LANE: PIN.
THE MOTHER SHOULD KEEP THIS FOLDER ALONG WITH HER WHILE GOING FOR ANC VISITS, DELIVERY, MEDICAL EXAMINATION ON BEING SICK
Mother's full name .. Husband's full name . Residential address: Village/ Town: District: State .. Phone number .
OBGYN BOLANGIR
STRAIGHT LANE, BEHIND CIVIL COURT BOLANGIR, ODISHA, INDIA 767001
OBGYN CLINIC BOLANGIR, ODISHA
Signed
Date
Abuse disclosed D
Routine question Asked
Seen alone
D
M M
Y
Y
AT Booking No Yes
D
D
M M
Yes No
Y
2nd Assessment
Y
W e e k 20 m a r ks the ha l fwa y po in t in y our pr e g na ncy. Your no w 10 ounce ba b y wil l be g in to po ke a n kick. You're ad l re a d y ne a r ing the e n d of your 2nd tr im e ste r which wil l be a t 27 we e ks.
Le g s a n d a rms be g in to d e ve l op ra p id l y in the ne xt 4 we e ks. Ba b y wil l be g in to suck a nd bl ink e y e s.
This we e k e nd s yo ur first trim e ste r. Com ing we e ks wil l bring re l ie f for m o rning sickne ss a nd bl a d d e r p re ssure .
via ul tra so und . Ba by d e ve l o p s this 4 we e ks from the size of a se sa me se e d to a kid ne y b e a n.
Misse d p e riod a nd tim e of wond e r . Sta y a ctive , e a t he a l thy, a nd re sist d rinking a l co hole. a t is e a sil y d e te cta bl e He a rtb
Domestic VIOLENCE
Week 24
Week 20
Week 16
Week 12
Week 8
Week 4
Expected Date of Delivery
Last Menstrual Day
Smt.
Details (inc. any referrals)
Week 39
Week 38
Week 37
Week 36
Week 32
Week 28
OBGYN CLINIC, BOLANGIR, ODISHA
Congratulations! Your baby is mature to be delivered in the following weeks. If you haven't delivered you will soon. Get ready to Welcome home Baby!
This week your baby reaches full term. By this time everything should be ready for baby to arrive.
Baby is practicing breathing motions. Braxton Hicks contractions will increase in frequency. Pack hospital bag.
During this period the baby will reach half of their eventual birth weight. Hair and toenails will grow.
Your baby has reached the premature threshold of survival. Baby can breathe spontneously.
OBGYN BOLANGIR
No prior perinatal morbidity or mortality Fetal growth adequate
Current pregnancy complicated by: Gestational hypertension Placenta previa (with or without bleeding) Other significant antepartum hemorrhage Twin pregnancy Gestational diabetes. Abnormal fetal growth (suspected intrauterine growth restriction or large for dates) PROM 32-36 weeks Preterm labour 32-36 weeks Rh or atypical blood group sensitization Hydramnios or oligohydramnios Fetal malposition (breech, transverse) at 36 weeks Postdates ≥ 41 weeks Anemia not responding to Fe (Hb <100 g/l) __________________________________
High order multiple gestation (triplets or greater) Fetal congenital anomaly Diabetes beyond Class D (end-organ involvement) Renal disease with hypertension ± ↓ function Heart disease, especially with failure Other significant severe medical illness _______________________________________
Pregnancy < 32 weeks with: Preterm labour and/or premature rupture Gestational hypertension with adverse conditions Antepartum hemorrhage ongoing Oligohydramnios IUGR, ≤10th %, reverse flow Doppler
Pregnancy at high risk: Pregnancies which are so complicated that the fetus and/or mother are obviously in danger. These patients may need to be transferred to tertiary centre for intensive care and birth. Clearly, there are patients who deserve to be placed in this risk category (with problems such as excessive antepartum bleeding, cord prolapse, or advanced uncontrolled premature labour) who cannot be transferred safely or in time to benefit the fetus or mother.
OBGYN BOLANGIR
Diabetes Mellitus Chronic hypertension Significant medical illness SCD / Thal. Obesity (BMI ≥ 35) Significant tobacco, alcohol, drug use Severe psychosocial issues Family history genetic disease or congenital anomalies Other significant family history, esp. DVT/PE and recurrent pregnancy losses Prior pregnancy history of: Preterm labour < 36 weeks Stillbirth or neonatal death Intrauterine growth restriction Previous uterine surgery including lower segment Cesarean section Cervical incompetence
Maternal factors:
Pregnancy at risk: The fetus/mother may be at risk. Closer observation of the pregnancy may be necessary. In addition, consultation with an appropriate specialist (obstetrician, Medicine, pediatrician, etc.) may also be necessary. These patients have to be managed by continuing collaborative care and birth in an obstetrical unit with intermediate level nursing facilities.
No pregnancy complications now or in the past No significant maternal medical disease
This assessment system is intended as a basis for planning the on-going management of the pregnancy. The risk factors or problems listed below are major examples only. Healthy Pregnancy, no predictable risk:
Two or more risk problems can combine to produce a high pregnancy risk. Such a patient may need to be placed in a higher risk category
Current Pregnancy Risk Assessment
22. STDs / HSV / BV / HBV 23.Tuberculo-sis Risk 24. Other
14. Genetic History: 15. Family history of: DM, DVT/PE, PIH/HT, thyroid, Postpartum depression, 16. Developmental delay 17. Congenital anomalies 18. Chromosomal disorders 19. Genetic disorders 20. Infectious Disease 21. Varicella susceptible
Abnormal findings details
Abnormal Findings
1. Hypertension 2. Endocrine 3. Urinary tract 4. Cardiac/Pulmonary 5. Liver, hepatitis, Gl 6. Gynaecology/ Breast 7. Hem./Immunology 8. Surgery 9. Blood transfusion 10. Anesthetic complications 11. Psychiatric Illness 12. Epilepsy/ Neurological 13. Other
HISTORY
EXAMINATION
Uterus Size: ____ weeks Adnexa
Cervix,
PRESENT PREGNANCY 1.Smoking 2. Occup/Environ. risks 3. Preconceptual folate 4. Iron 5.Calcium 6. Ht.______ Wt._______ BMI______ External genitalia Vagina
OBGYN BOLANGIR
Abdomen
Varicosities Extrem.
Breasts
Chest
Psychosocial : 25. Poor social support 26. Relationship problems 27. Emotional/Depression 28. Substance abuse 29. Family violence 30. Parenting concerns 31. Relig. / Cultural issues 32. Family History 33.Other Thyroid Cardiovascular
SS
Gravida
Contraceptive type-
Pregnancy Summary
AA
AA
HIV STATUS
ALTERNATE
Term
Preterm
Last used
Certain- Yes/ No
Spontaneous:
Induced:
Abortion
Smoking
,
5
4
3
2
1
LA
TSH
RBS PPBS
HBsAg
VDRL
Hb %
OUTCOME LB/FSB/ MSB/END
Results
Birth Weight
YEAR (at present)
LIVING/DEAD
OBGYN BOLANGIR
OTHER INVESTIGATIONS
INVESTIGATIONS
VB / CB
OBSTETRIC HISTORY
Gen / OBC / SC / ST . BPL APL Registration No. / Date TOBACCO: Y / N
Pregnancy Gestational NO. Age
Weight:
Living LCB
,FH ,NT / /
BLOOD GROUP ABO | Rh.
Age
No.of fetuses ,HC ,FL US EDD:
Occupation Education
Initial USG: Date: / / ,CRL ,GS BPD Gestation Weeks Days, Regular - Yes/ No Comments
Expected Date Of Delivery
Cycle q _____
LMP
AS
HUSBAND
SS
First Day of Last Menstrual Period
AS
Sickle Cell Status (HPLC)
WIFE
PHONE
ADRESS
Husband
CLIENT
NAME
STRAIGHT LANE, BEHIND CIVIL COURT, BOLANGIR, ODISHA
OBGYN CLINIC
Date
Date
BPD
HC
Gest.Age Pallor/ oed
AC
Pulse
FL
Weight
AFI
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
B.P
Heart
Placenta Position Grade
Chest
FHR
LIE / Present. FHS
FM Felt / Discussed
Single/ Multiple
Lie
Present. Doppler
ULTRASONOGRAPHY REPORT
Icterus F. Height
EXAMINATION
AFGA
Hb%
EFW
U.Alb.
COMMENTS
Signature
OBGYN BOLANGIR
CHIEF COMPLAINT
MEDICATION PRESCRIPTION DATE
NAME OF MEDICATION / DOSE
Dose
DIRECTIONS: Frequency Route AF/ BF Duration
ABBREVIATIONS : a.c. After Food, p.c. Before Food, BBF Before Break Fast. BiD Two Times a Day, TiD Three times a Day. o.d. Once a day p.r.n./ SOS as needed, HS at Bed Time
Quantity
Date of Return
OBGYN BOLANGIR
MEDICATION PRESCRIPTION DATE
NAME OF MEDICATION / DOSE
Dose
DIRECTIONS: Frequency Route AF/ BF Duration
ABBREVIATIONS : a.c. After Food, p.c. Before Food, BBF Before Break Fast. BiD Two Times a Day, TiD Three times a Day. o.d. Once a day p.r.n./ SOS as needed, HS at Bed Time
Quantity
Date of Return
OBGYN BOLANGIR