Antenatal History Format – This course is designed to understand the care of pregnant women and newborn: antenatal, intra-natal and postnatal; breast feeding, family planning, newborn care and ethical issues, The aim of the course is to acquire knowledge and develop competencies regarding midwifery, complicated labour and newborn care including family planning.
Antenatal History Format
I. Patient profile
✓ Full name:
✓ Age (in years):
✓ Hospital no:
✓ IP No:
✓ Marital status: Married / unmarried/ divorced/ separated
✓ Education status:
✓ Occupation:
Husband’s name:
✓ Age (in years):
✓ Education status:
✓ Occupation:
Type of family:
✓ Per capita income:
✓ ate of booking:
✓ Date of last antenatal visit:
✓ Date of admission:
✓ Obstetric score
- Gravida
- Para
- Abortion
- Living still born
II. Reason for hospitalization / Chief Complaints
✓ Onset
✓ Duration
✓ Severity
✓ Relieving factors
✓ Aggravating factors
III. Menstrual history:
✓ Age at menarche
✓ Duration of cycles
✓ Regularity
✓ Flow – heavy/moderate scanty
– clots
– no. of days
– Any dysmenorrhoea
– Relief measures
– Last menstrual period
IV. Obstetric history:
Present Obstetric history
✓ Is pregnancy confirmed: Yes / No
✓ When, where and how it was confirmed
✓ What test was done for confirmation?
✓ Quickening
✓ Immunization
Any more disorders like: Vomiting, haemorrhoids, heart burn, backache, bleeding, varicose vein, constipation, leg cramps, fever, leucorrhoea, anorexia, insomnia, other complaints.
Past Obstetric History
SI No | Date of delivery | Place of birth | Duration of pregnancy | Method of delivery | Course of pregnancy | Labor | Puerperium | Baby | |
| Sex | Wt | ||||||||
V. Family History:
Congenital diseases
Any hereditary diseases
Multiple pregnancy
Diabetes
Heart disease
Any mental retardation
Hypertension or PIH (in mother/ sisters)
Twin pregnancy
If yes, In whom? Mother / Father ?
VI. Medical Surgical History:
✓ Child hood disease
✓ Chronic disease like asthma, diabetes, epilepsy
✓ Previous surgery
✓ Injuries especially of back and pelvis
✓ Hepatitis, STD, HIV
✓ History of anemia
✓ Any medication taken at present or past
✓ Reason for use, date stopped
✓ Blood transfusion, allergic reaction VII.
Nutrition:
General nutrition
– veg /non-veg
Appetite
decreased/increased
Any eating disorders
VIII. Partner’s Health History:
✓ Genetic abnormalities
✓ Chronic diseases
✓ Infections
✓ Use of drugs such as cocaine alcohol
✓ Smoking habits: tobacco, cigarette
✓ Sexually transmitted diseases HIV/AIDS
✓ Blood type IX.
Psycho-social history:
✓ Emotional changes experienced
✓ Women’s and family’s reactions to present pregnancy
✓ Family support system Family members and friends
✓ Coping strategies
✓ Life style change
✓ Social relationships with the neighbours
✓ Financial support
Antenatal examination
✓ General Appearance:
✓ Nourishment:
✓ Body built:
✓ Height:
✓ Weight:
✓ Vital signs:
✓ Temp:
✓ Pulse:
✓ Respiration:
✓ BP
Mental status:
✓ Head to foot examination:
Skin turgor:
✓ Moisture:
✓ Warmth/Temp:
Face:
✔ Facial puffiness:
✔Lips: Cyanosis, dryness
Eyes:
✓ Peri-orbital oedema:
✓ Conjunctive: Pallor
Mouth:
✓ Tongue: Moisture
Chest:
Thorax:
Shape:
Symmetry of expansion: posture
Breath sounds:
Vesicular sounds: Wheezing/Rhonchi: Crepitations: Pleural rub
Heart: heart rate:
Location of apex beat/ Cardiac murmurs
Axilla: any lymph node enlargement
Breast: any tenderness / painful: tense / dilated veins/warmth/presence of crusta
Nipples: retracted/inverted/cracked
Abdomen
Inspection: Size, shape, contour, flanks, umbilicus, foetal movements, skin changes,
Contractions present/not.
Palpation: –
Fundal palpation:
Inference: Lie
Presentation –
Lateral Palpation:
Left side –
Right side –
Inference: Position
Pelvic palpation :-
First pelvic grip
Inference: Presentation
Engagement / not engaged
Attitude-
Pawlick Grip: Fixed/ Mobile
Auscultation:
– FHR
– rhythm
– location
Extrimities:
Ankle oedema:
Capillary refill:
Cyanosis:
Investigations
| SI no | Investigations | Patient’s value | Normal value | Inference |
Medications
| Sl.no | Name | Dose | Freq | Side effects | Nurses responsibilities |
Nursing Diagnosis
| Sl.no | Assessment | Nursing diagnosis | Objectives | planning and intervention | Implementation | Evaluation |
Health Education
1. Diet
2. Exercise
3. Hygiene
4. Immunization
5. Follow-up
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