Initials:_________ Case ID :_________ Date:_________

Maternal obstetric factors associated with low birth weight and neonatal outcome

Socio-demography 18 Previous pregnancy history:

1. Age : ___________Years Abortion
IUGR
2. Education,(completed school years): ___________
Preterm birth
LBW
3. Marital status:
Pregnancy interval (in months) :
4. Occupation: 19. Co-existing conditions
Total working hours per day:________ Anemia ! (Hb:_______)

Sickle cell disease !

5. Annual Income: Fever !

6. Total family members: Jaundice !

Personal Habits Heart disease !

7 Smoking: Active: Passive: Renal disease !

Respiratory disease !
!
8 Tobacco chewing : Malarial fever
!
HIV
!
9. Alcohol consumption during pregnancy:
UTI !

20. Pregnancy complications

10 Nutritional count:
Gestational Diabetes !

Chr. Hypertension !
11 Weight gain during pregnancy:
Renal disease !

Pre-eclampsia !
12 Height (cms):________ Weight (Kg)_______
BMI: Eclampsia !

13 Antenatal care: Bleeding P/V !

st nd
# of visits: 1 trimester 2 trimester
rd
3 trimester
Obstetric profile
21. Oligohydramnious:
14 Years since marriage
22. Labor onset:
15 Parity
Spontaneous
Induced:
16 Gestational age: Method:
By LMP :______________
By early trimester USG:___________ 23. Labor duration:
17 Previous pregnancy outcome: 24. Intrapartum: FHR abnormalities
i.
25. Meconium staining of liquor
26. Date of delivery:
ii.

27 Mode of delivery:
iii.

iv. 28. Indication for CS:

Initials:_________ Case ID :_________ Date:_________

Maternal obstetric factors associated with low birth weight and neonatal outcome

29. Birth weight : _______________gms

30. APGAR: 1min____________

5 min:
10 min:
31. Congenital anomaly

32. Neonatal morbidity:

Meconium aspiration

Septicemia

Jaundice

Respiratory distress

Intracerebral Hemorrhage

33. NICU admission

34 Intervention in NICU
Oxygen supplementation

IV fluids

Antibiotics

Phototherapy

Ventilation

35 Number of days in NICU

36. Condition at discharge:

Alive

Weight

Dead:

Cause of death:

Additional comments: