Antenatal Assessment

ANTENATAL HISTORY FORMAT

I. Patient profile

            Full name                                :

            Age (in years)                          :

            Hospital No.                            :

            I. P. No.                                  :

            Marital status                          : Married / unmarried/ divorced/ separated

            Education status                     :

Occupation                              :

Husband’s name                     :

Age (in years)                          :

Education status                     :

Occupation                              :

Type of family                        :

Per capita income                    :

Date of booking                      :

Date of last antenatal visit      :

Date of admission:

Obstetric score

             Gravida

             Para

             Abortion

             MTP

             Living

II. Reason for hospitalization / Chief complaints

·       Onset

·       Duration

·       Severity

·       Relieving factors

·       Aggravating factors

III. Menstrual history :

·       Age at menarche

·       Duration of cycles

·       Regularity

·       Flow - heavy/moderate scanty

              - clots

                          - no. of days   

·       Any dysmenorrhoea

·       Relief measures

·       Last menstrual period

·       Period menstrual period

IV. Obstetric history:

Present Obstetric history

·       Is pregnancy confirmed :    Yes  /  No

·       When, where and how it was confirmed

·       What test was done for confirmation

·       Quickening

·       Immunization

·       Any more disorders like :

Vomiting, haemorrhoids, heart burn, backache, bleeding, varicose vein, constipation, leg cramps, fever, leucorrhoea, anorexia, insomnia, other complaints.

       Past Obstetric History

Sl No	Date of  delivery	Place of birth	Duration of pregnancy	Method of delivery	Course of  pregnancy	Labor	Puerperium	Baby
								Sex	Wt.

V. Family History:

·       Congenital diseases

·       Any hereditary diseases

·       Multiple pregnancy

·       Diabetes

·       Heart disease

·       Any mental retardation

·       Hypertension or PIH (in mother/ sisters)

·       Twin pregnancy

·       If yes,

In whom ?     Mother  /  Father ?

VI. Medical-Surgical History:

·       Child hood disease

·       Chronic disease like asthma, diabetes, epilepsy

·       Previous surgery

·       Injuries especially of back and pelvis

·       Hepatitis, STD, HIV

·       History of anemia

·       Any medication  taken at present or past

·       Reason for use, date stopped

·       Blood transfusion, allergic reaction

VII. Nutrition:

·       General nutrition – veg / non-veg

·       Appetite – decreased/increased

·       Any eating disorders

·       24 hours recall

VIII. Partner’s Health History:

·       Genetic abnormalities

·       Chronic diseases

·       Infections

·       Use of drugs such as cocaine alcohol

·       Smoking habits : tobacco, cigarette

·       Sexually transmitted diseases – HIV/ AIDS

·       Blood type

IX. Psycho-social history:

·       Emotional changes experienced

·       Women’s and family’s reactions to present pregnancy

·       Family support system – Family members and friends

·       Coping strategies

·       Life style change

·       Social relationships with the neighbours

·       Financial support

ANTENATAL  EXAMINATION

General Appearance    :

Nourishment               :

Body built                   :

Height                         :

Weight                                    :

Vital signs                   : Temp             

                                    : Pulse               

                                    : Respiration 

                                    : B.P.                  

Mental status :

Head to foot examination :

     Skin turgor:    

     Moisture :

     Warmth / Temp :

Face:     

     Facial puffiness:

     Lips:                    Cyanosis, dryness

     Eyes:

Peri-orbital oedema:

Conjunctive : Pallor

     Mouth:

     Tongue:                         Moisture

Chest:

Thorax                         :           Shape

                                    :           Symmetry of expansion

                                    :           posture

Breath sounds             :           Vesicular sounds

                                    :           Wheezing / Rhonchi

                                    :           Crepitations

                                    :           Pleural rub

Heart                           :           heart rate

                                    :           Location of apex beat/ Cardiac murmurs

Axilla                          :           any lymph node enlargement

Breast                          :           any tenderness / painful

                                    :           tense / dilated veins / warmth / presence of crust

Nipples                        :           retracted / inverted / cracked

Abdomen

• Inspection :     Size, shape, contour, flanks, umbilicus, foetal movements, skin                  changes, Contractions present/not
• Palpation:

- Fundal palpation:

                                    Inference : Lie

                                    Presentation

            - Lateral Palpation:

                                    Left side – description

                                    Right side – description

                                    Inference : Position

-          Pelvic palpation :  

- First pelvic grip : Description

Inference : Presentation

                                                Engagement / not engaged

      Attitude

- Pawlick Grip: Fixed/ Mobile

                       

• Auscultation :      - FHR

                                   - rhythm                                              

                                   - location                                       

Extrimities :  Ankle oedema :

                       Capillary refill :

                       Cyanosis :