Woman's pregnancy notes

Personal details

NHI: ABC1234
Surname or family name: Jones
First name(s): Lisa
Previous surname: Smith
Address: 6 Linley Drive, Littleton, 8012
Phone: 023 876543
Work: 03 123456
Date of birth: 13/6/1982
Occupation: Manager – The Storehouse
Partner: Jack Smith
Woman’s residence: City
Woman referred by: Self
Community services card: No
Woman’s ethnic group: NZ Pakeha
Religious beliefs: Catholic
Next of kin: Jack Smith (husband)
Same address
GP: Dr Bill Conway
Diet: normal
Smoking: Gave up 4 years ago
Marijuana: No
Other substances: No

Obstetric history summary

Gravida: 2 Parity: 0
Number of spontaneous abortions: 1 at 8/52
Number of elective abortions: 0
LMP: (Make up your own dates) Sure about dates
EDD: (Make up your own dates)
Menstrual cycle Regular every 30 days
Length: 5 days
Oral contraceptives: No
Last cervical smear: 1 year ago
On National Register: Yes
Past pregnancies: NA

Maternal medical and surgical history

Height: 163 cm
Pre pregnancy weight: 68 kg
Previous uterine surgery(excl. cesarean): no
Previous infertility: no
History of depression/psychosis: Got a little sad when she had her miscarriage but needed no treatment
Essential hypertension: no
Diabetes: no
Pulmonary disease/asthma: no
Heart disease: had a heart murmur at birth which came right after a few days
STD: no, but gets thrush sometimes
Thyroid disease: no
Neurological disorder (epilepsy etc): no
Drug/or alcohol abuse: no
Breast surgery: had a small breast abscess when 15 years old but treated with antibiotics
Musculoskeletal disorder: no
Renal/urinary disorder:gets UTIs occasionally-last one 3 years ago
Allergies: gets hayfever for a couple of months in the summer
HIV risk: low
MRSA risk: low
Medication supplements: nil
Blood transfusion: no

Maternal family history

Diabetes: grandmother has late-onset
Hypertension: mother has just been diagnosed & started on meds
Intellectual disability: second cousin had downs syndrome but died when she was 10 years old
Congenital abnormalities: Brother had congenital dislocated hips & was in plaster for a few months when he was little -OK now

Paternal family history

Cousin had cleft lip

Birth plan

Place of birth: Birth unit
Early labour: Would like to stay at home as long as possible but at the same time, would like to be at the birth unit when things get going because I would hate to be stuck at home alone when giving birth
Monitoring in labour: I don’t want to be tied to my bed and stuck on a machine but I want baby to be safe & for midwife to keep a close eye on baby’s health
Positions for labour and birth: I want to be free to do what I find most comfortable. I want the midwife to suggest things to me if I am not sure what to do
Birth environment: Warm and cosy. I want Jack to feel welcome and comfortable
Pain management: I don’t want any medication if possible. Would like to try labouring in warm water. I don’t plan to give birth in water but would like to wait and see how I feel at the time
Third stage: No medication unless midwife feels it is necessary
Plans for placenta: Take home to bury in garden
Immediate care of baby: Please wipe off all the ‘gunk’. Would like to breastfeed as soon as possible after the baby has been born. Please can Jack cut the cord
Vitamin K: Not sure at this stage
Guthries test: Yes
Immunization: Worried about baby catching swine flu
Contraception: Condom

Ante natal record

Click on this link to see the woman's pregnancy notes.

Laboratory results

Booking:
HB 152 g/dL, Ferritin 66 ng/mL, Blood Group O+, Antibodies neg, HBsAG neg, VDRL neg, Rubella neg, Glucose not done, MSU neg, Cx Smear not required, vaginal swabs - not done

28 weeks:
HB 123 g/dL, Ferritin 42 ng/mL, Antibodies neg

36 weeks:
HB 120 g/dL, Ferritin 33 ng/mL, Antibodies neg, MSU neg, Strep B. neg

Scan results

12 weeks: NT: risk: 1:1099 No follow up

20 weeks: Singleton pregnancy, posterior placenta, anatomy appears normal, normal liquor volume, EDD agrees with dates. No follow up.