CLINICA MEDICA DR. DAVID MENJIVAR.

DOCTOR GUADALUPE DE MENJIVAR.

ULTRASONOGRAPHY

GYNECOLOGY AND OBSTETRICS.

PATIENT: ELSA VANEGAS.

AGE: 26 YEARS
DATE: 19 AUGUST 2021

FETUS: SINGLE PODAL ACTIVE

PLACENTA: FUNDAL GRADE I NON-PREVIA

FETAL HEART RATE: …… 144 LMP

MEASURES:

BIPARIETAL DIAMETER: 45 MM

ABDOMINAL CIRCUMFERENCE: 134 MM

FEMUR 29 MM

GESTATIONAL AGE: 19 2/7 SEM

ESTIMATED DUE DATE: JANUARY 11, 2022
ESTIMATED FETAL WEIGHT: 270 GR

FETAL MOV PRESENT

AMNIOTIC FLUID: NORMAL:

FETAL TONE: PRESENT

RESPIRATORY MOVEMENTS:

BIOPHYSICAL PROFILE:

COMMENT: SINGLE, PODAL, ACTIVE FROM 19 2/7 WEEKS.

NO VISIBLE FETAL ANOMALIES IN THE PRESENT STUDY.

MEASURES IN NORMAL LIMITS

(There appears a stamp with the number 783411066 below)

(There appears a seal with a signature)

(There appears a seal with a signature)

HAR:

DOB: 6/10/1994 (27yrs)

MRN: 300872396

(Ilegible) Date: 20/12/2021

AdmType: EL

SpknLang:

NEIGHBORHOOD AND STREET EL CALVARIO, IN FRONT OF OFFICE DEL SUR, LA LIBERTAD, TEL:
2301-3776.
SALVADOREÑO DEL SEGURO SOCIAL

SUBDIRECTORATE OF HEALTH

PERINATAL CARD- CLAM / WR - PAHO / WHO

NAME: VANEGAS

SURNAME: VANEGAS

DATE OF BIRTH:

Day: 11

Month: 06

Year: 1914

ETHNIC: white indigenous mestizo black other

ALPHA

BETA

STUDIES: none primary secondary university years at the highest level (illegible)

MARITAL STATUS: married union (illegible) single other

(There appears a seal)

FAMILY: no yes

TBC

Diabetes

Hypertension

Preeclampsia

Eclampsia

Another serious medical condition

PERSONAL

No Yes

No Yes

Genito-urinary surgery

Infertility

Heart disease

Nephropathy
Violence

HIV +

OBSTETRICS

LAST PREVIOUS

n/c <2500g

normal> 4000g

twins background

No Yes

previous pregnancies

abortions

3 consecutive abortions

delivieries

Vaginal

Caesarean sections

Live births

Stillborn

Live

Dead 1st week

After 1st week

END OF PREVIOUS PREGNANCY

Day month Year

PLANNED PREGNANCY

Less than 1 year

No Yes

CONTRACEPTIVE METHOD FAILED

Did not use

Barrier

IUD

Hormonal

Emergency

natural
CURRENT PREGNANCY

PREVIOUS WEIGHT

80 KG

SIZE (cm)

160

Last menstruation period

Day 20

Month 03:

Year 21:

Expected date of delivery

Day (illegible)

Month (illegible)

Year (illegible)

EG RELIABLE by

Last menstruation period

No

Yes

ECO 20 S

1St q

2nd q

3rd q

Last menstruation period ACT no yes

Last menstruation period PAS no yes

DRUGS no yes

ALCHOHOL no yes

VIOLENCE no yes

ANTIRUBEOLA

Previous does not know

Pregnancy no

ANITETANICS

In force no yes
DOSE 1st 2nd

Gestation month

EX NORMAL

ODONT

BREAST

No Yes

Normal not normal

Not carried out

visual insp

PAP

COLP

GROUP Rh - +

Immunization no yes

Yglobulin antiD

No yes N/C

TOXOPLASMOSIS - + not done

<20 weeks/gG

 20 weeks gG

1st lgM consultation

HIV <20 weeks

Requested not yes

Carried out not yes

 20 weeks

Requested not yes

Carried out not yes

Hb < 20 sem

< 11 0g

Fe/FOLATES

Fe/ FOLATES

Indicated
Fe/ FOLATES

Fe No Yes

Folates No Yes

Hb > 20 sem

< 11.0g

SYPHILIS-Diagnosis and Treatment

Test

No treponemal

- + w/g

< 20 weeks 11

 20 weeks
- + w/p

Treponemal

- + w/p n/c

(illegible)

(illegible)

- + w/p n/c

Treatment

No yes w/p n/c

(illegible)

(illegible)

No yes w/p n/c

Couple treatment

No Yes

w/p n/c

No Yes

w/p n/c

PRENATAL CONSULTATIONS

Day month Year

03 06 21

(There appears a seal dated 5 Jul 2021)

(illegible)

23 Apr 21

(illegible)

Gest age

(illegible)

21 2/7

24 1/7

(illegible)

Weight

50 kg

78 kg

76

78 kg

81 kg

PA

(illegible)

(illegible)

(illegible)

(illegible)

(illegible)

Altura uterina

(illegible)

18

23

25

Presentation

P
C

FCF (LPM)

150

150

140

Fetal Movements

Proteinuria

Warning signs, tests, treatment

(illegible)

Initials

Technical

(illegible)

(illegible)

Next appointment

(illegible)

BIRTH

ADMISSION DATE
Day month Year

CARD no yes

ABORTION

PRENATAL CONSULTATIONS

Total

HOSPITALIZATION IN PREGNANCY

No Yes

Days

PRENATAL CORTICOIDS

Complete

Incomplete

None

n/c

week

beginning

BEGINNING

Spontaneous

Induced

Cesar elec

MEMBRANE RUPTURE

Day month Year

No Yes

Hour min

ANTEPARTUM

<37 week

 18 hours

Temp >38ª

GEST AGE

At delivery

Weeks days

By last menstruation period by ECO

PRESENTATION SITUATION

Cephalic

Pelvic

Transverse

STANDARD FETAL SIZE

No

Yes

COMPANION

TDP P couple

TDP P relative

TDP P other

TDP P none

BIRTH

DEAD

Antepartum

VICO

Ignore moment

Hour min

Day

Month

Year

MULTIPLE order

No yes

DISEASES

None

1 or more

Previous hypertension no yes

Pregnancy induced hypertension no yes

Preeclampsia no yes

Eclampsis no yes

Heart disease no yes

Nephropathy no yes

Diabetes no yes

Ovular infection no yes

Urinary infection no yes

Preterm birth threat no yes

IUGR no yes

Premature rupture of membranes no yes

Anemia no yes

Other serious condition no yes

HEMORRHAGE

1st trim no yes

2nd trim no yes

3rd trim no yes

Postpartum no yes

Puerperal infection no yes

COD

Notes

BIRTH POSITION

Sitting

Squatting

Lying down

Episiotomy

No Yes

TEARS

Grade (1 to 4)

No

OCITOCICOS

Prebirth

No Yes

Post-delivery

No Yes
PLACENTA

Complete no yes

Withheld no yes

CORD LIGATURE

Early

No Yes

MEDICATION RECEIVED

Ocytocics in TDP no yes

Antibiotics no yes

Analgesia no yes

Local anesthesia no yes

Anteesthesia region no yes

General anesthesia no yes

Transfusion no yes

Others no yes

Specify

Code medic 1 medic 2

NEWBORN

SEX f m

Undefined

BIRTH WEIGHT

<2500G >4000G

P CEPHALIC CM

LENGTH

GESTATIONAL AGE sem days

FUM ECO ESTIMATED

WEIGHT

Suitable

Small

Big

OFF (min)
1er

5ª

REVIVAL

Stimulation no yes

Aspiration no yes

Mask no yes

Oxygen no yes

Massage no yes

Tube no yes

DIES IN THE PLACE OF DELIVERY no yes

REFERRED lod. Conj

Neonatology

Other hospital

ATTENDED DELIVERY

NEONATE

Med

Obstetrician

Nurse

Assistant

Student

(illegible)

Other

Name

CONGENITAL DEFECTS

No

Less

Higher

Code

DISEASES

None

1 or more
Code

NEONATAL SCREENING

VDRL - + not done

(illegible) - + not done

TSH - + not done

(illegible)

Bilirubin - + not done

Toxo IgM - + not done

Meconium 1st day no yes

Postpartum rubella no yes n / a

Yglobulin anti D no yes n / a

PUERPERIUM

Day hour

1C

PA

Pulse

Invol. Uter

(illegible)

(illegible) alive dies transfer

Day month year hour min

Dies during or in place of transfer no yes

AGE full days <1 day

FOOD AT DISCHARGE

Exclusive breastfeeding

Partial

Artificial

Face up no yes

BCG no yes

DISCHARGE WEIGHT

(illegible) MOTHER
Day month Year

Alive dies

Transfer

Place

(illegible) no yes

Full days from delivery

CONTRACEPTION COUNSELING no yes

CHOSEN METHOD

IUD post event

IUD

Barrier

Hormonal

Tubal ligation

natural

Other

None

Newborn certificate

PLACE

Newborn name

Responsible

Responsible

Uterine height patterns and maternal weight increase according to gestational age. Once the
gestational age is known, it will be located (illegible)
Consult immediately if you present:
 1. Bleeds Equal or more than normal. (Any month)
2. Dump water through the vagina. (Any month of pregnancy)
3. You have labor pains. (From the 4th month)
4. You have a severe headache. (From the 5th month)
5. Swells in the hands, face, feet above the ankle. (From the 5th month)
6. Look at lights or blur. (From the 5th month)
7. The child moves less than 12 times a day or less than 2 times an hour. (From the 7th
month)

(A box appears)

INCREASE IN MATERNAL WEIGHT

UTERINE HEIGHT

GESTATIONAL AGE (WEEKS)

PERINATAL CARD

(There appears a seal from El Salvador)

Prenatal check-up site

Place of delivery

Seal

Center of attention

In case of danger signs, consult immediately

Bleeding

Fever

Loss of liquid

Labor pain

Headache

Swelling

It is important that your first visit to the health center is before 12 weeks of pregnancy.

This card contains essential information for your health and that of your child. Carry it with you
at all times and hand it over to the health team whenever you require attention.

Comply with the appointments and recommendations given to you

In case of loss, please contact:

NAME: Elsa Vanegas Vanegas

ADDRESS:

PHONE:
LOCATION:

ULTRASONOGRAPHS

No.: DATE Important dates

1
2
3

VACCINATION

DOSE
DT 1 27 - September - 2021
DT 2
DT 3 = August 26 (illegible)
DT 4
DT 5
ANTIRUBEOLA

GESTATIONAL AGE (WEEKS)

MINISTRY OF HEALTH

DELIVERY PLAN SHEET

Step by step towards a Safe Motherhood

(8 images appear with illegible text)

SIGNS OF COMPLICATIONS BEFORE OR DURING LABOR

(4 images appear with illegible text)

SIGNS OF COMPLICATIONS AFTER DELIVERY

(4 images appear with illegible text)

Name and surname of the pregnant woman

Elsa Vanegas Vanegas

Age: 27 (illegible)

Address (illegible)

(illegible)

(illegible) (settlement neighborhood)

(illegible)

Health facility (illegible)

Birth Plan start date:

Name of the person who starts it:

Hospital where you plan to have your delivery attended:

HNSR

Person who will accompany you during the transfer to the delivery care

(illegible)

If the hospital is far away:

Do you plan to leave your community before your due date?

Yes No

Where would you go? Family Friends Maternal (illegible) house

Indicate the Address:

Name of the person who will transport the pregnant woman:

Mario jesus vanegas

Telephone or cell of the person who will transport the pregnant woman

73454423

It will be noted in each box (+) if it has it, it does and reinforce education by the health
personnel and it will note (-) if the answer is negative.

DATE (illegibl Obstetric There has Weight This Surname

e) complications already been gain formatio (responsibl
 (illegible) family according n e for
(correspondin involvement to (illegible) (illegible)
g to the or gestation with folic
images) participation al age acid
11/15/2 11/15/ + + + + (illegible)
021 21

Conditions that were created in support of the birth plan

Actions that the community has developed such as:

Transport

Childcare

Identification of alarm signs

Others

DANGER SIGNS IN THE NEWBORN

1. If the newborn has a fever or is cold

2. If the newborn can’t breastfeed
3. (illegible)
4. (illegible)
5. (illegible)

NEWBORN CARE

(There appear 4 images appear with illegible text)

5. Keep the newborn warm

(There appear 3 images appear with illegible text)

Radiography 1:

I am a boy

Baby
Radiography 2:

Abdomen

Head

Radiography 3:

(illegible)