Antenatal Visit

Patient Information

• 14/05/2024 10:15 AEST
• Antenatal Outpatient Clinic, Royal Brisbane and Women's Hospital

Subjective

• 36 weeks and 2 days
• The patient reports experiencing irregular, painless Braxton Hicks contractions primarily in the evenings, which resolve with rest and hydration.
• She reports strong, regular foetal movements meeting normal kick count parameters, with no recent changes in pattern.
• She notes a mild increase in clear, non-offensive physiological leukorrhoea, with no pruritus, dysuria, orPV bleeding/fluid loss.
• She experiences mild bilateral ankle swelling by the end of the day, which resolves overnight with elevation.
• She reports occasional gastro-oesophageal reflux managed effectively with calcium carbonate (Mylanta®) 10 mL PO PRN.
• She states her mood is stable and feels well-supported, scoring 4 on the Edinburgh Postnatal Depression Scale (EPDS) with no self-harm ideation.

Objective

• 36 cm
• Longitudinal lie, cephalic presentation, left occipito-anterior (LOA)
• 142 bpm, regular
• 3/5 palpable per abdomen
• 118/74 mmHg
• Protein negative, glucose negative, leukocytes negative, nitrites negative
• Mild non-pitting oedema is present in the bilateral lower extremities to the medial malleoli, with no facial or sacral oedema noted.

Assessment

• The patient is a 29-year-old G1P0 at 36+2 weeks gestation with an uncomplicated singleton pregnancy progressing appropriately.
• Diet-controlled gestational diabetes mellitus (GDM), mild iron deficiency anaemia on oral supplementation (ferrous fumarate 200 mg PO daily).

Plan

• We discussed non-pharmacological and pharmacological pain relief options for labour, with the patient expressing a preference for hydrotherapy, TENS, and nitrous oxide prior to considering epidural analgesia.
• We reviewed the setup and application of the obstetric TENS machine and use of the birthing ball for active labour positioning.
• Active versus physiological management of the third stage of labour was discussed; the patient consented to active management with oxytocin (Syntocinon®) 10 IU IM following the birth of the anterior shoulder.
• We reviewed the minor risks of neonatal hypoglycaemia and macrosomia associated with diet-controlled GDM, noting that her BGLs remain well within target ranges.
• A referral to the lactation consultant was placed for a brief antenatal review given her GDM status, and she will continue shared care with the midwifery group practice.
• The patient declined a routine vaginal examination and membrane sweep at 38 weeks unless clinically indicated for post-dates induction planning.
• We discussed hand expressing colostrum from 36 weeks gestation, and she was provided with a harvesting kit and storage instructions.
• The focus for the next appointment will be reviewing her home BGL logs, checking colostrum collection progress, and repeating routine antenatal observations.

Interventions

• Provided education on:
  • Signs of true labour versus prodromal labour
  • Warning signs requiring immediate presentation to the birth suite (reduced foetal movements, PV bleeding, SROM, severe headache, visual disturbances)
  • Antenatal colostrum harvesting technique and safe syringe storage
  • Active third-stage labour management and delayed cord clamping

Evaluation

• The patient and her partner actively engaged in the session, asking appropriate questions and demonstrating clear comprehension of labour onset signs and third-stage management.
• She expressed feeling confident and comfortable with her documented birth plan while remaining flexible if obstetric interventions become necessary.

Plan for Continuing Care

• The patient's understanding of when to contact the birth suite was verified, and all updates were documented in her handheld Pregnancy Health Record.
• Birth preferences were finalised and uploaded to the electronic medical record.
• Postpartum preparation was reviewed, including setting up safe sleeping environments, arranging the 6-week GP follow-up, and establishing early feeding support networks.
• No further ultrasound scans are required as the 36-week growth scan showed normal intervals; a group B streptococcus (GBS) low vaginal/anorectal swab was collected today.
• 28/05/2024 at 10:00 AEST

Additional Notes

• The patient has been actively attending a local prenatal yoga group and mothers' group in her community, which she finds beneficial for peer support.
• Her partner attended today's consultation, is supportive, and has arranged four weeks of paternity leave commencing from the estimated due date.