Antenatal Visit

Patient Information: - Date and Time of the Nursing Assessment: 2023-10-15 10:00 AM - Location: Maternity Clinic, Room 5 Subjective: - Gestation in weeks: 32 weeks - Braxton Hicks contractions details: Occasional, mild contractions noted - Foetal movement history or concerns: Regular movements, no concerns - Vaginal discharge details: Normal, no unusual discharge - Swelling details: Mild swelling in ankles - Other concerns reported: Occasional back pain - Mental health reported: Feeling anxious about delivery Objective: - Fundal height measurement: 32 cm - Foetal position: Cephalic - Foetal heart rate: 140 bpm - Engagement status: Not engaged - Blood pressure: 120/80 mmHg - Urine dipstick results: Negative for protein and glucose - Oedema details: Mild, in lower extremities Assessment: - Pregnancy status and gestation: Healthy pregnancy at 32 weeks - Known medical conditions: None Plan: - Labour management discussion details: Discussed signs of labour and when to call the clinic - Birth equipment setup and use details: Reviewed use of birthing ball and TENS machine - Third stage management options discussed: Active management preferred - Risks associated with medical conditions: None identified - Indications for consultation or referral and plans for same: None at this time - Declined procedures or interventions: Declined routine episiotomy - Antenatal expressing considerations: Advised to start expressing colostrum at 36 weeks - Next appointment focus: Monitoring foetal growth and maternal well-being Interventions: - Provided education on: - Signs of labour - Pain management techniques - Importance of hydration and nutrition Evaluation: - Patient and partner engagement and understanding: Both engaged and understanding of birth plan - Comfort level with birth plan: Comfortable and confident Plan for Continuing Care: - Record of understanding completion: Completed - Birth preferences finalization: Finalized - Postpartum preparation details: Discussed postpartum care and support - Plan to further pathology testing or ultrasound: Routine ultrasound at 36 weeks - Next appointment date: 2023-10-29 Additional Notes: - Patient's community involvement: Active in prenatal yoga class - Partner's support and involvement: Partner attending all appointments and classes