Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
Gravidity and Parity (G & P):
Estimated Date of Delivery (EDD):
Fetal movement: Any changes in perceived fetal movement (decreased, increased, or absent).
Maternal concerns: Any concerns the patient has regarding fetal growth or well-being.
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
Maternal weight and fundal height compared to expected for gestational age.
Leopold maneuvers: Assess fetal position and presentation.
Prenatal Testing:
Ultrasound:
Biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL) measurements and percentiles compared to gestational age.
Amniotic fluid index (AFI) measurement.
Presence of any Doppler abnormalities (umbilical artery Doppler, middle cerebral artery Doppler).
Non-stress test (NST) or biophysical profile (BPP) results (if performed).
Assessment:
Intrauterine growth restriction (IUGR):
Type of IUGR: Early-onset vs. late-onset
Severity of IUGR: Based on ultrasound measurements and percentiles
Etiology (potential causes): Consider maternal factors (chronic medical conditions, nutritional deficiencies, substance use), placental insufficiency, fetal abnormalities.
Plan:
Investigations:
Consider additional testing based on suspected etiology (e.g., karyotyping for fetal anomalies).
Fetal surveillance:
Increase frequency of prenatal visits and ultrasounds to closely monitor fetal growth and well-being.
Consider serial NSTs or BPPs to assess fetal oxygenation.
Management:
Address any identified maternal risk factors (e.g., blood pressure control, nutritional counseling).
Discuss potential benefits and risks of interventions like antepartum fetal heart rate monitoring or early delivery.
Delivery considerations:
Depending on severity and etiology of IUGR, discuss the possibility of early delivery to optimize fetal outcome.
Education:
Explain IUGR diagnosis, potential causes, and monitoring plan.
Discuss potential risks for the baby (e.g., prematurity, increased risk of complications during delivery).
Follow-up:
Schedule next appointment in [interval] based on the severity of IUGR and the plan.