HIGH RISK SCORING OF ANTENATAL MOTHER

Hospital: Medical College and Hospital Date of admission: 6/02/2019

Registration no: 100342887

ANTENATAL HISTORY COLLECTION

Name: Shahida Begum W/o: Amir Ahmed Age: 20 Years

Religion: muslim Education: Class V Occupation: Housewife

Duration of marriage: 1 years

Address: Village- Murgao P.S: Chanditala District: Hoogly

HISTORY OF PRESENT PREGNANCY:- History of bleeding since last one month in three
episode

OBSTETRICAL HISTORY: G- 1 P- 0 A- 0 L- 0

Period of gestation: 36 weeks 5Days

PAST MENSTRUAL HISTORY :

L.M.P- 03/06/2018 E.D.D- 10/03/2019 Cycle- Regular Dysmenorrhea- Nil

PAST SURGICAL HISTORY: Nothing significant

PAST HISTORY OF BLOOD TRANSFUSION: Nothing significant

FAMILY HISTORY OF ILLNESS: Nothing significant

PERSONAL HISTORY: She is non vegetarian and has no allergy to food and drug

GENERAL PHYSICAL EXAMINATION

pulse: 72 b/m Respiration: 26 b/m Blood pressure: 130/90 mm/hg

height:- 152cm Weight:- 64kgs

Symptoms:

a) Pain: Nil
b) Discharge: Nil
c) Micturition: Frequent
d) Digestion: Normal
e) Other symptoms: Nil
 f) General Health: Good

PHYSICAL SIGNS

a) Ear and nose: Clean

b) Teeth and gum: Normal
c) Tonsils and pharynx: Normal
d) Breast and nipple: Normal and clean
e) Heart : NAD
f) Lungs : NAD
g) Spleen: Not palpable
h) liver : Not palpable
i) skin: Moist
 Anal region: Normal
 vulva : Normal
 Groin : Normal

j) Abdominal wall: Striae gravidarum

k)Lymphatic : Nil

l)General condition: Normal

m)Any other sign &symptoms : Nil

ABDOMINAL EXAMINATION

Inspection

 Fetal movement : Present

 skin changes : Linea nigra & striae gravidarum

Date Fundal Height Abdominal Presentation and Relative size FHS / mint
Girth position of fetus of head to
In cm In weeks pelvis
12/02/2019 42cm 34 weeks 90cm Fundal grip:- Not engaged 140 b/m
Broad soft
irregular mass.
Left lateral grip:-
Smooth curved
mass.
Right lateral
grip:-
Small knob like
structure.
Presentation:
LOA
Treatment:-

Tab: Shelcal - 1tab OD

Tab: Austrin – 1tab OD

Advices:

 To take adequate rest and sleep in left lateral position

 To take nutritious diet
 To maintain personal hygiene and wear clean clothes
 To take temporary family planning method

Laboratory investigation:

a) Hemoglobin : 13g/dl
b) Blood sugar: 90mg/dl
c) VDRL: Negative
d) Blood group : type: A (+ve)
e) HIV: Non reactive
f) Urine: no sugar and albumin
g) Presentation: Cephalic presentation Amniotic fluid: adequate

Placenta:- posterior end encroaching the internal OS

RISK FACTORS

1. Age less than 18 years or more than 35 years 1

2. Maternal height less than 145 CM 1
3. Prime or multi more than five 1
4. Bad obstretical history 2
5. History of neonatal jaundice or RH incompatibility 2
6. Less than 45 kg or more than 90 kg 3
7. History of low birth weight babies 1
8. Previous uterine surgery 2
9. History of APH and PPH 2
10. History of manual removal of placenta 2
11. Anaemia(less than 6 grams%) 1
12. Febrile ailment in pregnancy 2
13. Pregnancy associated hypertension 2
14. Medical condition with pregnancy 2
15. Bleeding p/v(APH or abortion) 2
16. Abnormal presentation 2
 17. Matuirity less than 37 weeks and more than 45 weeks 2
18. PROM 2
19. Fetal distress 2
20. prolonged labour more than 20 hours 2
21. Uterine size less than period of gestation 2
22. Dai Handling/outside interference 2or3

Impression: primi, placenta previea = 1+2 = 3.