RH - MIS 509

(Revised 2008)

Maternal and Child Health Quarterly Return

MOH Division

BH-(TH)-Gampola

Code No.

RDHS Division

No

Reporting

Oct to Dec 2011

Actual Population
Urban & Rural

Vital events in MOH area

Infant Deaths Maternal Deaths Pregnant Mothers Pre-schoolers

No. Under care

Live Births Estate Displaced Estimated for this year Total

Normal

At Risk

Postpartum mothers

District birth rate (Previous year) MOH birth rate (Previous year)

Infants
No. reported by PHMM during the quarter 1-2 yrs 2-5 yrs

Activities

Previous quarter

Month
Total for Quarter July August September

Field activities (Information form RH-MIS 524)

1. Information on Eligible Families

No. of Eligible Families under care at the end of month

xxx

xxx

2. Antenatal care

Total pregnant mothers registered

No. of Pregnant mothers registered before 8 weeks

No. of Pregnant mothers registered between 8-12 weeks

Activities
No of Teenage (<20 yrs) pregnant mothers registered No of primies registered No. of pregnant mothers of P5 and above registered No. of registered pregnant mothers protected for Rubella Antenatal home visits by PHM First visits Subsequent visits No. of outside mothers

Previous quarter

Month
July August September

Total for Quarter

No. of mothers that left the area

3. Intra natal care No of Total deliveries reported

Institutional deliveries

Vaginal deliveries Caesarean sections By PHM

Home deliveries by PHM

Others trained Untrained

No. of mothers protected with T. Toxoid at the time of delivery No. of mothers tested for Grouping and Rh at the time of delivery No. of mothers tested for VDRL at the time of delivery No. of deliveries of outside mothers 4. Mothers with Antenatal Morbidities (reported during the 1st postnatal visit) Chronic Hypertension High BP Pregnancy Introduced Hypertension Chronic Diabetes Mellitus Diabetes Gestational Diabetes Mellitus Heart Disease Anaemia Ante Partum Haemorrhage Asthma Malaria Tubercolosis Sexually Transmitted Disease Liver disease Psychiatric Illness Epilepsy Urinary Tract Infections Other Diseases

Activities
5. Outcome of the pregnancy Total no. of. live births reported 2500g & more Single births Less than 2500g 2500g & more Multiple births Less than 2500g No of abortions No. of Still births No. of Maternal deaths 6. Postnatal care Post partum visits by PHM First visits Post partum visits Withing first 10 days Subsequent visits No. of visits during 11 to 28 days Around 42 days No. of mothers delivered supplemented with Vit A megadose Mothers with post-natal morbidities (First visits) Haemorrhage Fever Infections of reproductive tract Urinary tract infections Infected epis Seperated epis Foreign material in vagina Infected Caesarian scar Deep vein thrombosis Postpartum Psychosis Cracked nipple Engorged Breast Breast abcess High Blood Pressure Heart Failure Other Diseases 1 Postnatal Hospitalization First visits Subsequent visits

Previous quarter

Month
July August September

Total for Quarter

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Activities
7. Infant care

Previous quarter

Month
July August September

Total for Quarter

Infants registered by PHMM during the month Home visits for infant care Home visits for infant care First visits (after 42 days) Home visits for infant care subsequent visits Total no. of infants weighed No. of Infants who are underweight (<-2SD) No. of Infants who are severe underweight (<-3SD) No of infants who are overweight (>+2SD) No. of infants reported by PHMM Neonatal 1-7 days Between 8-28 days Post neonatal (after 28 days) Total No. of infant deaths investigated Causes of infant deaths - Asphyxia Causes of infant deaths - Neonatal Sepsis Causes of infant deaths - Congenital abnormalities Causes of infant deaths - Prematurity Causes of infant deaths - Others 1 8. Pre-school care (1 to under 5 years) xxx xxx xxx xxx xxx xxx xxx xxx

Home visits for child (pre-school) care

Total No. of pre schoolers weighed Pre-schoolers weighed (1-2 years) Pre-schoolers weighed (2-5 years) Total No. of pre-schoolers who are moderate underweight/below 3rd centille Pre-schoolers moderately underweight (1-2 years) Pre-schoolers moderately underweight (2-5 years) xxx xxx xxx xxx

Total No. of pre-schoolers with severe underweight/below 3rd centille

Pre-schoolers with severe underweight (1-2 years) Pre-schoolers with severe underweight (2-5 years)

xxx

xxx

Activities
Total No. of pre-schoolers who are overweight (>+2SD) Pre-schoolers who are overweight (1-2 years) Pre-schoolers who are overweight (2-5 years) No of child death (1-5 years) Accident Congenital abnormalities Diarrhoeal disease Respiratory disease Others 2 No. of children with AEFI 9. Family Planning Current users of modern contraceptive methods (end of the month) Oral pills Injectables IUD Implants Condoms Female sterilization Male sterilization Total current users of modern methods No of oral pill packets destributed by PHMM Total No. condoms distributed No. of condoms distributed by the PHMM No. of condoms distributed by PHI No. of couples with unmet needs of family planning No. of couples practicing natural/traditional FP methods No. of couples with sub-fertility Oral pills Injectables IUD No. of failures of FP (specify method) Implants Condoms Female Sterilizations Male Sterilizations Oral pills Injectables No. of severe compltcations of FP (specify method) IUD Implants Condoms Female Sterilizations No. of Home visits for Users of Modern Contraceptive Methods

Previous quarter

Month
July August September

Total for Quarter

xxx

xxx

xxx xxx xxx xxx xxx xxx xxx xxx

xxx xxx xxx xxx xxx xxx xxx xxx

xxx xxx xxx

xxx xxx xxx

Activities
10. Maternal Death Investigation

Previous quarter

Month
July August September

Total for Quarter

Maternal deaths notified within MOH area

No. investigated Haemorrhage Probable cause of death (After investigation) Pregnancy induced hypertension Sepsis Complications following abortions Heart disease complication pregnancy Hepatitis Obstructed labour Other conditions

MCH Clinic Activities (From RH-MIS 527)

1. Attendance at clinic Pregnant mothers first visits Pregnant mothers subsequent visits Infants First visits Infants subsequent visits Pre-school children first visits Pre-school children subsequent visits

2. Blood examinations

No. of clinics collecting samples for VDRL

xxx

xxx

VDRL

No. of VDRL specimens taken

No. of VRRL reported as reative No. of reffered No. of mothers tested for Haemoglobin No. of pregnant mothers with moderate anaemia Hb 711g/dl) No. of pregnant mothers with severe anaemia (Hb Blood Gp & Rh No. of specimen taken for grouping and Rh

Heamoglobin

Activities
3. Nutrition status of pregnant mothers

Previous quarter

Month
July August September

Total for Quarter

BMI (at first visit weighed before 12 weeks)

BMI Less than 18.5 BMI between 18.5 - 25 BMI more than 25 4. Family Planning Clinic Services Hospital Clinics Total packets of oral pills distributed Field Clinics Hospital Clinics Total doses of DMPA given Field Clinics Hospital Clinics No. of IUD used Field Clinics Hospital Clinics No. of Implants used Field Clinics No. of condoms distributed 5. Infant care 6 months 18 months No. of Vitamin A Mega dose given 3 years 5 years Hospital Clinics Field Clinics

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Well woman clinic activities

No. of functioning Well Women Clinics No. of WWWs with pap smear facilities No. of Clinics sessions conducted 1. Clinic attendance First Visit Age group of clients (First Visit) Under 35 years 35 years above 35 years Re-visits 2. No. of examinations done Urine testing for sugar Blood pressure measurement Breast examination Cervical visualization xxx xxx xxx xxx

Activities
3. No. of cases identified and refferred

Previous quarter

Month
July August September

Total for Quarter

Diabetes Mellitus Hypertension Breast abnormalities Cervical abnormalities Abnormal vaginal discharge

4. No. of Cervical (Pap) smears taken

5. No. of Cervical smear reports received during the month

No. reported abnormal during the month Classification of Pap smear report LSIL HSIL Glandular lesion ASCUS lesion

Malignancies HPV Infection Inflammatory smears No. of unsatisfactory smears No. of back referrals Information about staff Category Number in position at end of quarter Category Number in position at end of quarter

MOH AMOH PHNS SPHI Comments if any :

SPHM PHI PHM PPA

Prepared by : Name : Designation : Signature :

Certified by : Name : Designation : Signature :