National Safe Motherhood Program

PREGNANCY TRACKING

Year: 2019 Birthing Center: ____________________________

Region: ____________ VIII Address: ____________________________
Province: ____________ NORTHERN SAMAR Referral Center: ____________________________
Municipality: ____________________________
VICTORIA Address: ____________________________
Barangay: ____________ IBERTAD

No. Name Age Gravidity Parity Expected Date of Antenatal Care Check-Ups Pregnancy Outcome Mother and Child Civil Registration
(LN, FN, MI) Delivery (Date) (Place a check) Postnatal Check-ups (Date)
(Date)

1st tri = up to 2nd tri = 3rd tri = 28 weeks AOG and Live birth Preterm Stillbirth Abortion Day of Within 7 days Livebirth Maternal Stillbirth Early
12 weeks and 6 13-27 weeks more Birth Discharge/ after birth Death Newborn
days AOG and 6 days 24 hours after Death
AOG birth (0-7 days)
Name of BHW: _________________________ Barangay Health Station: _________________________
Name of Midwife: _________________________ Rural Health Unit: _________________________