The systematic procedure of gathering information about the client’s general health and her pregnancy status.
To determine and identify the health and socio-economic conditions likely to influence the outcome either negatively or positively and to direct care during pregnancy and childbirth.
a) On the first contact with an antenatal client seeking antenatal services
b) Any pregnant client seeking antenatal services
1. Environment for warmth, safety privacy, and comfort.
2. The client and companion’s readiness for the procedure in order to allay anxiety and promote cooperation
3. Availability of required supplies and Equipment for ease of access and efficiency.
Examine your ability to communicate effectively.
Review history-taking procedure.
Examine own cultural influences Wash and dry hands
Explain the procedure to the client and companion
>Safe, clean spacious, and dry room with visual and auditory privacy.
>Adequate seats or benches and a table
>Clean, dry, and comfortable examination couch
>Linen (a pair of bedsheets)
>Bedside stepping stool.
>Arrange seats to make provision for the same height, a square setting of 90° angles, full view of the client and companion with no barrier between the client, companion, and the midwife.
>Adequate space with adequate light
>Rinse with running water, liquid soap.
>Rinse with running water, liquid soap.
It disposable hand towel. ) they
Coded color bins.
Assemble and arrange the following items on a trolley or table:
Pens of different colors.
Antenatal record book.
Vital signs observation equipment.
Calendar and the gestation calendar wheel
1. Greet and welcome the client and her companion and offer them a place to sit to establish rapport.
2. Address the client by name for the patients’ respect and dignity.
3. Assume a relaxed sitting position that demonstrates the availability of time This enhances comfort, relaxation and promotes cooperation.
4. Inquire the language the client is comfortable with, this makes the client and companion feel accepted, relaxed and promotes disclosure.
5. Explain to the client the approximate time history taking is likely to take and what is required of her ensuring efficiency in communications and preventing anxiety.
6. Inquire from the companion(s) the relationship with the client to ensure privacy and confidentiality.
7. Discuss general topics for about one minuteThis allows for relaxation and promotes disclosure.
1. Take vital signs for baseline data.
2. Observe principles of interviewing techniques to determine the validity and accuracy of information.
3. Observe the client for non-verbal communication and validate them. This may reveal some information the client may not express verbally.
4. Ask open-ended questions and use simple language. This encourages self-expression.
5. Obtain, interpret and record complete information of the following;
• Address and telephone number
• Level of education
• Occupation of the client
• Name and contact of next of kin
• Alcohol use and Smoking and any other substance
The rationale for this is to identify clients and aids in tracking the patient in the event of follow up
(Specific diseases and conditions): Medical and surgical history (Specific diseases and conditions):
. TB, Heart Disease, Chronic Renal Disease, Mellitus, Epilepsy, Diabetes hypertension, psychiatric, thyroid conditions, hepatic diseases
. History of surgery and Anaesthetic complications.
. Sexually Transmitted Infections
. Reproductive tract conditions or diseases.
. HIV Status if known
. Other conditions depending on Prevalence in that region (e.g. Malaria, Sickle Cell Trait)
. Operations other than Caesarean Section
. Blood Transfusions
. Current use of Medication specify
. History of drug and food allergies
The rationale for this is to Identify women with special health conditions and those at risk for developing complications and refer them for a higher level of care for necessary interventions.
i) Conducted to determine the exact gestation by dates and aid in the calculation of the expected date of delivery.
ii) To aid in the management of labor and any abnormality like severe after pains and heavy bleeding after delivery.
• First day of Last menstrual period
• Menstrual cycle
• Menstrual problems e.g
This is done to identify any risk factor and prepare to act accordingly. This Include ;
• Number of previous pregnancies
• Duration of labor
• Mode of delivery
. Date and outcome of each event (live birth, preterm, stillborn)
• Birth weight
. Sex of the newborn and current status
• Maternal complications and events in previous pregnancies, specify which pregnancy, validate by records (if possible):
• Gynaecological operations
. Perinatal complications and events in previous pregnancies
• Use of FP method
• Type of FP method
• Duration of use
• Any complications resulting from FP use
• When and reasons for stopping or non-use
1. Explain to the client that the information required has been obtained. However, if more is required then it will be taken during the next visit.
This encourages the client/companion to clarify their issues of concern. Ensuring continuity of the care.
2. Ask the client and companion(s) if they have questions to ask.This ensures that the clients’ issues have been clarified.
3. Thank the client and companion(s) and prepare for physical examination and antenatal profile.
This demonstrates appreciation and promotes cooperation.
4. Document the findings accurately for record and subsequent references.
5. Wash and dry hands for infection prevention and control.
a. Comprehensiveness of history obtained to determine if further history is required
b. Adequacy of history in planning interventionsAdequate history is required to help plan interventions.
. Full history obtained
. Specific issues of concern to the client and companion
. Any anxiety observed from the client or companion
. Areas of history that require further clarification
. Relationship between the companion and the client during interaction