Vous êtes sur la page 1sur 10

INTRANATAL ASSESSMENT FORMAT Identification data: Name: Age: Hospital No.

: Education: Occupation : Husbands Name: Education : Occupation : Date & Time of admission : Reason for admission : Famil income : !er capita income : Present Obstetric History : "#! : EDD : !O$ : $!"A :

Antenatal history : % Trimester :

%% Trimester : %%% Trimester :

Past Obstetric history: &l. Dt.'(r. !lac Duration #et*o +ab No of e of of d of !uerperiu &e, present . deli)er birt* pregnan deli)er m & conditio c -eig n *t -eig *t

Family history Medical S!r"ical history: . !ersonal *istor : Diet/ rest/ e,ercise/ *abits Marital history: . 0onsanguit . Relations*ip Socio#economic stat!s: . Abilit to afford *ospital e,penses . Financial assistance

PH$SI%AL E&AMINATION Nouris*ment: +od built: Heig*t 1eig*t: 2ital signs : Temp : !ulse: . F' 0 . ' mt

Respiration : +.!. Mental stat!s : Head to foot e'amination : &3in furgor: #oisture : 1armt* ' Temp : Face: Facial puffiness: "ips: E es: !eri.orbital oedema: 0on4uncti)e : !allor #out*: Tongue: Abdomen

. ' mt . ' mm of Hg.

0 anosis/ dr ness

#oisture

Ins(ection : &i5e/ s*ape/ contour/ flan3s/ umbilicus/ foetal mo)ements/ s3in c*anges/ 0ontractions present'not Pal(ation:

. Fundal palpation:

%nference : "ie !resentation . "ateral !alpation: "eft side 6 description Rig*t side 6 description %nference : !osition . !el)ic palpation :

!el)ic grip : Description

%nference : !resentation Engagement ' not engaged Attitude

!a-lic3 $rip: Fi,ed' #obile

A!sc!ltation :

. FHR . r* t*m . location

Intranatal e)ents : Time of onset of labour pain Admission note : #aternal general condition 0ondition of uterus : containing ' not P * findin"s: 0er)ical dilation :

Effacement : &tation : #embrane : "i7uor : !el)is :

Description of % stage: Description of %% stage:

%ontractions Monitored !uls FHR +! Dat Tim e No. of 89mt 8mmH Fregnan Duratio e e 89mt contractions' .: g: c n : 9; minutes 0ontractions

Per *a"inal e'amination findin"s Date Dilation Time of Effacement &tation #embrane "i7uor cer)i,

Description of %%% &tage: Description of %2 &tage: 0ondition of mot*er 0ondition of bab details 1eig*t: 0r : 1eig*t: 0ord "engt*: !lacenta

Apgar &core: 0omplete'%ncomplete:

S$NTO%IN RE%OR+

Name: Hos(, No: Obstetric Score: I,P, No, +ia"nosis:

A"e: -ard:

Indication for o'ytocin dri(: Re ma r3s or an !rogres Effa ot* >terine s of cem er 0ontractions ! labour ent eff ul ect Res F. se s p8' H. 8' obs mt: R m er) t: ed 0e r)i %nt Fre Du &t cal ens 7ue rati ati dil it nc on on ati on

D at e & T i m e

%.2. s nt oci n in <;; ml R"' <= de, tros e. >ni ts 8dro ps' mt:

+.! 8m m H$ :

& i g n