Socio-demographic History:

• Name:

• Age:

• Religion:

• Marital status:

• Education:

• Occupation:

• Address:

• Native / Migrant:

• Informant:

• Obstetrical Score: G ___ P____ A____L_____ Still births____ currently with_______ of gestation(gestation in weeks)

• Patient admitted in the hospital on________(Date of Admission) or attending the ANC OPD.

Chielf  Complaints: 

State the chief complaints with which the patient presented. If it is a regular ANC visit, mention so.

1)

2)

3)

Present History: 

• Details of the chief complaints with which the patient presented.

Describe in detail the origin, duration, progress (ODP) and associated events.

• 1. Symptoms suggestive of complications 

     1. 1. Pain in abdomen

        2. Palpitations

        3. Easy fatigability and breathlessness at rest

        4. Swelling all over the body and puffiness of face

        5. Severe headache

        6. Blurring of vision

        7. Convulsion

        8. Bleeding per vagina

        9. Watery discharge per vagina

        10. Fever >38.5oC for more than 24 hours

        11. Persistent vomiting

        12. Reduced or absent foetal movements

        13. Preterm labour

• Any treatment taken for the current symptoms. 

Mention all the relevant details.

• Details of any current systemic illness and its treatment.

  1. 1. 1. Hypertension

        2. Diabetes

        3. Heart disease (Breathlessness on exertion, palpitations)

        4. Tuberculosis

        5. Leprosy

        6. Renal disease

        7. Epilepsy

        8. Asthma

        9. Jaundice

        10. Malaria

        11. Reproductive tract infections

        12. Sexually transmitted infections, HIV-AIDS

• Any history of exposure to radiation in current pregnancy.

• ANC Care details

  1. 1. 1. ANC registration done in which trimester

        2. Total no. of ANC visits till date/ frequency of visits

        3. Intake of iron folic acid tablets and  calcium tablets

        4. Immunisations taken - number of Td doses received and the trimester in which it was received

Menstrual History: 

• Age of menarche

• Date of last menstrual period 

• Calculate Expected Date of Delivery

• Past Menstrual Cycle - Duration ______________, Regularity _______________________, Pain during menses __________________ , Flow - less/moderate/heavy

Family Planning: 

Family planning method used and duration of its use. (planned or unplanned pregnancy)

Immunisation History: 

• Tetanus vaccine - Td (number of doses received and the trimester in which it was received).

• Covid-19 vaccine - Name of vaccine received, Number of doses received and date of last dose taken.

Past Obstetric History: 

• Gravida _____ Para _______Abortion _______Live birth _________ Stillbirth ________ . (Mention here if  any child born as live birth died subsequently and the cause of death. If there is history of recurrent early abortions, record the details and mention if any post-abortion complications occurred)

• Ask for each pregnancy - the birth history and complications and inj tetanus toxoid. State the present age and sex of child.

  1. • Details of the previous birth history 

       1. 1. Term of delivery 

          2. Place of delivery

          3. Nature of delivery

          4. Complications during delivery

          5. Delivery conducted by

          6. Birth weight of baby

          7. Did baby cry immediately after birth

          8. Breast feeding when started

          9. History of any prelacteal feeds

          10. Difficulties in breastfeeding

          11. Duration of breastfeeding

• History of complications or significant events in the past pregnancies 

  • 1. 1. Hypertension, Pre-eclampsia or Eclampsia

       2. Ante-Partum Haemorrhage (APH)

       3. A caesarean section / a instrumental delivery / breech delivery / manual removal of the placenta

       4. Perineal injuries/tears

       5. Excessive bleeding after delivery

       6. Puerperal sepsis

       7. Blood transfusions

Past History:  (If yes mention details)

• History of TB

• History of hospitalisation

• History of any major surgery in the past (especially Surgery on the reproductive tract)

Personal History: (If yes mention details)

• Addictions - Tobacco and alcohol consumption

• Allergies

• Adverse drug reactions

• Sexual exposure

• Bladder/ bowel complaints

• Sleep

• Appetite

• Physical exercise

Family History: 

• History of Twins in family 

• History of congenital malformations in family

• History of Hypertension or Diabetes in the family

• Any family member suffering or had TB

• Any current major chronic illness in family, including mental illness

• History of genetic disorders

• History of Thalassaemia or whether anybody in the family has received repeated blood transfusions. 

Socioeconomic History:

Details regarding the following should be obtained in history.

• Number of persons living in the family.

• Age and sex wise distribution of family members.

• Head of the family

• Relationship of family members to the head of the family.

• No. of earning family members and total income.

• Education and occupation of the Head of the family.

From the above information,

• Draw the family tree with the above information.

• State the type of the family.

• Calculate and state the socio-economic class using either BG Prasad Classification or Modified Kuppuswamy Classification.

If using Kuppuswamy classification calculate  

1. Educational status of head of family and state education score.

2. Occupation of head of family and state occupation score.

3. Monthly combined income of family and state income score.

4. Give the total score.

5. State classification as per Modified Kuppuswamy classification.                       

If using BG Prasad classification, 

1. 1. 1. Calculate per capita income per month.

      2. State the socio-economic class as per BG Prasad’s classification.

Environmental History:

• Locality: Urban slum / Urban Non slum / Rural

• Housing: Type of house i.e. kaccha / pukka /semi pukka, area of house, etc.

• No. of rooms:               Overcrowding: Yes / No

• Lighting & Ventilation: Adequate / Inadequate

• Water supply:

  • • Continuous/ Intermittent

    • Water purification method followed

    • Storage of water for drinking purposes or other household purpose

• Waste disposal:

  • • Garbage stacked before disposal (Bin / Plastic bag)

    • Disposal of garbage

• Latrine:

  • • Common/ separate

    • Indian/ western

    • Bathroom separate/Common

    • Open air defaecation

• Sullage:

  • • Drainage (piped / unpiped)

• Pets

  • • If pets kept, type and vaccination status of pets

    • In rural areas, animals kept in the house: Cattle/ Goat, Sheep/ Hens

• Complaints of pests (Mosquitoes / Cockroaches / Fleas / Ants / Lizards / Rodents)

• Screening of house for mosquitoes

• Sanitation

  • • Drainage facility. Open drains near the house.

    • Mosquito breeding places in and around the house.

    • If rural areas cattle sheds separate or in the house.

Social Cultural Practices:

• Dietary Practices - eating specific foods in pregnancy(e.g. drinking milk to have fair skinned baby), avoiding certain foods (e.g. not eating papaya due to the fear of abortion), limiting the quantity of food ( e.g. if the baby is big, the delivery is difficult).

• Rituals and Ceremonies during pregnancy (e.g. Baby shower).

• Delivery related practices (e.g. first birth at mother's place, home delivery).

• Restrictions on movements (e.g. not stepping out of the house during eclipse or lunar phase of the month).

• Not revealing pregnancy and registering in first trimester due to fear of evil eye.

Dietary History: 

Take dietary assessment using a 24-hour recall method on a typical day. Analyse her diet to check caloric, protein, iron and calcium intake and summarise as follows.

1. Patient consumes _______________(vegetarian /non-vegetarian food) food and eats ____ meals per day (no. of meals). 

2. Her total caloric intake is _____ kcals and _____ grams of protein.

3. Her diet is deficit / excess by ____ kcals and _____ grams of proteins.

4. Her diet also lacks / has limited / adequate intake of proteins, iron and calcium-rich food. 

General examination:

• Built_____________________  

• Weight in  ___________kg 

• Height of ____________ cms

• Pulse rate is  ____________ per min

• BP is ______ mm of Hg in supine position measured in the left arm

• Respiratory Rate is __________ per min

• Pallor / No signs  of pallor

• Icterus  / No icterus

• Cyanosis / No cyanosis

• Clubbing / No  clubbing

• Lymphadenopathy / No lymphadenopathy

• Pedal oedema is present / absent

• Breast examination is normal / revealed inverted nipple

Obstetric Examination:

• Inspection: 

• Palpation: 

• Fundal height ___________weeks 

• Symphysio-fundal height ____________cms

• Abdominal girth ___________cms 

• Fundal grip

• Lateral grip

• First pelvic grip

• Second pelvic group

• Auscultation: Foetal Heart Sounds

Systemic Examination:

• Cardiovascular system:

• Respiratory system:

• Central Nervous system:

Case Summary: 

Provisional Diagnosis:

Investigations:

Pharmacological Management:

Non-Pharmacological Management: