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Postnatal Case Study: Prenatal Record

This document summarizes a postnatal case study including information about the mother, pregnancy, delivery, and postpartum period. It includes sections on the mother's medical history, prenatal visits, labor and delivery details, newborn and postpartum clinical charts, and nursing diagnoses. The case study comprehensively documents physical assessments, vital signs, lab results, and outcomes at each stage of care for both mother and baby.

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130 views

Postnatal Case Study: Prenatal Record

This document summarizes a postnatal case study including information about the mother, pregnancy, delivery, and postpartum period. It includes sections on the mother's medical history, prenatal visits, labor and delivery details, newborn and postpartum clinical charts, and nursing diagnoses. The case study comprehensively documents physical assessments, vital signs, lab results, and outcomes at each stage of care for both mother and baby.

Uploaded by

kuruvagadda sagar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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POSTNATAL CASE STUDY

Name:………………………Age…….Obstetric score…………………………………………………

Hospital Number …………………………………………..

Date of Admission…………………………………………. Discharge Date……………………………………………


Condition of Mother…….……………………………
Date of Delivery……………………………………………. Baby…………………………………….
Date of Discharge…………………………………………...

Prenatal Record
Date of Booking…………………………………………… LMP…………………………………….......
Gestation at 1st visit……………………………………….. EDD…………………………………………

Medical History
Chronic illness…………………………………………… Allergy…………………………………….....
Surgery………………………………………………….. Communicable disease……………………….

Family History
Type of Family Nuclear………………………………… No.of Persons…………………………….....
Joint……………………………………………………...No.of Persons ………………………………

Diseases Chronic illness………………………………………………………………………………


Genetic disorders………………………………………………………………………………
Psychiatric disorder………………………………………………………………………………

History of Multiple Births ………………………………………………………………………………

Socloeconomic Background
Religion………………………………………………. Family Income…………………………………
Education: Husband…………………………………… Wife…………………………………………….
Occupation: Husband ………………………………… .Wife…………………………………………….

Menstrual History
Menarchy………………………………………………. Duration ………………………………………
Interval …………………………………………………. Flow …………………………………………

Marital History
Age of Marriage……………………………………….. Years Married…………………………..........
Consanguineious: Yes/No……………………………………………………

Dietary Pattern
Vegetarian……………………………………………….Non Vegetarian………………………………...
Likes…………………………………………………….Dislikes…………………………………………
Habits: Smoking/Drinking/Chewing Pan/Tobacco
PAST OBSTETRICAL HISTORY
Sl. Year Full Pre Abortion Type of
No. Term Term Delivery Baby Remarks
Sex Alive Stillborn Weight

Present Pregnancy
* Admission Notes
Admitted on ………………………………… at……………………………………………….am/pm
Contractions commenced on ……………….. at……………………………………………….am/pm
Height of Funds…………………………….. Contractions…………………………………………..
Presentation…………………………………. Position………………………………………………..
Engaged/Not Engaged/Free………………… FH R……………………………………………………
Bladder……………………………………… Bowels…………………………………………………
Special Observations……………………………………………………………………………………..

PRENATAL VISITS

Date of Weight Height Urine B.P. FHR Weeks of Height Positio Treatment
Booking Gestatio of n
n fundus
Protein Glucose

General Condition
B.P………………………………………………. TPR…………………………………………………..
Urine: Sp.Gravity……………………………….. Reaction………………………………………………
Protein………………………………. Glucose………………………………Acetone………………….
Examinations and Investigations
Blood Group……………………………….. Rh…………………………. Hemoglobin………………..
VDRL……………………………………… HIV………………………….. Other…………………….
Head……………………………………….. Lungs………………………….Breasts…………………..
Abdomen………………………………….. Perineum…………………………………………………..
CLINICAL CHART OF BABY
Date
Temperature M E M E M E M E M E M E M E
F C
104.0 40
103.1 39.5
102.2 39
101.3 38.5
100.4 38
99.5 37.5
98.6 37
96.8 36
Heart Rate/min
Respiration/min
Urine
Stool
Vomit
Jaundice
Weight(Kg)

CLINICAL CHART OF PUERPERIUM


Date
Temperature M E M E M E M E M E M E M E Fundu
s
in cm
F C
104.0 40.5 20
104.0 40 17.5
103.1 39.5 15
102.2 39 12.5
101.3 38.5 10
100.4 38 7.5
99.5 37.5 5
98.6 37 2.5
97.7 36.5
96.8 36
95.9 35.5
Pulse/min
Respiration/min
Blood
Pressure
Lochia type
Urine
Motion
Delivery Record
Onset of true labor Date………………………………….. Time………………………………………
Time of full duration: Date………………………………… Time………………………………………
Membranes ruptured at……………………………………. Spontaneous/Artificial……………………
PROM…………………………………………….
a. Delivery of Baby
Baby born at…………………………….am/pm, Male/Female……………………………………….
Mode of Delivery………………………………………………………………………………………
Condition of Baby Active/Limp/Asphyxiated
:Stillbirth/Macerated
Apgar Score……………………………………………………………………………………………
Treatment at Birth …………………………………………………………………………………….

b. Delivery of Placenta and Membranes


Delivered at……………………….……………………………………………………………am/pm
Spontaneously/Helped out/Manually removed……………………………………………………….
Type of Placenta………………………………………………………………………………………
Placenta and membranes: Complete/Incomplete……………………………………………………..
Weight…………………..……Cord length……………………Cord insertion………………….….
Any abnormality………………………………………………………………………………………
Total blood loss …………………………………………………………………………………….ml
Perineum:Intact/Episiotomy………………………………………………………………………….
Laceration………………………………………………………………………………..
Medications given. ……………………………………………………………………………………
…………………………………………………………………………………………………………

Length of Labor

Mode of Delivery ………………………………………………………………………………………..

Duration of Labor
First Stage: …………………………………………………………Hrs.……………………………Min
Second stage………………………………………………………. Hrs.………………………….…Min
Third stage. ……………………………………………………….. Hrs.………………………….…Min
Total . …….……………………………………………………….. Hrs.………………………….…Min

Condition of Mother following delivery


Pulse . …….……………………………………………………….B.P………………………………….
Uterus: Hard/Soft. . …….…………………………………………………………………………………
Vaginal bleeding. …….……………………………………………………………………………………
Breastfeeding initiated at . …….………………………………………………………………………….

List of Nursing Diagnoses (For Mother and Newborn)

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