Name - Contact No -

Part I: Sociodemographic Information

S. No Questions Responses and coding

101 Age
102 Marital status
103 Place of Residence
104 Religion
105 Education
106 Occupation

107 Family Income

108 Height

109 Weight (in KG)

110 BMI
111 Blood Pressure
112 Blood sugar
113 Thyroid profile
114 Haemoglobin
115 Family History
116 Alcohol/Tobacco consumption

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Part II: Obstetric History

S. No Questions Responses and coding

201 Total No of pregnancies Gravida(total pregnancies)
Parity(Deliveries after 28 weeks)
Live –
Stillbirth –
Abortions -
202 Previous Deliveries Vaginal –
LSCS – Emergency-
Elective -
203 Any maternal complication
204 Any fetal complication

205
206

Part III: Current preganancy

S. No Questions Responses and coding

301 NCD 1. Hypertension
2. Diabetes Mellitus
3. Thyroid Disorder
4. Anaemia
5. Obesity
6. Asthma
7. Heart Disease

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 8. Cancer
9. Dyslipidemia
10. Mental Health issues
11. Any other
302 Onset of NCD
1. Before Pregnancy
2. First Trimester
3. Second Trimester
4. Third Trimester
303 Treatment

304 Duration of Delivery 1. Term

2. Pre term
3. Post Term
305 Mode of delivery and Reason 1. Spontaneous vaginal
2. Vacuum
3. Forceps
4. Cesarean section
5. Induced
306 Obstetric complications 1. Yes
2. No
307 Maternal Outcomes
1. APH (Previa, Abruption)
2. PPH
3. PROM
4. Post-term pregnancy
5. Oligohydramnios
6. Polyhydramnios
7. Retained placenta
8. Induction/ Augmentation
9. CPD/obstructed labor

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 10. Cord prolapse
11. Uterine rupture
12. Sepsis
13. Maternal death
1. Others_____________
107 Duration of stay at Hospital
108 USG

Part IV: Fetal outcomes

S. No Questions Responses and coding

401 Fetal/neonatal complications 1. Yes
2. No
402 The outcome of the newborn 1. Birth weight
2. APGAR Score
3. Alive
4. Stillbirth/IUFD
5. Malpresentation
6. Prematurity
7. Breech
8. Twin
9. Congenital anomaly
10. Fetal distress
11. Neonatal death
403 If neonatal death, what was the
cause?

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