POSTPARTUM NEUROCHECK
HISTORY AND SENSORY EXAM
Patient Name:
MRN:
Height: _______________
Weight:_____________________
Previous neuro, back, or medical problems: Y / N ______________________________________________________
________________________________________________________________________________________________
DELIVERY:
Date _____/_____/_____
Type: (circle)
Baby's Weight: _____________
C-section / Vaginal → (spontaneous / vacuum / outlet forceps)
Position: vertex / breech ;
Stirrups: Y / N
Occiput: ROA / LOA / Post./ ROT/ LOT ;
Pushing duration: _____:_____ h
Length of time in Stirrups: ____________________________
_______________
Delivered by: ________________________________
ANESTHESIA:
Time: _____:_____
Nurse(s): ________________________________________
Duration pre delivery _____:_____ h
Type: epidural / spinal / combined spinal / epidural / general / none
Drugs (name, concentration, and dose) :
spinal
epidural
Anesthesia provider: initial _________________________________ delivering ___________________________________
SYMPTOMS:
Started: Date ___/___/___
Time ___/___/___ h
Initial description:
At present time:
Date ___/___/___
Time ____:____ h
Temp _______
COMMENTS:
WW.06.05A Fetal Maternal Newborn and Family Health Policy Procedure Manual Effective Date: 15 –OCT-2012
Refer to online version – Print copy may not be current – Discard after use
USE THE FOLLOWING NUMERICAL INDICATORS TO GUIDE YOUR ASSESSMENT:
0- Absent
1- Trace (palpable or visible contraction)
Consults/
Exams
2- Poor (active movement through full ROM with gravity eliminated)
3- Fair (active movement through full ROM against gravity)
4- Good (active movement through ROM against resistance)
5- Normal
Test
Time
Time
Time
Date
Date
Date
Examiner
Examiner
Examiner
Ordered
Completed
Neuro
CT Scan
MRI
EMG
NERVE ABNORMALITIES:
MOTOR
Hip Flexion
Hip Extension
Knee Extension
Hip Abduction
Hip Adduction
Ankle Extension
Ankle Flexion
Foot Inversion
Foot Eversion
Heel Stand
Toe Stand
Straight Leg
Buttock Lift
Bladder Function
REFLEXES
Patellar Reflex
Achilles Reflex
SENSORY
Obturator - not common
- Motor - adducts thigh
- Reflex - adductor thigh
- Sensory - medial
distal 1/3
proximal
of medial
thigh proximal thigh
- Root supply - L2-L4
Femoral Nerve
- Motor - knee extension and hip flexion
- Reflex - knee reflex
- Sensory -anterimed thigh, lower leg, and foot
- Nerve roots - L1-L4
Common Peroneal Nerve
- Motor - ankle & toe dorsiflexion/eversion
- Reflex - none
- Sensory - anterlat lower leg, inner & top of foot
- Nerve root - L4, 5; S1,2
Sciatic Nerve
- Motor - knee flexion / muscles below the knee
- Reflex - ankle reflex
- Sensory-inferior buttock, post thigh /
postlateral lower leg, outer dorsum of foot
- Nerve roots - L4-S2
Note: the fibres run 'true' in the
sciatic nerve - later fibres from
L5 and go to the peroneal nerve;
medial fibres from X2 and go to
posterior tibial nerve, therefore
can be difficult to determine
level of the lesion
WW.06.05A Fetal Maternal Newborn and Family Health Policy Procedure Manual Effective Date: 15 –OCT-2012
Refer to online version – Print copy may not be current – Discard after use
posterior tibial nerve, therefore
can be difficult to determine
level of the lesion
WW.06.05A Fetal Maternal Newborn and Family Health Policy Procedure Manual Effective Date: 15 –OCT-2012
Refer to online version – Print copy may not be current – Discard after use