Midwifery and Obstetrical Nursing – Practical

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Initial History Documentation of Antenatal Woman

Documentation of the history of an antenatal woman is a process of systematic collection of information to determine the adequacy of pregnant state.

OBJECTIVES

1. Assess general health of pregnant woman
2. Identify possible health problems
3. Plan antenatal care (ANC) for woman
4. Monitor progress of pregnancy
5. Identify mother’s at risk

ARTICLES REQUIRED

1. Antenatal card or history sheet
2. Pen

PREPARATION FOR INITIAL HISTORY DOCUMENTATION

1. Establish good rapport with the antenatal woman by ensuring a comfortable environment for communication.
2. Maintain privacy when recording history.
3. Proceed from informal to formal and simple data to complex data.
4. Be active and patient while listening.
5. Be a guide when ...