Prevention Of Post-Partum Haemorrhage Serious Adverse Event Notification (Health Facility / Community) Form

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Prevention of Post-Partum Haemorrhage
Serious Adverse Event Notification (Health Facility / Community)
Please complete Question in Bold 24-27, if woman was at the health facility or referred to one
1. Patient ID # |__|__|__|__|
2. Patient’s name:
3. Name of Health Facility Catchment area:
4. Payam:
____________________________________________
5. Village:
6. Women’s Age: /__/__/
7. Parity: /__/__/
8. Gravida: /__/__/
9. Date of delivery:
10. Time of Delivery
Day/Month/Year |___|___||___|___||___|___|
|___|___|: |___|___|
11. Place of delivery : (check one)
12. Serious Adverse Event: (check all
appropriate)
Home /__/ (1)
Health facility /__/ (2)
Excessive bleeding (post-partum
In transit from home to health facility /__/ (3)
hemorrhage) /__/ (1)
Other (please specify) /__/ (4)
Retained placenta /__/ (2)
High Fever >40 C /__/ (3)
Uterine Rupture /__/ (4)
Other (please specify) /__/ (89)
13. Date of Event onset:
14. Time of Event onset
Day/Month/Year |___|___||___|___||___|___|
|___|___|: |___|___|
15. Place of event onset
16. Enrolled in the Miso intervention (Provided
Home /__/ (1)
counseling, consented and given
Health facility /__/ (2)
misoprostol)
In transit from home to health facility /__/ (3)
No /__/ (1)
Other (please specify) /__/ (4)
Yes /__/ (2)
17. Did the patient take misoprostol for
18. Time of administration of Miso
prevention of PPH?
Within 3 minutes of Delivery /__/ (1)
No /__/ (1)
After 3 minutes of Delivery /__/ (2)
Yes /__/ (2)
19. Miso administration by:
20. Who was the attendant at birth?
Doctor/Midwife/Nurse /__/ (1)
Doctor/Midwife/Nurse /__/ (1)
Relative /__/ (2)
Relative /__/ (2)
HHP /__/ (3)
HHP /__/ (3)
TBA/__/ (4)
TBA/__/ (4)
MCHW /__/ (5)
MCHW /__/ (5)
Woman self or relatives /__/ (6)
Woman delivered alone /__/ (6)
Other (specify) /__/ (89)
Other (specify) /__/ (89)
21. What intervention was done at home:
22. Intervention by:
ORS /__/ (1)
Doctor/Midwife/Nurse /__/ (1)
Misoprostol (within 3 min after Delivery)/__/
Relative /__/ (2)
(2)
HHP /__/ (3)
Misoprostol (more than 3 min after
TBA/__/ (4)
Delivery)/__/ (3)
MCHW /__/ (5)
Other (specify) /__/ (89)
Other (specify) /__/ (89)
23. Please provide a summary of case management and outcome

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