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Newborn Care Screening Template -Form Fill
Facility Identification
Q01
Name of the facility
Q02
Type of facility
DH
CHC – FRU
CHC Non-FRU
Q03
Name of the district
Q04
Name of the block
Q05
Name of the investigator
Arrival Details and Risk Assessment
A01
OPD Registration Number
A02
Does the woman have MCP Card
Yes
No
A03
Date of Arrival
A04
Time of Arrival
A05
Reason for arrival
Routine check-up of pregnancy
Delivery Normal Arrived in Labor
Delivery (Planned C section)
Treatment of newborn
A06
If the woman is in labor, which stage of labor is she in?
Arrived in Labour- No complication.
Arrived in labour with complication.
Not arrived in labour but with complication
A07
Delivery Stage
Stage I
Stage II
Stage III
Stage IV
A08
Name of the Woman
A09
Phone number of the Woman
A10
Religion of the Woman
Hindu
Muslim
Others
A11
Caste of the Woman
Scheduled Caste
Scheduled Tribe
Other Backward Class
General
Don’t know
A12
Did the woman attend school?
Yes
No
A13
What is the highest standard the woman has completed?
Class 1- 5
Class 6- Class 10
Class 11- Class 12
Graduate
Postgraduate
A14
Do you belong to urban or rural area?
Urban
Rural
A15
What is the primary source of income for your household?
Farmer
Agricultural Day Labor
Non – Agricultural Day Labor
Service/ Salaried worker
Small/Cottage Industry
Business/ Traders
Rickshaw/ Van Pulling
Servant
Cook
Other self – employment
Petty Business/ Shop
Jobs
Skilled worker
Too old to work
Pension
Other (Specify)
Do not know
Maternal Complications Screening – Basic Details
B01
Items to be Observed.
Yes
No
B02
Mode of transportation to the facility?
108
102
AMBULANCE PRIVATE
SELF-ARRANGED VEHICLE
BY WALK
OTHERS
B03
Distance of your home from this facility (in kms)
B04
How long did it take you to reach this hospital? (in hours or minutes)
B05
Did the woman arrive at the facility directly or did she visit elsewhere?
Directly
Visited Elsewhere
B06
How many facilities in total had you visited for your delivery?
B07
What are the facilities you visited?
Sub-Centre
PHC/APHC
BPHC
CHC
CHC-FRU
UHC/UFW
District Hospital
Other public hospital
Private hospital/clinic
Medical college
Others (Specify)
B08
Where was the last facility you visited located?
B09
What was the reason you arrived at this facility from the last facility you visited?
Referred
Facility staff told to go to other facility.
Not admitted
Self decided
Doctor not available
Poor behaviour of staff
Poor quality of services
Medicine not available
Cost too much/services charged
Others
B10
What all documents were sent along with woman?
Referral-slip
BHT (Bed Head Tickets)
OPD slip
Lab test report 88=Others
None
Not applicable
B11
In the last facility, was any test performed?
Yes
No
B12
If yes, what was the test performed?
Height
Weight
Abdominal test
BP
Hb
Urine
Ultrasound
X-ray
PV Examination
RR
FHR
OTHER
B13
Condition of woman on arrival
Conscious
Semi-Conscious
Unconscious
B14
Did the women suffer from any injury before reaching the facility?
Yes
No
B15
Describe the injury
B16
Is the mother carrying more than one fetus?
Yes
No
B17
How many fetuses is the mother carrying?
2
3
More than 3
B18
Checks done by the health care provider upon arrival
B18_1
Blood Pressure
Yes
No
B18_2
Pulse
Yes
No
B18_3
Temperature
Yes
No
B18_4
Blood test
Yes
No
B18_5
Respiration Rate
Yes
No
B18_6
Fetal Heart Rate
Yes
No
B19
What was the Hb level of the woman the last time she took the test?
B20
Was the woman bleeding upon arrival?
Yes
No
Physical Risk Factors
C01
Age of the Woman
C02
Gestational Age of the Woman
C03
Date of last menstrual period
C04
Height of the Woman (in Feet and inches)
C05
Weight of the woman (in kilograms)
C06
Any deformity in cervix or uterus
Yes
No
Medical High-risk factors
D01
Any existing medical condition
Obesity
Thyroid
Hypertension
Severe Anemia
Gestational Diabetes
HIV positive
Tuberculosis
Other (specify)
D02
Did the mother take iron supplements during pregnancy?
Yes
No
High risk factors related to Previous Pregnancy
E01
Gravidity (Number of gravida)
E02
Number of Parity
E03
Outcome of each Parity
Live birth
Still birth
Miscarriage
E04
Did the mother experience any complications in any of the previous deliveries?
Yes
No
Enter details of the last pregnancy involving complications.
F01
Type of delivery
Normal
C Section
F02
What complications did she experience?
APH
PPH
Severe Anemia
Asphyxia
Gestational Diabetes
Eclampsia
Pre-Eclampsia
Other (Specify)_______________
F03
Did the baby experience any complications?
Yes
No
F04
What complications did the baby experience?
Premature baby
Low birth weight
Jaundice
Birth Asphyxia
Birth Injury
Other (Specify)______________
F05
Rh factor of the (previous) baby?
Rh +VE
Rh -VE
Don’t know
F06
Rh factor of the mother?
Rh +VE
Rh -VE
Don’t know
High risk factors related to Present Pregnancy (Answer by Observation/Doctor or Staff nurse diagnosis)
G01
Has this woman chosen for delivery observation?
Yes
No
G02
Unusual position of the fetus?
Yes
No
G03
Abruption of placenta or unusual position of placenta?
Yes
No
G04
History of oligohydramnios/ low level of amniotic fluid?
Yes
No
G05
Is it an Ectopic pregnancy?
Yes
No
G06
Vaginal Hemorrhage?
Yes
No
G07
Did the woman come alone or was accompanied by someone (birth companion)
Alone
A birth companion was present
G08
Who was the Birth Companion
Mother
Mother-In-Law
Sister
Sister in law
ASHA
ANM
Relative/Neighbor
Others (Specify)
Neonatal Complication Screening – Basic Details
H01
Name of the newborn
H02
Age of the newborn (in days)
H03
Sex of the newborn
Male
Female
H04
Condition of newborn on arrival (conscious/semi-conscious/ unconscious)
Conscious
Semi-Conscious
Unconscious
H05
Was the newborn a preterm baby?
Normal Baby
Preterm Baby
H06
Did the newborn suffer from any injury before reaching the facility?
Yes
No
H07
Describe the injury?
H08
Checks done by the health care provider upon arrival
H08_1
Respiratory Rate
Yes
No
H08_2
Pulse Rate
Yes
No
H08_3
Temperature
Yes
No
H08_4
Any physical deformity
Yes
No
H09
Does the newborn have any physical deformity?
Yes
No
H09A
What physical deformity does the newborn have?
H10
At birth was the newborn given BCG vaccine
Yes
No
H10A
At birth was the newborn given OPV vaccine
H10B
At birth was the newborn given Hep B (0) vaccine
Diagnosis and Referral
I01
What was the diagnosis of the complication?
Yes
No
I02
Who diagnosed the complication?
Specialist Doctor
MO
Staff Nurse
GNM
I03
Was the mother admitted to the facility
Yes
No
I04
Was the newborn admitted to the facility?
Yes
No
I05
Was the mother referred to higher facility?
Yes
No
I06
Was the newborn referred to higher facility?
Yes
No
I07
Which facility were they referred to?
Medical college
District hospital
CHC-FRU
Did not specify
I08
Was the mother/newborn given transportation service to the referred facility?
Yes
No
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