Integrated Antenatal, Labor, Delivery, Newborn and Postnatal Care Card”

Name of Facility: ___________________________________ Date: ____________________

ANC Reg.No: _____________ Medical Record Number (MRN):_____________

Name of Client: ______________________ Age (Years):____ Phone No: _________ Woreda: ________ Kebele: ______

LNMP:___/___/____ EDD:____/___/___ Gravida:____ Para: ____ Number of children alive: ______ Marital Status:___

INSTRUCTIONS to Fill Classifying form: Answer all of the following questions by placing a cross mark in the corresponding box.

OBSTETRIC HISTORY Yes NO

1. Previous stillbirth or neonatal death?

2. History of 3 or more consecutive spontaneous abortions?

3. Birth weight of last baby < 2500gm

4. Birth weight of last baby > 4000gm

5. Last pregnancy: hospital admission for hypertension or pre-eclampsia /eclampsia?

6. Previous surgery on reproductive tract? (CS, Myomectomy, fistula repair, repaired uterine
rupture, cervical cerclage)
7. Previous stillbirth or neonatal death?

CURRENT PREGNANCY

8. Diagnosed or suspected multiple pregnancy?

9. Age less than 18 years?

10. Age more than 35 years?

11. Isoimmunization (Rh -ve) in current or in previous pregnancy?

12. Vaginal bleeding?

13. Pelvic mass?

14. Systolic >140mm Hg and/or Diastolic Blood pressure >90 mm Hg

GENERAL MEDICAL

15. Diabetes mellitus?

16. Renal disease?

17. Cardiac disease?

18. Chronic Hypertension

19. Known ‘substance’ abuse (including heavy alcohol drinking, Smoking)?

20. Any other severe medical disease or condition TB, HIV, Ca, DVT...?

A “Yes” to any ONE of the above questions (i.e. ONE shaded box marked with a cross) means that the woman is not eligible
for the basic component of the new antenatal care model and require more close follow up or referral to specialized care. If she
needs more frequent ANC contact use and attach additional recording sheets
 II. Present pregnancy follow up schedule of ANC contacts
(weeks of gestation)
Contents of Care 1st Contact 2nd 3rd 4th 5th 6th 7th 8th
(better Contact at Contact at Contact at Contact at Contact at Contact at Contact at
before 20 WKs 26WKs 30Wks 34Wks 36Wks 38Wks 40Wks
12Wks)
Date of contact
Gestational age
History

Present Pregnancy History (complaint)

Family/Social History

General Appearance
Blood pressure
Physical Examination

Weight
Pallor
Breast
Chest
Abdominal examination Fundal height (wks)
FHB
Presentation
Pelvic assessment (as required/indicated)

Ultrasound (up to 24 weeks of gestation)

Haemoglobin
Blood group, RH
RPR/VDRL
Investigations

HIV (PITC) for pregnant

HIV (PITC) for partner
HBsAg
Urine test
Screening for active TB
Indirect coomb’s test for RH negatives
75 gm oral glucose test (for those at risk)

  Preventive anti-helminthic treatment                

Malaria prevention with ITN, and early diagnosis
               
and treatment
Medications & vaccines

Td vaccination                
Anti-D immunoglobulin at 28 weeks (for those
               
unsensitised RH negatives)
Iron and folic acid (supplement dose)                
ARV Rx (type)                
Syphilis Treatment                
HBV prophylaxis                

  Daily calcium supplementation                

  Nutrition/healthy eating                
PMTCT and testing                
Advice and counselling on

Family planning                
Breast feeding                
Hygiene                
Avoidance of harmful traditional practices                
Reduce caffeine intake                
Gender based violence specially IPV                
Birth Preparedness and Complication Readiness
               
  plan

Assessment (diagnosis, danger sign/symptom identified)        

Action taken        

Next Appointment        

Name and Signature        

III. Intrapartum Care and Follow up: Monitoring Progress of Labor using Parthagraph
III. Intrapartum Care and Follow up: Monitoring Progress of Labor using Parthagraph Federal Ministry o
Federal Ministry of Health
Name_______________________ Gravida____________ Para_________ MRN_________
Name_______________________ Gravida____________ Para_________ MRN_________
Date of Admission__________Time
Date of Admission__________
Time of admission_________ Ruptured Membranes_______
of admission_________ Ruptured Membranes_______
Hours_________
Hours_________

200200
190190
180180
170170
160160
Fetal
Fetal
150150
Heart
Heart
140140
rate
rate130130
120120
110
110
100
90100
80 90
Amniotic fluid 80
Amniotic
Mouldingfluid
Moulding
10
9 10
8 9 t ion
7 8 Aler Act
t ion
Cervix (cm)
(Plot x)
6 7 Aler Act
Cervix (cm) 5 6
(Plot x) 4
Decent of 5
head 3 4
(Plot O) 2
Decent of
head 1 3
(Plot O) 2
0
Hours
1 1 2 3 4 5 6 7 8 9 10 11 12

Time
0
Hours 1 2 3 4 5 6 7 8 9 10 11 12

5Time
4
Contraction
per 10mins
3 5
2 4
Contraction 1 3
per 10mins
Oxytocin U/L 2
Drops/min 1
Oxytocin U/L
Drops/min
Drugs given &
IV fluids

180
Drugs given &
170
IV fluids
160
Pulse
150180
140170
and
130160
120
Pulse
150
BP 110
100140
and
130
90
120
80
70110
BP

60100
Temp oC 90
80

{ 70
Protein

Urine Acetone 60
Volume
Temp oC

{
Protein

Urine Acetone
FMOH Ver 02/02 Volume
Delivery Summary
Date (DD/MM/YY)____________Time:________________
Mode of Delivery: SVD C/Section Vacuum/Forceps Episiotomy AMTSL: Oxytocine Ergometrine Misoprostol

Placenta: CCT Complete Incomplete MRP* Tear rep: 1st degree 2nd degree 3rd degree

NEWBORN: Single Multiple Alive Apgar score:______Still Birth: Mac Fresh

Sex: Male Female Birth wt. (gm.) ______Length (cm.) _____Term Preterm

BCG (Date):_______OPV 0(Date)_____ HBV birth dose Vit K TTC Skin to skin contact

Obstetric Cxn: Managed Referred

Eclampsia: PPH APH PROM/Sepsis Ruptured Ux Repaired Hysterectomy

Obst/prolg labor Feeding Option: EBF_____ ERF_____

HIV Testing accepted: Yes No: HIV Test result: P N

ARV Rx : for mothers (by Type) _________________ ARV Px for New Born (by type) __________

Remark: ______________________________________________________________________

Delivered by: ___________________________________ Sign: ________

*MRP=manual removal of placenta

IV. Postpartum Care

Date 24 hrs stay 25-48 Hrs 49-72 Hrs 73Hrs-7days 8-42 days Remarks
BP            

PR/RR            

Temp            

Uterus contracted/look for PPH            

Dribbling/leaking urine            

Anemia            

Vaginal discharge (after 4 Wks of delivery)            

Pelvic Exam (only if vaginal discharge)            

Breast Exam            

IFA supplementation            

Counseling danger signs/symptoms, FP, Hygiene,            

Nutrition, EPI, use of ITN, BF, etc given
Baby Breathing            

Baby Breastfeeding:            

Baby Wt (gm)            

Immunization            

HIV tested (Y/N)            

HIV test result : P/N            

ARV Rx for mother (By Type)            

ARV Px for Newborn(By Type)            

Feeding option : EBF/RF            

Newborn referred to chronic HIV infant care            

FP Counseled & provided (By Method)            

Action Taken            

Remark