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)

07

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

13

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

19

20

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