Upon admission to labor and delivery, the nurse should:

• Determine reason for admission
• Gather patient history
• Review prenatal health record
• Perform a physical examination of mother and fetus

Prenatal History

• Estimated date of delivery (EDD)
• Current gestational age
• Complications in pregnancy
• Results of prenatal testing
• Medications used in pregnancy
• Presence of vaginal discharge or bleeding
• Amniotic fluid status
• Presence of fetal movement
• Onset and pattern of contractions

Obstetrical History

• GTPAL (gravidity, #term births, #preterm births, #abortions, #living children)
• Length of labor
• Birth complications
• Neonatal outcomes
• Type of birth
• Vaginal
• Instrumentation
• Episiotomy
• Cesarean
• Reason for cesarean
• Type of incision
• Low transverse
• Classical

Medical History

• Chronic health problems
• Current medications including last time taken
• Time and description of last oral intake
• Allergies to food/medicine

Surgical History

• Complications with anesthesia
• Date/reason/type of surgery