40 2 STUDENT’S CASE BOOK

POSTNATAL ASSESSMENT ( 1 )

Name of the mother Reg No.

Age

Religion

Occupation Education

Address

Obstetrical Score Post Partum Day

Menstural History

PAST OBSTETRICAL HISTORY

MOTHE R CHILD
S.No. Date month and Place of Period of Pregnancy Labour Puerperium Sex Live Still birth Weight
year of delivery delivery Gestation
STUDENT’S CASE BOOK 40 3

PRESENT OBSTETRICAL HISTORY

S.No. Weight B.P Oedema H b% Urine Period Position Presenta- Remarks

SUGAR ALBUMIN of gestation tion

HISTORY OF PRESENT LABOUR :

Type of labour :

Duration of labour : Date of delivery :

Conducted by : Time of delivery :

CONDITION OF MOTHER IMMEDIATELY AFTER DELIVERY :

Temp RR B.P. Uterus

Bleeding
POST PARTUM EXAMINATION :

1. Uterus SFH

2. Lochia

Colour Odour Consistency

3. Perineum : Intact

Episiotomy
40 4 STUDENT’S CASE BOOK

4. Breast

5. Varicosities

6. Bowel and bladder functions

7. Rest

8. Nutrition

NEWBORN ASSESSMENT :

Name Sex

Height Weight

Head circumference

Chest circumference Abdominal girth

Temp RR FHR

Skin
Head

Face

Mouth

Neck

Chest

Abdomen

Umbilicus

Bladder

Genital Organs

Extremities

Back

Reflexes

Moro Rooting Sucking

Intrusion Tonic neck

Babinski Gag

Stepping Grasp Others

STUDENT’S CASE BOOK 40 5

11. Adjustment of the newborn :

12. Medical and Obstetrical managemet :

13. Needs of the mother :

14. Needs of the new born

40 6 STUDENT’S CASE BOOK

MANAGEMENT AND PROGRESS OF PUERPERIUM

MOTHER : BABY :
1. General condition. 1. General condition.
2. Vulval toilet sutures 2. Feeding
3. Posture 3. Umbilicus
4. Breast 4. Stool
5. Ambulation 5. Complications Infancy
6. Post natal exercises
Date Condition of Mother Condition of Child
Day -1 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -2 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -3 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -4 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -5 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -6 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.

Signature of Student Signature of Supervisor

STUDENT’S CASE BOOK 40 7

POSTNATAL ASSESSMENT ( 1 )

Name of the mother Reg No.

Age

Religion

Occupation Education

Address

Obstetrical Score Post Partum Day

Menstural History

PAST OBSTETRICAL HISTORY

MOTHE R CHILD
S.No. Date month and Place of Period of Pregnancy Labour Puerperium Sex Live Still birth Weight
year of delivery delivery Gestation
40 8 STUDENT’S CASE BOOK

PRESENT OBSTETRICAL HISTORY

S.No. Weight B.P Oedema H b% Urine Period Position of Presenta- Remarks

SUGAR ALBUMIN gestation tion

HISTORY OF PRESENT LABOUR :

Type of labour :
Duration of labour : Date of delivery :

Conducted by : Time of delivery :

CONDITION OF MOTHER IMMEDIATELY AFTER DELIVERY :

Temp RR B.P. Uterus

Bleeding
POST PARTUM EXAMINATION :

1. Uterus SFH

2. Lochia

Colour Odour Consistency

3. Perineum : Intact
Episiotomy
STUDENT’S CASE BOOK 40 9

4. Breast

5. Varicosities

6. Bowel and bladder functions

7. Rest

8. Nutrition

NEWBORN ASSESSMENT :

Name Sex

Height Weight

Head circumference

Chest circumference Abdominal girth

Temp RR FHR

Skin
Head

Face

Mouth

Neck

Chest

Abdomen

Umbilicus

Bladder

Genital Organs

Extremities

Back

Reflexes

Moro Rooting Sucking

Intrusion Tonic neck

Babinski Gag

Stepping Grasp Other

41 0 STUDENT’S CASE BOOK

11. Adjustment of the newborn :

12. Medical and Obstetrical managemet :

13. Needs of the mother :

14. Needs of the new born

STUDENT’S CASE BOOK 41 1

MANAGEMENT AND PROGRESS OF PUERPERIUM

MOTHER : BABY :
1. General condition. 1. General condition.
2. Vulval toilet sutures 2. Feeding
3. Posture 3. Umbilicus
4. Breast 4. Stool
5. Ambulation 5. Complications Infancy
6. Post natal exercises
Date Condition of Mother Condition of Child
Day -1 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -2 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -3 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -4 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -5 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -6 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.

Signature of Student Signature of Supervisor

41 2 STUDENT’S CASE BOOK

POSTNATAL ASSESSMENT ( 1 )

Name of the mother Reg No.

Age

Religion

Occupation Education

Address

Obstetrical Score Post Partum Day

Menstural History

PAST OBSTETRICAL HISTORY

MOTHE R CHILD
S.No. Date month and Place of Period of Pregnancy Labour Puerperium Sex Live Still birth Weight
year of delivery delivery Gestation
STUDENT’S CASE BOOK 41 3

PRESENT OBSTETRICAL HISTORY

S.No. Weight B.P Oedema H b% Urine Period Position of Presenta- Remarks

SUGAR ALBUMIN gestation tion

HISTORY OF PRESENT LABOUR :

Type of labour :

Duration of labour : Date of delivery :

Conducted by : Time of delivery :

CONDITION OF MOTHER IMMEDIATELY AFTER DELIVERY :

Temp RR B.P. Uterus

Bleeding
POST PARTUM EXAMINATION :

1. Uterus SFH

2. Lochia

Colour Odour Consistency

3. Perineum : Intact

Episiotomy
41 4 STUDENT’S CASE BOOK

4. Breast

5. Varicosities

6. Bowel and bladder functions

7. Rest

8. Nutrition

NEWBORN ASSESSMENT :

Name Sex

Height Weight

Head circumference

Chest circumference Abdominal girth

Temp RR FHR

Skin
Head

Face

Mouth

Neck

Chest

Abdomen

Umbilicus

Bladder

Genital Organs

Extremities

Back

Reflexes

Moro Rooting Sucking

Intrusion Tonic neck

Babinski Gag

Stepping Grasp Others

STUDENT’S CASE BOOK 41 5

11. Adjustment of the newborn :

12. Medical and Obstetrical managemet :

13. Needs of the mother :

14. Needs of the new born

41 6 STUDENT’S CASE BOOK

MANAGEMENT AND PROGRESS OF PUERPERIUM

MOTHER : BABY :
1. General condition. 1. General condition.
2. Vulval toilet sutures 2. Feeding
3. Posture 3. Umbilicus
4. Breast 4. Stool
5. Ambulation 5. Complications Infancy
6. Post natal exercises
Date Condition of Mother Condition of Child
Day -1 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -2 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -3 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -4 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -5 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.
Day -6 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6.

Signature of Student Signature of Supervisor