Maternity MOH 333 PDF
Maternity MOH 333 PDF
Maternity MOH 333 PDF
SDP Number:
Facility Name:
KMHFL Code:
Sub-County:
County:
R Mode of delivery Record the birth form,Record using key: 1=Normal delivery; 2= Caeserean Section; 3= Breech; 4= Assisted vaginal delivery
S No. of Babies delivered Record number of babies delivered in multiple pregnancy (e.g 2 in the case of twins) Name of mother should appear once in one row, details of babies in separate rows
T Placenta Complete Write “Y” for Yes if placenta is complete and “N” for No if not complete,BBA if baby is born before arrival and placenta expelled and not available to be examined
U Uterotonic given Record uterotoxin given 1=oxytocin 2=Carbetocin 3= None
V Vaginal Examination Record using the codes as follows: 1= Normal 2=Episiotomy 3=Vaginal tear 4=FGM 5=Vaginal warts
W Blood loss (in mls) Indicate the amount of blood loss during delivery in millilitres (mls)
(Alive/Dea
X Mother‟s Status after Delivery Write the condition of the mother after delivery
d)
Y Date Maternal death notified Record the date the Maternal Death was notified in the format dd/mm/yyyy
Z Delivery complications (Codes) (1 - 6) Record using the Codes as follows: 1=A.P.H. (Ante Partum Haemorrhage); 2=P.P.H. (Post Partum Haemorrhage); 3= Eclampsia; 4=Ruptured Uterus;5=Obstructed labour; 6=Sepsis
AA APGAR Score Low APGAR SCORE is 6 and below at 5 min. See APGAR score table at the bottom of these instructions:
AB Birth outcome Enter “LB” for Live Birth, “FSB” for Fresh Still Birth and “MSB” for Macerated Still Birth
AC Birth Weight (in grams) Enter the weight of the baby in grams
AD Sex Enter the sex of the baby “M” for Male or “F” for Female
Baby
Initiation of BF < 1 Hour (Y/N) Indicate 'Y' for Yes if Breastfeeding was initiated in less than one hour and 'N' if not
AE Kangaroo Mother Care (Y/N) Indicate 'Y" for Yes if baby initiated on Kangaroo Mother Care and "N" if not
AF Tetracycline at birth (Y/N) Indicate 'Y' for Yes if Tetracycline was given at birth and 'N' if not
AG Chlorhexidine applied on cord stump (Y/N) Indicate 'Y' for Yes if Chlorhexidine was given at birth and 'N' if not
AH Birth with deformities (Y/N) Indicate 'Y' for Yes if the baby had birth deformities and 'N' if not
AI Given Vitamin K Indicate 'Y' for Yes if the baby was given vitamin K and 'N' if not
AJ VDRL/ RPR Results (P/N) Indicate RPR/VDRL test result, P for Positive or N if Negative.
(P/N/KP/U Record HIV status from the last ANC visit. This can be copied from the Mother-Baby booklet. Enter P for Positive, N for Negative KP for known positive at 1st ANC visit and U for Unknown.
AK AT ANC
)
Kit Name: Write the name of the first HIV rapid test kit which you have used.
Lot No: Write lot number of the test kit. If the lot number changes in the middle of the page, skip one row and write the new lot number on the next row
AL HIV Status HIV Test 1 & HIV Test 2 (N/P/I/NA) Expiry Date: Write expiry date of the test kit.
Test Result: Write either of the following initials;
N: Negative (non-reactive)
(P/N/U/NA
AM HIV Results (Maternity) Record HIV status: Enter „P‟ for Positive, „N‟ for Negative „U‟ for Unknown and „KP‟ for known positive. Note 1: Only results for tests done in the maternity should be recorded here.
)
AN Issued From ANC (Y/N/NA) Enter Y if the mother was on HAART during ANC, N if she wasn‟t and NA if the mother was negative or had unknown status.
Mother
AO Issued at Maternity (Y/N/NA) Only for women tested at Maternity: indicate Y if started on HAART, N if not and NA if negative or had already been started from ANC.
ARV Prophylaxis
Only for babies of mothers tested at Maternity.
Indicate Y if provided with Infant ARV prophylaxis, N if not provided and NA if negative or had already been issued from ANC.
AP Baby (Y/N/NA)
Note: For mothers issued with Infant ARV prophylaxis at ANC but never carried to the maternity, issue the prophylaxis but record NA.
A score is given for each sign at one minute and five minutes after the birth. If
there are problems with the baby an additional score is given at 10 minutes.
A score at 5 min of 7-10 is considered normal, while 4-6 is low and requires
APGAR continued resuscitative measures. A baby with apgars of 3 and below
SCORING(AA) requires immediate resuscitation.
Delivery
(EDD)
(LMP)
4=Divorced 5=Separated
Gestation Mode of babies Placenta given Vaginal Blood status after Notified
Delivery Complications
Phone number at Birth Delivery delivered Complete Examination loss Delivery (Y/N)
Admission number
Parity (X+Y)
1) SVD 2=Episiotomy
Gravidae
2) CS 1=Yes 1=oxytocin 3=Vaginal tear
Date of Duration Date of Time of 3) Breech 2=No 2=Carbetocin 4=FGM Date Death
Admission Full Name (First, Middle, Last) Age (dd/mm/yyyy) (dd/mm/yyyy) Diagnosis of labour( Delivery Delivery (wks) 4) AVD Number 3=BBA 3= None 5=Vaginal warts (mls) (Alive/Dead) notified
(a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o) (p) (q) (r) (s) (t) (u) (v) (w) (x) (y) (z)
15-19years
20-24 years
AGE (d) Numbe r Maternal complications (y): Alive Dead No. of babies discharged alive (aw): Pre Term Babies (q): Above 25 years
Totals
10-14 years
15-19years No. with APH (y): Early Neonatal deaths (aw):(0-7days Underweight Babies (ab):
20-24 years No of mothe rs give n Ute rotonics
No. with PPH (y): Live Birth (aa): (u)
Above 25 years Late Neonatal deaths (aw):(8-28days Ox ytocin
Totals No. with Eclampsia (y): Birth with Deformities (ag): Carbatosin
Version: Jan2011
Ministry of Health: Maternity Register MOH333 Page 2
CTX To Mother
HIV Test 1 HIV Test 2
Partner Involvement
Delivery Conducted by
Kit Name: Kit Name:
Birth Notification
3=Not Applicable
3=Not Applicable
Lot No. Lot No.
Initiated Mother
on BF in TEO Birth with HIV Results To Baby in
VDRL/
MAT
stump
Birth Birth < 1hr given at deformity(Y Given RPR Expiry Expiry Issued Issued at Tested for HIV Test Status of Reasons
Outcome Weight Sex (Y/N) birth? /N) Vitamin K Results AT ANC / / / / Maternity From ANC Maternity HIV Results Date Baby for referral
Kangaroo
Mother
APGAR (LB/FSB/ Care Birth Notification A= Alive
Score MSB) (grams) (M/F) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (P/N/ND) (P/N/KP/U) (N/P/I/NA) (N/P/I/NA) (P/N/U/NA) (Y/N/NA) (Y/N/NA) (Y/N/NA) (Y/N/N/A) (Y/N/NA) (P/N/KP/U) (Y/N) (Enter Name) Number (dd/mm/yyyy) D= Dead Comments
(aa) (ab) (ac) (ad) (ae) (af) (ag) (ah) (ai) (aj) (ak) (al) (am) (an) (ao) (ap) (aq) (ar) (as) (at) (au) (av) (aw) (ax) (ay) (az) (ba) (bb)
Code.(e)
Mode of delivery ( r ) Number Initial test at L&D (ak): No. of babies applied chlorhexidine for cord care (af) Maternal deaths 10-14Years (w)
No. Normal deliveries ( r ) Positive Results L&D (al): No. of babies given tetracycline at birth (ae)
No. Caesarean Sections ( r ) No. of Infants intiatied on breastfeeding within 1 hour after Maternal deaths 15-19Years (w)
No. HIV positive deliveries (aa)(ak)
No. Breech Delivery ( r ) birth (ad) Maternal deaths 20 years plus (w)
No. Assisted vaginal delivery ( r )
No. of neonates given Vit "K" (ah) Maternal deaths audited
Adolescents (10-19 yrs) New HIV+ maternity (al)(e)
Adolescents (10-19 yrs) Started HAART maternity (an)(e)
Version: Jan2011