Midwife Antenatal Assessment Template

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.