INTRANATAL ASSESSMENT
Name:
Age:
Obstetric score:
Hospital Number:
Date of Admisssion:
Date of Delivery:
Date of Discharge:
Pre natal Record
Date of booking……………………………………………………..LMP………………………………………………..
Gestation at 1st visit………………………………………………EDD…………………………………………………
Medical History
Chronic illness:
Allergy:
Surgery:
Communicable disease:
Family history
Type of family:
No of persons:
Diseases Chronic illness: Hypertension:………………………..Diabetes………………………..
Genetic disorder:
Psychiatric disorder:
Multiple Births:
Socioeconomic background :
Religion:………………………………………..Family income: ……………………………………………….
Education: Husband……………………………………… Wife……………………………………………….
Occupation: Husband…………………………………… Wife……………………………………………….
Menstrual History
Menarchy: Duration: Interval:
Flow:
Marital History
Age of marriage………………………………………… Years married……………………………………..
Consanguineous:
Dietary Pattern
Vegetarian…………………………………………….. Non vegetarian………………………………………
Likes:
Dislikes:
Habits:
PAST OBSTETRICAL HISTORY
sr no year full pre abortio type of baby remarks
term term n delivery weigh
sex Alive still born t
Present Pregnancy
Admission notes
Admitted on………………………………………………………at……………………………………………..am/pm
Contractions commenced on…………………………………….at………………………………………am/pm
Period Of Gestation…………………………..Membranes : Intact………………………………………….
Ruptured On…………………………..at……………..am/pm
Height of Fundus…………………………………….Contractions……………………………………………..
Presentation………………………………………………………….. Position…………………………………..
Engaged/not engaged/free…………………………………… FHR………………………………………….
Bladder…………………………………………………………………. Bowels……………………………………..
Special Observations………………………………………………………………………………………………..
PRENATAL VISITS
Date of Weight Height Urine B.P FHR Weeks of Height Treatment
Booking Gestation of
fundus
Protein Glucose
General Condition
B.P. ……………………………………………………………………. T P R…………………………………………………………
Urine: Sp. Gravity ……………………………………………… Reaction…………………………………………………..
Protein………………………………………….. Glucose…………………………Acetone……………………………….
Examinations and Investigations
Blood group………………………………… Rh…………………Hemoglobin…….………………………………….
VDRL…………………………………………. HIV………………………Other………………………………………………
Heart……………………………………….. Lungs……………………Breasts……………..………………………………
Abdomen……………………………….Perineum…………………………………………………………………………………
Delivery record
Onset of true labor: Date…………………………………………………
Time…………………………………………………………..
Time of full dilation:
Date………………………………………………..Time………………………………………………………….
Membranes ruptured at…………………………………………………
Spontaneous/Artificial……………………………….
P R O M…………………………………………………………………………..
a. Delivery of Baby
Baby born at…………………………………..am/pm, Male/Female…………………………………………..
…………………….
Mode of Delivery………………………………………………………………………………………………………………..
Condition of baby: Active/Limp/Asphyxiated/Still birth/ Macerated
APGAR SCORING
S.N Sign 0 Neonate’s 1 Neonate’s 2 Neonate’s
o Score Score Score
1mi 5mi 1mi 5mi 1mi 5mi
n n n n n n
1 Respirator Absen Slow, Strong Cry
y effort t Irregular,Wea
k cry
2 Heart rate Absen Slow, less Over 100
t than 100
3 Muscle limp Some flexion Active
tone of limbs movemen
t
4 Reflex Absen Facial Cry
responses t grimace
to flicking
of foot
5 Color Blue - Body pink, Completel
Pale limbs blue y pink
0-2 Severe asphyxia Score at one minute……………………….
3-4 Moderate asphyxia Score at five minutes………………………
5-7 Mild asphyxia
8-10 No asphyxia
StillBorn / Macerated……………………………………………………………………
Cause……………………………………………………………………………………………
Treatment at Birth:
b. Delivery of placenta & membranes
Delivered at………………………………………………………………………………………am/pm
Spontaneous/Helped out/Manually removed: ………………………………………………..
Type of placenta:
Placenta & membranes: Complete/Incomplete:
Weight………………………………………Cord length……………………………….Cord insertion……………………….
Any abnormality:
c. Blood loss :
Before delivery of the Placenta …………………………………………………………………….ml
During delivery of thePlacenta ……………………………………………………………………..ml
After delivery of the Placenta ……………………………………………………………………….ml
Total ……………………………………………………………………………………………………………..ml
d. Perineum:
Intact………………………………….Episiotomy: ……………………………..Laceration: ………………………
Repair ……………………………………………………………..
e. Medications given: ……………………………………………………..
f. Length of Labor
Mode of delivery: …………………………………………………………………………………….
Duration of labor
First stage: …………………………………………………………………Hrs…………………………………………..min
Second stage: ……………………………………………………………Hrs…………………………………………….min
Third stage: ………………………………………………………………Hrs……………………………………………..min
Total: …………………………………………………………………………Hrs…………………………………………….min
g. Condition of mother following delivery
Pulse……………………………………………………………………….. B.P……………………………………………………
Uterus: hard/ soft…………………………………………………………………………………………………………………
Vaginal bleeding…………………………………………………………………………………………………………………..
Breastfeeding initiated at…………………………………………………………………