Patient
29-year-old female, G2P1001, 28w5d GA
Obstetric Summary
G2P1001. EDD: July 27, 2026 (dating consistent between LMP and 1st trimester ultrasound). Prenatal care began at 8 weeks. This pregnancy uncomplicated thus far.
Current Gestation: 28 weeks 5 days
LMP: October 20, 2025. Dating US at 11w3d confirmed EDD.
Previous prenatal visits at 12w (first-trimester screen), 16w (second-trimester screen), 20w (anatomy scan), 24w (glucose challenge), and today 28w5d (routine).
Subjective
Reports fetal movement felt regularly since 18 weeks, now feeling strong kicks and rolls throughout the day. Kick counts consistently >10 in 2-hour periods. No vaginal bleeding, leakage of fluid, or contractions. Some lower back discomfort and pelvic pressure, attributed to growing uterus. Mild pedal edema at end of day, resolves overnight. Sleeping reasonably well with body pillow. Mood stable. No headaches, visual changes, or epigastric pain.
Vital Signs
BP: 118/72 (stable, baseline 114-120/68-76 range)
Weight: 156 lb (+2 lb since last visit, total gain: 18 lbs)
HR: 76 regular
Urinalysis: negative for protein, glucose, leukocytes, nitrites
Fundal Height
28 cm (consistent with gestational age, 50th percentile). Fetal lie: longitudinal. Presentation: cephalic (by Leopold maneuvers). Fetal back left posterolateral.
Fetal Heart Rate
145 bpm, regular. Doppler auscultation. Good variability appreciated subjectively.
Screening Results
Glucose Challenge Test (24w): 118 mg/dL (PASS, <140 threshold)
Anatomy Ultrasound (20w): Normal anatomy. Placenta: anterior, 1.6 cm from internal os — low-lying placenta, not previa; placental edge to be reassessed at 32w. Amniotic fluid: adequate (AFI 12 cm). EFW: 50th percentile.
Sequential screen (12w + 16w): low risk for trisomy 21 and 18; MSAFP low risk for neural tube defects.
HIV, Hep B, Syphilis, Rubella: all non-reactive/immune as appropriate.
Blood type: A positive, antibody screen negative.
Plan
- Routine prenatal care continues — next visit scheduled for 32 weeks
- Transvaginal ultrasound at 32w to reassess the placental edge; report any vaginal bleeding promptly
- Tdap vaccine: administer today (27-36 week window) — provide cocooning education for household contacts
- Rhogam: not indicated (Rh positive)
- Start discussing signs of preterm labor, warning symptoms (severe headache, visual changes, epigastric pain, sudden swelling)
- Prenatal vitamins: continue daily
- Kick count instructions reinforced — report if <10 movements in 2 hours
- Birth plan discussion at next visit — review delivery preferences, epidural consideration, cord blood banking decision