ANTENATAL ASSESSMENT

IDENTIFICATION PROFILE: CASE NO -1

Name
Age
IPIOPD/ Registration No Rath Wlo Ra
Date of
Address Admission/ Visit: 909304899
3aloslaba3
Religion :
Hospital: HTMS

Obst
Gravidaetric:al score:
LMP Parity :
Living
Gestational Period EDD saosac23
Abortion:

HISTORY: for:
Education Wife y8YrsMonth
Occupation Wife: B.com Husband : M. Con
Family income
Type of House 20.00o Husband Manage
Kachal Pacca No of
Sanitation Facilities Rooms :
Family History: Cand Ventilation:
Type of family :
edeas No of
Hereditary Diseases (if any): Family Members: Adult:
History of twins lo Children:

Any other :Matemall Fraternal :

Significant History:
PERSONAL HISTORY
Sleep :
Habits : adequateAddictionAppetite : Alosanal
Afo
Allergy (Specify if any) :
Diet : (Veg/ Non Veg) : Alo Bladder and Bowel Habits-
Constipation/ incontinence
Any significant Diet
Habits in pregnancy and Number of Meals a
Day: 3
PAST MEDICAL AND delivery period
SURGICAL HISTORY:
Previous Medical illness and
Treatment (Specify if any)
Childhood illnessHepatitis/ TB/
Thyroid (hypo/hyper) l
Communicable diseases/ Diabetes
Long term drugs/blood
Asthma/Epilepsy
transfusion
Any Other significant illness
Any Previous Surgery
(Specify if any)
Abdominal/Pelvic/orthopedic operation :
12
MENSTRUAL HISTORY
Age of Menarche: yce : Regular/ Iregular Interval

Amount of bleeding (approx.) : alonal Associated Problems (if any) : 9

Treatment taken: Yes/No If yes Specify Treatment:
MARITAL HISTORY:
Age at Mariage : Years of Marital Life (stays with husband) :
Consanguineous Mamiage:Yes / No
Use of Contraceptive Yes/ No
If Yes Specify Type, Duration, And Any Associated Problems
Any Treatment for Infertility: Yes/No : f Yes Specfy Treatment Recelved:
OBSTETRIC HISTORY:
Past Obstetric History:
No of Living Children : 2¬0 Girls: Boys:

Abortions Spontaneous: MTP:

Age of First Child: Age of last Child:

Any congenital Abnormality / Disease in children
History of previous Pregnancy

Pregnancy Labour Mode of Nature of Baby (Sex,

Date
DeliveryN/D, C.S birth weight
S. Month & events-Pre/ events Puerperium
post term/ Prolongl Instrumental Immunization,
No year of (complication,
MTP/ Precipitatel delivery Recovery) Health
delivery Abortion induction indication

Present obstetric history:

General Health during Present Pregnancy Good
Complaints during Pregnancy iale ic Mel&t
Morning Sickness Yes/No
Minor Ailments (Specify)
Yes leadache)
Date of First Visit/ Registration for ANC

Gestational Age at first visit

Immunization (T/T) Yes/No Dose : 1/ 2rdDate :

Calcium, Iron &Folic Acid supplements (specify) : yes.

Any other Medications During pregnancy

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Antenatal Events during Present
First trimester: Pregnancy:
Morning sickness Yes/ No T/t takern
Mild/ Moderate /severe
Bleeding pv -T/A taken
Any other
significant problems
Antenatal Visits/ Reports
Hb% Height S.U eet Weight :

Urnine - Albunmin : B.P:

USG Report findings: Sugar

alo mal
Second trimester:
Minor Ailments-(if any specify) : Imedications :
Any T/t
Hospitalization Yes/No (if yes
Quickening : (Dateweek)
specify t/t taken)
Fetal Movements :
Any other
significant problems
Goo
Antenatal Visits/ Reports Height 5-4 jeet
Hb% Weight :

Urine - Albumin : B.P

3.00
USG Report /findings: Sugar
alornal
Third trimester
Minor Ailments-(if any specify): Any T/t Imedications :
Hospitalization Yes/No (if yes specify t/t taken)
Fetal Movements :
Any other
significant problems
Antenatal Visits/ Reports : Height : S
Hb% Weight :
Urine - Albumin : B.P
3.00
USG Report /findings : Sugar:
Antenatal visits/ records tng stei7icant
Date Ht & VWt B.P Gestational
Weeks
Fundal Presentation Urine Alb &
Height Position, FHS,
Rate Sugar; Hb%
2o|1o22 S.s feet nolo 6w
s1222 S.4 jet
lo wr
au12a, S.4 tet

23 ws 3 CM

3aC
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 Laboratory Investigatlons
Date
Hb%
Investigations Value In patient Normal Values

12.43ldl
ABO Rh
Btve
VDRL
HIV Aesate eatuepofte
Aeegate Negat podt
HbsAg Negati Deatin pos
Urine RIE, Alb &Sugar
TC DC

BT,:CT, PT
Blood Sugar Fasting, PPBS, Random n
(20-So
Stool RE kos -0. Smgldi
TORCH or any other Special investigations

EXAMINATION OF THE MOTHER

General Appearance
Body built thin/ averagel obese
Appearance - Gait Aor mal
Nourishment - Poorl Average/ Good
Height : S.u leet Weight :
Vital signs:
Temperature Pulse
Respiration Blood pressure :
Head :
Hair : Texture:
Colour: Booon m colo
Scalp Cleanliness: clean (aeed.
Eyes Pallor/ color change / Puffiness of eyes [periorbital edema]
Face : Facial uffiness I Chloasma
Mouth Teeth : Dental caries o Gums : Hypertrophy, bleeding
Tongue : Dry / coated / moist
Lips : pallor / cheliosis / dry / moist / cracked
Neck :
Inspection & palpation Thyroid enlargement : o

Lymph node enlargement:

Chest: Lungs - Clear : cleas Heart Sounds

Breast : Inspection Symmetry : Primary and Secondary areola : Good

Montgomery's tubercle
Nipples-Retracted/ flat / erectile /cracked/:
Palpation lumps / Presence of colostrum
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 Dru

Abdomen (Exposes the whole

Inspection abdomen till symphysis pubis)
Size of abdomnen Gestation]
Large / Small / to POG (Period
of
Shape of abdomen - Corresponding
Umbilicus
Longitudinally/transversely!
Contour of abdomen - Fullness of
flanks.
obliquely/
Pendulous / firm
ovoid /Spherical

Bladder
Skin Changes
flatvdepres ed/protrudes
- full / no full
Depression below umbilicus

Linea niagra,
White/Pink Scars Striaegravidarum
Veg
/ albicans

Visible fetal
movements : warm up.
Ask
Palpation: (Keep both hands of patient at the
the hands
together, to
patient to bend the knee, for sides. Rub examiners
pelvic palpation)
Abdominal girth
Fundal height- Symphysis
fundal height (SFH)-:
Fundal height in weeks
Fundal palpation-(Fundal
Lie Grip)(ldentify lie &Presentation)
Presentation -
lCephalicl
ongitudinalBreech/
oblique/ transverse
Shoulder
Lateral palpation- (Lateral Grip)
(Locate fetal back & extremities)
ldentify Position - LOA
LSA LOP
ROA
RSA ROP
Auscultation of FHS - (Identify point of highest
Rate/mt-: intensity)
Located LLQ
Umbilicus
RLQ
RULt flank
Pelvic palpation (First Pelvic Grip, Leopold 4th
Maneuver) ((dentify the pole of fetus in trne pelvio)
Freel Engaging/Engaged :
Pawlic maneuver-(Second pelvic Grip, 3rd Engaqed
Maneuver) (ldentify the size, mobility, & Tiexon)
Mobile/ Fixed, Flexed/ Deflexed (estimate in
fifths palpable above pelvic brim)
Lower Extremities
Varicose Veins Ao
Ankle Edema Yes
Genitalia:
Excessive discharge
FoulSmell Bleeding/ Show /:
Vulval edema ye
Vulval varicosity

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Drugs Prescribed
Name of drugs
Generic Name Dosage Action

Tab
Tab
calctu Cefachol
Ca lciu
Sooma (oal
Talo Telmestran lertrone Soomoal
Somloral
Fesos SusBale
Any Risk
Factors identified
Risk Factors
High Risk
LOw Risk

Remarks

Antenatal Teaching|Advices
Nutrition

Follow Up
Rest & Sleep
Exercise& work adezuate steep
Use of Comfort
devices Soft piLloo .cohele sleepinq sttn
Warning signs tfecclache, vormlt, ble edlinq leohi te or yed)
Minor discomforts & Naugea. Uom?t Constipatioo.2eneabr
Remedies
Sex
Male lkemale
Signs &
Symptoms of true labour : .louses back paîn, stvonq. g eqlog
Con trction
Any other required nursing
problems discussed GAM
’-Avo?d Sugas Containing 6ood
Regnlas Exercire,
sleep.
Regnlas chedt up and m edicabion as by paesCsp

Signature of student Signature of supervisorl CI

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