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High-Risk Antenatal Assessment Report

This document provides a risk scoring for an antenatal mother named Shahida Begum who is 20 years old and 36 weeks and 5 days pregnant. She has a history of bleeding for the past month. Her examination found her height to be 152cm, weight to be 64kg, and fetal heart sound to be 140bpm with the fetus in left occiput anterior position. Her risk factors include being a primigravida and having a placenta previa, giving her a total risk score of 3. She was prescribed medications and advised on diet, rest, and temporary family planning.

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Ishika Roy
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66 views4 pages

High-Risk Antenatal Assessment Report

This document provides a risk scoring for an antenatal mother named Shahida Begum who is 20 years old and 36 weeks and 5 days pregnant. She has a history of bleeding for the past month. Her examination found her height to be 152cm, weight to be 64kg, and fetal heart sound to be 140bpm with the fetus in left occiput anterior position. Her risk factors include being a primigravida and having a placenta previa, giving her a total risk score of 3. She was prescribed medications and advised on diet, rest, and temporary family planning.

Uploaded by

Ishika Roy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

HIGH RISK SCORING OF ANTENATAL MOTHER

Hospital: Medical College and Hospital Date of admission: 6/02/2019

Registration no: 100342887

ANTENATAL HISTORY COLLECTION

Name: Shahida Begum W/o: Amir Ahmed Age: 20 Years

Religion: muslim Education: Class V Occupation: Housewife

Duration of marriage: 1 years

Address: Village- Murgao P.S: Chanditala District: Hoogly

HISTORY OF PRESENT PREGNANCY:- History of bleeding since last one month in three
episode

OBSTETRICAL HISTORY: G- 1 P- 0 A- 0 L- 0

Period of gestation: 36 weeks 5Days

PAST MENSTRUAL HISTORY :

L.M.P- 03/06/2018 E.D.D- 10/03/2019 Cycle- Regular Dysmenorrhea- Nil

PAST SURGICAL HISTORY: Nothing significant

PAST HISTORY OF BLOOD TRANSFUSION: Nothing significant

FAMILY HISTORY OF ILLNESS: Nothing significant

PERSONAL HISTORY: She is non vegetarian and has no allergy to food and drug

GENERAL PHYSICAL EXAMINATION

pulse: 72 b/m Respiration: 26 b/m Blood pressure: 130/90 mm/hg

height:- 152cm Weight:- 64kgs

Symptoms:

a) Pain: Nil
b) Discharge: Nil
c) Micturition: Frequent
d) Digestion: Normal
e) Other symptoms: Nil
f) General Health: Good

PHYSICAL SIGNS

a) Ear and nose: Clean


b) Teeth and gum: Normal
c) Tonsils and pharynx: Normal
d) Breast and nipple: Normal and clean
e) Heart : NAD
f) Lungs : NAD
g) Spleen: Not palpable
h) liver : Not palpable
i) skin: Moist
 Anal region: Normal
 vulva : Normal
 Groin : Normal

j) Abdominal wall: Striae gravidarum

k)Lymphatic : Nil

l)General condition: Normal

m)Any other sign &symptoms : Nil

ABDOMINAL EXAMINATION

Inspection

 Fetal movement : Present


 skin changes : Linea nigra & striae gravidarum

Date Fundal Height Abdominal Presentation and Relative size FHS / mint
Girth position of fetus of head to
In cm In weeks pelvis
12/02/2019 42cm 34 weeks 90cm Fundal grip:- Not engaged 140 b/m
Broad soft
irregular mass.
Left lateral grip:-
Smooth curved
mass.
Right lateral
grip:-
Small knob like
structure.
Presentation:
LOA
Treatment:-

Tab: Shelcal - 1tab OD

Tab: Austrin – 1tab OD

Advices:

 To take adequate rest and sleep in left lateral position


 To take nutritious diet
 To maintain personal hygiene and wear clean clothes
 To take temporary family planning method

Laboratory investigation:

a) Hemoglobin : 13g/dl
b) Blood sugar: 90mg/dl
c) VDRL: Negative
d) Blood group : type: A (+ve)
e) HIV: Non reactive
f) Urine: no sugar and albumin
g) Presentation: Cephalic presentation Amniotic fluid: adequate

Placenta:- posterior end encroaching the internal OS

RISK FACTORS

1. Age less than 18 years or more than 35 years 1


2. Maternal height less than 145 CM 1
3. Prime or multi more than five 1
4. Bad obstretical history 2
5. History of neonatal jaundice or RH incompatibility 2
6. Less than 45 kg or more than 90 kg 3
7. History of low birth weight babies 1
8. Previous uterine surgery 2
9. History of APH and PPH 2
10. History of manual removal of placenta 2
11. Anaemia(less than 6 grams%) 1
12. Febrile ailment in pregnancy 2
13. Pregnancy associated hypertension 2
14. Medical condition with pregnancy 2
15. Bleeding p/v(APH or abortion) 2
16. Abnormal presentation 2
17. Matuirity less than 37 weeks and more than 45 weeks 2
18. PROM 2
19. Fetal distress 2
20. prolonged labour more than 20 hours 2
21. Uterine size less than period of gestation 2
22. Dai Handling/outside interference 2or3

Impression: primi, placenta previea = 1+2 = 3.

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