POSTNATAL CASE SHEET

Ms _ _ _, a _ _ _ yr. old female, resident of _ _ _, who is a _ _ _ by occupation, educated

upto _ _ _ and is married to Mr _ _ _, a _ _ _ by occupation for the last _ _ _ yrs. Pt. is
para_ _ _ _ (PTPAL) (with previous _ _ term/preterm/abortion), was admitted on _ _ _
with _ _ _ (complaints at the time of admission) and had spontaneous/induced, full-
term/pre-term, vaginal delivery/(elective/emergency) caesarean section for _ _ _
(indication of CS) on _ _ _ at _ _ _ (time).
At present she (does not have any complaints) she has

Chief Complaint(s) of:

I) __________________________________ X ____________________
II) __________________________________ X ____________________

HOPI:

1. Elaborate the chief complaints (onset, duration, progression, severity, radiation,

aggravating and relieving factors etc.)

Present Obstetrics History:

P T_P_A_L_

ANTEPARTUM

1. Pt conceived _ _ _ yrs. after her marriage/Last Child Birth

2. Planned/unplanned conception; spontaneous/conceived after treatment of
infertility/contraception failure
3. Booking status (when), JSY benefits (±registered)
4. How was the pregnancy confirmed?
5. Was she on regular antenatal check-up? When was her first antenatal visit? Total
no. of ANC visits.
6. USG scans done (how many & when). Level II sonography (Targeted anomaly
scan)
7. Did she take Iron & Folic Acid?
8. Was she immunised with TT?
9. Any other drug intake (eltroxin/antihypertensive/antidiabetic)
 10. Fever with rash
11. Radiation exposure
12. Any h/o of any hospital admission (Why, how long, treatment received)
13. Any other complications e.g.
Bleeding/spotting, leaking PV, any other medical or surgical problems

INTRAPARTUM

1. Date, time and place of delivery

2. Duration of pregnancy (POG), EDD
3. Labour- Onset (spontaneous/induced, if induced reason of induction), Timing
(term/preterm/post-term),
Timing of rupture of membranes
Duration of labour- 1st, 2nd, 3rd stage
Any complications during labour (including 3rd stage complications)
4. Mode of delivery- vaginal/caesarean section (if vaginal, episiotomy given or not;
if CS, indication of CS)
Any instrumental Interference- Forceps/Ventouse application
5. Status of newborn (live or dead)
Did the newborn cry immediately after birth? (if not, was any resuscitation given
to the newborn?)
Sex, Birthweight
When was the newborn breastfed?

POSTPARTUM

1. Lochia- Amount, colour, odour

2. Is the mother able to breastfeed the newborn well?
3. Is the newborn immunised at birth?
4. Has the newborn passed first urine and stools?
5. Any other complaint(s) by the mother
6. Has the mother opted for contraception (PPIUCD)?

Past Obstetrics History:

In case of Multipara, previous obstetrics events are to be recorded chronologically as

follows:
S.No. Date/Year Antenatal Labour Place of Method of Baby at birth Puerperium
period events delivery delivery
Wt. & Sex
Cried at birth
APGAR score
Breast fed
Immunisation

Menstrual History:

LMP

PREVIOUS MENSTRUAL CYCLE:

Age of menarche -
Cycle length -
Duration -
Amount of flow -
Passage of clots -

Past history:

Medical: HTN, DM, TB, Asthma, Epilepsy, STD, HIV/AIDS, Heart disease, Bleeding
Problems, Drug intake, Blood transfusion, any h/o hospitalisation

Surgical:
General surgical : appendectomy, cholecystectomy, any other surgery
Gynaecological : D&C, myomectomy, fistula repair

Treatment history:

Current treatments

Personal History:

Diet (veg/non-veg), appetite, sleep, bladder, bowel, contraception opted after delivery,
smoking or alcohol habit, allergy
Dietary History:

% deficit in calories and proteins

Family History:

Type of family, No. of family members, significant events last year, social relations,
stress in family, legal issues, taboos/stigmas
Any h/o DM, HTN, TB, blood dyscrasia, known hereditary disease, h/o of twining in
family.

Socio-economic history:

Total income :
SE status :

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DIAGNOSIS:
Ms _ _ _ is a _ _ _ yr. old para_ _ _ on day_ _ _ of (normal) puerperium (with_ _ _).