Intranatal Assessment

INTRANATAL ASSESSMENT FORMAT

Identification data:

Name:

Age:

Hospital No. :

Education:

Occupation :

Husband’s Name:

Education :

Occupation  :

Date & Time of admission  :

Reason for admission :

Family income  :

Per capita income :

Present Obstetric History :

LMP :

EDD :

POG :

GPLA :

Antenatal history :

I     Trimester :

II    Trimester :

III   Trimester :

 Past Obstetric history:

Sl. No.	Dt./Yr. of delivery	Place of birth	Duration of pregnancy	Method of delivery	Puerperium	Baby
						Sex & weight weight	present condition

Family history

Medical/Surgical history: 

- Personal history : Diet, rest, exercise, habits

Marital history:

- Consanguity

- Relationship

Socio-economic status:

- Ability to afford hospital expenses

- Financial assistance

PHYSICAL   EXAMINATION

Nourishment:

Body built:

Height

Weight:

Vital signs       : Temp :                  - F/ º C

                          Pulse:                    -  / mt

                          Respiration :         -  / mt

                          B.P.                       - / mm of Hg.

Mental status :

Head to foot examination :

     Skin furgor:    

     Moisture :

     Warmth / Temp :

Face:     

     Facial puffiness:

     Lips:                    Cyanosis, dryness

     Eyes:

Peri-orbital oedema:

Conjunctive : Pallor

Mouth:

Tongue:                         Moisture

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 :  

• Pelvic grip : Description

Inference : Presentation

                                                Engagement / not engaged

      Attitude

• Pawlick Grip: Fixed/ Mobile

 

• Auscultation :      - FHR

                                   - rhythm                                                

                                   - location                                        

Intranatal events : Time of onset of labour pain

Admission note : Maternal general condition

                             Condition of uterus : containing / not

P/V findings: Cervical dilation :

                       Effacement :

                       Station :

                       Membrane :

                       Liquor :

                       Pelvis :

Description of I stage:

Description of II stage:

 Contractions Monitored

Date	Time	Contractions			FHR (1mt.)	BP (mmHg)	Pulse (1mt)
		Fregnancy	Duration	No. of  contractions/10 minutes

Per Vaginal examination findings

Date	Time	Dilation of cervix	Effacement	Station	Membrane	Liquor

Description of III Stage:

Description of IV Stage:

            Condition of mother

            Condition of baby                                                                   Placenta details

                                Weight:                                                               Weight:

                                     Cry:                                                                Cord Length:

                       Apgar Score:                                                                Complete/Incomplete:

SYNTOCIN RECORD

Name:                                                                                                 Age:                Hosp. No:                               I.P. No.                  Ward:

Obstetric Score:                                 Diagnosis:                                                                               Indication for oxytocin drip:

Date & Time

I.V. syntocin in 500 ml RL/5% dextrose. Units (drops/mt)

B.P (mmHG)

Pulse (/mt)

Resp(/mt)

F.H.R

Uterine Contractions

Progress of labour

Effacement

Remarks or any other effects observed

Sign

Intensity

Frequency

Duration

Station

Cervical dilation