SEWA BHAWAN HOSPITAL, JAGDISHPUR

MATERNAL HISTORY AND NEONATAL EXAMINATION RECORD

Mothers Name Age Occupation Mothers (IP.no) Babys (IP.no)

Fathers Name

Obstetrics History G P L A
Date of Admission: Time of Admission:
Present Pregnancy Booked Unbooked Antenatal care at

LMP Gestation Tetanus Toxoid 0 1 2 Steroid 1 2

PIH Oedema Fits APH

Complications: GDM on Diet Insulin Other drugs
Placenta previa Bleeding
Hb Blood group Rh
Investigations:
Urine Albumin VDRL HBs Ag HIV

USG Finding: Cephalic/ Breech/ Transverse/ Cord around the Neck - Once/Twice

Onset of Date Spontaneous / Induced Oxytocin / Others

Labour Time
Membrane Date
Ruptured
Home/Hospital/ Spontaneous/Artificial/____Hrs before Delivery
Time
Amniotic Normal / Excessive / Decreased / Absent / Clear / Meconium stained / Foul smelling
Fluid:
Drugs in Labour : Antibiotics /Tramadol/Others No of Pv Exam: In SBH: Outside:

Delivery Normal / Vacuum / Forceps / Emergency LSCS / Elective LSCS

Indications Fetal distress / Prev LSCS/ NPL /CPD / Eclampsia /Placenta previa /
of LSCS : Scar Tenderness / MSAF

Duration Of Labour: 1st stage 2nd stage

Date of Birth Time of Birth Weight at Birth

 Baby Sex: Age at 1st exam. Condition at Birth
Resuscitation Y/N
APGAR SCORE Oxygen Y/N
Score Score Score 1 min 5 min 10 min
score 0 1 2 B &M Venti Y/N
Blue Extremities Pink
Colour Pale Blue Endotracheal Y/N
Absent Irregular crying
Resp Effort ET Suction Y/N Aspirate + / -
Limp Flexion Active
MuscleTone Drugs*
Absent HR <100 HR >100
Heart rate
None Grimase Cry
Response Inj Vit K given Y / N Passed Stool Y/N
Total
Eye care given Y / N Passed Urine Y / N

Neonatal Examination Cord care given Y / N Stomach wash Y / N

Exam at ( N-normal, Ab-Abnormal ) Birth

Head:Eyes, Ears,Mouth,Palate
Fontanelles- Depressed/Bulging Immunisation given(Tick): OPV / Hep B / BCG
Chest or Respiratory Problem
Mother Educated : Breast Feeding / Baby Care/ Vaccination
Heart sound, Heart Rate
Abdomen: Distention,Hernia,Defect
Anus: Imperforate, Normal
Spine:Defect,Sinus, Hair Tufts Condition at Discharge: Improved / Not Improved/
Genitals: Female LAMA / Absconded / Expired / Referred
Male: Testis
Limbs : Upper&Lower limbs
Skin: Pallor, Jaundice
Tone / Neuro- Floppy,Rigid Discharge Weight :
Reflexes: Suck, Moro

Diagnosis

Single/Twin Live Term/Preterm Boy/Girl Baby Born by NVD/Forceps/LSCS

Plan: Keep at mothers side / Transfer to nursery / NICU

Signature Of The Nurse Examined

Doctor Incharge