Socio-demographic History:

1. Name:

2. Age:

3. Religion:

4. Marital status:

5. Education:

6. Occupation:

7. Address:

8. Native / Migrant:

9. Informant:

10. Obstetrical Score: G ___ P____ A____L_____ Still births____

11. Number of living children:

12. Date of Admission:

13. Date and Time of Delivery:

14. Sex of child:

Chief  Complaints: 

Details of chief complaints - origin, duration, progress (ODP) and associated events

1)

2)

3)

Birth History (Current):

1. Date of Delivery:

2. Sex of the baby:

3. Birth weight of baby:

4. Term of delivery:

5. Nature (Type) of delivery:

6. Place of delivery:

7. Delivery conducted by: 

8. Any complications during delivery?:

9. Did the baby cry immediately after birth?:

10. When was breastfeeding started?:

11. History of any pre-lacteal feeds:

12. Any difficulties in breastfeeding:

13. Immunization status of Neonate:

Present History: 

Ask for the history of

1. Excessive bleeding (how many pads or pieces of cloth are getting soaked with blood - should be less than 5 per day)

2. Convulsions or loss of consciousness

3. Pain in the legs

4. Abdominal pain

5. Fever

6. Burning micturition, dribbling or retention of urine 

7. Breast engorgement or tenderness

8. Is there foul-smelling vaginal discharge

Assess if  she feels unhappy or cries easily (post-partum depression, usually occurs 4-7 days after delivery)

Mothers' care during the antenatal period

1. History of immunization(Td)

2. Details of ANC registration

3. Any complication

4. Total no. of ANC visits

5. Intake of Iron Folic acid tablets

6. Intake of Calcium tablets

7. Significant events during pregnancy

8. No. of Home visits done by health worker (if any)

Past History:

Ask for any major previous illness like TB, chronic illnesses or surgery.

Personal History:

1. History of addictions

2. History of allergies

3. History of adverse drug reactions

4. Bladder/ bowel complaints

5. Sleep

6. Appetite

7. Physical exercise

Family History:

1. Communicable Disease - TB

2. Chronic Disease - HT / DM / Asthma

3. Mental Illness

4. Genetic Disorder

5. History of thalassaemia or if anybody in the family has a disease that requires repeated blood transfusions. 

Menstrual History:

LMP ________ EDD: ______ ( to know if the delivery was at term or not)

Marital History:

1. Age at Marriage: ________ years

2. Consanguineous Marriage: Yes / No

Family Planning:

Ask if any family planning method has been adopted or intends to be adopted.

Past Obstetric History:

Ask for each past pregnancy - the details of the previous pregnancy outcome:

1. Date of Delivery:

2. Sex of the baby:

3. Birth weight of baby:

4. Term of delivery:

5. Nature (Type) of delivery:

6. Place of delivery:

7. Delivery conducted by: 

8. Any complications during delivery? (e.g. excessive bleeding after delivery, puerperal sepsis, blood transfusions) :

9. Did the baby cry immediately after birth?:

10. When was breastfeeding started?:

11. History of any pre-lacteal feeds:

12. Any difficulties in breastfeeding:

13. Duration of breastfeeding:

14. Immunization status:

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.

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. Calculate per capita income per month.

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

Environmental history:

1. Locality: Urban slum / Urban Non slum/ Rural

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

3. No. of rooms:               Overcrowding: Yes / No

4. Lighting & Ventilation: Adequate / Inadequate

5. Water supply:

   • Continuous/ Intermittent

   • Water purification method followed

   • Storage of water for drinking purposes or other household purpose

6. Waste disposal:

   • Garbage stacked before disposal (Bin/Plastic bag)

   • Disposal of garbage

7. Latrine:

   • Common/ separate

   • Indian/ western

   • Bathroom separate/Common

   • Open air defaecation

8. Sullage:

   • Drainage (piped/ unpiped)

9. Pets

   • If pets kept, type and vaccination status of pets

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

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

12. Screening of house for mosquitoes

13. Sanitation

12. • 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.

Socio-cultural Practices:

Elicit the socio-cultural practices prevailing in the family. Examples

1. Giving pre-lacteal feeds.

2. Giving Massage to the baby.

3. Putting oil in the nose, ears and eyes.

4. Putting kajal in the eyes.

5. Special diet for the mother.

6. Massage post-delivery to the mother.

Dietary History: 

Take dietary assessment using a 24-hour recall method. 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.

3. Her diet is deficit /excess by ____ kcals.

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

General examination:

1. Consciousness / Orientation:

2. Built / Nutrition:

3. Weight :

4. Height:

5. Temperature:

6. Pulse:

7. BP:

8. Respiratory Rate:

9. Pallor/icterus/ cyanosis/clubbing/oedema/lymphadenopathy/

10. Breast Examination:

Normal /inverted nipples

Any lumps or tenderness

Observe breastfeeding.

11. Examination of Vulva and Perineum:

Check Episiotomy wound.

Look for any swelling, tear, pus discharge.

12. Examine the pad for bleeding to assess if the bleeding is heavy and see if the lochia is healthy and does not smell foul (for puerperal sepsis).

Systemic Examination: 

Alimentary system (Per Abdomen)

1. Inspection - In caesarean section check scar.

2. Palpation - Check if the uterus is involuted or not. (Normally the uterus will be well contracted i.e. hard and round)

Cardiovascular system:

Respiratory system:

Central Nervous system

Case Summary: 

Pharmacological Management:

1. Treatment:

2. Supplementation:

IFA tablets containing 60 mg elemental iron and 500 mcg of Folic acid - one tablet daily for 180 days.

Calcium Tablets containing 500 mg of Calcium and 250 IU of Vitamin D - two tablets daily for 180 days.

Non-Pharmacological Management:

1. Post-partum Care and Hygiene.

   1. • Wash the perineum daily and after passing stools.

      • Change pads every 4-6 hours or more.

      • Bathe daily.

      • Wash hands before and after handling the baby, especially after cleaning the baby and before breastfeeding.

2. Take adequate rest and sleep.

3. Advice on Breastfeeding the baby.

4. Teach the mother how to bathe the baby, and maintain warmth.

5. Dietary advice.

   1. • Eat more than the pre-pregnancy state. An additional 600kcals are required in the first six months following delivery.

      • Eat protein-rich, iron-rich, and calcium-rich foods.

      • E.g. milk and milk products, such as curd and cottage cheese; green leafy vegetables and other seasonal vegetables; pulses; eggs; meat, including fish and poultry; groundnuts; ragi; jaggery; fruits, such as mango, guava, orange, sweet lime and watermelon).

6. Seek immediate medical advice if any of the danger signs appear.

7. Avoid sexual intercourse till 6 weeks after delivery.

8. Use family planning - Birth spacing / permanent methods.

9. Bring the child for immunisation at the scheduled date. 

10. Follow-up.

11. Register the birth at the ward office(urban) or gram panchayat(rural).