BLDEA’s SHRI B.

M PATIL INSTITUTE OF NURSING SCIENCES

VIJAYAPUR

INTRANATAL FORMAT
IDENTIFICATION DATA

Name : I.P Number:

Age : Unit :

Religion :

Education :

Occupation :

Date of Admission: Timing :

Date of Delivery :

Present complaints :

Past labour history:

G ______ P ____ A _____ L _____ S ______

Sl No Year Nature of Nature of Sex of child Remarks

pregnancy puerperium
History of present pregnancy:

a) Date of booking:

b) LMP : EDD :

c) gestationl weeks till date from LMP :

d) Antenatal attendance :

 Immunization : immunized / not immunized

 Any minor disorders : yes / no

If yes, specify ____________

 No. of Antenatal visits :

 Details of delivery

 Details of pregnancy :
First trimester :

Seccond trimester :

Third trimester :
History of present labour :

A) FIRST STAGE OF LABOUR :

a) commencement of contraction on :___________ at _________am/pm

b)vital signs T_____ P_____ R _____ BP

c) Foetal Heart Rate __________ , Location ________

d) Duration of Ist stage

Per vaginal examination Examination Findings :

FINDIGS :

Time Cervical Cervical Members Station

Dilatation effacement

B) SECOND STAGE OF LABOUR :

MOTHERS DETAIL

a) Membranes ruptured spontaneously at _________________ / artificially

ruptured at ________________

b)colour of the liquor ___ __________________

c) cervix fully dilated at ____________________

d) Duration of II stage ______________________

e) Type of delvery_________________________
f) Type of Episiotomy done __________________

g) Episiotomy Note

h) I V Methergin administration- yes/No

BABY DETAILS

1) Born at _________

2)Sex______________

3)Apgar score at 1min_______ at 5min______

4) caput formation – yes / No

5) Resuscitation details of baby

C) THIRD STAGE OF LABOUR

a) Placenta and membranes

 Delivered at _________
 Duration of III stage_________
 Completeness of placenta __________
 Type of placenta _______________
 Cord insertion________________
 Weight__________________

b) Approximate blood loss

c)Condition of uterus

D) FOURTH STAGE OF LABOUR.

 MOTHER

i) Vital signs

T______ P______ R______ BP_______

ii) Bleeding________

iii)Uterus__________

iv) Bladder_________

BABY

 Weight-
 Meconium –
 Urine –
 Vit K –
 Congenital anamalies –
 Breast fffding initiated at –

TRANSFER NOTE:

Mother and Baby transferred to Postnatal Ward at _________on _________