Labor and Delivery

Topics: Childbirth, Obstetrics, Pregnancy Pages: 4 (766 words) Published: April 14, 2014
STUDENT_________________ HEALTH CARE OF WOMEN Date______________________

Labor And Delivery Assessment Worksheet

Patient initials:Age:Marital Status:DOB:

Admission Date and Time:Vital Signs: BPTPR

GravidaTermPretermAbortionsLiving Children

LMPEDCGA by datesGA by sonogram

Received Prenatal Care?YesNoWhere?

GA at 1st prenatal visitGA when FHTs first heard

Blood Type:Hgb/Hct:Urinalysis:

Identified risk factors:





Fluid color:ClearMeconiumVaginal bleeding:YesNo

Sterile Vaginal Exam:DilatationEffacementStationN/A

Fetal Evaluation:FHR baseline: Periodic changes: (e.g., accels, decels)

NST: date(s) performed: result:reactive nonreactive

Ultrasound: date(s) performed:BPP: Date PerformedScore:

Previous OB/GYN Surgery:Procedure and Date

Present Medications:

Labor medication:Delivery Analgesia / Anesthesia

Method of delivery:Time of Delivery of baby:Time of delivery of placenta:


INFANT DATA: Sex:Weight:

APGAR scores:1 min.5 min.10 min.

Heart rate
Muscle tone
Reflex Irritability
Respiratory effort

Do before clinical and get from your text:

Explain types of electronic monitoring, both fetal and UCs: What is it?Advantages / Disadvantages? INTERNAL / DIRECT: IUPC - A small catheter that is placed along side the baby. Measures the strength and duration of contractions more accurately than the external monitor. FSE - The internal lead is called a 'fetal scalp electrode' (or FSE). It is only used to monitor the baby's heart rate during labor, usually if external monitoring is not being reliable...
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