OBSTETRIC DATABASE

A.
Patient name: Admission date: Age:
Race: Date cared for patient:
Date and time of delivery:

B. Patient profile:
Birthplace: Birth date:
Present occupation: Approximate income:
Insurance: Work habits & stress:
Education:
Marital status: No. of years: No. of marriages:
No. of children: Ages of children: Religion:

Home situation:
No. of people living in home: Relationship with family:
Availability of family:
Usual daily schedule:
Usual vacation:
Hobbies or special interests:
Appetite:
Usual diet:
Ever been on a special diet:
Approximate fluid intake x 24hrs:
Cultural/religious food
preferences
Sleep habits (any special routines
or equipment needed)

Personal hygiene:
Type of bath preferred: When:
Oral hygiene: When:

Habits (alcohol, tobacco,

exercise)
Behavior during assessment:
Describe patient’s ability to communicate and understand necessary medical & nursing instructions:

Identify techniques utilized by patients to handle stress:

C. History:
Family history: especially diabetes, hypertension, tuberculosis, renal disease, hemorrhagic tendencies, allergy,
congenital anomalies:

Father of infant’s history:

Age: Height: Weight: Blood type: Rh:
Occupation:
Medical and/or
surgical history:

Prior pregnancies:
Gravida: Term: Pre-term: Abortion: Live:
Birth weight of previous children: 1. 2. 3. 4.
Any problems with previous children during neonatal period (respiratory, jaundice, feeding, heart, etc.)

Any problems during prior pregnancy(ies):

Any problems during prior labor(s) and delivery(ies):

Patients history:
Ht: Non-pregnant wt: Pregnant wt:
Medical history:
Surgical history:
Allergies:
Transfusions:
Had rubella: Yes: No:
Had menarche: Duration: Flow: Interval: LMP
Problems with infertility: Yes: No
If yes, explain:
Contraceptive method(s)
used prior to pregnancy:
Contraceptive method(s)
now planned:

D.
Current Pregnancy: EDC:
Antepartal period:
Problems in antepartal period (elevated blood pressure, bleeding problems, nausea/vomiting, URI, UTI, etc):

Prenatal care: Yes: No:

If yes, explain
information
given:
Was father involved in
Yes: No:
classes:

Labs and diagnostic tests:

Type of test Gestational week Result
Pregnancy test
Pap smear
Serologic test for Syphilis
G.C. Culture
CBC
Rubella Titer
Antibody Screen
UA
Blood type / Rh
Blood sugar
Sonogram
Estriol levels
Amniocentesis
Non stress test
Other:

Labor and delivery:

Fetal presentation (Vertex, Breech, etc.):
Type of delivery (vaginal, c-section, and spontaneous,
use of forceps, or vacuum extractor):

Date Time
Membranes ruptured:
Onset of labor:
Complete cervical dilatation:
Delivery of infant:
Delivery of placenta:

Complications (bleeding, prolonged labor, PROM,

meconium, PIH, occiput posterior, abnormal FHR
pattern, etc:
Labor medications: Dosages:
Continuous electronic fetal
Yes: No
monitoring:
Scalp
If yes, give type: Toco: Ultrasound:
electrode:
Type of anesthesia:
Delivery room medications:
Episiotomy: None: Medial: Mediolateral:
Laceration: None: Perineal: Vaginal: Cervical:
Repaired: No: Yes:

Neonate
Apgar scoring
Criteria 1 min 5 min
Heart rate
Respiratory efforts
Muscle tone
Reflex irritability:
Color:
Total:

Sex : Weight: Height:

Spontaneous
Yes: No:
respirations:
Blood Direct
Rh: Pos: Neg:
type: coombs:
Medication administered to neonate at delivery:
Any observed abnormalities: Yes: No
If yes, explain:
Present condition of neonate:

Postpartal period
Temperature: Pulse: Respiration: BP:
Breast feeding: Bottle feeding:
Conditions of breast: nipples:
Engorgement: Yes: No:
Wearing well fitted supporting bra: Yes: No:
Fundal height: Firmness:
Lochia: Amount: Color: Odor:
Perineum: describe by REEDA scale:
Hemorrhoids Yes: No:
Homan’s sign Positive Negative
Present psychological adjustment: “Taking in” “Taking hold”
Postpartal blues: Other:
If other, explain:
Nutritional intake:
Comfort needs: location of discomfort:
Need for medication: Yes No:
If yes, give type:
How often:
Bladder function:
Bowel function:
Other complications:
Lab values:
Hgb/Hct on admission
Hgb/Hct 1st or 2nd postpartal day
Indirect coombs Done Not done If done, Pos Neg

E.
Parent/infant relationship:
Was this a planned pregnancy Yes: No:
Did parents desire sex of neonate Yes: No:
Have parents had success in raising other
Yes: No:
children
Explain (i.e. are previous children presently
living with parents? Assess this area by
monitoring other children and listening to
comments made and by information from chart
and staff, etc.

Mother/infant interaction:
How soon after delivery saw infant:
When were your observations made:
How did mother greet baby when he/she was
brought to her?
(Verbal and nonverbal behavior):
- What did she call the baby?
- What did she say to the baby?
- What did she say about the baby?
Other:
- Describe her touching of the infant:
- Describe eye contact with the infant:
- Describe infant’s behavior in
response to mothering

Describe her ability to do and/or feelings (if unable to observe) about doing the following:
Feeding
Bathing
Dressing
Soothing

Father/infant interaction:
Does the father participate in visiting times? Yes: No:
- If so, what does he do with the baby

Mother/father interaction

F. Current medication: (state why patient is taking each current medication):

Drug Dose Times Purpose

G. Long term patient goals: