PNC with newborn

Name , Age , Address with nearest health facility and distance from it , Occupation

Family members , age , relation and occupation

Pedigree chart
SES based on rural or urban location
Presenting complaints(if any)
She is a GPLA – appropriate score
Maternal complaints - pain abdomen, bleeding PV, Discharge PV, suture related, LSCS related, breast
problems, weakness, myalgia, bladder & bowel habit etc
New born related - Baby cried immediately or not. Feeding inifeeding problem, jaundice, congenital
anomaly etc
If no complaints , Events leading to delivery and outcome briefly.

HOPI:
Elaborate the duration of presenting complaints
Describe the onset and duration of labour pains and leaking PV(if present)
Evaluate events of admission and course in hospital leading to delivery and outcome of delivery as in
full term/ Preterm normal vaginal delivery or LSCS
(Delivered a male/female, term/preterm baby on _________ (date) by normal vaginal delivery/
forceps/vaccum/LSCS, cephalic/breech (meconium passage if present).
Baby cried immediately after birth or not, evaluate birth weight, Apgar score
Episotomy given or not, any postpartum complaints - Bleeding, inversion, placental
Breast feeding started within __________ hours, history of prelacteal feeds (if any),whether
colustrum was given or not
Vaccines given to child at birth
Whether birth registration done or not
History of present pregnancy: Trimester-wise
LMP
EDD: __________ (by USG if available)
Evaluate
If the pregnancy was spontaneously conceived?

If the pregnancy was wanted?

How the pregnancy was diagnosed? by UPT/ ultrasonography/blood HCG levels and from where it
was done.
 Whether registration was done and whether booking was done? If yes where , If not, why- reasons:
Aware but don’t want to go , not aware , inaccessible health facility , family not interested due to….,
religious reason.
When was 1st ANC visit
1st trimester: h/o nausea & vomiting, Bleeding pv , burning micturition, Drug intake, rashes,
radiation & trauma
Etc. All negative history to be included.
TT – period of gestation when tetanus toxoid was given , if taken on 1 st contact. Blood investigations
if any on 1st contact..
FA and Calcium in 1st trimester.- regular /irregular intake - reasons
Any high risk factor for foetus/motherx
Total ANC visits
Contact with anganwadi worker, issued Mamta card
2nd trimester: quickening, fatigue, blurring vision, bleeding pv, burning micturition, discharge pv
Etc
IFA and calcium – if the pregnant woman is on regular medications and if non-compliant, reasons to
be evaluated
OGTT done or not
Ultrasonography DONE
TT second dose when and from where
3rd trimester:
Fetal movementsany danger sign, high risk factor for mother or child
Total ANC visits
Treatment & investigations given
Total weight gain during pregnancy
Present delivery outcome – cry , meconium
Breastfeeding history
Started immediately or later- how much time passed. If no – reason
Colostrum / prelacteal feeds given
Frequency of feeds
Urine output of baby
Immunization history – BCG , OPV AND HEP B
Obstetric history
GPLADS
Sl.n Type of Place of Age/sex Birth Cryafter birth Breast feeding – Immunization Development
o delivery delivery Wt time of start, & nutrition
 (immediate/delayed) Duration of status h/o
EBF, start of
complementary
feeding

Menstrual history:
1. LMP:
2. EDD:
3. Age of attainment of menarche
4. Regularity - once in how many days, total number of days
5. History of any passage of clots, pain
Marital history
1. Age at marriage and duration of marriage
2. Consanguious / non consanguious
3. Contraceptive usage – gaps between pregnancy
Past history
HTN/DM/TB/UTI/hospitalization/surgical illness
Personal history: Tobacco or any other addictions , diet type , appetite , urine and bowel movements
after delivery, sleep
Family history: History of twins, congenital malformations, any other disease which can affect her
pregnancy outcome
Diet history: Calorie intake , protein intake , any deficits by 24 hour recall method and food
frequency questionnaire of 1 week
Salt , oil and wheat intake of month divided by number of members of family
Environmental history:
Type of house .Number of rooms , separate room for mother and baby
Water supply – drinking water purification. Covering food and water
Sanitation- waste , waste water disposal
Psychosocial history: Relationship with family and neighbours cordial. Any mood changes of
mother.
Examination of mother:

GPE:
Vitals:
Anthro:
Breast Examination: swelling/tenderness/lump/any discharge. Nipples
Thyroid enlargement
Systemic examination : Examine for
P/A: uterus hard & contracted/ soft non tender, measure distance of uterus from
symphysis pubis
Organomegaly
Any free fluid
Striae & linea nigra
Scars
Examination of newborn:
GPE: child is active/sleeping /crying while examination
Cry: good/poor
Activity: limp/good
Feeding: poor/good

Pallor Icterus Cyanosis

(look in palm, not in eyes)

Present/absent

Vitals Anthropomentry

HR length

Temp Weight

Capillary refilling time Head circumference

RR Chest circumference

Head to toe examination:

Head: Fontanelle (Ant fontanelle: closes at 1 and half year, Post fontanelle: closes at 2-3 months),
look for any caput formation, birth injury marks: forceps or other
Eyes: corneal discharge
Ear:
Mouth: lips,deciduous teeth, cleft lip, cleft palate
Skin: icterus (level of icterus if present), cyanosis, birthmarks, rashes
Back: tuft of hair, cyst
Umbilical cord: any redness or discharge
Genitalia: Phimosis, undescended testis
Anus: patency
Any other congenital anomaly
Maturity assessment

Hair

Sole crease

Ear

Breast nodule

Genitalia

Urine passed:____________
Faeces passed:____________
Reflexes:
Palmar grasp
Rooting suckling
Moros
Systemic examination:
CVS
RS:
Per abdomen:
CNS
KAP:
Her health related Services related Child care related

Adequate rest & Increased food Regular check up Exclusive breast feeding:
intake initiation, duration, frequency

IFA & Calcium tablets birth registration of child Avoidance of prelacteal feeds

Proper hygiene, Episotomy care, immunization and regular Complementary feeding: when to
breast care growth monitoring of child start and what to start
 Common breast problems and Anganwadi services Harms of bottle feeding
danger signs

Contraception: abstinence for 6 JSY scheme Keeping baby warm

weeks & birth spacing

Role of ASHA, ASHA visits to Danger signs in child

her house.

Attitude:
Practise
Birth preparedness
Had arranged transport, clothes, finances and accompanying person . Awareness regarding
blood donor and arrangement for same.
Diagnosis:
___________ year old female belonging to ________ SES, APL/BPL, a ________ day PNC with
_________ complications/normal. With healthy newborn baby, full term/preterm, delivered by normal
vaginal or LSCS or assisted by_____ with _______ problem. Immunized till date & feeding problem

Web of causation : (if any)

Medical Interventions:
Investigation: As per case, Hb, blood grouping of baby, Hb of mother
Treatment: Drugs for mother, Immunization to baby
Advices and Appreciation of mother
For mother New born

Rest & hygiene Hand wash before touching the new-born

Breast care, episiotomy care Warmth : rooming in, KMC, covering extremities
with caps, socks, delayed bathing, extra-clothing to
prevent hypothermia

Increased food intake Timely & complete immunization

Post partum exercise and mobilisation No prelacteal feeds

Exclusive breast feeding: 8 times per day including
night feeds for 6 months, on demand feeding, burping
following feeding, not to give any foods including
water during first 6 months
 Explain position & signs of attachment

Regular intake of IFA and calcium for 6 months Complementary feeding to be started at 6 months with
dahlia, mashed potato etc

Danger signs: foul smelling discharge pv i.e Lochia, Explain dangers of bottle feedings
Fever,Breast abscess
Motivate mother for katori spoon feeding – when
needed

UTI, DVT, thrombophlebitis Danger signs of new born: ARI, ADD, Fever,
hypothermia (feet should be warm)
Encourage early ambulation
If there is any danger sign, doctor should be consulted
immediately

Inform about ASHA visit’ How to make ORS, home assisted fluid
JSY benefit
Awareness of PMSMA , Rajshree yojana , ICDS.
Birth registration of child
Anganwadi services utilization
Contraceptives:Abstinence for 6 weeks, Condoms or
IUCD, if family is complete-advicesterilization

Explain about Mamta card and its utilisation – growth

monitoring , feeding practices , milestones ,
management of mild disease and danger signs
identification. Immunization chart.