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)


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Documentation in Nursing and Midwifery: Australian edition Copyright © 2022 by Tanya Langtree and Elspeth Wood is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.