MODULE 1 OB-HISTORY and OB-Physical Assesment

NCM 107 A - CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
RELATED LEARNING EXPERIENCE
Module: ELICITING OBSTETRIC HISTORY AND PERFORMING OBSTETRIC

ASSESSMENT
Overview:
Obstetric history involves the ability to obtain an accurate and relevant information regarding the
patient’s current and previous pregnancies. Some of the questions are highly personal, therefore
good communication skills and a respectful approach are absolutely essential.
Obstetric assessment is an important component of comprehensive obstetric care. It is a tool used

to evaluate the physical, medical, psychosocial, familial and environmental factors that affects the
condition of the mother, infant or both.
This module will explain how to elicit obstetric history and demonstrate how obstetric assessment
is done.
.
Note: It is not always possible for female nurses to attend to female patients. Eliciting obstetrical
history and assessment should be performed in a respectful manner by maintaining privacy during
the conduct of the interview and assessment and confidentiality in disclosed information is a must.
Through this patients will generally not perceive the care of a person of the opposite gender to be
offensive or embarrassing.
Module objectives:
After this module the student will be able to:
1. Discuss the purposes of eliciting obstetric history.
2. Explain the principles in performing obstetric assessment.
3. Obtain obstetric history in a logical, organized, respectful and thorough manner.
4. Perform obstetrical assessment independently as a nursing procedure.
5. Utilize appropriate language and non-verbal techniques to facilitate communication.
6. List the materials needed in electing obstetrical history.
7. Recognize the importance of eliciting obstetrical history.
8. Demonstrate consideration for patient’s feelings, limitations and sociocultural background
9. Document accurately the procedure done.
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OBSTETRIC HISTORY
Purposes:
1. To gather essential information related to maternal concerns.
2. To determine the history of pregnancies and complications.
3. To educate mother in the entire process of pregnancy.
4. To reassess mother’s level of understanding about pregnancy.
Assessment:
1. patient’s baseline/ demographics

2. family history
3. past and present medical history
4. pertinent menstrual history
5. history of past pregnancies and complications
Determine:
1. Pregnancy History
G – gravida, P – para, T – term, P – preterm, A – abortion, L – live births
2. Complications
3. Allergies
4. Medications
General Considerations:
In the conduct of an interview during obstetric history taking, the following should be taken into
consideration:
1. Provide privacy to the patient at all times.
2. Assess the level of understanding of the patient
3. Use the preferred language and terminologies that are familiar to the patient.
4. Observe an appropriate distance in communicating to the patient.
5. Ensure confidentiality on the information disclosed.

Preparations:
1. Materials:
a. Obstetric History Form
b. Chart
c. Pen
2. Client:
a. Explain the procedure and its purposes.
b. Provide privacy to the patient.
c. Determine the level of understanding and whether the client is experiencing any
discomfort.
N.B. If an informant is needed to assist the client make sure that companion is
knowledgeable on the patient’s condition.
OBSTETRICAL HISTORY
Patient’s Baseline Data are demographics that are collected from the patients or informants that
contains the essential information needed prior to the intervention. These includes the
characteristics of an individual or population, e.g. age, gender, occupation, and etc. which can be
used as basis or reference in the ongoing process or study. Below are examples of baseline:
Name: Civil Status:

Age: Birthdate:
Address: Educational Attainment:
Occupation:
Chief Complaint:
Drug / Food Allergy:
Family History contains the past information of a family which traces their past medical, and mental
health conditions. These also includes the behaviors and diseases that are inherent to the family.
Past Medical History is record of information about a person’s health. This includes information
about allergies, illness, surgeries, immunizations, and results of physical examination and
diagnostic tests. It may also contain other pertinent information like medication, diet, exercise
program and therapies.
Pertinent Menstrual History contains the information regarding the start of the monthly period, the
amount of discharges in a cycle and its irregularities.
Menarche is the first occurrence of menstruation which are usually painless and occurs with
warning. This occurs between ages of 10 to 16 years old in most girls but there are instances that it
occurs 10 years old below.

Cycle of menstruation varies in length among women, but an average is to have a period every 28
days. Regular cycles may range from 21 to 40 days are considered normal. This has four phases:
1.) follicular phase - first day of the period and ovulation wherein estrogen level rises as an egg is
to be released (before the release of egg), 2.) Proliferative phase - concentrations of estradiol
influences the endometrial lining or uterine lining builds back up again 3.) ovulation phase - the
release of egg from the ovary (egg release) 4.) luteal phase – occurs after ovulation wherein the
lining of the uterus normally gets thicker to prepare for pregnancy (after egg release).
Amount of menstrual discharge ranges from 10 to 35 ml. each soaked normal-sized tampon or
pads holds a teaspoon (5ml) of blood which means that soaking seven normal sized pads or
sanitary products in a whole period is normal.
History of Past Pregnancies
Gravida – number of pregnancies regardless of duration, the number of times a woman

has conceived and outcome
Para – number of pregnancies that has reached viable age
– birth after 20 weeks gestation, regardless if the infant is born or dead
Term – a delivery that is after 37 weeks
Preterm – delivery that is less 37 weeks
Abortion – spontaneous or elective
– less than 20 weeks
Living – living children
Examples:
Ana is a first time mother. If she had twins, gravida would be 1 and para would be 1
because it’s a single pregnancy and a single delivery.
G1P1T2P0A0L2
Ruby is experiencing her fourth pregnancy. Her first pregnancy ended in a spontaneous
abortion at 8 weeks, and the second resulted in the live birth of twin boys at 38 weeks, and the
third resulted in the live birth of a daughter at 34 weeks.
G4P3T2P1A1L3
Types of Delivery
Natural Birth is a vaginal labor and delivery with limited to no medical intervention that involve a
variety of choices
Vaginal Birth is the natural method of birth of offspring through the vagina

Spontaneous vaginal delivery is a vaginal delivery that happens on its own, without
requiring doctors to use tools to help pull the baby out. This occurs after a
pregnant woman goes through labor. Labor opens, or dilates, her cervix to at
least 10 centimeters.
Assisted birth (also known as an instrumental delivery) is when forceps or a ventouse
suction cup are used to help deliver the baby. Ventouse and forceps are safe
and only used when necessary for you and your baby. Assisted delivery is
less common in women who've had a spontaneous vaginal birth before.
Partial Breech is when one of the baby's knees is bent and his foot and bottom are closest
to the birth canal. The body of the fetus is then rotated 180 degrees in the
reverse direction to deliver the other shoulder and arm. If trunk rotation is
unsuccessful. Posterior shoulder is delivered first.
Complete Breech is when both of the baby's knees are bent and his feet and bottom are
closest to the birth canal.
Abdominal Delivery is the delivery of a fetus by surgical incision through the abdominal wall and
uterus
Primary Cesarean is a surgical procedure by which a baby is delivered through an
incision in the mother's abdomen, often performed because vaginal
delivery would put the baby or mother at risk
Vertical Cesarean Section is a vertical incision on the uterus causes less bleeding
and better access to the fetus, but renders the mother unable to attempt a
vaginal delivery.
Horizontal Cesarean Section is sometimes called "the bikini cut wherein an
incision on the skin of the abdomen 1–2 inches above the pubic hairline is
done.
Low Segment Transverse he doctor cuts through the lower uterine segment of the
uterus, which typically doesn't involve the same tissue as a classical C-
section. This region of the uterus has less muscular fiber, and is less easy to
tear or rupture with future labors.
Outcome of Delivery
Stillbirth is the delivery, after the 20th week of pregnancy, of a baby who has died. A baby
is stillborn in about 1 in 200 pregnancies which is caused by infections, birth
defects and pregnancy complications, like preeclampsia.
Multiple Birth occurs when two or more child are delivered that can either be twins, triplets
and so forth.
Year Type of Delivery Outcome of Place of Attended by

Delivery Delivery whom
Normal Multiple Birth Cebu City Dr. Agravante
2020 Spontaneous
Vaginal Delivery
History of Present Pregnancy

Last Menstrual Period. By convention, the first gestational week of pregnancies is marked
by the first day of a woman's last menstrual period (LMP). If her menstrual periods are regular and
ovulation occurs on day 14 of her cycle, conception takes place about 2 weeks after her LMP.
Expected Date of Delivery is an estimated date of when your baby is due. Most
pregnancies last around 40 weeks (or 38 weeks from conception), so typically the best way to
estimate your due date is to count 40 weeks, or 280 days, from the first day of your last menstrual
period (LMP).
Age of Gestation is the common term used during pregnancy to describe how far along the
pregnancy is. It is measured in weeks, from the duration of pregnancy which starts from the first
day of the Last Normal Menstrual Period (L.N.M.P.) to the current date. The later months of
pregnancy known as the Expected Date of Delivery (E.D.D.)
A normal pregnancy can range from 38 to 42 weeks. Infants born before 37 weeks are considered
premature.
NB. Estimation of gestational age is more accurate with ultrasonography in the first
trimester.
Nagele’s Rule
Begin with the first day of the last LMP – add a year, subtract three months, add seven
days
Example:
LMP was May 12, 2013
Add year – 2013 +1 = 2014
Subtract three months – 5 – 3 = 2 (February)
Add seven days 12 + 7 = 19
Answer = February 19, 2014 estimated due date
Quickening is the moment in pregnancy when the pregnant woman starts to feel or
perceive fetal movements in the uterus.
Prenatal History include information on the mother's pregnancy, such as prenatal exposure to illicit
drugs, toxins, or infections; maternal diabetes; acute maternal illness; trauma; radiation
exposure; prenatal care; and fetal movements. Below are the common questions asked during
history taking:
When was your first prenatal visit?

How often?
Did you receive any teaching regarding prenatal?
Care?
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Labor and Delivery?
Postpartum?
Newborn?
By whom? Where?
Medications taken along the course of pregnancy?
Was it prescribed?
By whom?
Medication for allergies?
Appetite while pregnant:
Weight gain:
Food likes and dislikes:
Fluid Preferences:
Sleeping habits:
Usual bedtime:
No. of hours of sleep:
Nap habits:
If unable to sleep, what things you would do to help you?
Discomfort that you felt:
Pregnancy also known as gestation, occurs when a sperm fertilizes an egg after it's released from
the ovary during ovulation. The fertilized egg then travels down into the uterus, where implantation
occurs. A successful implantation results in pregnancy.
Presumptive Signs and Symptoms (Changes felt by Woman)
M – Morning sickness
A – Amenorrhea
C – Change in Breast
F – Fatigue
L – Lassitude
U – Urinary Frequency
Q – Quickening (8th – 20th Week)
Probable (Changes observed by the examiner)
C – Chadwick’s sign – bluish discoloration of the vaginal wall

H – Hegar’s sign – softening of the lower uterine segment
U – Uterine enlargement – at 12 weeks gestation felt just above the symphysis pubis
P – Positive pregnancy test – presence of Gonadotropin in urine
B – Ballottement – sinking and rebound of fetus
O – Outlining of the fetal body
G – Goodell’s sign –softening of the cervix
S – Souffle, Contraction and Braxton Hicks (painless contraction at 28 weeks)
Positive (Definitive Signs of Pregnancy)
Fetal Heartbeat – 12 weeks by Doppler

– 18 to 20 weeks by auscultation
Fetal Movement – felt by the examiner usually at 20 weeks
Fetal Skeleton – by sonography or X-ray
Contraction – is when the muscles of your uterus tighten up like a fist and then
relax. Contractions help push your baby out. When you're in true labor, your contractions last about
30 to 70 seconds and come about 5 to 10 minutes apart.
Frequency – beginning of one to the beginning of the next contraction

(report if less than 2 minutes)
Duration – beginning to end of one contraction
(report if less than 90 seconds)
Intensity – strength of the ache
Discomfort Duration Intensity Frequency Relief

Measures
1st trimester
2nd trimester
3rd trimester
Health Teachings:
1. Eating a healthy diet is especially important for pregnant women. Your baby needs healthy
food, not sugar and fat. Eat plenty of colorful fruits and vegetables, whole grains, calcium-rich
foods, and foods low in saturated fat.
2. Vitamin Intake. Make sure to get plenty of folic acid and calcium. You can get these and other
necessary vitamins and minerals from food and a standard multivitamin.
3. Stay Hydrated. A pregnant woman’s body needs more water than normal. Aim for eight or more
cups each day.
4. Proper prenatal care. Women should get regular prenatal care from a healthcare professional.
Mothers who don’t get regular prenatal care are much more likely to have a child with low birth
weight. If available, consider group prenatal care.
5. Don’t drink alcohol. Women should not drink alcohol before and during their pregnancy and
while breastfeeding. Drinking alcohol increases the risk of having a baby with fetal alcohol
spectrum disorder (FASD). FASD can cause abnormal facial features, severe learning disabilities,
and behavioral issues.

6. Don’t smoke. Smoking is unhealthy for you and your unborn child. It increases the risk of SIDS
(sudden infant death syndrome), premature births, miscarriages, and several other unhealthy
outcomes.
7. Avoid certain foods. There are certain foods that women should avoid eating while pregnant.
Do not eat: raw or rare meats, liver, sushi, raw eggs (also in mayonnaise), soft cheeses (feta,
brie), and unpasteurized milk. Raw and unpasteurized animal products can cause food poisoning.
Some fish, even when cooked, can be high in mercury.
8. Exercise daily. Daily exercise is great for most pregnant women. Check with your doctor to find
out how much physical activity would be right for you.
9. Get plenty of sleep. Ample sleep (7 to 9 hours) is important for you and your baby. Try to sleep
on your left side to improve blood flow to you and your child.
10. Reduce stress. Reducing stress is crucial for improving birth outcomes. Pregnant women
should avoid, as much as they can, stressful situations. Recruit your loved ones to help you with
this.
11. Get vaccinated. Pregnant women are susceptible to various disease. Vaccines that are
essential and appropriate for pregnant women are highly encouraged.
12. Right timing. Choose the right time to become pregnant. Readiness and preparation must be
considered in getting pregnant.

OBSTETRIC ASSESSMENT
Purposes:
1. To identify or screen the high risk cases.
2. To apply appropriate intervention on the complications detected early by examination.
3. To initiate nursing management in promoting a healthy pregnancy.
4. To educate mother based on the findings.
5. To remove the fear about delivery and to gain confidence before labor.
Assessment:
Assess for:
1. general appearance
2. nutrition
3. vital signs
4. weigth
5. uterine size
6. heart rate of mother and fetus
7. cervical check (checked after 40 weeks – dilatation, effacement, fetal presentation and
station)
Determine:
1. Status of the mother
2. Status of the fetus
General Considerations:
In the conduct of an obstetric assessment, the following should be taken into consideration:
1. Establish rapport to the patient.
2. Provide privacy to the patient at all times.
3. Assess the level of understanding of the patient
4. Use the preferred language and terminologies that are familiar to the patient.
5. Observe an appropriate distance in communicating to the patient.
6. Observe hand hygiene and aseptic technique especially when using equipment.
7. Avoid unnecessary exposure.
8. Create a comfortable environment and be empathetic.
9. Dispose used materials appropriately.
10. Ensure confidentiality on the information disclosed.

Preparations:
1. Equipment/ Materials:
Thermometer BP Apparatus Stethoscope
Penlight Dressing sets Gloves
Fetal Doppler Weighing scale Tape Measure
2. Client:
a. Explain the procedure and its purposes.
b. Provide privacy to the patient.
c. Determine the level of understanding and whether the client is experiencing any
discomfort.
N.B. - If the client preferred to have a female nurse to assess, approach in a
respectful manner and explain according to situation.
- If an informant is needed to assist the client make sure that companion is
knowledgeable on the patient’s condition.
PROCEDURE/STEPS RATIONALE
1. Introduces self. Establishes rapport to the patient.
2. Identifies patient. Determine the correct patient.
3. Assemble all equipment needed. Save time and effort. Check and organize the
equipment.
4. Performs hand washing. Prevents cross contamination.
5. Determines patient’s baseline data. Reference data

6. General Appearance Provides clues to the patient’s physical condition like the
Note for overall impression of a presence of illness and diseases.
woman’s health and well-being.
Observe on the manner in which the
woman’s health dresses, the way she
speak and body posture.
Inspect for signs of careless hygiene,
unwashed hair, inappropriate or
soiled clothing, sad facial expression.
Skin
7. Inspect the skin. Note Determine the presence of potential skin diseases.
hyperpigmented areas associated Redness of the skin indicates the need to reassess
with pregnancy. patient’s need for position changes.
8. Observe for vascular markings Identify possible cardiovascular complications during
associated with pregnancy. gestation.
9. Inspect hair and nails. Provide an overview of the hair and nail. Check for
presence of lice and tissue perfusion.
Head and Scalp
10. Inspect for symmetry and normal Facial asymmetry may indicate neurological impairment.
contour. Unusual contour indicates possible disease condition.

11. Palpate for any tenderness. Tenderness may indicate trauma or injury.
12. Inspect for hair distribution, thickness determine
and excessive dryness or oiliness.
13. Inspect for presence of lesion, dandruff or Cutaneous changes is often a result of
masses. hormonal changes.
14. Inspect the face. Check for mask of Hyperpigmentation known as melisma or
pregnancy; note color, pigmentation, edema. chloasma is common among pregnant women.
Eyes
15. Inspect eyes. Examine cornea, lens, iris and Gives an overview of the surrounding structure
pupil. Note the conjunctival color. of the eyes.
16. Inspect for any visual disturbances. Presence of any visual disturbances
experienced by majority are mild and
temporary. Occasional blurriness and light
sensitivity could indicate dangerous condition
brought buy preeclampsia or gestational
diabetes
Nose
17. Inspect the nose for nasal congestion. Pregnancy rhinitis is a symptom that occurs
during pregnancy that causes nasal congestion.
Ears
18. Inspect the ears using a penlight. Swelling in the nasal lining that is connected to
the tubes of the ears (Eustachian tube) may be
blocked easily.
Mouth, teeth and Throat
19. Inspect the mouth. Pay particular attention to Gives an overview of the condition of the oral
the teeth (dental caries) and the gingival cavity. Presence of tooth decay and gingivitis
tissues, which may appear swollen and indicates poor oral hygiene. Dry mucus
slightly reddened. Observe for cracked membrane indicates decreased hydration.
corners of the mouth.
20. Inspect the throat. No redness or exudates Pregnant women often becomes congested,
present. which can lead to sore throat.
Thorax and Lungs
21. Inspect, palpate, percuss and auscultate the Determine the status of the chest.
chest.
22. Assess for respiratory rate and rhythm. Respiratory resistance increases while
respiratory conductance decreases during
pregnancy.
23. Auscultate bilaterally lung sounds. Breathing may be affected by the increase in
the hormone progesterone, which causes to
breathe in more deeply.
Heart
24. Palpate the apical impulse. Cardiac output increases wherein Heart rate
speeds up at a rate of 70 beats per minute to
80-
25. Auscultate for heart rate, presence of Pregnant women may develop underlying
occasional murmur and palpitation. irregularities of the heartbeat due to the increased
volume of blood flowing.
Breast and Nipple
26. Inspect and palpate the breasts and nipple for Breasts become larger and veins become more
symmetry and color. notcieable on the skin. The nipples and the
areola becomes darker,
Back
27. Observe for exaggerated lumbar curves Lordosis is usually seen in pregnant woman. It
compensates for the movement of their center
of gravity and posterior shift of body weight.
Abdomen
28. Inspect the abdomen. Determine the size of the fundus and position of
the baby.

29. Ask the client to recline with a pillow under Positioning allows facilitation of assessment
her head and her knees flexed. and comfort.
30. Note striae, scars, and the shape and size of Striae gravidarum are atrophic linear scars that
the abdomen. are most common tissue changes during
pregnancy.
31. Assess the shape and contour by measuring Defines the gestational age with 2 centimeters
the fundic height. per week.
32. Perform Leopold’s Maneuver Determines the fetal presentation and position
of the fetus.
33. Determine the location, rate and rhythm of Provides the general status of the
the fetal heart. cardiovascular system of the fetus
34. Auscultate fetal heart rate. Normal fetal heart rate is between 120 to 160
beats per minute.
Genitalia
35. Inspect external genitalia. Note hair Assess the condition of the female reproductive
distribution, color of skin, varicosities organ for any unusualities.
and scars.
36. Observe for presence of discharges; Distinguish the normal and abnormal
odor, color, amount discharges of the female genitalia. Leukorrhea
is a mild-smelling sometimes odorless vaginal
discharge is expected.
Rectum
37. Inspect the anus and rectum. Note Provides an overview of the anal and rectal
color, varicosities, lesions, tears or status. Presence of fistulas, hemorrhoids and
discharge. other discharges indicates prompt attention.
Extremities
38. Inspect the legs for varicose veins. Increases the risks of hemorrhoids and
impedes return venous flow.
39. Inspect the hand and legs for edema. Swelling of the feet, ankles and hands
accompanied by pain, redness or warmth,
indicates possible blood clot.
40. Obtain knee and ankle reflexes. Determine the integrity of the neurological
function of the patellar and ankle reflex.
41. Observe for waddling gait. Myopathic gait is caused by muscle weakness
in the pelvic girdle.

PERFORMANCE CHECKLIST
(OB Physical Assessment)
Name: ______________________________Course/Year/Section: _______________
GRADING CRITERIA; LEGEND:

Performance of Task:
5. Perform task correctly and accurately 5- Excellent (E) 2- Needs Improvement
(NI)
4. Perform task systemically 4- Very Satisfactory (VS) 1.- Incorrectly
Performed(IP)
3. Finishes procedure on time 3- Satisfactory (S) 0- Not Performed (NP)
2. Perform task with case and confidence
1. States correct rationales/terms.
E VS S NI IP NP
Meets Meets Meets Meets Meets Not
PROCEDURE/STEPS all at at at at Performed
criteria least least least least 0
5 4 3 2 1
1. Introduces self.
2. Identifies patient.
3. Assemble all equipment needed.
4. Performs hand washing.
5. Determines patient’s baseline data.
6. General Appearance
Note for overall impression of a
woman’s health and well-being.
Observe on the manner in which the
woman’s health dresses, the way she
speak and body posture.
Inspect for signs of careless hygiene,
unwashed hair, inappropriate or
soiled clothing, sad facial expression.
Skin
7. Inspect the skin. Note
hyperpigmented areas associated
with pregnancy.
8. Observe for vascular markings
associated with pregnancy.
9. Inspect hair and nails.
Head and Scalp
10. Inspect for symmetry and normal
contour.

11. Palpate for any tenderness.
12. Inspect for hair distribution, thickness
and excessive dryness or oiliness.
13. Inspect for presence of lesion, dandruff or
masses.
14. Inspect the face. Check for mask of
pregnancy; note color, pigmentation, edema.
Eyes
15. Inspect eyes. Examine cornea, lens, iris and
pupil. Note the conjunctival color.
16. Inspect for any visual disturbances.
Nose
17. Inspect the nose for nasal congestion.
Ears
18. Inspect the ears using a penlight.
Mouth, teeth and Throat
19. Inspect the mouth. Pay particular attention to
the teeth (dental caries) and the gingival
tissues, which may appear swollen and
slightly reddened. Observe for cracked
corners of the mouth.
20. Inspect the throat. No redness or exudates
present.
Thorax and Lungs
21. Inspect, palpate, percuss and auscultate the
chest.
22. Assess for respiratory rate and rhythm.
23. Auscultate bilaterally lung sounds.
Heart
24. Palpate the apical impulse.
25. Auscultate for heart rate, presence of
occasional murmur and palpitation.
Breast and Nipple
26. Inspect and palpate the breasts and nipple for
symmetry and color.
Back
27. Observe for exaggerated lumbar curves
Abdomen
28. Inspect the abdomen.


29. Ask the client to recline with a pillow under
her head and her knees flexed.
30. Note striae, scars, and the shape and size of
the abdomen.
31. Assess the shape and contour by measuring
the fundic height.
32. Perform Leopold’s Maneuver
33. Determine the location, rate and rhythm of
the fetal heart.
34. Auscultate fetal heart rate.
Genitalia
35. Inspect external genitalia. Note hair
distribution, color of skin, varicosities
and scars.
36. Observe for presence of discharges;
odor, color, amount
Rectum
37. Inspect the anus and rectum. Note
color, varicosities, lesions, tears or
discharge.
Extremities
38. Inspect the legs for varicose veins.
39. Inspect the hand and legs for edema.
40. Obtain knee and ankle reflexes.
41. Observe for waddling gait.
CI’s Observation/Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________
Date and Time Performed:
Significant Observation: __________________________________________________

__________________________________________________________
_________________________ ______________________
CI’S Signature: Student’s Signature
Prepared by: Rowell Bernard T. Dawat, RN, LPT, MSpEd, MSN(c)

References
AMBOOS (2020). OB/GYN: History and Physical Examination. Retrieved from:

https://www.amboss.com/us/knowledge/OB/GYN:_history_and_physical_examination
Balita, C. (2005). Ultimate Learning Guide. 2005 Edition. Quintin Printing Press
Johnson, J.Y. & Boyd-Davis, E. (2007). Maternal and Child Health Nursing Care of the Children &
Childbearing Family. Lippincott Williams & Wilkins
Meadows, A. (2021). 12 Ways to Say Healthy During Pregnancy. Retrieved from:

https://brighamhealthhub.org/12-ways-to-stay-healthy-during-pregnancy/


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NCM 107 A - CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)

RELATED LEARNING EXPERIENCE

Module: ELICITING OBSTETRIC HISTORY AND PERFORMING OBSTETRIC

Obstetric assessment is an important component of comprehensive obstetric care. It is a tool used

A Legacy of Excellent Education in Virtus et Scientia 1

1. patient’s baseline/ demographics

A Legacy of Excellent Education in Virtus et Scientia 2

Name: Civil Status:

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History of Past Pregnancies

Gravida – number of pregnancies regardless of duration, the number of times a woman

Vaginal Birth is the natural method of birth of offspring through the vagina

Year Type of Delivery Outcome of Place of Attended by

History of Present Pregnancy

A Legacy of Excellent Education in Virtus et Scientia 5

When was your first prenatal visit?

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A Legacy of Excellent Education in Virtus et Scientia 6

Presumptive Signs and Symptoms (Changes felt by Woman)

Probable (Changes observed by the examiner)

C – Chadwick’s sign – bluish discoloration of the vaginal wall

Positive (Definitive Signs of Pregnancy)

Fetal Heartbeat – 12 weeks by Doppler

Frequency – beginning of one to the beginning of the next contraction

Discomfort Duration Intensity Frequency Relief

A Legacy of Excellent Education in Virtus et Scientia 8

A Legacy of Excellent Education in Virtus et Scientia 9

A Legacy of Excellent Education in Virtus et Scientia 10

A Legacy of Excellent Education in Virtus et Scientia 11

A Legacy of Excellent Education in Virtus et Scientia

A Legacy of Excellent Education in Virtus et Scientia

A Legacy of Excellent Education in Virtus et Scientia 14

Name: ______________________________Course/Year/Section: _______________

GRADING CRITERIA; LEGEND:

A Legacy of Excellent Education in Virtus et Scientia

A Legacy of Excellent Education in Virtus et Scientia

A Legacy of Excellent Education in Virtus et Scientia 16

Date and Time Performed:

Significant Observation: __________________________________________________

Prepared by: Rowell Bernard T. Dawat, RN, LPT, MSpEd, MSN(c)

A Legacy of Excellent Education in Virtus et Scientia 17

AMBOOS (2020). OB/GYN: History and Physical Examination. Retrieved from:

Meadows, A. (2021). 12 Ways to Say Healthy During Pregnancy. Retrieved from:

A Legacy of Excellent Education in Virtus et Scientia 18

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