Antenatal Record - Family Medicine Reference Page 4
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4Postnatal Visit
No of weeks postpartum
Date
(YYYY/MM/DD)
History
Review of birth
Vaginal
Operative
Cesarean
Baby’s Health / Concerns
Baby’s Name
Breastfeeding
Breastfeeding concerns
Yes
No
Bladder function
Lochia / Menses
Bowel function
Perineal discomfort
Rubella immune
Smoking history
Yes
No
Vaccinated
Pap smear status
Physical Examination
Weight
B.P.
lb / kg
mm Hg
Affect
Thyroid
Breast exam
Abdomen
Perineum
Pelvic exam
Discussion Topics
Emotional problems / depression
Preconceptual folate to begin prior to next pregnancy
Contraception
Sexual / Relationship concerns
Social support
Family violence
Follow-up and advice re: future pregnancies and risks
Signature of physician or midwife
Postnatal Visit
Canary – Mother’s chart – forward to hospital
Pink – Attendant’s copy
White – infant’s chart
7530-4655
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