Clinic9.

DateAttendance No.
8.ObstetricalHistorylep\osy
S 7. ofBooking 4.ofAdmission
6 Date 5. ofDelivery
Date 3. Date 9 1.
4|26q5s/23 FamiGestation
ly Name:
Booked
613|wil Kg. Year
InWt.
History /Un
at
Alb 1 Ms
nilvil
Io-o 32 Pregnancy
Complication
Abortion/
Urine During Visit Booked:
Sugar cetcs Suritha
uolvoil 3 :15)323
|8-l4pm
:Hl3lb3
8oepn
at t
Thcva Qg+6 : Bockod
POSTNATALRECORD
DELIVERYAND
Hgofmmm B.P. tFull
em
Preterm/
an wcoles
melttus,
Mother
is Age
GestationWeeks of fhagnang
-Pcat no
uhoetaloss
Delivery Typeof siyrititante

36m weeks in/ kypeterien,.Communiocd

Cms Fundus Ht.of
Caphald
25cm 42 Complication
Puerperium
Labour/
duing P
Presentation ard aß L
cephele caphaleIS6 cephalicephaik4O A
Sex her
heedituy
Weight Birth mother
(38 minute FHR.
per s]4|E.D2.D3.: L.M622.P.:2s
Baby 324|4Reg.No.
Condition
BirthHealth at
isie
KLtagen 7Ligen |TPjucaliun
|Tivogen
TPejukleieuto Folicacid T
TRejuolctun Treatment & nown
Tegucaloit Remarks
Folicácicl discaso
Status
DM. ike
Gle
RemarksifAny:Observations:
N Uine:Special11.2 Blood
Respiration: Pulse: Foetal
Engagement: Admissionon: Condition
General Breasts :
Assessment:
a4Temperature:
98b°F General11.1 ociptoPosition:
Not Adsquate
et Liqur 11, Group:
Blood
ofFundus:
36cHeigGestation:
ht Periodof Imnunization Investigations10. -
Pressure: Admision
Heat
Rate:
|lo CrtooY
to Stats:
labour
|0 aDmt
enggd Examinations
Room: Consistency
Soft :
AlbuminNI mm min Imin wohs at
ofHg had
Bowel: Presentation:
verte ampm
8-00 ELIZA/HIV/TEST:
Biatier:Intact/Ruptured
Membranes
on:ontractions
a
emhil doss V.D.RL.:
Sugar I Gobed
Lungs:hacro
S,S,Heat: commenced
of
by on: aníop
Nagetiee
foloes l323
Contractions: at
Weight:(6om
Height: Ccdtheter egoti
Blood Ag:Hbs
at:
NipplesPtotudah
lo30 at:
and
th, Sugar
:A5
am'p mn
ondition
Birth: at Date: ofDelivery:
ofLabour:
Length Summary:
ofDelivery:
Mode Type Labour14. FulExpulsive
l Method
ofPain
ReliefVaginal13. 12.
Baby ReasonMembranes Examination Labour
Cervical
born T
1s|3l23 Contractions/Commenced
Dilatation
at P|R|BP Progress
at: ruptured
ndution
a. at Chart
First
stage stage at:
ls Total Third
stage Second |Contraction
Vogi
doliayndolivey
al Niovmal |3o a ooam
of D|I
am/pm Tme:
ated Apgar laboY
on FHRIntake
Output
122
Score o0
hr13
s
hrs 2 (s3l23
1 hrs hrs 5
min

Boy/Girl
am/pm |RNLE
mins mins mins mins admitte th
t wirsa
min1o
s5 spontaneously/artificial y. irombte
Pla<nta duinod
liquorCx
ARNDOng: (enfinemont
(sol oog
3ife mother
Conpofol
E*PARsehaton Cm
4 c(u done
Observation
hyondolivorg
and dilatct
(it-oarm-2:
15pm) Qoopm 413l23 lu
iomostcsn
cypolod it 2cm ccion
(2:15 fox
2:54W:
kg ,pnti ,
on 507 d;la
bu i an
pm |sl3l23 Jný n
uniRL
|STVEPrepatadia Care
addan In Skin Nursing
Treatment/
- TVE
|6lsl28 Nethacen
iven. mg Pictoin,
(230 eL

pm)
 Conpiccions.
Uleaw 16. Uterus: Pulse/min Blood
loss:
Total membrances: Placenta
and
15. intact/pisiotonny
DrigsPerincum Spontarcoasly/Assisted/Manually
Contha
insertion:
Cond Teofplacenta: membranes:
removed Placentaand
nmalintely
gtaded Condition Condition Treatmnent
given

Cenda pressure
gobl
Bloodfollowing before
Puernerium: of OtherAny delivery
After Duing binthat
labvour
labour
Covd
Covd
deliverv: adniiterodC3
claNpd
clonod,
rosent
BlVagi
ecdingal Tom/Degree
/Jncomplete: Healthy :
Cord Complete /Infarcts
cordaacla Length: Budon
Sun
120(80 Deliv|ered
3o at:
2
e)
dme,
dne,
ofHgmm
woll: Kovtotm
% o-vit t
°ceic
Repaiwircdrh
pm.am
/
Brdast o
Weight:
J23

toadig m
en
PARTOGRAPH
Name
Gravida1 Para Hospital number 232L |4
Date of admission1|2l23
Time of admission 0opm Ruptured membranes hours
200
190
180
170
160
Fetal 150
heart 140
rate 130
120
110
100
90
80

Amniotic fluid cC
Moulding a
Duration 10

<20 sec

HH 2040 sec 8 Alert Action

7
>40 sec Cervix (cm)
(Plot X) snou
Intensity
5
Mild

Descent 3
Moderate of head
(plot O) 2
Strong 1

Hours
Time

Contractions
per 10 mins 3

Oxytocin UIL
drops/min 12152c2u 232354d

Drugs given
and IV fluids

|Iyf RL
180
170
160
Pulse o 150
140
and 130
120
BP 110
100
90
80
70
60

Tenp°c-T
Ptotein

Urine acetone

volume

Page No.
 THE PUERPERIUM
(MOTHERS CHARI)
TINE
TMEIMETMIEIM EMETMETMEJME MEJ METN
DATE
DAY
EMELME
101

103

102

101

100

40

11.50
97

Th
Nursing
96
PULSEE
RESP M
2

23
22 4C%
M 24
%l20
BP
BOWEi 12d9
URINE
LOCHIA Passd
R
Passod ussc
Rbrd Pab
BREAST

BABY CHART
Name: Bo Surittha
Sex: Nale
300

Date of Birth: 15|3]23

Tme: (2: 1 pm
210
180

Birth Weight: 9-64 150

Vg 20
BIRTH
WEIGHT
Lenglh: 48em
Head Circumference: B0em on
(Based
Spine: Jo spina bitid g
Anus: 120 PROCESS
Patent 150
Date of separation: 180
210
Congenital anomalies: Ni 240
NURSING
Reflexes of the new born: 30

Possibo 330
36

TEMP 17.
URINE
Page No. STOOLP
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