History of Pregnant Women (Initial Visit)

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1. Definition An examination technique which is carried out through a conversation
between a midwife and a pregnant woman directly or with other people who
know about the condition of a pregnant woman, to obtain data on pregnant
women and their medical problems during the initial visit or first visit.
2. Aim Obtain data or information about problems that are being experienced or felt
by the patient
3. Reference Varney, H, Kriebs, JM, Gegor, C L. 2007. Textbook of Midwifery Care. 4th
Edition Jakarta: EGC
4. Procedure / Steps 1. Introduction
a. Welcoming clients and someone who accompanies mom in a
friendly manner
b. Introducing yourself to clients
c. Asking the mother's identity
d. Ask the mother's blood type
2. Conduct subjective data assessments
a. Current pregnancy history
1) HPHT, whether normal menstruation or not
2) Fetal movement
3) Signs of danger or trouble
4) General complaint
5) Medicines, vitamins, and herbs that are consumed
6) Specific concerns
b. Previous pregnancy history
1) Number of pregnancies
2) Number of children born alive
3) Number of premature births
4) History of pregnancy / multiple births
5) Number of miscarriages
6) History of labor with action (vacuum, forceps, cesarean section)
7) History of bleeding at delivery and postpartum
8) History of pregnancy with high blood pressure
9) Baby weight <2.5 kg or> 4 kg
10) Another problem
 c. Current / past medical history
1) History of cardiovascular disease
2) History of hypertension
3) History of diabetes
4) History of malaria
5) History of venereal disease - HIV / AIDS
6) History of kidney disease
7) History of other diseases
d. TT immunization screening
1) TT 1
2) TT 2
3) TT 3
4) TT 4
5) TT 5
e. KB history
1) The type of KB used
2) KB side effects
3) Reasons for discontinuing family planning
f. Socio-economic history
1) Marital status
2) Client and family response to pregnancy
3) Family support
4) Decision making in the family
5) Nutrients consumed during pregnancy
6) Healthy living habits (smoking, alcohol, NAFZA)
7) Workload and daily activities
8) Place and desired health worker to assist with delivery
3. Document the results of the assessment

5. Flow Chart (if

Introduct  History  Phisycal  Laboratory
needed) ion taking examination examination

Result

Normal Abnorma
lity

Essential care according to Essentialcare plus

Trimester adittional care
according to midwife
competencies and
law

Documentation
6. Related unit