OD Date of Admission/ Vist : Address Obstetrical score: 61 Abortion ° Gravida: 2 Parity: 02 Living ae So) hen & [2019 LMP Gestational Period Soureale EY corti for 4 yreintonth HISTORY: Cal Education Rihana) . ver ‘Occupation > Wife ub End | Husband Familyincome : —1SO00-/ sronth Type of House Kacha/ Pacca Kio of Rooms: ——°———_ Ventilation: Sanitation Facilities: Ne Family History: rf 66 ‘Adutt; 25 — Children ; -6}-—_ Type of famiy: Tait no of Family Members: 0 Hereditary Diseases (if any) : et ee See ee History of twins No Any other Significant History : \ PERSONAL HISTORY Sleep : pies ‘Appetite ; Nowmal _ ‘Aleray;(Sneaiy eny) 2) Hats 4094 paceion :—NLo ladder and Bowel Habits Constipation/ incontinence Diet: ( Veg/ Non Veg) : Hatin Cionty Number of Meals a Day: Any significant Diet Habits in pregnancy and delivery period : PAST MEDICAL AND SURGICAL HISTORY: Previous Medical iliness and Treatment (Specify if a r Yo) Boronic ne) Cy ener.MENSTRUAL HISTORY ‘age of Menarche mount of bleeding (approx ) resent tan: Yess MARITAL HISTORY: ‘age at Marriage consanguineous Marriage se of Contraceptive ir Yes Specify Type, Duration, And Any Associated Problems ny Treatment for In OBSTETRIC HISTORY: past Obstetric History: No of Living Children Girls: ——0 Boyal ——— Spontaneous : ——=———— ‘Abortions, ‘Age of last Child ‘age of First Child ‘Any congenital Abnormality / Disease in children History of previous Pregnancy deliv Nowa || r ) sc she) 4° a ed Al-DUAL CAMERA+ Yes/No (if yes specify t/t taken) a Sata moe (Cm A Mit Repos: Ha: BSS ie, 64 Ke pp: Wo/to mms ns ORE, any specify): No Any Tit medications : pant Ouiee | Yes/No oes ea peo eee eee e@ O 51s [¢ me] at Pa ed Al DUAL CAMERAEXAMINATION OF THE MOTHER General Appearance + Body built - thin/ average/ obese i) + Appearance - Gait Nomeat + Nourishment - Poor/ Average! Good Height 4.2222 UCU cs gg Vital signs = Temperature e Respiration Head : 2h = Pallor/ color change / Puffiness of eyes {p eriorbital € + Facial puffiness / Chloasma :- Teeth: Dental caries NLO eo SHOT ON REDMI Y3 Al DUAL CAMERAwarm up. ASK ners hands togetner: 1° Lett Cons MAE nove ndicaking spine a ie Saintes. a @o ae Ze UNM \yiavGis. Good Gat Warning signs . a rea Sled onan Minor discomforts & Remedies plannivg m Sex Signs & Symptoms of true labour : e @ TOMO > Al DUAL CAMERAAlergy (Specify any) ; MoSer* ‘and Bowel Habits- Constipation! incontinence 0| MENSTRUAL History a | ‘Age of Menarcne : LY fe ase cycle | + Amount of bleeding (approx) : Treatment taken: Yes/No pe MARITAL HISTORY: Yes) No Yes/ No ‘And Any Associated Problems YesiNo : If Yes Specify Treatment Received Giris Abortions ——— Spontaneous Age of Fi = Age of last Child Any congenital Abnormality / Disease in children History of previous Pregnancy Pregnancy Date 8. [Month a | oventesicel si | | p R Present obstetric history: General Health during Present Pregnancy Complaints during Pregnancy Morning Sickness Yes/No 1a TOM Me] SIP ce) PN etry O emedications ey Se | r ) soe) 1°) ed PLU Nee Laie.Laporatory Investigations Hb% =ve -V oe Negative Ae fo, cool ecimea) 122 gm/olk [84 | TORCH or any other Special investigations EXAMINATION OF THE MOTHER ral Appearance = Body built - thin/ average/ obese + Appearance - Gait \lormot oan Nourishment ~ Poor! Average/ GS6d LSE On oo 68 Ger Height = Vital signs = & f Terperstre :, 106 ps Respiration ; 2 breath| nie iced pressune | 2 (aaa Head : : Scalp Cleanliness nko eal a + Pallor/ color change / Putfiness of eyes (periorbital edema] Eyes we Face : Facial puffiness / Chloasma : : Teeth : Dental caries Pebsenboure. 4 Mouth Tongue : Dry / coated / mofst : Lips: pallor / cheliosis / dry / moist / Neck : nspection & palpation : Thyroid enlargement : —Ivecion below umbitous Mee. Rae mad sft in poe inate jenko extromilies of fs r ) O SHOT ON REDMI Y3 PNP LUL Nene Laise.yAny Risk Factors identified Risk Factors High Risk Low Risk Remarks Antenatal Teaching/Advices Nutrition Follow Up Rest & Sleep Exercise& work Use of Comfort devices Waming signs Minor discomforts & Remedies Sex z 4 ain th ‘ ie Signs & Symptoms of true labour : aun r) SS nme Ine) Al DUAL CAMERA; —2byear eign Te te. Voc _ Hospital; CHC. Savoie Neg — i Abortion S S820 gop: —to|c}21 Pe OS isis tor; 24 vreionth : 2] Ltd _ i ee ee 7 Wie: HowseSibe tenong ; Ruriners + —20000 / pew ont, ma «Reh Pa of oe: Pires — ventiaion: Adequate r ) e) SHOT ON REDMI Y3 PLU Nene Laise.NTreatment taken : Yes/No MARITAL HISTORY: Age at Marriage : ~2A428°° Vea of Mal Consanguineous Marriage: Yes/No = of Contraceptive : Yes/No w= ify Type, Duration, And Any Associated Problen Yes/No : If Yes Specify Tr us It Yes Any Treatment for Infertility OBSTETRIC HISTORY: Past Obstetric History: iris ; Spontaneous : Age of last Child > No of Living Children : Abortions Age of First Child Any congenital Abnormality / Disease in children : History of previous Pregnancy Present obstetric history: General Health during Present Pregnancy Complaints during Pregnancy Morning Sickness Yes/No ATs ee) PUM Aarea. easeoor (wore 0 hy ayy ee a Wee plane) S101 ee) a Salo Ly @02 joey: UISBOIUO / SSOULING 12: 7 an sofa yo seed e6Uey0 0}00 HOHe + sseulluea|a(Swied ou us sms 0 ejod ow Anuop)) (ennouEW op plotiony ‘> wey A ‘snomquin ary (Aysueju is04614 40 aulod Aynuep)) dow vsy vou VST yor 7 Dy Camere -@ yoeq [B12} e}e007) (dlup es9¥e7) -uoned / ssi seme es - | | ‘esieasuey /enbygoyeuipny6uc) — Igoneurpry6uo} sueoiqie / wruepnesBoeis'esBeu eau) - “i ny YOu / Ky — snojiquin mojeq uossseideq / sepnuioid/pesseidepney — CL it, — sca LOR MO] 1 0 ee) {uoerseo 10 poued] Od o1 Buspuodseui0d / NEWS spe 96. @o Pht= :unoge! ona Jo swoIduiks y subig nd PNT FIC xes paso SeIPSWIeY *B SHOJWODSIP JOUIW suBis BuIWeN ‘se01nap Hiojulo9 40 es. 30M *gESIDI0X3 p : deals 3 188 PL yrs fe ee IS dn mono mn fe Samora haere WA ont ae ae sooiapy/6urysee) [eIeUIUY suewed sr MOT sie USIH suowes 4S poypuep! sioioes ¥sI4 AU [or ins pen 3et | SW eer ee ie ego Hoorn abore 0] 3 | Sa fe neo _o — 00 ie Be FSP rneriea ess SS YesiMonth Bore laid ae: 3 * pesseol Patiend aot pastes 2 Wie = foo. Husband Pdes uoite ae acca No ae Be worittcton: SS ae eee “No of Famiy Members? ——! adut: —S—— cooren « oles 2 ee ee eee coat isb\¢ ____ r) SHOT ON REDMI Y3 Al DUAL CAMERA ae Amount of “Treatment taken MARITAL HIST ‘age at Maid Consanguined Use of Cont At Yes Speci Any Treat oBsTETRI Past Obst No of Livi oodions Age of F ‘Any con HistoryMENSTRUAL HISTORY ge of Menarche ; S24 ¢e aa amount of bleeding (pprox): 2B ‘Treatment taken : Yes/No (yes Soc ee MARITAL HISTORY: ‘ ‘ge at Manioge : 2546279 Years of spar Ue! ly Consanguineous Marriage: Yes / No—— ‘ Use of Contraceptive Yes! No —= if Yes Specify Type, Duration, And Any Associated Problems. + ‘Any Treatment for Infertility : Yes/No: if Yes Specify Treatment Received © OBSTETRIC HISTORY: Past Obstetric History: No of Living Children: —— Gis Abortions : Spontaneous : ————— Age of First Child: 2420~% po of last Chi = pbtend ‘Any congenital Abnormality / Disease in children History of previous Pregnancy pate | Preananey | Labour 's. | Month & events-Pre/ events- No | year of | Post term/ | Prolong / ‘i MTP) Precipitate/_ very | abortion | induction | » Mahe [at tern Prolomaech Present obstetric history: ‘General Heath during Present Pregnancy : fl SHOT ON-REDMIY3 Ee ey eT ry@ (@) SHOT ON REDMI Y3 Al DUAL CAMERALaboratory Investigations Ls TORCH or any other Special investigations _ | EXAMINATION OF THE MOTHER General Appearance Body built thin/ average/ obese + Appearance - Gait Noma! — + Nourishment — Poot! Average! Good Height : Vital signs Temperature Respiration Head : ac: Tome (Roe Me. 2 Scalp: : Cleanliness : Eyes : Pallor! color change / Puffiness of eyes Face + Facial puffiness / Chioasma : Mouth + Teeth Dental caries ALemtg Tongue : Dry /-coated / holst ry SHOT ON REDMI Y3 Al DUAL CAMERAysy ‘dn wuem o} ‘seyje60) SPUP! apt inry Comin 2 ee 1y ssoulwexe any “SepIs 94 12 Wwened JO SHOT ON REDM-Y3 EU Neel tay @0Any Risk Factors identified Risk Factors High Risk Low Risk Remarks Antenatal Teaching/Advices Nutrition, Follow Up Rest & Sleep Exercise& work Use of Comfort devices Waring signs Minor discomforts & Remedies Sex e@ O $1 500] PL ed CVE Nee TSS yyDate of Admission/ Visit: on : re S Piiages Nucleun = ‘Address —Santjiad Nesao Obstetrical score: Gravida: —2-——.. party portion imp ore ape Aten? Seetnal Pood : MW cekit Yds spenied for; ——t——— Yrs/Month HISTORY: 7 Education Wite : —aCradiuote paper i ceupaton Meteors atend “is Family income 20, pr Jaconl, Type of House Kachay Pacca No — ever siayon Ad carant 3 Sanitation Faciities : Aves table Oa Family History: Type of famiy: Joi No of Famiy Members: 06 rgut: OS chtaren » © Hereditary Diseases (if any) : Ao No History of twins LO — - Matemal/ Fraternal Any other Significant History : No PERSONAL HISTORY Sleep AEE toe: loro eens No Addiction :—Nio__ Bladder ane ; | ( Veo! Non Veg): “4 Teno of el 9 Dey: —Lestela/cl oy Si yt etree: hae r ) O sc (80) 44°) ne) Al DUAL CAMERAssp oy + plu ise] J0 2By # snoaueyuods :A10ySIH 91121840 1563 ‘AMOLSIH ORULILSEO SAMOLSIN TLISVN OY ON/SeA : Ueye) 1UOLUNESL + (xoNdde) Buypaeiq jo wuNoWy1U6IOH + sodeR /SI81A 12H oY 1 Sj : stone Ay, rs may oe Te ree suds 91 ereUsILY sweygeud weoyutis 20440 Kuy :kousuBaid woseid Buunp siuend Ie REE? rma) t Xe)EXAMINATION OF THE MOTHER General Appearance + Body built = thin/ average/ obe + Appearance - Gait Nosy + Nourishment ~ Poor! Average! Good Height : 10" cs, Weight « Vital signs Temperature Respiration Head : Hair: Texture : © Pallor/ color change / Puffiness of eyes : Facial puffiness / Chloasma :- mi SHOT ON REDM! Y3 C ) Al DUAL CAMERAyay POG [Period of Gestation] a ps ‘obliquely! ovoid ‘(Spherical q 5 ie aiprarudes / Depression below ‘umbilicus Bia esha Nt Lines niagreStiaegraviderum / albicans Be free Aca a ands of paint atthe sides. Rud examiners hands fogetner, (0 2 knee, for pelvic palpation) ee al ee ym up. Ask ee Grip)(identity lie & Presentation) Jongiuainalobique! transverse LSA er e@ (@) SHOT ON REDMI Y3 PMOL ener. 70 goeeles +4 dnt [Maly leve Any Risk F Risk Factor High Risk Low Risk Remarks Antenatal Nttition Follow Up Rest & Si Exercises Use of C Warning Minor disTro. | SuliphaJ! calesterol | Caleesat | hes Elvc Rete Rantec Ranitdine Tab levothyroxing Levoth SS Any Risk Factors identified Risk Factors High Risk Low Risk any Nigh or loro oak & Remarks Antenatal Teaching/Advices tuk pleut 6| water, Sapam Nutrition Doink pleut 6| roster DM = 3h a Ts ; Follow Up Na even woeelel Rest & Sleep Rhys © i_cola Auhewd alee Wow, het water paw Sees Lleedii Exercise& work Use of Comfort devices Warning signs Minor discomforts & Remedies Sex r } O co) (Oe) Ped CNEL Neer TSS vy‘Abortion * pe, chefs 2 YrsiMon} Tol ao werk — Mariod for f*—— i pe ee eet te re aduguct fe oer: Daou — Ventilation: ta hl e SHOT ON REDMI Y3 Veer emer is 70MENSTRUAL HISTORY ‘Age of Menarche = As pass A Sending Cente Trederent tice: You MARITAL HISTORY: ‘age at Marriage : 214, Years of Marital Life (stays with husbs Pope gxineous Naroge = Ser Ne Be i erienive Yes! No Specify Type, Duration, And Any Associated Problems = ire If Yes Specify Treatment Received = ‘Any Treatment for Infertility ; Yes/No OBSTETRIC HISTORY: Past Obstetric History: No of Living Children ————— Spontaneous ‘Abortions | ——— ‘Age of last Child » Age of First Child ‘Any congenital Abnormality / Disease in children History of previous Pregnancy r ) SHOT ON REDMI Y3: Veer ener iis 7.0ts during Present Pregnancy: ‘Vt taken _ Yano Nia Moderate foovere | = Se din Ss Weight = Tit taken “Any other significant problems “Anionatal Visis/ Reports : Height Hom = = ‘Second trimester: Minor Ailments any speci) Hospitalization : YesNo (if yes speci Ut taken) Quickening (Daterweek) pam ts ne en ole Fetal Movements ‘Any other significant problems —e—__—_ — Iirlenatel Viets/ Reports = Height: —LLS Ch Weight ' oy../ 0) pp, ibid 4 c ae cue 1 hen . Be args, fedivals bin Croerk ju Teaaves he Third trimester Ko ‘Minor Allments-(f any specify) : No ___— Any Tt meaications + Yes/No (if yes specify Ut taken) ere cy ee ou No io um Hospitalization Fetal Movements : ae Signiteant problems Be nee ke m He + Weight ppp al2o/te a ae ent Bed Maher oka ae Becing lve dee 4 Mwerle 42 7 iw tephalti pe exe dodiy r Yo) Teme Wit lx Ne Al DUAL CAMERA —Laboratory Investigations h wil = \ cli fund “Ow Neos eats | cumime EXAMINATION OF THE MOTHER General Appearance + Body built + Appearance «Nourishment ~ Poor! Average! GOod Height : — _ viene» oe Vital signs 4 Temperature £ _____ Pte: — pA bieats [niin x Respiration cath | mtn sood pressure ; 122 BB mame Head : Hair; Texture oe Slcaex Dark Scalp nee snd owed Pallor! color change / Puffiness of eyes [periorbital edema] Face 2 Fabia putnness ( Chioaema Lloasws aren AO bl cu Mouth Teeth : Dental caries __ Gums : Hypertrophy, bleeding yo Tongue : Dry / coated / moist Lips: pallor / cheliosis / dry / moist / cracked Neck Inspection & palpation : Thyroid enlargement : Hensal = —_—§— Lymph node enlargement St tg cme: — £1 ——— sats SS nomad“all aviderum / albicans Pree inca, niagra,Siiaes a £Oa Seen rer, to warm up. ASK a riont at the sides. Rub examiners hands togeth Ris (keep: both hands of Pl , om Hig : &{ Uno ‘Symphysis fundel height (SFH} : at in wooks : “2. i undal Tape Binet LOE IG ee A Gripy(identiy lie & oe bubtoc ah Pe xe poe FE oa Jongitudinalioblique! transverse : sraucl Breech! Shoulder yas ult Coin ectepedg wt = bade Bes Ratt chore Fak HE : (Locate fetal back & extremities) spineeg Is Toeaigake tae Se BR econ at Sree cB. ROP extrencition Hf ghee (Lateral Grip) Maneuver) (Identify the pole of fetus in the pelvis) T Yen REDMI We) Al DUAL CAMERA“se Me L Thon Fea rons satphal tee =" Calerfero] = : Or nag Folic Ae ta wo. Ge 2 ia r oe bi Teak Lardtse | Routioli cg oe Se J = Any Risk Factors ic 4 Risk Factors \ : neo figh Risk } ji = ow Risk DAS is Rotient “ny Met howvin ntenatal Teaching/Advices ink pleuhy 6/ safer, Tron Wek ed utrition : ew Up adic eth ee est & Sleep Bhp 2 na in Aw fercise& work Antereta! excer. s0 of Comfort devices d Winus' Lok pogther = aming signs nor discomforts & Remedies:ae — panier vat: OFT ees Bathe Hospital + 1 a : pes yronih of oii 14 emma Husband ae Wee, mie Wile Mizoon [alonty ——— peu oD Ventilation: ode : Kenn Pai No come: Oe » _Availab amily History: “ype ot amy Tut no of Family Members: tnt; 2 — coitren : 4 itary Diseases (if any) = prinuar Allergy (Specity if any) : SE ore e+ ast nd vel Habis Costin =¥ soy Te m0] 19) a ed WV bein} 3) cielor-V t=:MENSTRUAL HisTORY MARITAL HISTORY OBSTETRIC HISTORY: past Obstetric History: lo © Regular regular Interval ‘Avsooiatod Probleme (It any) pede Yours of Marital Lito (stays with husband) ¢ SSO ae woclty Treatment Received pontaneou: ‘Age of last Child Age of First Child any congenital Abnormality / Disease in children ; Prat 0 History of previous Pregnancy Pregnancy | Labour Mode of Date | events-Pre/ | _avonts- | |DelivaryN/D, C8 S. | Month § | post term/ | Protong / | Instrumental ee mTP/ | Precipitate/ | delivery delivery | abortion | induction | — indication Aor, y fulehia | ak tem] Pov lowged Uagical dalisven