Templates for Prenatal Care Visits

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🩺Patient: 

Relevant history

  • Personal Hx
  • Medical: None 
  • Surgical:  None
    Psychiatric: None
    Tobacco: No  Alcohol: No  Drugs:  No
    Pesticide Exposure:  No
    Allergies: NKDA
  • Obstetric History (GTPAL).

Gestational age: 

Assessment

  • Pregnancy Course: Normal
  • Risks Identified: 
  • Main Complaints:  None 

First Trimester  

  • Results
  • Blood type:     positive
  • CBC: Hemoglobin >11 g/dL, hematocrit > 33%, platelets 150–400/mm³. Ferritin:
  • HbA1c: <5.7%.
  • STD Tests: Negative for HIV, syphilis, chlamydia, and gonorrhea.
  • Lead Level: <5 μg/dL. 
  • Quantiferon test: Negative
  • Urine culture: Negative 
  • Cervical cytology NILM and HPV HR negative in

Dating US (//):   w  d – normal IUP. No redating was necessary 

  • Prenatal screening Natera: low risk. Is a
  • Carrier screening (14 diseases): negative

Plan

  •  Prescriptions: prenatal vitamins
  •  OB panel + STD testing (requested)
  •  Dating ultrasound (requested) 
  •  NIPT/genetic screening (by CPSP)
  •  Counsel: nutrition, warning signs (bleeding, pain)
  •  Follow-up: 4 weeks or sooner

Second Trimester 

  • Results
  • Anatomy US (//): GA w d, EFW g ( %), AF normal, no previous placenta, no gross anatomic defects. Cervical length of
  • CBC: Hemoglobin >10.5 g/dL, hematocrit >32%. Ferritin: 
  • OGTT: Fasting <92 mg/dL, 1-hour <180 mg/dL, 2-hour <153 mg/dL.
  • Urine culture: negative

Plan

  • Prescriptions: Prenatal vitamins, oral iron
  • Ultrasound: Anatomy scan (18–22 weeks).
  • Labs: OGTT, CBC, ferritin and urine culture (at 24–28 weeks)
  • Vaccinations: Tdap (27–36 weeks).
  • Patient Education: Fetal movement awareness. Warning signs (contractions, LOF, vaginal bleeding). 
  • Follow-Up: in 4 weeks or sooner if needed.

Third Trimester

  • Results
  • CBC: Hemoglobin >11 g/dL, hematocrit >33%. Ferritin: 
  • STD Tests: Negative for syphilis, chlamydia, and gonorrhea.
  • Urine culture: negative
  • Fetal Growth Ultrasound:(//): GA w d, EFW g (%). Normal growth curve, appropriate amniotic fluid volume. Vertex presentation
  • Group B Streptococcus (GBS): Negative.

Immunizations: Tdap on 

Postpartum birth control: 

Plan

  • Prescriptions: Prenatal vitamins, oral iron 
  • Labs: CBC, Ferritin, CT, GC, RPR, urine culture (32-34 weeks).
  • Ultrasounds: Growth ultrasound (32–36 weeks).
  • GBS screening (36–37 weeks).
  • Delivery Plan Discussion: Birth location in NMC, labor signs, emergency contacts.
  • Patient Education: Warning signs (reduced fetal movement, contractions, LOF, vaginal bleeding,vascular spasmodic symptoms). 
  • Follow-Up: 3 weeks  or sooner if needed.

Postpartum visit

  • Routine six-week postpartum evaluation.
  • Other concerns: no
  • Pregnancy identified risks: .
  • Delivery Complications: 
  • On   the patient had a
  • Outcomes: Live born 
  • Weight    APGAR   Gestational age at birth
  • Postpartum course: uncomplicated.

Postpartum status

  • Bleeding: Lochia status:resolved.
  • Breastfeeding: uncomplicated.
  • Urinary/Bowel Function: normal.
  • Pain: No
  • Mental Health: EPDS of    
  • Birth control: