DEPARTMENT OF NURSING

NUR 125 Maternal- Child Nursing

INTRAPARTUM ASSESSMENT*

Student___________________________________Date__________
Time of Assessment_______________________________________

Brief Summary: (Reason for intrapartum admission):

Fill out each area. If data is not available, put Data Not Available and give reasons. Be sure to review chart
before discharge for missing lab data.
I. Identifying Data
A. Clients initials__________ Age____________ Ethnic Origin________________

Chart #_______________ Marital Status___________Religion_______________

Gravida__________Para__________ T__________P__________A___________

Living children____________________________________________________

Gestational week_________________L N M P___________________________

EDC by Nageles rule___________________ EDC by sonogram____________

Membranes intact____________________ Ruptured______________________

II. Patterns of Health Care for this client: None / intermittent / preventive / problem
oriented
Type of health facilities used: physicians office, clinic, emergency room, other

_______________________________________________________________________

Date of 1st OB visit_________________________# of visits____________________

General Appearance

Height___________Weight__________Pre-pregnant weight____________________
Vital signs @ assessment: B/P________P_________RR_________T___________
FHR with location___________________________________________________
Vital signs range T________P_________R_________B/P____________________

Date of Quickening_____________________EFW_________________________

III. Problems prior to pregnancy

Adult illness
Hospitalization
Allergies

IV. Maternal family medical history give relationship

A. Cardiovascular G. Diabetes onset insulin dependent

B. Pregnancy induced hypertension H. Kidney disease
C. Cancer I. Tuberculosis
D. Hematological J. Congenital anomalies
E. Neurological K. Multiple pregnancies_____twin____
F. Psychiatric

* Indicate in red ink or pencil any abnormal data. Abnormal data is the rationale for
nursing diagnosis identified for the client.

V. Paternal data:
Initials of father of baby____Status of Health______Occupation________________
Lives with Mom YES NO
Health considerations: Examplesickle cell, hemophilia, street drug use, TB, STD,
HIV________________________________________________________________
Fathers pertinent family medical history: sickle cell, hemophilia, etc.

___________________________________________________________________

VI. Review of maternal systems [Client HISTORY]

A. Integument
B. Head
C. Eyes
D. Ears

E. Nose & Sinuses

F. Mouth & Throat
G. Neck
H. Lymphatic
I. Breast
J. Respiratory
K. Cardiovascular
L. Gastrointestinal
M. Genitourinary
N. Musculoskeletal
O. Endocrine
P. Hematopoietic
Q. Neurologic
R. Reproductive
Menarche
Vaginal bleeding
Vaginal discharge, itching
Birth Control: what_______________when___________&stopped______
Sexuality any concerns/problems/needs to discuss

VII. Previous Pregnancy History

Gestation Length

Type of Delivery
Complications

Sex

Infant Condition at
Birth

Current Health of
Child

1.

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1.

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3.

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3.

4.

4.

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4.

VII. Personal Data

Level of Education
Childbirth classes
Insurance
Employment
Description of living environment

IX. Present Pregnancy

Planned pregnancy YES NO Support person

Onset labor date: Time:

Date, time & Method ROM: Vaginal bleeding
Complications: Fluid description

Diagnostic assessment procedures performed as sonogram, amniocentesis, etc.

Stress, non-stress test______________________________________________
Medications

4.

Exposure to infection
Type of anesthesia desired
Special request:

X. Physical Exam
Head
Neck
Breast
Lungs
Cardiovascular
Extremities
Abdominal Fundal Ht.
Fetal presentation & position
Vaginal Exam
Dilatation
Effacement
Station

XI. Intrapartum Summary

Labor:
FHR baseline
FHR variability
FHR periodic change

U/A frequency
duration
intensity
Summary:
Analgesia
IVs
O2

XII. Delivery Summary

Time of birth Method Anesthesia
*Agar Episiotomy EBL

Procedures Bonding

[state why if not <10]

XIII. Recovery time

T. P. R. B/P Fundas

Lochia (Amount)

XIV. Maternal lab data [include Normal values] Include lab form

XV. Summary of family adaptation

XVI. Teaching Learning Needs

XVII. Ongoing Assessment and Behavioral Manifestations