Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
Gravida [parity] [Gestational age] weeks requesting induction of labor.
Document the specific reason for induction, such as:
Post-term pregnancy (42 weeks or greater)
Preeclampsia or chronic hypertension
Intrauterine growth restriction (IUGR)
Oligohydramnios (low amniotic fluid)
Premature rupture of membranes (PROM) with no contractions after a certain timeframe
Maternal medical conditions requiring delivery (e.g., diabetes)
History of Present Illness:
Onset and duration of any pregnancy complications.
Bishop score (assessment of cervical ripening) – if available.
Fetal movement (normal or decreased).
Past Medical History:
Previous obstetric history (number of pregnancies, deliveries, abortions, cesarean sections).
Past medical and surgical history (relevant conditions).
Current medications and allergies.
Family History:
Family history of uterine rupture (uncommon).
社会史 (shè huì shǐ) Social History:
Tobacco, alcohol, or illicit drug use during pregnancy.
Physical Examination:
Vital signs (maternal and fetal).
Abdominal examination: assess fetal lie, presentation, and Leopold’s maneuvers.
Pelvic examination:
Assess cervical dilation, effacement, station, and membranes (ruptured or intact).
Confirm fetal head engagement (if applicable).
Fetal Monitoring:
Baseline fetal heart rate (FHR) and variability.
Presence of any accelerations or decelerations.
Laboratory Tests:
Group B Streptococcus (GBS) status (if not already known).
Complete blood count (CBC) – if indicated.
Non-stress test (NST) or biophysical profile (BPP) – if clinically indicated to assess fetal well-being.
Imaging Studies:
Ultrasound:
Confirm fetal position and amniotic fluid volume.
Assess for any contraindications to vaginal delivery (e.g., placenta previa, vasa previa).
诊断 (zhěn duàn) Diagnosis:
Induction of labor for [reason, e.g., post-term pregnancy].
Treatment Plan:
Discuss the chosen method of induction based on cervical status and Bishop score:
Cervical ripening agents (misoprostol, cervidil) – to soften and open the cervix.
Artificial rupture of membranes (ARM) – may be done after some cervical ripening.
Oxytocin (Pitocin) – to stimulate contractions.
Pain management plan (epidural analgesia, other options).
Continuous fetal monitoring.
Antibiotics (if GBS positive).
Prognosis:
Discuss the likelihood of successful vaginal delivery and potential risks of induction, such as:
Uterine hyperstimulation
Fetal distress
Cesarean delivery
Patient Education:
Explain the induction process and potential timeline.
Importance of communication regarding pain and fetal movement.
Risks and benefits of induction and vaginal delivery compared to cesarean section.
**Physician Orders:**
Specific details regarding the chosen induction method and dosage.
Frequency of cervical examinations and fetal monitoring.
Pain management plan.
Antibiotics (if applicable).
Nursing Notes:
Document:
Vital signs (maternal and fetal) at regular intervals.
Uterine contractions (frequency, intensity, duration).
Cervical examinations and Bishop score changes.
Fetal heart rate tracing findings.
Administration of medications and fluids.
Patient education provided.
Next Steps:
Continue monitoring labor progress and fetal well-being.
Adjust the induction plan as needed based on maternal and fetal response.
Consider cesarean delivery