SUFFOLK COUNTY COMMUNITY COLLEGE
SCHOOL OF NURSING
OBSTETRIC NURSING ASSESSMENT TOOL
Student's Name __________________________________________ Date of care ________________________
Patient's Initials ___________ Marital Status _________ Age _______ Height __________ Weight __________
Date of Admission ____________T ________ P ________ Apical _________ Resp. ________ BP ___________
Allergies (Drugs, Food, Tape, Dyes and others) ____________________________________________________
Reason for Admission ________________________________________________________________________
Definition of Diagnosis _______________________________________________________________________
Past Medical and Surgical History:
A. Previous hospitalization; injuries; surgeries_______________________________________________
B. Childhood/Adult illnesses_____________________________________________________________
C. Immunization history (especially note rubella status)______________________________
D. Current health habits:
NO
YES
1. exercise

 Identify: _________________________________________
2. smoking

 PPD __________________
3. alcohol

 Frequency? _______________ How Long? _____________
4. caffeine intake

 Identify? _________________Frequency ______________
E. Current medications:
Name, Dose, Frequency and reason for use: _____________________________________________
__________________________________________________________________________________
Patient’s Family Medical History: **___________________________________________________________
Prenatal History:
**not always used BEFORE DELIVERY
A. G: _______; P:________; ** ( T:________; P: ________; A: ________; L: _______)
B. Blood Type & Rh ________Pertinent Lab Data: H&H ________ WBC _________PLTS__________
C. Describe prenatal care
1. Date prenatal care began______________
2. Type of care (e.g.;  clinic;  private physician;  nurse midwife,
etc.)___________________
3. Client perception of prenatal care experience:
 satisfactory
 unsatisfactory  other:
Explain _________________________________________
D. Nutritional status during pregnancy
1. Weight gain (include pre-pregnant and pre-delivery weights)____________________
2. Typical dietary patterns during pregnancy___________________________________
3. Use of vitamin/mineral supplementation. Identify
___________________________________
E. Describe any health problems encountered during pregnancy and duration
1. Hypertension ______________________________________
2. Diabetes
______________________________________
3. Bleeding
______________________________________
4. Infections
_____________________________________
5. Accidents
_____________________________________
F. Childbirth Preparation Classes: Were they attended?
 NO  YES
G. Describe family response to pregnancy
1. Planned/unplanned _________________________________
2. Family support_______________________________________________________________
Describe: _________________________________________________________________________
Intrapartal History
A. Describe Labor
1. Time of Onset _____________ Duration _______________ Contraction pattern _______________________
2. Rupture of Membranes: Time __________ Spontaneous  Artificial Color ________ Odor _______FHR 3.
Type of pain management used ____________________4. Type of anesthesia used _____________________
5. Use of augmentation (Pitocin; Prostaglandin gel) _________________
6. Support system in labor __________________
B. Describe Delivery
G________P________ (post delivery)
1. Type: _________________ Time: ______________Outcome: __________________________________
2. Immediate post-delivery attachment experience ______________________________________________
3. Medications used immediately following delivery _____________________________________________
4. Client's perception of experience ___________________________________________________________
5. Complications __________________________________________________________________________
Fundus/Lochia
Fundal height: Expected location/position this postpartum day (reference to umbilicus, as above or below in fingerbreadths.) ___________________________________________________________________________
Consistency (firm, boggy, firm with massage) ____________________________________________________
Lochia: Color (rubra, serosa, alba) __________________ Expected color _______________________________
Amount (scant, moderate, heavy, constant ooze, trickle, clots) ______________________Odor______________
Describe safety concerns and patient learning needs related to amount of and expected duration of lochia.
___________________________________________________________________________________________
___________________________________________________________________________________________
NURSING DIAGNOSIS _________________________________________________________ NONE
IDENTIFIED
Perineum
Episiotomy: ________ Type ________________________________ Laceration __________________________
Discomfort (location, intensity, duration) __________________________________________________________
Inspect perineal area (edema, ecchymosis, hematoma) _______________________________________________
Comfort Measures (medications, ice, tucks, sitz baths, perineal sprays, correct position when sitting, etc.)
___________________________________________________________________________________________
Describe patient's learning needs related to care of the perineum (perineal care, pad application, healing of
episiotomy, etc.) _____________________________________________________________________________
___________________________________________________________________________________________
NURSING DIAGNOSIS ________________________________________________________ NONE
IDENTIFIED
Cesarean Section
Incision (low transverse, classical) __________________ Dressing (dry, intact, drainage) __________
Discomfort (location, intensity, duration)__________________________________________________
Inspect Incision for REEDA ____________________________________________________________
Abdomen (soft, distended, rigid) __________________________________
Bowel Sounds (present, not present) __________________________
Flatus (passing, not passing)____________ _________________________
Lungs (auscultation, percussion) _____________________________________
Legs (tenderness, edema, condition of pulses) _____________________________________________________
Epidural/Spinal site (bleeding, ecchymosis, erythema) ______________________________________________
NURSING DIAGNOSIS _________________________________________________________NONE
IDENTIFIED
Elimination
A. Healthy History:
1. Usual urinary and bowel pattern: color, consistency, odor _______________________________________
2. Elimination habits: frequency, timing, presence of discomfort _________________________________
first voiding ____________________ second voiding _______________________
B. Presence/condition of hemorrhoids _________________ Comfort measures __________________________
C. Use of stool softeners/laxatives ______________________________________________________________
NURSING DIAGNOSIS _________________________________________________________________
NONE IDENTIFIED
Nutritional/Metabolic Pattern
A. Health History: Understands importance of postpartum (and lactation) nutritional needs (explain)
_____________________________________________________________________________________________
_______
Desired post-pregnant weight __________Diet order __________
B. Condition of oral cavity _______________________C. Condition of skin, hair, nails ___________________
D. Condition of abdomen __________________________________E. Auscultate bowel sounds_____________
F. Inspect color, contour, presence of scars and striae ________________________________________________
NURSING DIAGNOSIS __________________________________________________________________ 
NONE IDENTIFIED
Sleep/Rest Pattern:
Describe pattern as it currently exists:
A. Ability to:
1. fall asleep:
 good  fair  poor
2. stay asleep:
 good  fair  poor
3. awake & feel rested:  good  fair  poor
B. Patterns of sleep disturbance (e.g. awakened for infant feeding; awakened for nursing procedure; awakened due
to noise, etc.) __________________________________________________________________________________
C. Use of sedatives (Identify)
______________________________________________________________________
D. Include objective data (e.g. circles under eyes, inability to concentrate, mood changes, fatigability, drowsiness)
Explain:
_______________________________________________________________________________________
NURSING DIAGNOSIS ________________________________________________________________ 
NONE IDENTIFIED
Role/Relationship
A. Describe pattern as it currently exists including significant others, lifestyle, residence, safety measures in home,
education, occupation/profession, social/recreational activities, communication ability.
___________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________________
B. Describe role changes resulting from pregnancy _________________________________________________
C. Describe maternal/infant relationship:
1. Maternal role attainment _________________________________
2. Perception of infant _____________________________________
D. How does mother relate to infant (rooming in, touching, eye contact, unwrapping, holding close, smiling,
talking, calling by name)?
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify if she is in "taking in" or "taking-hold" phase? (circle one)
Describe family/infant interaction. _______________________________________________________________
NURSING DIAGNOSIS ______________________________________________________________  NONE
IDENTIFIED
Sexual Reproductive
A. Health history
1. Date and results of last Pap smear _______________________________________________
2. Knowledge of SBE (self breast exam) ____________________________________________
3. Perception of resumption of sexual activity ________________________________________
4. Plan for birth control (type) ____________________________________________________
5. Breasts (soft, engorged, firm, discomfort, redness)___________________________________
6. Nipples (redness, prominence (everted/inverted), pain, cracks, fissures) _______________________________
B. Describe present care of the breasts (hygiene, support, schedule and duration of breast-feeding, use of
nipple shield, creams and ointments used, etc.) _____________________________________________
C. Describe patient's learning focus related to care of the breasts (films viewed, hygiene, support, breast feeding,
diet, use of shields, manual expression, feeding schedule, etc.) _____________________________
NURSING DIAGNOSIS
__________________________________________________________________________  NONE
IDENTIFIED
Knowledge Deficit
Based on your assessment, list parents' learning focus, and describe your nursing interventions in the following
areas: Infant Care (bathing, feeding, circumcision care, normal newborn characteristics, sleeping, clothing, bowel
movements, need for contact and stimulation)
__________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
A. Teaching performed and method
____________________________________________________________________
B. Patient and family response
________________________________________________________________________
NURSING DIAGNOSIS ________________________________________________________________
NONE IDENTIFIED
Revised 9/08