OBSTETRIC PHYSICAL ASSESSMENT TOOL

OBSTETRIC PHYSICAL ASSESSMENT TOOL



Patient's Name: _____________________________    Date: ___________

Physician: ___________________              Diagnosis: ___________



A. Obstetrical History

a. Menarche: ________

b. EDC: ________

c. AOG: _______

d. LMP: ________

e. Gravida: _____ Para: _____ (TPALM: ____)



B. Initial Physical Assessment

a. Breast: size ( )Equal ( )Unequal (R or L)

shape ( )Symmetrical ( )Asymmetrical



b. Nipples: ( )Inverted ( )Everted ( )Lump

Discharges: ______________ Color: ___________



c. Abdomen: ( )Linea Nigra ( )Well Groomed ( )Striae Gravidarum

Other skin alteration: ___________________



d. Perineum: ( )Scars ( )Warts ( )Rashes

Discharges ( )

Characteristic: Color: ________ Odor: ______

Consistency: ( )Transparent ( )Turbid

Other alteration: ________________



C. Anthropometric Measurements

a. Height: ________cm

b. Weight: _______kgm

c. Fundic Height: ________cm



D. Vital Signs

BP: ________mmHg CR: ______bpm RR: _______cpm

Temp.: _______˚C FHT: _____bpm

Position: ___________



E. Ante-Partum Assessment

a. Fundic Height: _________cm

b. Fundic Position (Leopold’s Maneuver):

Fetal Position: _________________

Fetal Lie: ______________________

Fetal Presentation:_____________

Engagement: _________________



c. Fetal Heart Rate: _______



SIGNS of PREGNANCY



Presumptive Signs Probable Signs Positive Signs

Breast changes Serum Laboratory Tests Sonographic evidence of fetal outline

Nausea vomiting Chadwick’s sign Fetal heart audible

Amenorrhea Goodell’s sign Fetal movement felt by examiner

Frequent Urination Hegar’s sign

Fatigue Sonographic evidence of gestational sac

Uterine Enlargement Ballottement

Quickening Braxton Hicks sign

Linea Nigra Fetal outline felt by examiner

Melasma

Striae gravidarium



F. Intra-Partal Assessment

( ) Lightening ( ) Mucous plug/Bloody show/Pink show

Rupture Membrane: PROM Time: _____

SROM Time: _____

Amniotomy Time: _____

Amniotic Fluid:

Characteristic: ( ) clear ( ) Meconium stained

( ) straw ( ) Greenish brown

( ) yellow stained

Odor of Fluids: ( ) with odor ( ) No odor

Quantity of Amniotic Fluids: ( ) Oligohydramnios _______cc

( ) Polyhydramnios ________cc













Uterine Contractions:



Time Frequency Duration Interval Intensity























G. Labor & Delivery Assessment

First Stage: Cervical Dilatation



Latent (0-4cm) Active (5cm) Transition (8-10cm)

Time Cm

10

9

8

7

6

5

4

3

2

1

0 1 2 3 4 5 6 7 8 9 10



( ) Bloody Show ( ) Nausea & Vomiting

Perineum: ( ) beginning to bulge Time: _____

( ) crowning Time: _____

( ) urge to bear down









H. Second Stage: Fetal Expulsion

Presenting Part: __________

FHT: _____________________ bpm

Breathing: control with contraction ( ) panting breathing ( )

Pain: tolerable ( ) not tolerable ( )

Anxiety: mild ( ) moderate ( ) panic ( )

Perineum: Episiotomy done( ) not done ( ) type: _________

Laceration ( ) 1st ( ) 2nd ( ) 3rd ( ) 4th ( )

Types of Delivery: NSD ( ) LSCS ( ) Forcep ( )

VBAC ( ) Maureceaus maneuver ( )

Fundal pressure ( )

Quantity of blood loss: ___________cc.



I. Third Stage: Placental Separation

Three signs of Placental Separation:

( ) Culkin’s sign

( ) Lengthening of the cord

( ) Gushing of blood: _____cc

Cotyledons: ( ) Complete ( ) Incomplete

( ) Duncan ( ) Shultz

Characteristic: ( ) Succenturia ( ) Circumvallata

( ) Battledore Placenta ( ) Accreta



J. Post-Partum Assessment



Vital Signs: BP- ____mmHg CR- ____bpm

RR- ____cpm Temp - ____C

Breast: ( ) Engorged ( ) Not Engorged

( ) Lactating ( ) Not Lactating

Nipples: ( ) Inverted ( ) Everted

Fundic Height: ________cm

Fundus/Uterus: ( ) firm ( ) relaxed ( ) contracted

Bladder: ( ) full ( ) empty ( ) discharge _______

Bowel: ( ) spontaneous ( ) constipated ( ) LBM

Perineum: ( ) Episiotomy

( ) RME ( ) LME ( ) ME

( ) Swelling ( ) Hemorrhoids ( ) Hematoma

( ) Discoloration ( ) Multiple Laceration

Lochial Discharges: ( ) odor ________

Amount: __________

Color: ( ) Rubra ( ) Serosa ( ) Alba

Rooming-In: ( ) Breast feeding ( ) Bottle Feeding ( ) Mixed Supplement/others: _____