Question

OB Physical Assessment Tool

Name of Client :                                                   Date of Assessment:

Age :

Address:

Chief Complaint(If any):____________________________________

I. Obstetrical History:

    a)   Menarche: ___________________

    b.) Last Menstrual Period (LMP: ________________

    c.) Expected Date of Confinement (EDC):_____________________   

           (based on Naegele’s Rule)

    d) Age of Gestation ( Based on LMP):_________________________

    e) Trimester of Pregnancy ( based on AOG)

          First Trimester    (0-13 weeks): ________ weeks

          Second Trimester (14-26 weeks):_______ weeks

          Third Trimester    (27-40 weeks):_________weeks

   f) Obstetrical Score

               Gravida:_______________    Para : ___________

                Term: ________                       Pre-Term :____________         

               Abortion:_______                    Living:__________

               Multiple Birth:________________

II. Physical Assessment:

     

          General Survey: _______________________________________

           ____________________________________________________

                            

           Mental Status:_________________________________________

           Anthropometric measurements :

                Height: ___________ (ft. and inches)        Weight:_______ kgs

                BMI:______________

           Vital signs:

                      Temperature:_______                Blood Pressure:_______

                      Pulse Rate:_________                 Respiratory Rate:______

            Breast :

                         Size:   Equal:_______               Unequal:__________

                         Shape: Symmetrical :______ Asymetrical:_______

                         Remarks:__________________________________

           

           Nipples:

                            Everted:________                 Inverted:________

                            Lump:__________

                            Discharges:   Present: _________       Absent: _______

          

          Abdomen :

                           Linea negra: _______         Striae gravidarum:____

                           Leopold’s Maneuver:

                                  Fundic Height:______________( hypothetical )

                                  Fetal Heart tone:___________ (hypothetical)      

Instruction: Assuming that you are to perform Leopold’s maneuver to , explain the following to your client in your own words:

                  a) What is Leopold’s maneuver

                  b) Describe how each maneuver will be performed

                  c) Possible findings of each maneuver

      First Maneuver:

           Findings: _____________________________________________

     Second Maneuver :

           Findings: ____________________________________________

   

     Third Maneuver :

          Findings: ____________________________________________

     Fourth Maneuver :

          Findings: ____________________________________________

    Perineum:

                   Scars:_______ Warts:_______ Rashes:________

                  Discharges :

                       Color :_________          Odor:__________

                       Appearance : Transparent (clear):_____

                                                 Turbid (unclear):______

III. Signs of Pregnancy

Direction: Interview your client, list down and categorize the signs of pregnancy presently experienced by your client.

Presumptive	Probable	Positive

Answer 1

ANTENATAL ASSESSMENT

1. DEMOGRAPHIC DATA

• Name of client
• Age
• Husband's name
• year of marriage
• Educational status
• Occupation
• Address
• date of assessment

2. CHIEF COMPLAINTS

If any like headache, shortness of breath, pedal edema, leaking per vagina, itching etc

3. OBSTETRICAL HISTORY

• Menarche: age at which menses attained
• LMP: FISRT DATE OF LAST MENSTURAL CYCLE
• Expected Date of Confinement: using Naegele' rule, add 9months and 7 days to the LMP
• Age of Gestation: calculate based on LMP. Eg; LMP is 12/12/2019. Today's date is 23/7/2020. Total number of days is 223, dividing the total days by 9, we get the age of gestation at present. Here it is 24⁺⁷weeks of gestation.
• OBSTETRICAL score : GRAVIDA means pregnancy, no.of pregnancy. PARA means how many times delivered, LIVING means how many delivered are live, abortion, multiple pregnancy
• Check the vital signs of the mother and the anthropometric measurements including BMI.

BREAST & NIPPLES

Assess

• the size of breast
• Consistency
• symmetry
• distended veins
• Primary & secondary areola
• Montgomery tubercles
• nipple protractility
• Nodules/lumps
• AXILLARY nodes
• Discoloration
• Tenderness
• Milk Discharge

​​​​​​​ABDOMEN

INSPECTION

​​​​​​​ASSESS:

• Shape of abdomen (oval, saucer shape depression, round)
• Size
• Contour: Linea Nigra, straie gravida
• Lightening, muscle wall laxity, flank fullness
• Skin changes: shiny abdomen, surgical scars
• Visible fetal movements
• Dilated veins
• Pendulous abdomen

​​​​​​​PALPATION

• FUNDAL PALPATION: to check the part of fetus lies at fundus. If it is head of fetus , it feels like hard, round, firm and ballotable mass. If it is breech, it feels like soft, indefinite mass
• LATERAL PALPATION: To check the body parts on either sides of the abdomen. If it is back of fetus , it will be continous, smooth resistance. If it is limbs, it will feel like palpable nodules.
• PELVIC PALPATION: PAWLICK'S GRIP: To check presenting part by asking mother to bend the knees. PELVIC GRIP : To judge size, flexion, mobility,, engagement & ballotment of the presenting part.

PERINEUM

Assess

• hygiene
• Any discharge
• Bleeding
• Edema
• Pruritis
• Infection
• Odour
• Scars

​​​​​​​LEOPOLD'S MANUEVER

It is used to determine fetus's presentation & position.

Maneuver 1: FUNDAL GRIP

• Palpating the upper abdomen to determine the size, shape, mobility & consistence of the fetal part present at the fundus

​​​​​​​Manuever 2: UMBILICAL GRIP

To assess the location of the fetus's back. Perfo this manuever by placing the right hand on one side of the mother's abdomen while using the left hand to explore the mother's uterus on the right side. Repeat this step on the opposite side using the opposite side.

Manuever 3: PAWLIK'S GRIP

Assessing the part of fetus above the inlet

Manuever4 : PELVIC GRIP

​​​​​​​EXPLAINED ABOVE