Integrated Maternal and Newborn Care Basic Skills Course ...

visit, etc.). Listen carefully to all the answers; the client’s answers are important and will help
you identify the problems. Write down the important points in the answers.
There are two types of histories:
• A routine history: This type of history is taken for every woman coming in for routine
antenatal, postnatal, family planning, services, etc. Everyone who comes in for care will
be asked the same questions, and the information will be documented on a standard
form.
• A targeted history: This type of history is taken when a client comes in with a complaint.
You will tailor the questions you ask around the complaint that the client has and will get
information from the client that will help you identify problems or make a diagnosis.
The following skills are important for taking a complete history:
• Make sure the woman feels welcome.
• Help the woman feel comfortable with your actions.
• Provide a private area to talk and assure the woman of confidentiality.
• Encourage the woman to talk and ask questions.
• Ask questions in a kind and interested way.
• Listen carefully to all the answers.
Ask specific questions about signs and symptoms to help identify the problem(s). The client’s
answers about her problems are the findings of this first step. The results from this first step will
guide the provider through step 2.
Note: If the woman comes with an emergency, you will ask very few
questions, as immediate action may be required. You may have to ask
questions of the family who accompanies the woman.
Step 2: Perform a targeted physical examination
After explaining to the woman what you are planning to do, examine the areas of the client’s
body that relate to the information you gathered in step 1. A physical examination includes
observation, palpation, percussion, auscultation, and smell.
There are two types of physical examinations:
• A routine physical examination: Sometimes you will need to do a general or full
examination of the body. In the case of a woman registering (booking) for antenatal care,
you will need to know about the condition of her entire body. A general examination of
the body may also help you to find problems that the woman herself has not recognized.
This also applies to a baby who may be just brought in for a routine service such as
immunization.
• A targeted physical examination: This type of physical examination is performed when a
client comes in or a baby is brought in with a problem. You will tailor the physical
examination around the complaint that the client has and will get information that will
help you identify problems or make a diagnosis.
Results from the physical examination are the findings of this step. Order laboratory or other
diagnostic tests as needed.
Examination of the baby has some other components that are described in chapter 9 and in
Appendix B.
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Integrated maternal and newborn care
Basic skills course