Initial Assessment:
Name and gestation: Sarah Jones, 28 weeks
Name: Sarah
Appointment type: Routine
How are they feeling since last appointment with midwife: Feeling well, no concerns.
Who is present at appointment: Sarah Jones, Midwife
Recent activities: Sarah mentioned a recent weekend trip to the coast.
Updates from previous appointments: Reviewed blood pressure and fetal movements.
Pets: One cat, called Whiskers.
Physical Assessment:
BP: 120/70 mmHg
Urinalysis results: Negative for protein and glucose.
Palpation: Cephalic presentation, fundal height 28cm.
Fetal Heart: 140 bpm.
Movement history: Regular fetal movements felt.
Growth chart: Growth is tracking along the 50th percentile.
Reflux, nausea, vomiting: No reflux, nausea or vomiting.
Current medications: Prenatal vitamins.
Symptoms of Preeclampsia or PET: No symptoms.
Vaccinations: Flu vaccine administered.
Any abnormal symptoms: No abnormal symptoms.
Blood and Scan Results:
Recent blood results: All within normal range.
Recent scan results: Ultrasound showed normal fetal development.
Medications:
Current medications: Prenatal vitamins.
Vaccination status: Flu vaccine administered, Whooping Cough vaccine discussed and accepted, Covid vaccine discussed and declined.
New medications started: None.
Prescriptions: Prenatal vitamins.
Emotional/Social:
How they are feeling and coping with pregnancy: Feeling happy and excited.
Mood: Positive.
Feelings about the baby: Excited to meet the baby.
Family relationships: Supportive partner and family.
Whether they are getting out of the house and meeting up with friends: Yes, regularly meeting friends.
Work and maternity leave plans: Planning to take maternity leave from 38 weeks.
Preparation for Baby:
Colostrum harvesting: Discussed colostrum harvesting.
Baby purchases: Cot and pram purchased.
Car seats: Car seat purchased.
Clothing: Baby clothes purchased.
Nappies: Nappies purchased.
Room preparation: Nursery is being prepared.
Extra supports: No extra supports needed.
Family supports: Supportive family.
Education:
Education topics covered: Gestational Diabetes, Safe sleep, fetal movements.
Educational resources provided: Handouts on fetal movements.
Referrals:
All referrals: None.
Birth Plan:
* Vitamin K (IM)
* Skin-to-skin
* Delayed cord clamping
* Partner to cut the cord
* Breastfeeding
* Pain relief (Epidural)
* Monitoring
* Hospital birth
Plan:
Future plan: Next appointment in 2 weeks.
Next appointment: 15 November 2024
Create note from context: Continue with prenatal vitamins.
Topics for next visit: Discussing labour and delivery.
