ANTENATAL ASSESSMENT

PROFILE OF MOTHER:
Name of the mother

Mrs.Megala

Age

24 years

Educational status

6th standarad

Occupation

Housewife

Religion

Hindu

Address

w/o Mr Kumar,2/59,parani koil street,Kanchipuram

Marital status

Married

Date of admission

26.08.2014

I.P. no

22390

Ward

AN ward

LMP

25.12.2013

EDD

02.10.2014

Obstetrical score

G2 P1 L0 A1

Weeks of gestation

36 weeks

Reason for hospitalization

complains of lower abdominal pain and bleeding since

morning. Client admitted for evaluation.

PEDIGREE CHART:-

Key points:
Male
Female
dead

Present pregnancy

FAMILY MEDICAL HISTORY:-

There is no family history of multiple pregnancy/ DM/ PIH/genetic disorders/

communicable diseases/ psychiatric illness
others

PERSONAL HISTORY:Sleep/ rest

: Adequate

Activities of daily living

: She is doing regular house holding work

Hygiene

: Maintained

Elimination

: Bowel habits -Regular

Hobbies/ interest

: watching T.V and reading books

IMMUNIZATION HISTORY
Immunised with 2 doses of Injection tetanus toxoid
MENSTRUAL HISTORY
Age at menarche:
Menstrual cycle:

13 Years
Regular 3/30 days

MARITAL HISTORY:
Married since 3 years. Non consanguineous marriage
CONTRACEPTIVES:
Not used

Bladder habits-Regular

PAST HISTORY:In 2012 mother had emergency LSCS and delivered still born boy baby in IOG for
fetal distress with MSL with hand prolapsed.Inj anti D 100mg given
PAST OBSTETRICAL HISTORY:S.N
O
1
2

YEAR

MODE OF DELIVERY

SEX

WEIGHT

GENERAL CONDITION

2012
2014

LSCS
Present pregnancy

boy

2.2kg

Still birth

PRESENT MEDICAL HISTORY:Client came with c/o lower abdominal pain and bleeding admitted for evaluation.
PRESENT OBSTETRICAL HISTORY:First trimester: H/O nausea, vomiting, pica, anorexia, constipation is there. There is no
exposure to drugs/ radiation/infection/any other
Second trimester: NO H/o heart burn, but back ache, muscle cramps is there.
Anaemia, GDM, PIH, any other
Quickening felt at 5months
Weight gain: normal
Third trimester: H/o heart burn, constipation,
frequency of micturation , any other
lightening: yes
fetal movement: normal
Antenatal checkup

date

Weight in Urine
kg
Albumin

sugar

BP

Weeks of
gestation

Ht of fundus in
weeks/cms

Presentation

4.6.14
5.7.14
5.8.14
26.8.14

52kg
54kg
58kg
64kg

nil
nil
nil
nil

110/90
110/90
110/80
110/80

22weeks
26weeks
30weeks
34weeks

20cm
26cm
32cm
36cm

breech
breech
breech
breech

nil
nil
nil
nil

PHYSICAL EXAMINATION

General condition:-conscious oriented

Height: - 147cm

weight:- 52kg Gait:-normal

Head: - normal black colour hair

Face:- there is no changes
Eyes:- conjunctiva pink
Ears:- normal hearing
Nose:-no obstruction
Mouth:-no dental carries
Neck:-no lymph node
Chest:-symmetrical normal vesicular breathing
Extremities[ upper and lower]:-normal range of motion

OBSTETRICAL EXAMINATION
Breast: symmetrical primary and secondary aerolar present No cracked nipple and no
inverted nipple.
Abdomen
Inspection
Size - more than the period of gestational age.
Shape - globular shape
Contour - firm
Umbilicus - protruded
Skin changes - lenia nigra and striae gravid arum present
Scar - previous caesarean scar present.
Visible Fetal movement - present

Flanks - full
Palpation
Abdominal girth-100 cm
Fundal height - 38cm
Fundal palpation- hard round mass present on the upper pole of the uterus that denotes fetal
head.
Lateral palpation: multiple fetal limbs may also be palpable in lateral palpation.
Pelvic palpation: A soft mass present in the lower pole of the uterus that denotes fetal
buttocks.
Auscultation: hearing two fetal hearts is not diagnostic as one can often heard over a wide
area in a single pregnancy .
SUMMARY OF FINDINGS
Lie-longitudinal
Presentation-sacrum
Attitude-flexio

Investigations
Blood
Group A negative
Hb 11.5gms
HIV -NR

blood sugar -90mg/dl

hepatitis B-NR

any other

Urine test-Albumin ,sugar nil

Stool examination-not done
Ultrasound examination-36 weeks DCDA twins
Non stress test-reactive

VDRL-NR

Nursing diagnosis

Anxiety related to outcome of baby as evidenced by asking questions

knowledge deficit regarding breast feeding technique as evidence by asking about breast
feeding
Imbalanced nutrition less than body requirement related to inadequate intake of food.
Discomfort related to multiple pregnancies
Activity intolerance related to over distended abdomen

Disturbed sleep pattern related to hospitalization.