stacy's practice lisa lee taylor - delivered on...

stacy's practice Lisa Lee Taylor - Delivered on 8/30/14

first name

Lisamiddle name

Leelast name

Taylorpreferred name language

Englishrecord #

1545500DOB

1/4/86

age

29gender

Femalemaiden name

Leecity of birth

New York, NYssn

*********marital status

Marriedrace/ethnicity

Other

ethnicity sub-category

Not Hispanic/Latinooccupation

Accountantemployer

DynCorpreligion

Christianhighest education

BA/BS Degreeliving will

Noorgan donor

Yes

email

[email protected]

1409 Summer Dell Courtcity

Planoaddress 2

apt #15zip

75098state/province

Texas

primary phone

mobilenumber

(483) 398-2922secondary phone

worknumber

(483) 232-9001emergency contact

Jim Grayphone number

(483) 398-2923

relationship

Husbandcomments

that is his cell numberemergency contact 2

Berry Shrakephone number

(483) 398-3244relationship

Father in law

comments

he cannot answer his phone during his work hours of 9am - 5pm

Financial Information

payment type

Self-Paydo you receive WIC?

No

Current Pregnancy

are you pregnant?

Yes

last normal period

7/23/13

conception date

8/6/13

ultrasound 1 edd

4/28/14

est. due date based on

Last Normal Period

est. due date

4/25/14fetal heart heard

Yesdate

12/14/13fetal movement felt

12/8/13delivery site

Homepre-preg wt

125

your feelings about this pregnancy

Very excited and a little nervous!partner's feelings about this pregnancy

He is also very excited!partner name

Billy Joel

have you had any of these problems during this pregnancy?

nonepregnancy exposure

OTC Drugs, Caffeine, Cats, VitaminsGTPAL

4/2/0/1/2

Printed on 2/21/14 Record # : 1545500 PRIVATE & CONFIDENTIAL -


Father of Baby (FOB)

FOB name

Jim Robert GrayDOB

8/28/82number

mobile (273) 238-2929email

[email protected]

1409 Summer Dell Court

city

Chicago

street address 2

apt #15

zip

89566

state

Illinois

share private info w/FOB

Yes

married to FOB

Yes

ssn

*********

city of birth

Detroit, MI

race/ethnicity

Pacific Islanderethnicity sub-category


Computer Programmer

employer

Capital One Bankreligion


Some College


Father of Baby (FOB)

FOB name

Jim Robert GrayDOB

8/28/82number

mobile (273) 238-2929email

[email protected]

1409 Summer Dell Court

city

Chicago

street address 2

apt #15

zip

89566

state

Illinois

share private info w/FOB

Yes

married to FOB

Yes

ssn

*********

city of birth

Detroit, MI

race/ethnicity

Pacific Islanderethnicity sub-category


Computer Programmer

employer

Capital One Bankreligion


Some College

Father's of Baby's History

Please indicate if the father of the baby (FOB) has ever had any of these conditions

Tobacco Use - Active 18-30 he smokes about a pack a day

Genetic History

Have either you or the FOB ever had a baby with birth defects?

Yes - FOB has a daughter that was born with webbed toes

Did you or the FOB have a birth defect yourselves?

No

Does the FOB have a history of pregnancy losses with another partner (miscarriages or stillborns)?

No

If you answered yes to the last question, have either of you had genetic counseling?

No

If you answered yes to the last question, have either of you had chromosomal studies?

No

Are you or the FOB of Jewish ancestry?

Yes

If you answered yes to the last question, have either of you had a Tay-Sachs screening test?

No

Are you or the FOB black?

No

If you answered yes to the last question, have either of you had Sickle Cell screening test?

No



Will you be 35 or older when the baby is born?

NoWill the FOB be 50 or older when the baby is born?

No

Do you have any objections to receiving blood or blood products?

No

Genetic History

Have either you or the FOB ever had a baby with birth defects?

Yes - FOB has a daughter that was born with webbed toes

Did you or the FOB have a birth defect yourselves?

No

Does the FOB have a history of pregnancy losses with another partner (miscarriages or stillborns)?

No

If you answered yes to the last question, have either of you had genetic counseling?

No

If you answered yes to the last question, have either of you had chromosomal studies?

No

Are you or the FOB of Jewish ancestry?

Yes

If you answered yes to the last question, have either of you had a Tay-Sachs screening test?

No

Are you or the FOB black?

No

If you answered yes to the last question, have either of you had Sickle Cell screening test?

No


Will you be 35 or older when the baby is born?

NoWill the FOB be 50 or older when the baby is born?

No

Do you have any objections to receiving blood or blood products?

No



1st Fetus : miscarried on 5/04 at 8 weeks pregnant

1st Pregnancy Fetuses : Single

1st Fetus : live birth delivered on 10/05 at 42 weeks pregnant

gestational age

42wksbirth weight

7lbs 4oztotal length of labor

22hoursinduced

Yesinduction method

Pictocinplace of delivery

Hospital

delivery type

Vaginalanesthesia

Epiduralvaginal tearing

Noepisiotomy

Yesname of baby

Jim David Graygender

Male

2nd Pregnancy Fetuses : Single

Complications :

SUA/2 vessel cord, Preterm labor/ROM

Comments :

client went to hospital for preterm labor at 32 weeks pregnant. They administered progesterone for a few hours. No more incidents occured after that.


gestational age

39wksbirth weight


10hoursinduced

Noplace of delivery

Birth Centerdelivery type

Vaginal

anesthesia

Nonevaginal tearing

Yesepisiotomy

Noname of baby

Mark Robert Graygender

Male

3rd Pregnancy Fetuses : Single

Complications :

Placenta previa, GBS+, Postpartum hemorrhage

Comments :

client described the postpartum hemorrhage as being very minimal


1st Fetus : miscarried on 5/04 at 8 weeks pregnant

1st Pregnancy Fetuses : Single


gestational age

42wksbirth weight


22hoursinduced

Yesinduction method

Pictocinplace of delivery

Hospital

delivery type

Vaginalanesthesia

Epiduralvaginal tearing

Noepisiotomy

Yesname of baby

Jim David Graygender

Male

2nd Pregnancy Fetuses : Single

Complications :

SUA/2 vessel cord, Preterm labor/ROM

Comments :

client went to hospital for preterm labor at 32 weeks pregnant. They administered progesterone for a few hours. No more incidents occured after that.


gestational age

39wksbirth weight


10hoursinduced

Noplace of delivery

Birth Centerdelivery type

Vaginal

anesthesia

Nonevaginal tearing

Yesepisiotomy

Noname of baby

Mark Robert Graygender

Male

3rd Pregnancy Fetuses : Single

Complications :

Placenta previa, GBS+, Postpartum hemorrhage

Comments :

client described the postpartum hemorrhage as being very minimal

Family History

Please indicate if anyone in your immediate family or FOB has had these conditions

High Blood Pressure - Mother Active 30-50 her mom is on various meds to reduce her blood pressure

Congenital Abnormalities - Sister or Brother Resolved under 18 under 18

my brother was born with a cleft palate which was corrected by surgery

Strokes - Paternal Grandfather Active after 50 my grandfather had 3 strokes before passing away



Your Mother's History

pregnancies

5complications

she had a c-section with me due to her high blood pressure

live births

4miscarriages

1


Your Mother's History

pregnancies

5complications

she had a c-section with me due to her high blood pressure

live births

4miscarriages

1

Your Health

cur wt

138wt gain

13blood type

B+

medical conditions

Thyroid problems - Active 5/16/02 I take medication to regulate my thyroid

Ulcers - Resolved 12/14/00 6/14/02 I had ulcers probably caused by stress after a couple years they went away

Heart Problems - Active 12/15/82 I have a congenital heart murmur

Heart Problems - Active 4/15/91 I have Atrial fibrillation

Medications

medications or supplements?

Yes

medication :

Clarinex 8/14/06 5mg Once daily Dr. Fierdbock I take medication to help with my seasonal allergies

Astelin 4/15/09 1cc As needed Dr. Fierdbock I take medication to help with my pet allergies

Enoxaparin 10/14/96 25mg twice daily Dr. Schuligin I take medication for my heart condition

drug allergies?

Yes

drug allergy :

Penicillin 8/13/00 I get a rash and anaphylaxis

NSAIDs 8/13/00 I get urticaria/angioedema

food allergies?

Yes

food allergy :

Peanuts 8/14/81 vomiting

Lactose (Milk) 8/14/86 I have GI issues



Life Style

I regularly consume :

Caffeinated Soda, Coffee, Herbshow do you exercise and how often?

I go to cross fit courses 3 times a weekcurrent stress level

Medium

typical stress level

Low

source of stress

work and finances

are you being abused?

No

history of abuse?

No

do you feel unsafe?

No

comments

client use to also take anti-depressants but is fine now

Your Health

cur wt

138wt gain

13blood type

B+

medical conditions

Thyroid problems - Active 5/16/02 I take medication to regulate my thyroid

Ulcers - Resolved 12/14/00 6/14/02 I had ulcers probably caused by stress after a couple years they went away

Heart Problems - Active 12/15/82 I have a congenital heart murmur

Heart Problems - Active 4/15/91 I have Atrial fibrillation

Medications

medications or supplements?

Yes

medication :

Clarinex 8/14/06 5mg Once daily Dr. Fierdbock I take medication to help with my seasonal allergies

Astelin 4/15/09 1cc As needed Dr. Fierdbock I take medication to help with my pet allergies

Enoxaparin 10/14/96 25mg twice daily Dr. Schuligin I take medication for my heart condition

drug allergies?

Yes

drug allergy :

Penicillin 8/13/00 I get a rash and anaphylaxis

NSAIDs 8/13/00 I get urticaria/angioedema

food allergies?

Yes

food allergy :

Peanuts 8/14/81 vomiting

Lactose (Milk) 8/14/86 I have GI issues


Life Style

I regularly consume :

Caffeinated Soda, Coffee, Herbshow do you exercise and how often?

I go to cross fit courses 3 times a weekcurrent stress level

Medium

typical stress level

Low

source of stress

work and finances

are you being abused?

No

history of abuse?

No

do you feel unsafe?

No

comments

client use to also take anti-depressants but is fine now

Gynecologic History

age of 1st period

13periods/year

12period freq.

30period duration

7 - 8 Daysperiod flow

Lightbleeding bet. periods

Yes

irreg. periods

Nopainful periods

Nolast pap smear

4/19/13abnormal pap smear?

Nocomplications with birth control

weight gain, some nausea

Sexual History

1st intercourse age

22

recent birth control used

discontinued the pill in feb last year

have you ever had any of the following conditions?

Ovarian cysts - Resolved 2/14/06 2/14/08 after some time they just disappeared, praise God!

Infertility - Resolved 2/14/12 11/14/13 After using Clomid I finally got pregnant!



Prenatal Visits

Wks Wt BP Pulse FM FHFetal

Posit…FHT

Edema

Protein / Glucose

Internal Exam

Phys. Exam

Labs

40 142 145/98 85 +1 27 ROA 140 None Neg / Neg 60%, 5, -2 No No

visit date

4/25/14, 6:56 AM

performed by

Jenny Watters

plan & procedures

ct. here for postdates prenatal visit. Gave white folder. Went over ways to encourage labor. Stripped membranes per client request. Encouraged to see Chandra Crisp. RTC 1 or prn


Prenatal Visits

Wks Wt BP Pulse FM FHFetal

Posit…FHT

Edema

Protein / Glucose

Internal Exam

Phys. Exam

Labs

40 142 145/98 85 +1 27 ROA 140 None Neg / Neg 60%, 5, -2 No No

visit date

4/25/14, 6:56 AM

performed by

Jenny Watters

plan & procedures

ct. here for postdates prenatal visit. Gave white folder. Went over ways to encourage labor. Stripped membranes per client request. Encouraged to see Chandra Crisp. RTC 1 or prn

38 142 122/81 83 +1 25 ROA 120 None Neg / Neg No No No

visit date

4/18/14, 6:56 AM

performed by

Jenny Watters

plan & procedures

Ct. here for routine prenatal visit. Feels that baby is lower and is having some sciatic pain. Going to let Chiropractor know about it. Answered some questions. RTC 2 wks.

37 139 128/81 81 +1 25 ROA 120 None Neg / Neg No No Yes

visit date

4/7/14, 6:56 PM

performed by

Jenny Watters

plan & procedures



visit date

3/23/14, 9:20 AM

performed by

Jenny Watters

plan & procedures



visit date

3/9/14, 9:20 AM

performed by

Jenny Watters

plan & procedures



visit date

2/25/14, 10:44 AM

performed by

Stacy Smith

plan & procedures





visit date

2/18/14, 10:44 AM

performed by

Stacy Smith

plan & procedures




visit date

2/18/14, 10:44 AM

performed by

Stacy Smith

plan & procedures



visit date

2/5/14, 8:20 PM

performed by

Stacy Smith

plan & procedures


25 130 124/75 85 +1 23 ROA 120 None +1 / +2 No No Yes

visit date

1/12/14, 8:20 AM

performed by

Stacy Smith

plan & procedures

Ct. here for routine prenatal visit. Went over postpartum questions. Denies headaches, blurred vision or seeing spots. RTC 1 wk.

Lab Result

C&S

Negativeprotein

Negglucose

Neghematocrit

38.6%blood type

B+antibody screen

Negative

Lab Result

hemoglobin

13.8g/dLHep B

NegativeHep C

Negativegonorrhea

Negativechlamydia

PositiveHIV

NegativeGBS

Positivesyphilis

Nonreactive

TRPNon-Immune

lab comments

This is where the lab comments would go.



Admissions

Admission TimeContractions Onset

TimeEst.

WeightLast Food Eaten Last Time Slept Discharged

8/30/14, 4:09 AM 8/30/14, 12:57 AM 145 deli sandwich f… slept during t… 8/29/14, 7:07 PM, Ho…

Est. Weight

145Last Food Eaten

deli sandwich for dinnerLast Time Slept

slept during the day yesterday for about 9 hours

location

Birth Center


Admissions

Admission TimeContractions Onset

TimeEst.

WeightLast Food Eaten Last Time Slept Discharged

8/30/14, 4:09 AM 8/30/14, 12:57 AM 145 deli sandwich f… slept during t… 8/29/14, 7:07 PM, Ho…

Est. Weight

145Last Food Eaten

deli sandwich for dinnerLast Time Slept

slept during the day yesterday for about 9 hours

location

Birth Center

8/29/14, 1:59 AM 8/28/14, 11:47 PM 145 tacos yesterda… two nights ag… 8/29/14, 8:53 AM, Ho…

Est. Weight

145Last Food Eaten

tacos yesterday eveningLast Time Slept

two nights ago for about 7 hourslocation

Birth Center

Labor Flow

Status TimeLabor Status

BP HR TmpFetal

Posit…FHT

Contraction Freq/Dur/Int

Internal Exam

Input / Output

8/30/14, 6:30 AM Delivered

birth of head

8/30/14, 6:28 AMtime of birth (body)

8/30/14, 6:29 AMfirst cry

8/30/14, 6:32 AMbaby caught by

Jenny Watterslocation

Birth Center

baby presentation

LOAdelivery type

Spontaneousnuchal cord

Nonuchal hand

Nofluid appearance

Meconiumfluid volume

Moderate

maternal position

Lithotomy

supervised by

Stacy Smith

performed by

Jenny Watters

other assistants

Kelly Myong, Doula

comments

baby born

8/30/14, 6:21 AM 2nd Stage 100 No

performed by

Jenny Watters

comments

still in a semi squat and pushing strong.

8/30/14, 6:15 AM 2nd Stage 140 3, 60, Strg No

performed by

Jenny Watters

comments

semi squatting by the tub, strong pushes and head is showing on the perineum.



8/30/14, 5:44 AM active 186/45 92 98.9 120 3, 60, Strg No

performed by

Stacy Smith

comments

Getting off of potty. Leaning over birth ball on bed.


8/30/14, 5:44 AM active 186/45 92 98.9 120 3, 60, Strg No

performed by

Stacy Smith

comments


8/30/14, 5:13 AM active 186/45 92 98.9 120 3, 60, Strg No

performed by

Stacy Smith

comments


8/30/14, 5:06 AM Membra…

ROM Time

8/30/14, 5:04 AMfluid appearance

Lightfluid volume

Moderaterupture type

Spontaneousmaternal position

Sittingperformed by

Stacy Smith

comments

out of the water. Going to sit on the potty backwards. Moaning through ctx. Feels a constant pressure

8/30/14, 4:46 AM active 186/45 92 98.9 120 No

performed by

Stacy Smith

comments

out of the water. Going to sit on the potty backwards. Moaning through ctx. Feels a constant pressure

8/30/14, 4:12 AM active 120 No

maternal position

Reclining

performed by

Stacy Smith

comments

leaning over side of tub

8/30/14, 3:44 AM active 120 No

maternal position

Reclining

performed by

Stacy Smith

comments

leaning over side of tub

8/30/14, 3:14 AM active 130 No

maternal position

Sitting

performed by

Stacy Smith

comments

in tub relaxing and moaning through ctx

8/30/14, 2:29 AM active 130 No

maternal position

Sitting

performed by

Stacy Smith

comments

in tub relaxing and moaning through ctx



8/30/14, 2:29 AM active 130 No void,t…

Input / Output

void,threw up

performed by

Stacy Smith

comments

getting in tub


8/30/14, 2:29 AM active 130 No void,t…

Input / Output

void,threw up

performed by

Stacy Smith

comments

getting in tub

8/30/14, 1:58 AM active 130 3, 60, Strg No water

maternal position

Squatting

Input / Output

water

performed by

Stacy Smith

comments

Contractions getting stronger

8/30/14, 1:29 AM active 130 2, 70, Mod No water

maternal position

Birth StoolInput / Output

waterperformed by

Stacy Smith

8/30/14, 12:57 AM active 170/65 85 98.7 LOA 140 3, 60, Mod 40%, 4, 0 void

maternal position

Sitting

Input / Output

void

performed by

Stacy Smith

comments

Ct. in early labor. Everything appears normal

8/29/14, 8:53 AM active 186 83 98.2 LOA 120 No

performed by

Stacy Smith

comments

Contractions wained off sending client home

8/29/14, 8:14 AM active LOA 120 30, 2, Mild No

maternal position

Recliningperformed by

Jenny Watters

8/29/14, 3:14 AM active LOA 130 6, 2, Mild No water

maternal position

Side

Input / Output

water

performed by

Jenny Watters

comments

Ct. laying down to get some rest

8/29/14, 2:44 AM active 175/60 80 98.8 LOA 120 7, 1, Mild No water

maternal position

Reclining

Input / Output

water

performed by

Jenny Watters

comments

Contractions seem to be slowing down a bit

8/29/14, 2:24 AM active LOA 120 7, 2, Mild No water

maternal position

RecliningInput / Output

waterperformed by

Jenny Watters



8/29/14, 2:04 AM active 170/65 85 98.7 LOA 120 5, 2, Mild 10%, 2, -1 void

maternal position

Sitting

Input / Output

void

performed by

Jenny Watters

comments



8/29/14, 2:04 AM active 170/65 85 98.7 LOA 120 5, 2, Mild 10%, 2, -1 void

maternal position

Sitting

Input / Output

void

performed by

Jenny Watters

comments



Printed on 2/21/14 Record # : 1545500 PRIVATE & CONFIDENTIAL - Page 12


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