C-Section Post-Partum Progress Note

Front 1

Subjective

Back 1

Ask about pain control, diet (and if tolerating), nausea, vomiting, flatus, ambulation, voiding, vaginal bleeding (lochia), and breastfeeding (and how it is going and long-term plans). Ask about post partum birth control plans and circumcision for male neonates.

Front 2

Objective Components

Back 2

VS and I/O’s:
CV:
LUNGS:
ABD/Incision:
EXT:
Labs:

Front 3

Key to I/Os

Back 3

Include UOP over 24hrs (calculate rate per hr).

Front 4

Typical Labs

Back 4

If POD #1. Typically CBC.

Front 5

A&P Sentence

Back 5

Age, G_P_ _ _ _ POD # s/p (type of C/S) for (indication), doing well.

Front 6

Components of Plan

Back 6

CVS/Heme:
GU:
FEN/GI:
Neuro:
Proph:
Breastfeeding:
PPBC: post partum birth control plan

Front 7

Example CVS Heme:

Back 7

AFVSS. CBC appropriate for EBL (or pending)

Front 8

Example GU

Back 8

Adequate UOP overnight, plan d/c foley, and await void

Front 9

Example FEN/GI

Back 9

HLIV (hep-lock IV); Advance diet to general (ADAT)

Front 10

Example Neuro

Back 10

transition to PO pain meds

Front 11

Example Proph

Back 11

SCDs, encourage ambulation

Front 12

Example Breast-feeding

Back 12

Lactation consultant PRN

Front 13

What else might you include at end?

Back 13

** Include blood type and rubella status in your note- pt may need Rhogam or MMR postpartum