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Operational Guidelines
December 2014
FOREWORD
PREFACE
The successful implementation of NRHM since its launch is 2005 is clearly evident by the
India aims to achieve the Millennium Development Goal 5 of reducing maternal mortality. During
many fold increase in OPD, IPD and other relevant services being delivered in the Public
the last two decades, India has witnessed a significant reduction in the quantum of maternal deaths.
health institutions, however, the quality of services being delivered still remains an issue.
Furthermore, to reach the goal we need to have a true representation of the causes of maternal deaths,
The offered services should not only be judged by its technical quality but also from the
so as to identify gaps and take corrective measures. Traditionally, the analysis of maternal deaths has
perspective of service seekers. An ambient and bright environment where the patients
been the criteria of choice
are for evaluating
received medical
with dignity andand systemic
respect alongcauses.
with prompt care are some of the important
factors of judging quality from the clients’ perspective.
As you are aware, Maternal Death Review system has been institutionalised in India. However, much
moreTillneeds to beof known.
now most the States’The pregnant
approach women
toward who issuffer
the quality based severe complications
on accreditation and
of Public come
Health close by
Facilities
to maternal death but do
external organizations notatdie
which areisthe
times hard“near-misses”
to sustain overwhich need
a period to be
of time investigated
after that supportfor finding
is withdrawn.
programme gaps.
Quality can onlyDue to the success
be sustained, of ismodern
if there medicine,
an inbuilt maternal
system within deaths are
the institution fewer
along withinownership
number but by the
thereproviders
are innumerable
working in“near miss”As
the facility events which
Aristotle saidhave the is
“Quality potential tobut
not as act teach us lessons.
a habit”
NearQuality Assurance
miss cases often(QA) is cyclical
precede process
the loss which
but are needsignored
largely to be continuously monitored
because nothing against
(death) defined standards
happened. Once
and measurable elements. Regular assessment of health facilities by their own staff and state
we unfold the reasons for the near miss cases, we can take effective measures to avoid these eventualities. and ‘action-
planning’
I hope for traversing
that these guidelinesthewill
observed
be an gaps is the onlytool
empowering wayfor
in having a viablecolleges,
the medical quality assurance prgramme
where majority of in
nearPublic Health.
miss cases areTherefore, the Ministry
likely to happen. of Health
Knowing theand Family
cause welfare
of near (MOHFW)
misses hasto
can lead prepared a comprehensive
taking measures for
system of the quality assurance which can be operationalzed through the institutional mechanism and platforms
further improvement of health outcomes.
of NRHM.
I believe that the MNM Guideline will be useful to the States in identifying the required action
I deeply appreciate the initiative taken by Maternal Health division and NHSRC of this Ministry in preparing
needed for improving both maternal and neonatal health.
these guidelines after a wide range of consultations. It is hoped that States’ Mission Directors and Programme
Officers will take advantage of these guidelines and initiate quick and time bound actions as per the road map
placed in the guidelines.
Lov Verma
Secretary (HFW)
(Anuradha Gupta)
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Government of India
Department of Health and Family Welfare
Anuradha Gupta, IAS Ministry of Health and Family Welfare
C. K. Additional
Mishra, IASSecretary & Nirman Bhawan, New Delhi - 110011
Mission Director, NRHM
Additional Secretary &
Telefax : 23062157
Mission Director,
E-mail NHM
: anuradha–gupta@outlook.com
Telefax : 23061066, 23063809
E-mail : asmd-mohfw@nic.in
FOREWORD
(Anuradha Gupta)
(C. K. Mishra)
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LokLF; ,oa ifjokj dY;k.k ea=kky;
fuekZ.k Hkou] ubZ fnYyh & 110011
Government of India
Department of Health and Family Welfare
Anuradha Gupta, IAS Ministry of Health and Family Welfare
Dr. Rakesh Kumar,
Additional Secretary &
IAS Nirman Bhawan, New Delhi - 110011
Mission Director, NRHM
JOINT SECRETARY
Telefax : 23062157
Telefax : 23061723
E-mail : anuradha–gupta@outlook.com
E-mail : rk1992uk@gmail.com
E-mail : rkumar92@hotmail.com
FOREWORD
The successful implementation of NRHM since its launch is 2005 is clearly evident by the
many fold increase in OPD, IPD and other relevant services being delivered in the Public
FOREWORD
health institutions, however, the quality of services being delivered still remains an issue.
The offered services should not only be judged by its technical quality but also from the
Maternal mortality is a perspective
critical event
of to assessseekers.
service the quality of a health
An ambient andcare system.
bright The standard
environment where indicator
the patients
for measuring this is the Maternalwith
are received Mortality Ratio
dignity and (MMR),
respect alongdefined as the
with prompt ratio
care of theofnumber
are some of
the important
maternal deaths per 100,000
factors live births.quality
of judging Due to improved
from health
the clients’ care, there has been decline in MMR
perspective.
globally and in India as well MMR has declined steadily. There is a need to further accelerate this
Till for
decline nowachieving
most of the States’
our approach
national toward the quality
and international is based
targets on accreditation of Public Health Facilities by
and goals.
external organizations which at times is hard to sustain over a period of time after that support is withdrawn.
WomenQuality
whocanhave
only be sustained,
survived if there is an inbuilt
complications duringsystem within the
pregnancy andinstitution alonghave
childbirth with been
ownership by the
studied
providers working
as surrogates in thedeaths
of maternal facility As
andAristotle said “Quality
been termed is not Near
Maternal as act Miss.
but a habit”
Reviews of such cases are
considered a less threatening approach to improve maternal health care by the service providers.
Quality Assurance (QA) is cyclical process which needs to be continuously monitored against defined standards
and measurable elements. Regular assessment of health facilities by their own staff and state and ‘action-
With this tool, we will be able to identify the delays during the near miss and thereafter and take
planning’ for traversing the observed gaps is the only way in having a viable quality assurance prgramme in
corrective action. Moreover, service providers are happy to report MNM since ultimately the life of the
Public Health. Therefore, the Ministry of Health and Family welfare (MOHFW) has prepared a comprehensive
mother is saved; this has been proved during the pilot conducted on MNM.
system of the quality assurance which can be operationalzed through the institutional mechanism and platforms
of NRHM.
This will enable us to utilise the opportunities to prevent the deaths of mother who might face a similar
fate. I As Near
deeply Miss occurs
appreciate much more
the initiative takenfrequently
by Maternalthan maternal
Health divisiondeaths, a more
and NHSRC reliable
of this quantitative
Ministry in preparing
analysis can provide a comprehensive profile of the health system functioning.
these guidelines after a wide range of consultations. It is hoped that States’ Mission Directors and Programme
Officers will take advantage of these guidelines and initiate quick and time bound actions as per the road map
Nearplaced
misses are guidelines.
in the relatively simpler to analyse and easier to resolve. This knowledge will help in
identifying the contributory factors of maternal deaths so that actions can be taken at community and
health systems level. I am sure that these guidelines will definitely bring a sharper focus on decreasing
number of maternal deaths and morbidities in India.
(Anuradha Gupta)
FOREWORD
The successful implementation of NRHM since its launch is 2005 is clearly evident by the
PROGRAM OFFICER’S MESSAGE
many fold increase in OPD, IPD and other relevant services being delivered in the Public
This is well known thathealth
complications during
institutions, pregnancy
however, andofchild
the quality birth
services candelivered
being take place
stillatremains
any point of
an issue.
time, so it is important The
thatoffered
the basic and emergency
services obstetric
should not only care health
be judged facilitiesquality
by its technical remainbut in also
readiness
from the
in terms of infrastructure,
perspective of service seekers. An ambient and bright environment where the such
HR, equipments etc. for timely management of complications. If patients
complications are not managed on time sometimes they become fatal. Government of India
are received with dignity and respect along with prompt care are some of the importantinitiated
Maternal Death Review to know
factors the gap
of judging in thefrom
quality implementation of the programme and take corrective
the clients’ perspective.
action.
Till now most of the States’ approach toward the quality is based on accreditation of Public Health Facilities by
The review however is not able to capture those pregnant women who suffered complications and
external organizations which at times is hard to sustain over a period of time after that support is withdrawn.
delivered but
Quality canjust
only missed the fatality.
be sustained, Asisyou
if there know,system
an inbuilt there within
are several advantages
the institution of with
along investigating
ownershipnear
by the
missproviders
cases e.g.working
they are more common than maternal deaths, provide useful
in the facility As Aristotle said “Quality is not as act but a habit” information on the same
pathways that leads to morbidity and death, less threatening for service providers as women has
survived, women
Quality Assurancecan(QA)
be interviewed and as
is cyclical process a result
which needsmore
to berealistic
continuouslyanalysis of gaps
monitored can be
against done.standards
defined Thus
investigating severe maternal
and measurable elements. morbidity (near-miss)
Regular assessment helps to
of health identify
facilities bywomen at highest
their own staff andrisk of maternal
state and ‘action-
deathplanning’
and helpsfor allocate
traversingresources especially
the observed inthe
gaps is theonly
areaway
where it is needed
in having most.
a viable quality assurance prgramme in
Public Health. Therefore, the Ministry of Health and Family welfare (MOHFW) has prepared a comprehensive
I would like to express that these guidelines would not have been possible without the constant
system of the quality assurance which can be operationalzed through the institutional mechanism and platforms
encouragement
of NRHM. from Mr. C.K Mishra, AS&MD & Ms Anuradha Gupta, Ex AS& MD. Dr. Rakesh
Kumar, Joint Secretary (RMNCH+A) headed the expert group meeting and gave valuable inputs in
framing this appreciate
I deeply guideline. the initiative taken by Maternal Health division and NHSRC of this Ministry in preparing
these guidelines after a wide range of consultations. It is hoped that States’ Mission Directors and Programme
I would like to acknowledge the contribution of all members of the Expert Group in developing the
Officers will take advantage of these guidelines and initiate quick and time bound actions as per the road map
content of these technical and operational guidelines. I would also like to acknowledge my colleagues
placed in the guidelines.
in MH Division especially Dr. Dinesh Baswal, DC(MH) and development partner’s for their valuable
efforts and inputs in developing this document.
The present guidelines are an empowering tool for the OBGYN Department of Medical Colleges where
majority of near miss are likely to happen. Systematic review of such cases can help to bring forth
various contributory factors whether it is medical, social, economical and other factors for necessary
corrective actions which could be taken at State, District or at Community level for reduction in
maternal mortality and morbidity. (Anuradha Gupta)
I. Introduction 15
VIII. Budget 24
IX. Annexures
3. MNM-R register 43
Once the MNM is confirmed using the tool given in the guideline for diagnosing MNM, the MO/HOD of OBG-
GYN notifies it to the FNO within 24 hours. There upon FBMNM-R form is filled by MO/HOD with support
from FNO and submitted to district within a week. A copy of the same is kept with the institution for records,
The Medical Superintendent with support from FNO and taking inputs from HOD/MO of the department
will review the case. In the monthly review meeting the MNM-R committee members will be invited. The
review reports will be sent to the district for further action. A snap shot of the process is given in the flow
chart below;
{
Facility based review of cases & undertaking local corrective action
Analysis & Feedback
Data feeding
The clinical findings, investigations and interventions have been put under three broad categories
(Annexure 2)
These broader categories have further been segregated under different clinical situations like haemorrhage,
sepsis, hypertension etc. So it is important for the MO in-charge of the case to carefully see criteria for
identification of MNM Case (Annexure-2) and scrutinise the suspected MNM case. A snap shot of the
process involved in diagnosing and notifying MNM - R is given in the flow chart below;
The results of investigations which make women fall under MNM category are identified
MNM-R TOOLS
MNM-R is complementary to MDR and purpose of MNM-R is to identify the gaps in service delivery at the
earliest which will ultimately help in preventing maternal morbidity and mortality.
The committees;
●● Review MNM cases and share the findings for corrective action with all the concerned departments
●● Analysis & Feedback - A statement of detected gaps, identified best practices, corrective measures to
be taken should be sent to state nodal officer for state review meeting
1. Facility Based Maternal Death/ Near Miss Review Committee (FBMNM-R Committee)
2. District level CS/CMO Maternal death/ Near Miss Review Committee (DBMNM-R Committee)
The State Task Force for MDR committee will also support implementation of MNM-R at the state level.
Maternal Health division of MoHFW with support from NHSRC will provide monitoring support to all the
states.
●● Identifying the level and names of the health facility (Initially Medical Colleges) where program will
be implemented
●● Collect relevant data on MNM cases district-wise/institution-wise and carry out detailed analysis
●● Ensuring availability of different formats and other requisite tools before initiation of program
●● Priority action and timeline for the gaps identified under MNM and periodic review of progress
●● Facilitate the preparation of an annual MNM-R report for the state and organize a dissemination
meeting to sensitize the various service providers and managers. The annual report may contain
typical maternal death case studies which may be used during the training of medical and paramedical
functionaries.
●● To make sure that the budgetary requirement of MNM-R reflects either in the state/ NHM PIP
1. Maintain the line list of facility based MNM cases in the district; facilitate the data entry and ensure
FBMNM-R at the district level
2. Organize monthly District level MNM-R meetings under the directions of the CMO; maintain the
minutes of meetings; follow up on actions to be taken and prepare the Action Taken Report
3. Participate in meetings of the State Level Task-force and follow up on specific recommendations
pertaining to the district
4. Undertake planning and budget estimates for MNM-R in the district where the programme is
implemented
5. To make available the necessary equipment/ supplies (especially laboratory diagnostic facilities) in
advance to all such health facilities conducting MNM-R in the district
●● Form MNM-R Committee(may include Staff of OBGYN, Anaesthesia, Nursing, Blood Bank, Other
relevant individuals)
●● Forwarding the MNM-R tool with case sheet to district CMO/CIVIL SURGEON within a week
●● Preparing meeting calendar and calling the committee on a designated day and date
●● Send the report and its findings to district CMHO/ Civil Surgeon
●● Identify MNM as per the indicated criteria and record in the relevant register
●● Complete FBMNM-R form and send to the MNM-R Nodal officer of the facility within 48 hours of
patients discharge
Training Plan
The basic premise of the training plan is that all personnel directly involved with the MNM-R process get
trained and all other officers whose cooperation is required in the smooth conduct of review (as well as
follow up actions based on recommendations of the MNM-R Committees) get oriented in the concept and
process of MNM-R.
A one day sensitization cum training of trainers for the states will be conducted at the national level by the
National Health System Resource Centre (NHSRC) under the guidance of MH division of Ministry of Health
and Family Welfare.
At the state level a half day sensitization meeting involving all convergent departments and state nodal
officers from the directorate, SIHFW, SHS will be held. A one day training at the state level will invite the
faculty (FNO, HOD, MS etc.) of the notified institutions along with District officers.
At the institution level MOs of all departments in the facility will sensitized in a half-day session, followed by
one day training of the faculty directly involved in the MNM-R.
The training schedule depicting the cascade of trainings undertaken at State, District and Institutional level
is given below;
Individual facilities should ensure availability of all the relevant data both in hard and softcopy. Since a large
set of data is captured, analysis of data for surveillance, interventions, corrective actions etc. will be a challenge.
Centralised online software to feed the data, carry out analysis and generate reports for action will be developed
in due course by GOI. The data of individual facilities can be transferred to this portal once this portal is developed.
The Nodal officers will evaluate the important variables and identify the gaps for initiating corrective measure
so as to prevent such morbidities in future. The major outcomes which need to be focussed in are number of
women in a centre reporting with MNM or become MNM, the causes of MNM, referral places and the quality of
care given, antenatal care and its quality, identified complications in pregnancy, labour care and complications in
delivery, iatrogenic injuries, requirement of blood & its availability, interventions needed to save the women, good
practices & reasons in terms of delay 1, 2 or 3
Training cost
Note:
*** TA to be given as per state norms.
* The state need to adjust the training norms as per the training load of the district and state.
# Support is provided to conduct of CDR meetings at various levels (district committee, facility committee etc.). The same funds can
be utilized for conduct of MNM-R meetings.
## for sensitization meetings, cost of tea/snacks plus incidental expenses(photocopying, printing, telephone, Fax etc.) @3000/- may
be booked. Since only local people are involved, no TA/DA is required except cost of outstation resource persons, which needs to
be separately budgeted in PIP.
________________________________________________________________________________________
MCTS No
(mandatory)
FBMNM-R NO. (Of the facility) (with Date / Month / Year)
NOTE :
This form must be filled for all cases of Maternal Near Miss as per Definition and criteria
( as per Annexure 1)
FB MNM-R number must be put serially e.g 001-dt-mth-yr.
Mark with √ wherever applicable
For Date use Day/Month/Year format. For time use 24hours clock format.
Complete form at the time of discharge of woman with Maternal Near Miss, keep photocopy & send
original to Nodal Officer MNM - R Committee
New series starts with new year
Attach copy of discharge summary with this form
1. GENERAL INFORMATION
e. Complete address______________________________________________________________
f. Education: Illiterate literate Upto 5th class 6th to 12th class Beyond 12th class
g. Below Poverty Line status: BPL Certificate / Self certified Not BPL
j. Date and time when became near miss : Day Month Yr Hours.
Mins
3. TYPE OF ADMISSION
a. Self b. Referred
4. REFFERAL
a. If referred from outside, no. of places visited prior Specify Type, - Public, How many
c. From last visited place before referral, referral slip completed: Yes No
5. ILLNESS DURATION
6. STATUS AT ADMISSION
b. Antenatal < 22 weeks > 22 & < 34 weeks > 34 & < 37 weeks
d. Days since delivery/abortion: Within 24 hrs. >24 hrs.- 1week >1 week - 6 weeks.
Not applicable
Antepartum Bleeding
Intrapartum Bleeding
Viral such as Hepatitis/HIV AIDS/Others, Malaria, Dengue, Scrub Typhus, Other infections occurring in
Infection
Antepartum Intrapartum Post partum Post abortal
Labour related
Prolonged / Obstructed / Rupture uterus Inversion of Uterus Retained placenta Any other
Disorders
Incidental/ Accidental Disorders E.g. Surgical including Iatrogenic, Trauma, Violence, Anaesthetic complications, etc.
8. ANTENATAL PERIOD
A. If Yes,
a. Gynaecological b. Family
Details
10. COMPLAINTS WITH DURATION (Please tick all the presenting complaints)
Systems
At the time
At the time
Examination At Admission Examination At Admission of Near
of Near Miss
Miss
Abdominal Findings
Temp (oC) Scars
Pulse/min Soft / Guarding
Respiration/min Tenderness
Blood pressure Organomegaly
Pallor Lump
Icterus
Cyanosis Bowel Sounds
General
Cervix
Per Speculum
Clubbing
Vagina
Lymph Nodes Enlargement
Others
Oedema (Feet/Face)
Plantar -Extensor/Flexor
Others
Any neurodeficit
Uterus Size
Any abnormality detected
CVS
Uterus Position
Uterus Consistency
Uterine tenderness
RS
Fundal height
Uterine contraction pres- Others
Abdominal Findings
ent/absent
Presentation/Position
Estimated Baby size
Any Others
Liquor
Hb Creatinine
TLC/ DLC Urea
Platelet Na+
KFT
Peripheral Smear K+
Blood
Bleeding Time,
Clotting Time
Clot observation time HIV – I & II
Blood group, Rh type HBsAg
Alk phos
Fundus
SGPT Ophthalmoscopy
Exam.
SGOT
Bilirubin (Total)
LFT
Indication
Vaginal Caesarean Section Laparotomy
(CS/Instrumental)
Pregnancy
Multiple
gency uterus Pregnancy
Normal
Breech
Episiotomy Forceps Vacuum
* In Ectopic pregnancy woman does not deliver, but fetus may be removed during Laparotomy
Others
a. Received: Yes No
1 Whole Blood
2 Packed cells
3 FFP
4 Platelets
Outcome
Stillborn
Cardiovascular
system Respiratory System
Genital
System
Hematological System
Resuscitative Procedures/Intubation
Mechanical Ventilation
Digitalization
Evacuation
Hysterectomy
Dialysis
Management of Ketocidosis
Anticoagulant therapy
Others
Specify
System Example Y N
ANC INC PNC
Infrastructural issues
Lack of medications,
instruments, equipments or
consumables
Present Facility/facilities Non utilization of available
medications, instruments,
equipments or consumables
Designation Date:
Institution
Designation Date:
Institution
• For diagnosis of Near Miss, the patient should meet Minimum 3 criteria: one each from 1) clinical findings(either symptoms or signs), 2) investigations & 3) interventions done Or
Any single criteria which signifies cardio respiratory collapse as indicated with heart ( )symbol
1.1 PREGNANCY SPECIFIC OBSTETRIC AND MEDICAL DISORDERS
HAEMORRHAGE Spontaneous Any Bleeding from or into • Altered conscious state • Acute fall Hb < 5 gm % or 30 % fall in • ICU admission requiring
• Abortion the genital tract leading to • Tachycardia >120/min Low haematocrit (fall in hemoglobin so as resuscitative (CAB) or cardio
• Air Hunger volume pulse to affect oxygen saturation) respiratory support
Termination
• Syncopal attacks • Bradycardia <40/min • Fall in oxygen saturation below • Blood & blood products
of Pregnancy 90 % transfusion (more than 90 ml/kg
• Tachypnea >40/min body weight/ >5 units of blood)
(Safe/Unsafe) • PaO2 : FiO2<200
• Bradypnoea < 6 /min • Use of cardiotonics/
• Ectopic Pregnancy • PaCO2>50mm Hg
• Blood pressure vaso pressors
• Gestational Trophoblastic • Platelet < 20,000 (Acute Decline in
Disease - Systolic < 90 mmHg platelet count more significant) (Mephentine/Dobutamine/
• Antepartum hemorrhage - Diastolic < 60 mmHg • Clot observation time > 7 min. or Dopamine etc)
-Placenta previa any other test done which proves
• Circulatory collapse requiring
deranged coagulation profile
-Placental abruption • Absent peripheral reflexes Emergency Surgery for
• Oliguria with output < 30ml/hour • Serum creatinine >3.5mg/dL controlling blood loss such as
• Scar dehiscence urgent Evacuation, Laparotomy
• ECG – Ischemic
• Rupture uterus with or without Hysterectomy,
changes, ST inversion, Internal Iliac Ligation or
• Surgical injury during labour,
elevation any Suturing of tears with a
Caesarean Section/ Forceps or
background of hemorrhage
Vacuum delivery
• Dialysis- peritoneal/
• Third Stage complications, e.g.
hemodialysis (renal replacement
Inversion of uterus, retained
therapy)
placenta, Cervical tear, others
• Post partum haemorrhage
-Atonic
-Traumatic
• Amniotic Fluid Embolism
PaO2 : Partial pressure of oxygen in the blood, FiO2 : Fraction of inspired oxygen, PaCO2 : Partial pressure of carbon dioxide in the blood.
36
pregnancy • Abdominal pain • Persistent rise in Temp >39.2ºC, ( >15,000/cu mm) like (CAB) or cardiorespiratory support
• Septic • Distention of abdomen not responding to routine • Microbial culture positive • Shifting to intravenous fourth general
treatment for organisms Antibiotics like(Sulbactum+ Cefoperazone
Abortions Spontaneous • Vaginal foul smelling combinations, Imepenum etc)
discharge • Hypothermia temp < 37 0 C • Ultrasound
• Prelabour rupture of • Blood component transfusion ( upto 90 ml
membranes Term/Preterm • Decreased urinary • Pulse rate > 120/min shows intra uterine/ /kg body weight/ >5 units of blood)
• Puerperal sepsis output • Thready, low volume pulse pelvic/ abdominal
collection • Use of cardiotonics/
• Post surgical procedures ( E.g. • Altered consciousness • Tachypnoea> 20/min
• Imaging modality vaso pressors
Cesarean section, laparotomy, • Difficulty in breathing • Rebound tenderness of
evacuation, manual removal of abdomen, guarding, rigidity showing bladder/bowel (Mephentine/Dobutamine/
placenta , others ) /uterine injuries Dopamine etc)
• Clinical evidence of septic focus
in body, e.g.. air under diaphragm • Surgical procedure done (Evacuation,
Pus discharge from Laparotomy for Drainage of pus,Repair of
Bladder, Bowel and /or Hysterectomy)
wound, cervix or vagina
• Dialysis – peritoneal /hemodialysis ( renal
replacement therapy)
HYPERTENSION • Hypertensive disorders of • Convulsions • Altered conscious state • Proteinuria > 1 gm/dl • ICU admission for resuscitative procedure
pregnancy (Pregnancy induced • Diminution/Blurring • BP >160/110mm Hg • S. Creatinine >3.5 mg /dL like (CAB) or cardiorespiratory support
hypertension, Preeclampsia, of vision • Non responder to Magnesium sulphate
Eclampsia, • Deep Jaundice • Elevated S Bilirubin (> 6
• Severe epigastric pain • Oliguria / anuria / haematuria mg/dL) • Mechanical Ventilation
HELLP Syndrome)
• Severe headache non • coma • ALT, AST( >100 IU/L) • Blood & blood products transfusion (more
responsive to pain • Thrombocytopenia than 90 ml/kg body weight/ >5 units of
killers • Coagulation failure blood)
<20,000
• Difficulty in breathing • Pulmonary edema • Use of cardiotonics/
• Haemolysis on
• Palpitations • Evidence of circulatory peripheral smear vaso pressors
LIVER • Acute fatty liver of pregnancy • Convulsions • Unconsciousness • Elevated Serum • ICU admission for
DYSFUNCTION / • Acute Fulminant hepatic failure • Altered behavior • Deep jaundice Bilirubin (> 6mg/dL) resuscitation and
FAILURE
• Bleeding from various • Hepatic flaps, tremors • Abnormal liver enzymes cardiorespiratory support
sites • Abnormal bleeding sites ALT,AST • Resuscitation
(nose, gums, IV access ports, - haematuria, haemetemesis, (> 100 IU/ L) • Mechanical ventilation
varices) haemoptesis, bleeding gums etc.
• Abnormal ECG • Blood and
• Coagulation profile component transfusion (more than 90 ml/kg body
deranged weight/ >5 units of blood)
• USG showing
showing changes of
Acute fatty liver
Fibroscan showing changes
of acute fatty liver
38
DYSFUNCTION / ( antepartum, postpartum) specially at night • Dyspnoea • Abnormal like (CAB) or cardiorespiratory support
FAILURE • Palpitations echocardiography • Ventilatory support
• Organic Murmurs
• Chest pain • Cardiomegaly • X ray chest • Digitalisation
• Orthopnoea • Signs of CCF/LVF (with shielding of • Use of cardiotonics
abdomen) showing Gross
Cardiomegaly
• Acid Base values
PH <7.35 or >7.45
PCO2 >50 or <30 mmHg
PO2 arterial < 80 mmHg
Anaemia • Iron /Folic Acid Deficiency • Dyspnea • Severe Pallor • Hemoglobin below 5 gm/dl • ICU admission for
• Sickle cell Disease • Palpitations • Jaundice • Hemoglobin status not able to resuscitative procedure like
maintain O2 (CAB) or cardiorespiratory
• Thallasemia • Syncopal Attack • Tachycardia- pulse rate >120/ support
• Aplastic Anaemia • Altered conscious min saturation of 90%
• Blood /component
state • Tachypnea>20/min • Platelet < 20,000 transfusion ( Upto 90 ml /kg/ >5
• Features of Sickle cell • Tender, inflamed joints • Clot observation time > 7 min. or units of blood)
crisis such as bone any other test done which proves • Use of cardiotonics/
• Sternal tenderness
pains, joint pains, acute deranged coagulation profile
abdominal pain etc • Spleenomegaly vaso pressors
• Elevated S Bilirubin
• Swelling over body • Anasarca (Mephentine/Dobutamine/
( > 6 mg /dL)
Dopamine etc)
Respiratory • Asthma • Breathlessness /Air • Tachycardia- pulse rate >120/ • Various lesions on chest X ray • ICU admission for
Dysfunctions • Tuberculosis hunger min (with shielding of abdomen) specific to resuscitation and
• Pneumonia • High/Low grade fever • Tachypnea - >20/min disease Cardiorespiratory
• Chronic weight loss • Orthopnea • Abnormal Acid Base Support, and or Endotracheal
• Abnormal Chest signs values
Intubation
( Ronchi, Crepts, Absent breath PH <7.35 or >7.45
sounds) PCO2 >50 or <30 mmHg
• Signs of Cardiorespiratory failure PO2 arterial < 80 mmHg
• Cynosis, flaps PO2 venous <40 mmHg
Cardiac • Rheumatic Heart Disease • Breathlessness/Air • Tachycardia - pulse rate >120/ • Abnormal ECG • ICU admission for
Dysfunctions • Congenital Heart Disease hunger min • Abnormal Echocardiography resuscitative procedure like
• Orthopnea • Bradycardia > 40/min (CAB) or cardiorespiratory
• Cardiomyopathies • Abnormal Acid Base values support
• Aortic Aneurysm • Palpitations • Irregular pulse PH <7.35 or >7.45 mmHg • Ventilatory support,
• Collagen Disorders • Paroxysmal nocturnal • Tachypnea > 40/min PCO2 >50 or <30 mmHg
dyspnea • Digitalisation
• Bradypnoea < 6/min PO2 arterial < 80 mmHg
• Chest pain • Use of cardiotonics
• Organic murmurs PO2 venous <40 mmHg
• Cardiomegaly
• Tender hepatomegaly
• Signs of CCF/LVF
Pitting edema, raised JVP, basal
crepts etc.
Hepatic • Cirrhosis of liver • Yellowness of urine / • Deep Jaundice • Elevated Serum Bilirubin (>6 mg /dL) • ICU admission for
Dysfunction • Portal hypertension eyes/other body parts • Hepatic flaps/ tremors • Abnormal liver enzymes ALT,AST (> resuscitative procedure like
• Convulsions 100 IU / L) (CAB) or cardiorespiratory
• Acute liver failure • Abnormal bleeding sites support
• Altered behavior - haematuria, haematemesis, • Abnormal ECG
haemoptysis, bleeding gums etc. • Mechanical
• Bleeding from various • Clot observation time > 7 min. or
sites • Abnormal bleeding from nose, any other test done which proves Ventilation
gums, I/V sites, varices deranged coagulation profile • Blood and
( nose,gums, IV access
ports, varices) • HepatomegalyAscites • Imaging modalities showing component
hepatomegaly ,splenomegaly and any
transfusion
other abnormalities
ENDOCRINAL • Gestational diabetes mellitus • Altered • Features of circulatory collapse • Ketoacidosis pH < 7.35 • ICU admission for
DISORDERS • Diabetes mellitus conscious state • Neurological deficit like RBS > 200 g/dL resuscitative procedure like
muscular weakness, paresis, (CAB) or cardiorespiratory
• Breathlessness / Air • Abnormal ECG support
Diabetic Hunger plegia
• Electrolyte • Mechanical
Ketoacidosis • Palpitations • Altered consciousness
imbalance ( Sr Na < 129 Ventilation
• Convulsions • Coma
K <3.2 - >5.5 • Resuscitative
• Bladder/Bowel
dysfunction Procedures
• Management of
Ketocidosis (Insulin
or glucagon)
• Thyrotoxicosis • Palpitations • Altered consciousness • Sr T4 .elevated ( >200 IU) • ICU admission for
• Thyroid storm • Convulsions • Coma • Low TSH (< 0.2 IU) resuscitative procedure like
(CAB) or cardiorespiratory
• Pheochromocytoma • Bladder/Bowel • Tachycardia pulse > 120 bpm • Ischaemic changes on ECG support
dysfunction • Elevated Vinyl mandilic acid
39
Procedures
Neurological • Epilepsy • Syncopal attacks • Altered conscious state and • Abnormal EEG • ICU admission for resuscitative
40
coma procedure like (CAB) or
Dysfunction • Cortical vein thrombosis • Convulsions • Abnormal acid –base status
cardiorespiratory support
• Unconscious state • Abnormal reflexes ( hyper or • CT/MRI head showing abnormalities
absent) • Shifting to intravenous
Antibiotics fourth generation
• Paresis/plegia
• Mechanical ventilation
• Cardiorespiratoy failure
• Heparanisation
Renal • Medico renal disease e.g • Reduced / absent urine • Oliguria - < 400 ml urine • USG showing renal abnormalities • ICU admission for
Dysfunction / chronic/acute renal failure resuscitative procedure like
• Edema all over body output in 24 hours not • Doppler USG
Failure (CAB) or cardiorespiratory
• Renal artery stenosis • Breathlessness (due to responding to fluid therapy and showing stenotic renal support
• Transplant complications volume overload) diuretics
artery • Need for dialysis peritonel/
• Collagen Disorders • Unconscious state • Anuria
• Deranged KFT hemodialysis
• Coma
Accident/assault/ • Trip or fall • History of trauma • Altered conscious state • Acute fall Hb < 5 gm ( fall in • ICU admission for
surgical problems • Vehicular accident or accident, suicide • Tachycardia > 120/min, hemoglobin so as to affect oxygen resuscitative procedure like
attempt saturation) (CAB) or cardiorespiratory
• Violence low volume pulse support
• Syncope • Fall in oxygen saturation below 90 %
• Blunt trauma abdomen • Bradycardia <60/min • Blood &blood products
• Pain (abdominal or • PaO2 : FiO2<200
• Assault pertaining to specific • Tachypnea >20/min transfusion ( more 90 ml/kg
•
Infections • Malaria • High grade fever (with/ • Altered conscious state • Leucocytosis • ICU admission for resuscitative
• Dengue without chills and • Persistent rise in Temp >39.2 ( >15,000/cumm) procedure like (CAB) or
rigor) ˚C, not responding to routine cardiorespiratory support
• H1N1 viral Disease • Toxic granules on peripheral smear
• Yellowness of urine treatment • Shifting to intravenous
• Lower respiratory tract • Low platelets(<50,000) Antibiotics of fourth generation
infections • Altered behavior • Hypothermia temp , 37 O C
• Microbial culture positive for (Sulbactum+ Cefoperazone
• ARDS • Breathlessness • Pulse rate > 120/min organisms combinations, Imepenum)
• Meningitis • Abdominal pain • Tachypnea> 20/min • Dengue , paracheck, malarial parasite • Blood component
• Enchephalitis • Abdominal Distension • Chest signs (Crepts, crackles, positive on ELISA/ peripheral smear transfusion ( upto 90 ml /
• Unconscious state ronchi, decreased or absent air • H1N1 ELISA positive
• Infective hepatitis entry) kg body weight/ >5 units of blood)
( A,B,C,E) • Convulsions • Spinal fluid positive for infection • Use of cardiotonics/
• Neck rigidity
• HIV/AIDS • Elevated serum bilirubin (>6 mg) vaso pressors
• Coma
• Scrub typhus • Abnormal liver enzymes (> 100 IU) (Mephentine/Dobutamine/
• Bleeding from various sites
• Nephritis • Abnormal ECG Dopamine etc)
• Other • Abnormal EEG • Injectable antimalarials
• Clot observation time > 7 min. or • Use of drugs to relieve cerebral
any other test done which proves odema (Mannitol)
deranged coagulation profile
• Antiretroviral therapy
• Positive Hepatitis markers
• HIV ELISA positive
42
Infarction • Cerebral embolism (stroke) • Air hunger • BP : 1) Systolics <90 mhg. pertaining to disease resuscitative procedure like
• Abnormal ECG (CAB) or cardiorespiratory
• Cardiac embolism • Collapse 2) Disystolics <60 mhg. support
(myocardial infarction) • Acute chest pain • Weak pulse • CT/MRI showing Lesion
• Blood component
• Syncope • Abnormal chest signs (Ronchi, transfusion ( upto 90 ml /kg
Crepts, effusion) body weight/ >5 units of blood)
• Cardiorespiratoy failure • Use of cardiotonics /
• Sweating, cold and clammy skin vaso pressors
(Mephentine/Dobutamine/
Dopamine etc
• Anticoagulant therapy
• Drugs to reduce cerebral
odema (Mannitol)
DISTRICT: ________________________________________________________________________________________________________________________
Year:__________________Month:___________________
Sr Name Hus- Age Address MCTS Date & Admitted Admitted with Admitted as Near Interventions Date of Remarks Signature of the Doctor Incharge
No band’s / with No. Time of with no Disorder* Miss done # Discharge with designation and date
Partner’s mobile Admission Disorder
Name and Signature with date
name no. 1/2/3
1 2 3 Designation
*1 - Pregnancy specific obstetric and medical disorder/s 2 - Preexisting disorders aggravated in pregnancy 3- Accidental/ incidental disorder/s
43
## This register to be printed at A3 size for actual use
Notes