Welcome to Midwifery & Obstetrical Nursing Blog!!

Welcome to Midwifery and Obstetrical Nursing Blog!

This blog is a platform for me to share all my lecture notes on Midwifery Nursing. Hope this will be useful to all the nursing students out there! Happy Reading!

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 :

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