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High RiskPregnancy
NormalPregnancy
Name
W/o Or D/o
IPD/ Registration No.
District
Name of level 3 Delivery Point
Type: DH/CH/CHC
RCH Portal No.
Mobile :
Mobile :
Name of Birth Companion
Caste : General SC ST OBC Don't know
Aadhar Card No
Date & Time of Admission
Date & Time of discharge
Mobile :
02
,
03
2-jsV] ek¡a dh iYl vkSj ykbdj dk jax (f>YYkh QVus ij) ns[ksA
4cm
ek¡ dk rkieku ukia s ---------- ek¡ dk ch-ih-ukia s f’k’kq dh ân; xfr ukia s---------- ----------
4- bUtDs ’ku eXs uhf'k;e lYQVs dh ijw h [kjq kd n s ¼ykfs Mxa vkjS fQj eUs Vus la s ½ ;fn % ek ¡ dk
izlo 'kq: gks tk,5- D;k dkWfVZdksLVsjkWbM fn;k\
[kqjkd % bUtsD'ku MsDlkfeFkklksu 6 fe-xzk- IM fnu esa nks ckj nks fnu rd gj 12 ?k.Vs ds varjky ij ¼dqy 4 [kqjkd½
tkap & 1 HkrhZ ds le;
10- iwoZ vfuok;Z gSA
9-
3lsfYl;l fMxzh Qk+ jus gkbV ;k
7-
;wfju
ek¡ dh th-Mh-,e dh fLFkfr8-
ikWthfVo usxsfVo irk ugha
bUlqfyu dh t:jr gS gk¡ ugha
;fn th-Mh-,e- ikWthfVo gS rks,e-,u-Vh- tkjh j[ks
bUlqfyu ij gS rks igyh [kqjkd jksd nsa] [kwu esa 'kqxj dh tk¡p gj nks ?k.Vs ij djsaAvkSj jsxqyj bUlqfyu ,u-,l ¼NS½ esa MkWDVj ds crk;s vuqlkj nsaA
laØe.k ls cpko ds fy, ;wfuoZly lko/kkfu;ksa ¼fizdkW'kUl½ dk ikyu djsaA
6- ;wfju ,oa CyM lsEiy dysD'ku
gk¡ugh
11- t:jr gksus ij LVkQ dks lgk;rk ds fy, cqyk,a (vxj ek¡ dks fuEu esa ls dksbZ ,d Hkh ijs'kkuh gks rks )
izlo ds nkSjku cFkZ daisfu;u (izl lgk;d ifjtu) o dks lkFk jgus nsaA
f'k'kq dks 6 ekg rd flQZ Lruiku
1- vxj fuEu esa ls dksbZ [krjs dk ladsr fn[ks rks mPPk fpfdRlk laLFkk esa jsQj djsa vkSj dkj.k dk mYYks[k djsa%&;ksfu ls jDr L=ko ân; jksx ;k vU; cM+h chekjh [kwu dh vR;f/kd dehxaHkhj isV nnZ rst cq[kkj rst fljnnZ vkSj /kqa/kyk fn[kuk (Severe Anemia)lkal ysus esa ijs'kkuh >Vds csgks'k gksukQhVy ewoesaV esa deh ;k vuqifLFkfr psgjs ij lwtu lkal ysus esa rdyhQiwjs 'kjhj esa lwtu iwoZ esa C-Section fd;k x;k gkscncwnkj ;ksuh L=ko iqjkuh chekjh tSls& Vh-ch-] vLFkek] mPPk jDrpki] Mk;fcfVt
fcuk t:jr ds izlo ds nnZ c<+kus ds fy, vkDlhVksflu@vU; ;wVªksVksfud ugha nsuk pkfg,A
f'k'kq f'k'kq
,Ycqfeu
12- ek¡ vkSj izlo lgk;d ifjtu dks budh lykg ns%
,d
vko';d Mªx Vªs ¼vkWDlhVksflu] batsD'ku eSxlsYQ] ,aVhckW;ksfVDl] batsDVscy ,afVckW;ksfVDl] ,aVhfjVªksokbjy] ehtksizhLVksy] batsD'ku foVkfeu ds&1 vkfn½ fMysojh Vªs] ,fifl;ksVkWeh Vsª] csch Vªs],eoh, Vªs] bejtsalh Mªx Vªs ,oa ihihvkb;wlhMh Vªs dh miyC/krk lqfuf'pr djsaA ihih,p Vªs o bDysfEl;k Vªs Hkh rS;kj j[ksaA
Number of ANC visits done : .................................... Booked ............................ Unbooked .......................................
LMP : .............................................................................. EDD ........................................................................................
Gravida, Parity, Abortion ...................... Living Children ......................................... Married life : ....................... Years.
TT Received : Dose I Dose II Only Booster
Please also specify other significant history:
Family history (if significant) Ask for Diabetes Mellitus, Hypertension, Asthma : ....................................................................
Allergies/adverse reactions, if any:
Treatment prescribed/taken before admission : .....................................................................................................................
.............................................................................................................................................................................................
.............................................. ..................................... .................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
TB Hypertension Heart disease
Diabetes Asthma Infertility Others ......................................
Past/Present Medical History, If yes, then Please tick (ü)
Still Birth : Death of a foetus having birth weight ³ 500 gm or gestational age ³ 20 weeks or crown - heel length of 25 cm or more.
Amenorrhea...............Months Bleeding P/V Leaking Labour Pains
Breathlessness Fever Convulsions
PPH Epigastric pain Headache Odema
Retained placenta Planned C Section Hand Prolapse Blurring of vision
Postpartum Infections Cord Prolapse
Post Operative Complication Any Other complaint (Please Specify) ..........................................................................................
GDM Positive
Prolonged / Obstructed labor
On the way delivery Home Delivery
SYMPTOMS AND SIGNS AT THE TIME OF ADMISSION:
Complication in previous pregnancy, If yes, then Please tick (ü)
APH Eclampsia PIH
Anaemia Obstructed labour PPH
Congenital anomaly Sepsis C Section
Twins Breech/Abnormal Lie Blood Transfusion
GDM Abortion Any other, please specify
Hypothyroidism Still Birth
Fresh SB
Macerated SB
High risk at the time of admission Yes No
04
05
lWeight .........................................................................................
lTemperature .................................................................................
lBP ...............................................................................................
lPulse ...........................................................................................
lRespiration .................................................................................
General Examination at the time of admission:
Pallor Present Absent
Jaundice Present Absent
Body Oedema Present Absent
Other ...................................................................................................
Systemic Examination:Heart ................................................................. Lungs ................................................................. Breast .................................................................
Show : + - Cervical Os : Open Closed Cervical Dilatation (in cms) ...........................................................................
Cervical effacement : Uneffaced <20% 20-40% 40-60% 60-80% Fully effaced
Pelvis : Adequate Inadequate Bordeline
Membrane Rupture: Yes No
Colour of Amniotic fluid Clear Meconium Stained Blood Stained
............................................................................................................................................................................................................................
Provisional diagnosis : ..........................................................................................................................................................................................
Treatment advised : .............................................................................................................................................................................................
...........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Fundal height (Gestational period) (in weeks) .......................................................................
Lie/presentation : Cephalic Breech Transverse Oblique
Uterine Contraction : Mild Moderate Strong
Foetal movement: Normal Increased Decreased Absent
Foetal Heart Rate/minute ....................................................................................................................................................................................
Pre - Term : Yes No.
Abdominal Examination:
P/V Examination (Comment on Os, cervical effacement, membranes, presenting part and pelvis ):
Investigations done before admission
lBlood Grouping &Typing
lHb
lUrine Albumin
lUrine Sugar
lBlood Sugar
lBlood Sugar
lP.S.for M.P.
lHIV
lVDRL
lHbs Ag
lThyroid Profile
lUSG
lOthers
Investigations advised during admission
Absent Traces + ++ +++ ++++
Random ............................. OGTT ..................................
Fasting .................................. PP ...................................
T3 ................... T4 ................... TSH ............................
Date .................................. ............................................
Findings .................................. ......................................
.................................. ...................................................
Absent Traces + ++ +++ ++++
Random ............................. OGTT ..................................
Fasting .................................. PP ...................................
T3 ................... T4 ................... TSH ............................
Date .................................. ............................................
Findings .................................. ......................................
.................................. ...................................................
Hb gm% after last dose of Iron sucrose
Notes :
06
1 2 3 4 5
ANC weeks/PNC days
Date
Iron Sucrose Dosage(200 mg each dose)
3-
izlo ds nkSjku 18 ?kaVks ls vf/kd le; ls f>YYkh dk QVuk A24 ?kaVs ls T;knk dh izlo ihM+k ;k ckf/kr izlo Afltsfj;u gksus ij A
1-
2-
rk
bUtDs ’ku eXs uhf'k;e lYQVs dh ijw h [kjq kd n s ¼ykfs Mxa vkjS fQj eUs Vus la s ½ ;fn %
vkSj ihB vkSj iSj lgyk dj izsfjr djsaA
( )
5-
tkap&2 izlo ds fcydqy igys ;k izlo ds nkSjku o rqjUr ckn
;fn th-Mh-,e- gS rksikWftfVo,e-,u-Vh- tkjh j[ks
bUlqfyu ij gS rks igyh [kqjkd jksd nsa [kwu esa 'kqxj dh tk¡p gj nks ?k.Vs ij djsaAvkSj jsxqyj bUlqfyu ,u-,l ¼NS½ esa MkWDVj ds crk;s vuqlkj nsaA
ek¡ dh th-Mh-,e dh fLFkfr4-ikWftfVo usxsfVo irk ugha
bUlqfyu dh t:jr gS gk¡ ugha
6-
nks lkQ lw[kh csch 'khV
yks izs'kj lD'ku e'khu
uotkr f'k'kqek¡ ls Ropk ls Ropk ds laidZ esa j[ksa
tUe gksrs gh uotkr f'k'kq ij vkbZMsUVhfQds'ku VSx yxkuk ,oa dsl 'khV ij QqV fizaV ysuk lqfuf'pr djsaA
dh
7-
8- ,d
08
bUtsD'ku Vitamin K1 I/M nsaA Mkst % uotkr f'k'kq dk otu 1 fdxzk ls vf/kd & 1 fexzk uotkr f'k'kq dk otu 1 fdxzk ls de & 0-5 fexzk
d`f=e lkal nsA
vko';d gksus ij bUV~;wcs'ku esa foyac u djsaA
dh xbZ A9- izR;sd izlo i'pkr
DYkSEi@/kkxk
09
eSa ----------------------------------------------------- iq=@iq=h @iRuh -------------------------------------------------------------- vk;q ------------------------------------
fuoklh ------------------------------------------------------------------------------------------------ Lo;a --------------------------------- ;k vU; ---------------------------- vk;q --
---------------------------- fj'rk ¼iq=@iq=h@ekrk @ firk @ iRuh ½ ij fpfdRldh; @'kY; @fltsfj;u @ fu'psruk@ funku izfØ;k
@PPIUCD yxkus @ iksLV ikVZe efgyk ulcanh@ [kwu p<+kus ¼Blood Transfusion½ dh lgefr iznku @ djrh gWaw A
bl mipkj @ izfØ;k @ fltsfj;u @ fu'psruk @PPIUCD yxkus @ iksLV ikVZe efgyk ulcanh@ [kwu p<+kus
¼Blood Transfusion½ ls laHkkfor [krjksa ds ckjs esa eq>s lwfpr dj fn;k x;k gSA
eSa bl lgefr i= ij Lo;a] fcuk fdlh ncko ds] vius iw.kZ gks'kks gokl esa gLrk{kj dj jgk @ jgh gWwa A
Delivery Notes
y
APH
Labor
MgSo4 for severe PE/E :given
Condom LAM None
(e.g. anti-hypertensive / ARM) given...........................................
LSCS Reason ......................................................................................
Augmentation of labor done : Reason ............................................................
Dexamethasone given
Performed
Uterotonic used Carboprost Methyl Ergometrine
Yes If yes-Number of doses ............
(Name)............. ...... ..................................................................
Gynaecologist Medical Officer Staff Nurse ANM
Antibiotics to mother given Yes No Reason .................................................
Outcome of PregnancyFresh SBMacerated
Designation:
Neonatal Death (Other than still birth) :
Cause of death & time ..................................................................................................................... ..................................................................................................................... ...................................
10
Spontaneous Abortion
Thromboembolism
PIH
Maternal Death: Cause of ................................time ..................................deathDirect Obstetric Cause
Any other, specify .............................
Indirect Obstetric Cause
PPH managed through : Uterotonics Bimanual uterine compression
Aortic compression Condom Tamponade
Normal Assisted : Forceps/ Vacuum (Neonatal injury after assisted del. Yes No)
Full term live birth Pre-mature live baby
Single Twins Multiple Not Applicable
Operation/Obstetric Procedure Notes
Indication for LSCS
Fetal Distress Contracted Pelvis Previous LSCS Abnormal position of fetus
Non progression of Labor Elective Placenta Previa Macrosomia
Accidental Hemorrhage Other Specify ..............................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
Type of Anesthesia : GA Spinal Epidural Local
Name of Anesthetist : ......................................................................................................................................................
Notes ............................................................................................................................................................................
Name of Gynecologist/ EmONC Trained MO/ Surgeon :.......................................................................................................
Name of Assisting Doctor :.............................................................................................................................................
Name of Staff Nurse : ....................................................................................................................................................
Time at Procedure started .............................................. Procedure ended .......................................................................
Operation Notes, by operating Surgeon : ..........................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
.....................................................................................................................................................................................
......................................................................................................................................................................................
.....................................................................................................................................................................................
Condition at transfer to ward : ........................................................................................................................................
Mother : .......................................................................................................................................................................
Baby : ..........................................................................................................................................................................
Treatment advised : ......................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
LSCS Assisted delivery Laparotomy for ectopic pregnancy
Any Other Procedure Specify.....................................................................................................................................
ForcepsVacuum
11
given :
Pulse ...................... BP ...................... Temperature .....................
FOOT PRINT NEW BORN 2NEW BORN 1
12
Baby Notes Number of Birth: Single / Twin Pregnancy/ Multiple / Not Applicable
Delivery Conducted by (Name) ....................................................... Designation. ..............................................................
Did the baby require resuscitation: Yes/No Whether resuscitation done in labour room: Yes/No
If Yes, which type of resuscitation: Initial Steps Bag & Mask Chest Compression Medication
APGAR at: 1 min.................. 5 min.................. Baby shifted to: Mother side Observational care Admission in SNCU
SNCU Admission for : Apnea/Gasping Prematurity Birth Asphyxia Respiratory Distress
Congenital Defect Other LBW Jaundice Hypoglycemia Other
SNCU (Doctor Name): ......................... SNCU (Nurse) Name: ............................. Ophthalmic Assistant (Name) ...............................
Vaccination : BCG : Yes /No OPV : Yes/No Vitamin K 1mg (>1kg): Yes/No Vitamin K 0.5 mg (<1 Kg) Yes/No
Hepatitis B: Yes/No
Congenital Anomaly1. Head and Spine :
Neural Tube Defects: Anencephaly Encephalocele Spina Bifida Arhinencephaly Holoprosencephaly Hydrocephalus Microcephaly2. Face: Asymmetrical Dysmorphic3. Eye
Eyelid: Hemangioma Ptosis (partial closure of the lid) Coloboma (gap)Eyeball: Anophthalmos MicrophthalmosInside Eye: Corneal clouding Coloboma of Iris Congenital cataract Congenital Glaucoma
4. Ear: Anotia Microtia Low set ears5. Mouth and Lips Cleft Up Cleft Palate Both6. Abdomen and Anus:
Scaphoid and Sunken Diaphragmatic Hernia : Distended. Congenital Intestinal ObstructionHerniation of gut: Gastroschisis OmphaloceleAnus: Imperforate anus Anorectal malformation
7. Urinary Tract:Bladder: Bladder ExstrophyUrinary Stream: Posterior Urethral ValveLower Abdomen: Prune belly
8. Genitalia:Ambiguous: Indeterminate SexUrethral Opening: Hypospadias
9. Limb: Limb reduction Defects Club Foot Polydactyly Syndactyly Oligodactyly10. Chromosomal Down Syndrome Other11. Others:
14
Baby 1 Baby 2Sex (Male/Female/ Ambiguous ) :
Birth Date ( DD/MM/YYYY ) :
Birth Time (AM/PM) :
Weight (in Kg) :
Gestational Age (Weeks ):
Maturity (Term/Preterm ):
Was the baby dried immediately after birth using clean dry
sheets:
Skin to Skin Contact :
Breast feeding (within 1 hour):
Whether ENBC given according to GOI guidelines?
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
IM ;k IV
fn[kkbZ nsus okys VqdMs fudkys ,oa MRP djsa
@usfojkfiu fn;k x;k ?
1-
bUtsD’ku esXusf’k;e lYQsV dh iwjh [kqjkd ns (yksfMax vkSj fQj esUVhusal) ;fn % 3-
eka W5-
8-
6-
(Manual removal of placenta) ;k2-lsfYl;l fMxzh Qk+ jus gkbV
ek¡ dh th-Mh-,e dh fLFkfr4-
ikWftfVo usxsfVo irk ugha
bUlqfyu dh t:jr gS gk¡ ugha
;fn th-Mh-,e- ikWftfVo gS rks,e-,u-Vh- tkjh j[ks
bUlqfyu ij gS rks igyh [kqjkd jksd nsa [kwu esa 'kqxj dh tk¡p gj nks ?k.Vs ij djsaAvkSj jsxqyj bUlqfyu ,u-,l ¼NS½ esa MkWDVj ds crk;s vuqlkj nsaA
vxj f'k'kq dk otu 2000 xzke ls de gks rks daxk: enj ds;j lqfuf'pr djsa A
7- tUe ds 1 ?k.Vs ij thMh,e okyh ek¡ ds f'k'kq ds [kwu esa 'kqxj dh tk¡p dh ugha gk¡] dh xbZ
tUe ds ckn th-Mh-,e- okyh ek¡ ds f'k'kq ds [kwu esa 'kqxj dh tk¡p 1 ?k.Vs esa 'kq: djds gj 4 ?k.Vs esa djuh gS tc rd ,d LFkk;h jhfMax u vk tk,A
tUe ds ckn ,sls uotkr f'k'kq esa gkbiksXykblhfe;k dh laHkkouk cgqr c<+ tkrh gS A
;k blls T;knk ;k fuEUk esa ls dksbZ gks &
Birth weight < 2000 gm - 2mg/kg or 0.2 ml/kg fnu esa ,d ckj 2000-2500 gm - 10 mg or 1 ml fnu esa ,d ckj >2500 gm - 15 mg or 1.5 ml fnu esa ,d ckj
usohjkihu dh [kqjkd %6 g¶rs rd
15
Post-Delivery HB % (before Discharge), only once
A A A A A A
Foul Smelling
N N N N N N
Foul Smelling Foul Smelling Foul Smelling Foul Smelling Foul Smelling
Yes No Yes No Yes No Yes No Yes No Yes No
NoYes NA NoYes NA NoYes NA NoYes NA NoYes NA NoYes NA
A A A A A A
Feeding Counselling onBreast milk expression
16
Treatment advisedby Doctor
Note : If GDM+ve, Check blood glucose F/PP and advise accordingly.
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Good LethargicNo responseTo Stimulation
Good LethargicNo response
StimulationTo
Good LethargicNo response
StimulationTo
Good LethargicNo response
StimulationTo
Good LethargicNo response
StimulationTo
Good LethargicNo response
StimulationTo
GoodPoor
GoodPoor
GoodPoor
GoodPoor
GoodPoor
GoodPoor
DifficultNormal
Fast
DifficultNormal
Fast
DifficultNormal
Fast
DifficultNormal
Fast
DifficultNormal
Fast
DifficultNormal
Fast
Absent
Present
Absent
Present
Absent
Present
Absent
Present
Absent
Present
Absent
Present
Infected
DryInfected
DryInfected
DryInfected
DryInfected
DryInfected
Dry
Yes No Yes No Yes No Yes No Yes No Yes No
17
Treatment advisedby Doctor
1-
2-
3-
4-
f'k'kq Lruiku u dj jgk gks @Lruiku esa dfBukbZ
mipkj] fuxjkuh vkSj t:jr gksus ij mPPk fpfdRlk laLFkk esa jsQj dhft,
Lruiku
60
lsfYl;llsfYl;l
36
38
lsfYl;l fMxzh Qk+ jus gkbV
:
ch
th-Mh-,e- okyh efgykvkas dks 6 g¶rs ckn [kwu esa 'kqxj dh tk¡p ds fy, cqyk;saA
gkbiksXykblhfe;kgkbiksXykblhfe;krst lkal@lkal ysus esa dfBukbZnkSjs iM+uk@>Vds vkukuhyk iM+uk
@lqLr¼ihfy;k½
;k blls T;knk gks
18
;fn Lruiku vPNk ugha gS % Lruiku esa enn djsa] NqV~Vh esa nsjh djsa
a ekW dks iw.kZ Lruiku djokuk fl[kk,a
1. Name of the facility :
Assisted delivery /LSCS/ Evacuation ..........................................................................
...............................................................................................................................................................
Post-Delivery Hb% ........................
...............................................................................................................................................................
Fresh
Macerated
Condition of mother at the time of discharge ....................................................................
Baby-1 Baby-2
Time of Birth .............
Ambiguous Ambiguous
Weight : _____ Kg ____ gm Time of Birth ..................
Vit K1 given Yes No
Referred to SNCU
KMC Initiated in weight <2000 gms. Yes No
Treatment advised to baby Multivitamin Drops Antibiotics
at the time of discharge Calcium Others, Please specify ............................................
21
2. RCH Portal No.
Full-term
;g
fMLp
ktZ fVdV g
S] dEI;wVj }kjk tujsV
u g
ksus d
h fLFkfr e
sa bl
s QkM+dj fgrxzkgh dks nsaA
Single Twins Multiple
Thyroid Profile
Blood group and type
Investigation at the time of discharge
If mother Rh-ve, blood group type of baby
Breathing Difficulty - Apnea / Birth Asphyxia
Hypoglycemia
Hep B
22
*izlo mijkar 6 ekg rd vk;ju dh ,d xksyh ,oa dSfY'k;e dh nks xksyh izfrfnu ysaA
30
60
30
60*IFA Tablet * Calcium Tablet
Condom Yes No LAM Yes No
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