Obstetrics Post-OP HISTORY TAKINGPiyush Ranjan Sahoo

• Chief Complaints

pain/fever/wound complication/urinary retention etc. headache, vomiting

if not having any, tell- __yr female P (no. of child) on __ day of

puerperium with no specific complain.

History of Present Illness-Describe pain—onset, location, duration,

character, association, aggravating n relieving factors, radiation, with reln to time.

-Describe fever (puerperal pyrexia)—type, asso. with any other factor.

-Wound complication- Infection, stitch problem, pain at wound site, any bleeding/discharge, or swelling.

-Urinary retention- (look for catheterisation n accordingly present history) frequency of urination, urinary output.

Hist. of past illness

medical hist. surgical hist.(obs/gynaec/general)

Family History

Mention as routineIf Any relevant finding, mention.

Menstrual historyMenarcheprev. cycleLMPGA on the day of surgery, EDD.Cycle- duration of flow, amount of flow,

association (e.g. pain), regular or not.

Personal history

OccupationEducationSESwt gainDietAddictionsB/B habit

Obs hist.-No. of pregnancy

Yr of pregnancy

Duration of Pregnancy(complications if any)

Duration oflabour

Mode Ofdelivery

NatureOf puerperium

BabySex weight Health

of the child

If dead, cause ofDeath.

HIST. OF PRESENT PREGNANCY

Antenatal events-

1st trimester events-Morning sickness, fever (with rashes or not),

vomiting, bleeding PV, Abd pain (may be due to UTI/ectopic pregnancy)

Medication hist.- Folic acid(neural tube development)

USG done or not( for location of pregnancy & uterine anomaly)

ANC (booked case or not). Visits-

Continued…2nd trimester events- Abd pain, bleeding PV, quickening,

PIH(blurring of vision, pedal oedema), Glucose challenge test ( to know GDM).

Medication hist.- Fe(not in 1st trimester, causes vomiting n GI prob.), Ca+2 (to prevent osteoporosis), TT( 1st dose at 16 wks, 2nd dose after 4-6wks).

USG done or not. – ANC

Continued…3rd trimester events- Abd pain, PIH, GDM, Bleeding PV.Med history-Fe, Calcium ..contd or not. USG –ANC.

Labour events-

Pain- durationBleeding Leaking

Puerperal events-

Bleeding (for PPH)Any complications or illness

Fetal outcome-

Wt-Crying, feeding, colour, CRTAny abnormalityImmunization

General examn-Ht n wt, built, gait, pulse, BP, RR, temp.,

PICKLEBreast examn- Inspection- skin, nipple n areola, engorged

veins, any dischargePalpation-lax, tender or not, any massThyroid examn- (optional)Abdominal examn- ( same as medicine)

***No percussion is to be done.

Thank u