Antenatal Case Card

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