Appendix 2
Pregnancy Systematic Approach for Antenatal Assessment – Documentation Guidelines
Situation/reason for presentation summary – Start notes with a brief summary of any significant events that led to today’s presentation (e.g., pv bleed, fall, reduced fetal movements).
Current pregnancy details:
· Model of care
· Allergies
· Gravida/parity
o Gestation
o EDD
o Placental location
o Bloods –
§ Group & antibodies
§ Serology
§ Vaccinations
· Obstetric history – previous delivery gestation/mode of delivery
· Current medications
Risk factors including management plan
· GBS status
· Weight
· Antenatal VTE score
· Diabetes
· Abnormal Ultrasound findings
· PPH risk
· 3rd/4th degree tear
· Other risks
Observations on arrival
· Temperature
· Pulse
· Resp rate
· BP
· Urinalysis
Ask about and record for associated signs/symptoms (Hypertension– headaches, blurred vision, epigastric pain, oedema) (Febrile – urinary symptoms, maternal/fetal tachycardia, contractions)
Abdominal palpation
· Fundus – lie, presentation/attitude, position, engagement
· Fetal movements
· Fetal heart rate
Adopted from Queensland Health Antenatal Assessment documentation sheet (V.4)