TAGOLOAN COMMUNITY COLLEGE

COLLEGE OF MIDWIFERY

POST PARTUM ASSESSMENT TOOL

Part 1: Demographic Data:

Name: _______________________________________ Age: ___________
Address:
_________________________________________________________________
Date of Birth: ________________ Educational Attainment:
______________
Religion: _______________ Occupation: __________________________
Reason for Visiting the Healthcare facility:
___________________________________________

______________________________________________________________________________
_______
Date of Interview: ___________________________________

Part 2: Vital Signs:

Temperature: ____________ Pulse Rate: _____________ Respiratory
Rate: ____________
Blood Pressure: _________ Height: ______________ Weight:
_____________

Part 3: Health History:

Health Problems Encountered during RECENT PREGNANCY: [please encircle]

NO YES
NO YES
NO YES
NO YES
NO YES

Past Health History: [Any previous illnesses other than those listed
above/ hospitalizations/ allergies during the most recent pregnancy
and labor?]

______________________________________________________________________________
_________________

______________________________________________________________________________
_________________

______________________________________________________________________________
_________________

______________________________________________________________________________
_________________
Family History: [Health of parents, siblings, spouse. Include factors
such as cancer, heart, or kidney diseases, diabetes mellitus, asthma,
hypertension and mental illness]
________________________________________________________________________
_______________________
________________________________________________________________________
_______________________
________________________________________________________________________
_______________________

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 ________________________________________________________________________
_______________________

Part 4: Functional health History:

Physical: Description of patients general appearance, hygiene,
grooming, signs of distress, physical capabilities.
________________________________________________________________________
________________________
________________________________________________________________________
________________________
________________________________________________________________________
________________________

Mental: check orientation to time, place, person; Description of

patients functioning educational status; ability to answer questions;
level of understanding.
________________________________________________________________________
________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________

Emotional: description of clients emotional status. Attitude towards

newborn and motherhood including cconcerns/ feelings
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________________

Spiritual: description of patient spiritual life, number of times she goes

to church, religious organization affiliation. Religious beliefs and
practices regarding diet, birth and blood transfusions
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________________

Part 7: Obstetrical History

Date of Last Menstruation Period: ___________ Date of delivery:
__________
Gravida: ___ Term: ___ Preterm: ____ Abortion: ____ Livebirth: ____
Stillbirth: ______
Presence of Multiple Gestation: _____________
Birth interval of current to immediate past pregnancy: _____________

Please check () to indicate findings

PREVIOUS CAESAREAN SECTION

3 CONSECUTIVE MISCARRIAGES
STILLBIRTH
POST PARTUM HEMORRHAGE

Part 8: Postpartum Findings

Code Guide for Maternal Discomforts responses

Code Interventions of patient
1 none

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 2 Self-medicated
3 Sought advice of family member/ relatives
4 Consulted traditional birth attendant/hilot/
mananabang
5 Consulted health center
6 Consulted physician in private practice
7 Consulted physician in government practice
8 Others__________ [specify]

Part 9: Current Medications

Name of Dosage & Route Classification
Medication Frequency

Part 10 Sleep/Rest Pattern

Before Pregnancy During Pregnancy

Usual Sleep Pattern/

Bedtime

Factors affecting sleep

Part 11: Maternal Nutrition [indicate frequency of meals/food likes &

dislikes/usual timing of meal]
Diet: _______________________
Pattern/Food/ Fluid Intake:
Breakfast:
_____________________________________________________________________________

Lunch:
______________________________________________________________________________
___

Dinner:
______________________________________________________________________________
__

Appetite [describe]:
__________________________________________________________________

Part 12: Elimination

Micturition Bowel Movement

Frequency
Usual Amount
Consistency

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Usual Appearance

Is the patient taking diuretics? ____________ If Yes, state reasons:

_____________________________
Is the patient taking laxatives? ____________ If yes, state reasons:
_____________________________

Part 13:Coping/Stress

Any stressful situations ever experienced during the course of present

pregnancy?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________

Stress Management used/ Relaxation techniques employed:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________

Part 13: Laboratory Result

Laboratory Results Normal Interpretation Midwifery

Exam Values Consideration
s/
Interventions

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 I. Physical Assessment (System Review Chart) Date: ____________

Vital Signs:
Pulse: BP: Temp.: RR: Height:
Weight:

EENT

( ) Impaired vision ( ) blind ( ) pain ( ) hard of hearing

( ) reddened ( ) drainage ( ) gums ( ) deaf
( ) burning ( ) edema ( ) lesion ( ) teeth
( ) no problem

RESPIRATORY:
( ) asymmetric ( ) tachypnea
( ) apnea ( ) rales ( ) cough
( ) barrel chest ( ) bradypnea
( ) shallow ( ) bronchi ( ) sputum
( ) diminished ( ) dyspnea
( ) wheezing ( ) chest pain ( ) cyanotic
( ) No problem

CARDIOVASCULAR
( ) arryhythmia ( ) tachycardia ( ) numbness
( ) diminished pulses ( ) edema ( ) fatigue
( ) irregular ( ) bradycardia ( ) murmur
( ) tingling ( ) absent pulses ( ) pain
( ) No problem

GASTRO INTESTINAL TRACT

( ) obese ( ) distention ( ) mass
( ) dysphasia ( ) regididty ( ) pain
( ) No problem

GENITO-URINARY and GYNE weak

( ) pain ( ) urine color ( ) vaginal bleeding
( ) hematuria ( ) discharge ( ) noctoria
( ) problem -

NEURO
( ) paralysis ( ) stuporous ( ) unsteady ( ) seizures
( ) lethargic ( ) comatous ( ) vertigo ( ) tremors
( ) confused ( ) vision ( ) grip
() No problem

MUSCULOSKELETAL and SKIN

( ) appliance ( ) stiffness ( ) itching ( ) petechiae
( ) hot ( ) drainage ( ) prosthesis ( ) swelling
( ) lesion ( ) poor turgor ( ) cool ( ) deformity
( ) wound ( ) rash ( ) skin color ( ) flushed
( ) atrophy ( ) pain ( ) ecchymosis
( ) diaphoretic () moist
( ) problem

[Sources: Department of Health- Home Based Mothers Record;Lippincott

Maternal-Newborn Reviews series; Misamis University College of Nursing OB
Assessment Tool; National Demographic and Health Survey Tool; Research
Institute for Mindanao Culture Maternal Survey; University of the Philippines-
Open University OB Assessment Tool; Public Health Nursing in the
Philippines]

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