Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for cervical insufficiency (CI), evaluation of new symptoms, or prenatal visit (specify).
SOAP
Subjective (S):
History of Present Illness:
Briefly summarize the patient’s obstetric history, including:
Gravidity (number of pregnancies) and parity (number of deliveries)
Previous history of preterm delivery (PTD) with second-trimester painless cervical dilation on exam or previable PROM (ruptured membranes)
Current gestational age
Any recent vaginal bleeding, spotting, pelvic pressure, or cramping
Past Medical History:
Briefly summarize relevant past medical history, including:
Previous surgeries, particularly uterine surgeries (e.g., cervical conization)
Underlying medical conditions that might contribute to CI (e.g., connective tissue disorders)
Social History:
Briefly inquire about:
Occupation and physical demands of work (potential risk factors for CI)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a pelvic exam to assess:
Cervical length (measured by transvaginal ultrasound)
Presence of cervical dilation or funneling
Fetal fibronectin test (if indicated) – a test to assess the likelihood of preterm birth
Imaging Studies (if performed):
Briefly mention findings from recent transvaginal ultrasound, such as:
Cervical length measurement
Assessment (A):
Cervical Insufficiency Diagnosis:
Based on history, physical exam findings, and ultrasound measurements, assess the presence or risk of CI.
Risk Stratification:
If CI is diagnosed, consider risk stratification for preterm birth based on cervical length and other factors.
Plan (P):
Cervical Cerclage (if indicated):
Discuss the potential benefits and risks of a cerclage (surgical stitch placed in the cervix to prevent dilation) for high-risk patients.
Pelvic Rest:
Advise pelvic rest (avoiding strenuous activity or heavy lifting) as needed.
Progesterone Supplementation (if indicated):
Consider initiation of vaginal progesterone suppositories to help maintain cervical closure in some cases.
Serial Cervical Length Monitoring:
Schedule regular follow-up visits with transvaginal ultrasound to monitor cervical length and assess for signs of impending preterm delivery.
Fetal Monitoring:
Consider additional fetal monitoring (e.g., non-stress test) based on gestational age and risk factors.
Delivery Plan Discussion:
Depending on gestational age, cervical length, and presence of symptoms, discuss a potential delivery plan for suspected or confirmed preterm labor.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., maternal-fetal medicine specialist)
Education provided to the patient about CI, risk factors, and management options
Importance of recognizing and reporting symptoms suggestive of preterm labor
Addressing psychosocial concerns related to a high-risk pregnancy
Referral for high-risk pregnancy support groups (if applicable)