine – No known thyroid issues, no changes to appetite, no weight change, no tiredness/lethargy

Gastrointestinal – No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.

Genito Urinary – no Dysuria, hematuria, frequency, urgency. No spotting.

Musculoskeletal – no joint tenderness, redness or swelling

Neurological – No headaches, no weakness, no history of seizures

Psychology – No changes in mood, no anxiety

Hematology – Denies easy bruising

Current Medications:
Prenatal vitamins. Vitamin B6 and doxylamine (Diclectin) for nausea.

Allergies:
No medication allergies.

Estimated Date of Confinement:
February 18th

Gynecologic History:
The patient experienced menarche at 12 years of age and reported regular menstrual cycles prior to conception. She has a history of intrauterine device use for approximately 12 years, which was removed prior to her most recent pregnancy, with no additional intrauterine device inserted after removal. She is compliant with cervical cytology screening, with her most recent Papanicolaou test performed a few months postpartum and within the recommended three-year interval. There is no reported history of sexually transmitted infections. The patient has undergone one prior cesarean section. She expresses interest in permanent sterilization via tubal ligation as part of her family planning considerations.

Objective:
Vital Signs:
Weight: 200 pounds. Height: 5 feet 4 inches. Body mass index: 32.46. No other vital signs provided.

Physical Examination:
General – Appears well, no obvious discomfort

ENT – No cervical lymphadenopathy, throat normal with no erythema or exudates.

Cardiovascular – Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no JVD, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.

Respiratory – Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.

Skin – No rashes, no dry skin, no skin infections

Breasts: Normal symmetrical appearance, no erythema, skin changes or tethering, no inverted nipples. Non-tender normal breast tissue on palpation with no palpable masses. Normal axillary lymph nodes on palpation.

Abdomen – Normal bowel sounds, abdomen soft and tender, no distension, uterus palpable

Genito Urinary – External genitalia normal, no inguinal adenopathy, normal pelvic examination

Musculoskeletal – No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.

Neurological – Alert and oriented in time, space and person, normal gait, strength 5/5 in upper and lower limbs, CN 2-12 grossly intact, coordination intact.

Assessment:
Clinical Impression:
Thirteen-week intrauterine pregnancy, gravida 4, para 1, with prior cesarean section and ongoing management for nausea.

Problem:
Early intrauterine pregnancy, history of prior cesarean section, nausea in pregnancy.

Assessment and Plan:
- Supervision of high-risk pregnancy due to prior cesarean delivery (V23.82): The patient is currently 13 weeks gestation with a history of one previous cesarean section. She is considering her options for delivery, including trial of labor after cesarean section versus elective repeat cesarean section. The interval between deliveries will be greater than 18 months, which is favorable for trial of labor after cesarean section. The patient was counseled regarding the indications for elective repeat cesarean section, including malpresentation and abnormal placentation, and informed that trial of labor after cesarean section may be considered unless contraindications arise. Ongoing prenatal care and monitoring are planned.

- Nausea and vomiting of pregnancy (643.01): The patient is currently taking prenatal vitamins, vitamin B6, and doxylamine for management of nausea. She was prescribed these medications due to severe symptoms. The patient was counseled regarding the use of these medications and their potential side effects, including drowsiness.

- Contraceptive counseling and sterilization request (V25.09): The patient expressed interest in permanent contraception via tubal ligation at the time of delivery. She was counseled that bilateral salpingectomy can be performed at the time of cesarean section if she elects for surgical delivery. The patient was advised that a decision regarding sterilization can be finalized closer to the time of delivery.

Surgery Discussion:

• Purpose of the Surgery: The main objective of the proposed surgical intervention is permanent sterilization through bilateral salpingectomy (tubal ligation) to prevent future pregnancies. This procedure may be performed concurrently with cesarean section if the patient elects for surgical delivery.
• Alternatives: The alternative to surgical sterilization discussed was to attempt a trial of labor after cesarean section with no sterilization, or to consider other non-surgical contraceptive methods.