ANTENATAL HISTORY COLLECTION FORMAT

Demographic Data

Name :

Age :

Address :

DOA:

I.P.No:

Unit :

Religion :

Education :

Occupation :

LMP

EDD

Obstetrical score: G3P2L2A0

Period of gestation:

Diagnosis :

Chief complaints

Present complaints

Present obstetrical history :

Pregnancy was diagnosed by UPT. She undergone regular antenatal check up.

Minor ailments, any complications, no. of antenatal visits, immunization status,

medication or radiation exposure or medical –surgical events during pregnancies.
 First trimester

Hb%, HEG/morning sickness, Threatened abortion, medication or radiation

exposure, UTI. Thyroid dysfunction

Second trimester

Any complications(APH, PET,Aneamia, GDM etc) immunization status(TT), medical

–surgical events during pregnancies,quickening.

Third trimester

Presence of oedema, varicosities, lower backache, posture, frequency of

micturition, any complications(APH, PET,Aneamia, GDM etc.

Past obstetrical history:

Mrs. X is a G3P2L2 mother.

Sl. Month Pregnancy Labour Puerperium Baby

No &Year
Duration Complication Fullterm/ Mode Uneventful/ Wt Sex Alive/ Immu
preterm of eventful stillbirth nizati
delivery on
In weeks Abortion ,IUD
1
2
Menstrual history: Mrs X attained menarche at the age of ---yrs. Cycle is regular
with 4-5 days duration and the amount of flow is minimal.No history of
dysmenorrhea or menorrhagia .

Marital history: she got married ---yrs back and there is no history of
consanguinity in their marriage.

Family history: She belongs to a nuclear family and there is no multifetal

pregnancy, diabetes, HTN, TB, hereditary , psychiatric illness, or any others.

Personal history : She is not having bad habits likesmoking or alcohol, sleep
pattern is normal, bowel& bladder pattern is regular/altered. She maintains good
personal hygiene and no history of food or drug allergies. No history of
contraceptive practices prior to pregnancy.

Past Medical history : Relevant history of past medical illness

Past Surgical history : previous relevant surgical history (general or

gynaecological). LSCS not included.

Examination :

General physical examination

Build :obese/average/thin

Nutrition : good/average /poor/BMI

Ht . wt.

Vital signs :

Head:

Eyes: conjunctiva is red in colour and no signs of jaundice

Ears:

Nose :

Face: there is no facial puffiness and periorbital odema. Mask of pregnancy is

present or absent.

Mouth: Tongue, teeth, gums and tonsils: glossitis,stomatitis(malnutiriton)

Neck: thyroid gland and lymph nodes

Breast:

Inspection:

both breasts are symmetrical, nipples are erect , areola is hyperpigmented,

montgomery’s tubercles and visible veins are evident.
 Palpation: circular method centre to periphery. breast is soft and there is
no tenderness. Axillary lymph nodes are absent.

Respiratory system: RR

Cardiovascular system :HR

Abdominal examination

Inspection

Size: appropriate to gestational age

Shape: longitudinally ovoid with cylindrical/spherical shape

Contour: firm/relaxed

skin condition: linea nigra and stria gravidarum are present. Previous
surgical scar present/not

umbilicus: flat/ dimpled/ protruded

flanks: full/ not full

visible fetal movements : are evident

bladder: empty

Palpation

Abdominal girth

Fundal height

In cm:

Weeks:

Fundal : broad, soft and irregular mass suggestive of breech/ smooth, hard
and globular mass suggestive of head.

Lateral:
 Left : smooth ,curved , continuous and resistant mass indicates back

Right: knob like irregular parts indicates limbs

Pelvic:

Pawlik’s grip : fetal head is mobile

Pelvic grip: Hands are diverged, so head is engaged

Hands are converged, so head is not engaged

Auscultation: FHS:

Findings :

Gestational age: Attitude:

Lie: Engagement :

Presentation: FHR:

Position:

Lower extremities :

Odema of legs: both legs. Pitting odema

Sites- medial malleolus, doralis pedis, anterior surface of the lower1/3 of

the tibia(press the site for 5 sec. with thumb). Pitting odema leaves a small
depression or pit after finger pressure is applied to the swollen area.

Degrees of odema:

2mm -+1

4mm -+2

6mm -+3
 8mm -+4

varicosity of legs.

Perineum : vaginal discharge, odema

Investigations

Investigations Patient’s value Normal value Remarks

Any other investigations( USG, X-ray)

Medications

Name Dosage Action Indications Side effects Nurses

/route responsibility

I.V fluids, Blood transfusion etc

Nursing diagnoses

Nursing care plan

Health education

Recording and reporting

 POSTNATAL HISTORY COLLECTION FORMAT
Demographic Data

Name :

Age:

Addres :

DOA:

I.P.NO:

Unit:

Religion:

Education:

Occupation:

LMP

EDD

Obstetrical score: P3L3 A0

Period of gestation:

Mode of delivery:

Date of delivery

Indication for L.S.C.S

Diagnosis:

Chief complaints
Present complaints

Present obstetrical history:

Mrs . X got admitted to SMBI for safe confinement /with the complaints of
------------on.

Antenatal history

Pregnancy was diagnosed by UPT. She undergone regular antenatal check up.

Minor ailments, any complications, no. of antenatal visits, immunization status,

medication or radiation exposure or medical –surgical events during pregnancies.

First trimester

Hb%, HEG/morning sickness, Threatened abortion, medication or radiation

exposure, UTI, thyroid dysfunction

Second trimester

Any complications (APH, PET, Aneamia, GDM etc), no. of antenatal visits,
immunization status(TT), medical –surgical events during pregnancies ,quickening.

Third trimester

Presence of oedema, varicosities, lower backache, posture, frequency of

micturition, any complications(APH, PET, Aneamia, GDM etc), no. of antenatal
visits.

Intranatal history:

Vaginal delivery

Mrs X is shifted to labour room for induction at --- on---. With the aid of RMLE and
good uterine contractions, she delivered an alive term M/F baby of birth weight
---kg at --- on----.Baby cried immediately after birth . Apgar score was---. Placenta
 and membranes expelled out completely and episiotomy incision was sutured.
Breast feeding was initiated within half an hour.

L.S.C.S

Mrs . X is shifted to O.T for L.S.C.S with the indication of ----at—on---. Abdomen
was opened by modified pfennenstiel incision and extracted an alive term M/F
baby of birth weight ---kg at --- on----.Baby cried immediately after birth . Apgar
score was---. Placenta and membranes expelled out completely. Abdomen was
closed in layers. . Breast feeding was initiated within 2 hours. Baby was shifted to
NICU for observation and mother was shifted to SICU.

`Postnatal history: present complaints and condition

Condition of the mother and baby is good. uterus is hard and involuted. Breast is
soft, no engorgement and lactating well. Episiotomy wound/ L.S.C.S incision is
healthy. bleeding-mild/moderate/severe. Lochia rubra is present in normal limits.
Baby is healthy and active. She has complaints of pain in the lower abdomen and
episiotomy site/ breast engorgement.

Past obstetrical history: Mrs. X is a P3L3 mother.

Sl. Month Pregnancy Labour Puerperium Baby

No &Year
Duration Complication Fullterm/ Mode Uneventful/ Wt Sex Alive/ Immu
preterm of eventful stillbirth nizati
delivery on
In weeks Abortion ,IUD
1
2

Menstrual history: Mrs X attained menarche at the age of ---yrs. Cycle is regular
with 4-5 days duration and the amount of flow is minimal.No history of
dysmenorrhea or menorrhagia .

Marital history: she got married ---yrs back and there is no history of
consanguinity in their marriage.
Family history: She belongs to a nuclear family and there is no multifetal
pregnancy, diabetes, HTN, TB, hereditary , psychiatric illness, or any others.

Personal history: She is not having bad habits like smoking or alcohol, sleep
pattern is normal, bowel& bladder pattern is regular/altered. She maintains good
personal hygiene and no history of food or drug allergies. No history of
contraceptive practices prior to pregnancy.

Past Medical history : Relevant history of past medical illness

Past Surgical history: previous relevant surgical history (general or

gynaecological)

Examination :

General physical examination

Build :obese/average/thin

Nutrition : good/average /poor

Ht . wt.

Vital signs :

Head:

Eyes: Pallor : sites noted are lower palpebral conjunctiva,dorsum of the tongue,
nail buds.

Jaundice : sites noted are bulbar conjunctiva,under surface of the tongue,hard

palate, skin.

Ears:

Nose :

Face:

Mouth: Tongue, teeth, gums and tonsils: glossitis,stomatitis(malnutiriton)

 Neck:

Inspection & palpation

lymph node, thyroid gland, range of motion

Systemic examination

Respiratory system

Cardiovascular system:

Gastrointestinal system:

Postnatal assessment

Date Vital Signs

Breast Uterus Bowe Bladde Lochia Episiotomy Homan Emotional
T P R BP l r Sign Status

Breast:

Inspection : both breasts are symmetrical, nipples are erect and

cracked/retracted/inverted, areola is hyperpigmented, montgomery’s
tubercles and visible veins are evident.

Palpation: circular method centre to periphery,palpation(place the

patient’s hand behind the head before palpation)

Breast is soft and there is no tenderness. Axillary lymph nodes are absent.

Abdomen

Uterus :
 Inspection : C.S wound,previous surgical scars, skin changes – linea ,
striae albicans

Palpation : bulky/firm, fundal height, consistency, after pains

Bowel: auscultate the bowel movements

Bladder:

Lochia: colour, amount, odour

Blood loss after childbirth is assessed by the extent of perineal pad

saturation. Scanty <2.5cm, light <10cm, moderate >10cm, heavy- one pad
saturated within 2 hours.

Episiotomy: RMLE is present

REEDA

Homan’s sign:

Emotional status:

Extremities:

Odema on both legs. (Sites- medial malleolus, dorsalis pedis, anterior surface of
the lower1/3 of the tibia(press the site for 5 sec. with thumb), capillary refill.

varicosity of legs:

Newborn assessment
Name of the baby

Sex

Term/preterm

Day :0/365

Weight Length Head circumference Chest circumference

Temperature Heart rate Respiration

General appearance

Posture

Active/lethargy/ Cry

Skin :Colour: jaundice, pink/cyanosis, skin turgor

Others

Birth marks: mangolian spots, port wine stain, hemangiomas

Vernix, milia, lanugo visible blood vessels over the abdomen, Rashes

Head to foot examination:

Head : size/shape/caput/cephalhaematoma/fontanels/hairs

Face : overall appearance/well-placed/symmetric features

Eyes: placement of the eye/ distance between the Eyes /symmetry/ discharge/

pupils/ eyebrows/hyperbilirubinemia/blinking /doll’s eye reflex

Nose: placement/patency/nasal flaring/configuration of bridge of

nose/discharge,milia

Ears: placement/low set ears/well-formed/firm cartilage/open auditory canal/

response to voice

Mouth : assess lips for colour,configuration,movement/cyanosis/cleft lip/ palate/

gums/ Epstein pearls/tongue/sucking pads inside the cheek/oral thrush/

uvula in midline/saliva-mouth moist/reflexes-rooting,sucking,extrusion.

Neck: inspect and palpate neck

 Short, thick, surrounded by skin folds/no masses/freedom of movement
from side to side, flexion,extension/thyroid gland-not palpable/head held in
midline(head control)

Chest: shape-almost circular,barrel shaped/tip of the sternum prominent/

symmetric chest movements/ retractions/ auscultate heart sounds,

breath sounds

Breast :nipples-prominent, well formed, symmetrically placed/breast nodule-3-

10mm/witch’s milk/

Abdomen :

rounded,prominent,dome-shaped, abdominal distension/palpate liver-1-

2cm below the right costal margin/ausculate bowel movements-note
number,amount, character of stools.

Umbilical cord –

arteries and vein,bleeding,drying, odorless,cord clamp, infection(foul

odor, redness, purulent discharge)cord fallen, Omphalocele

Genitalia :

Palpate femoral pulse

Female – general appearance, clitoris,discharge,vaginal orifice,urinary

meatus, urination, presence of vernix between folds.

Male – general appearance/penis/prepuce(covering the plans penis & not

retractable) /scortum-rugae ,testes-descended/urination, hypospadias,

epispadias

Back:
 Inspect and palpate :spinal alignment,enlargement, masses/sacrum –

dimpling, a tuft of hair/palpate vertebral column/trunk incurvation

reflex/magnet reflex

Buttocks: presence of mangolian spots, Anal patency, meconium passage

Extremities : degree of flexion/range of motion/spontaneous movements/no.of

fingers & toes/plantar creases/webbing of the hands and feet/

acrocyanosis/ soles of feet/clubfoot/ Talipes

signs of hip dislocation – ortholani, barlow,alli’s or galaezzi’s sign

Reflexes :

Reflexes Eliciting the reflex Response inference

Glabelllar
Doll’s eye
Corneal reflex
Papillary reflex
Sneezing reflex
Rooting reflex
Sucking &
swallowing reflex
Extrusion reflex
Tonic neck reflex
Moro reflex
Startle reflex
Palmar & plantar
grasp
Trunk incurvation
reflex
Magnet crossed
extension
Babinski reflex
Stepping /walking
reflex
Crawling reflex

Investigations

Investigations Patient’s value Normal value Remarks

USG,X-ray

Medications

Name Dosage Action Indications Side effects Nurses

/route responsibility

I.V fluid, blood transfusion

Nursing diagnoses for mother and baby

Nursing care plan

Health education

Recording and reporting

Progress note

Discharge summary

Conclusion