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FETOMATERNAL OUTCOME IN HIGH-RISK PREGNANCY WITH NON-REASSURING CARDIOTOCOGRAPH PAROPAKAR MATERNITY AND WOMENS HOSPITAL, THAPATHALI, KATHMANDU A. GENERAL INFORMATION 1.Study ID / Case Number: 2.Hospital Registration No.: 3.Date of Admission: 4.Date of Delivery: 5.Name (Initials only): 6.Age: 7.Address: 8.Phone Number: 9.Informed Consent Taken: □ Yes □ No 10.Assent (for minors): □ Yes □ No 11.Parental Consent (if minor): □ Yes □ No B. MATERNAL HISTORY 1. Obstetric History Gravida: Para: Abortion: Living: Last Menstrual Period (LMP): Expected Date of Delivery (EDD): Gestational Age at Admission: 2. Antenatal Care Booked / Unbooked: □ Booked □ Unbooked Number of ANC visits: Tetanus toxoid received: □ Yes □ No Iron/Folic acid supplementation: □ Yes □ No 3. High-Risk Factors (Check all that apply) □ Pregnancy-Induced Hypertension (PIH) □ Eclampsia □ Gestational Diabetes Mellitus (GDM) □ Oligohydramnios □ Polyhydramnios □ IUGR □ Rh-Negative Pregnancy □ BOH (Bad Obstetric History) □ Anemia □ Postdated Pregnancy (>40 weeks) □ PROM/PPROM □ Other: ________________________ 4. Past Obstetric History (Details of previous pregnancies) Year GA at Delivery Mode Outcome Remarks C. PRESENT PREGNANCY DETAILS Presenting Complaints: _____________________ Gestational Age on Admission: _______________ Labor Status: □ In Labor □ Not in Labor Rupture of Membranes: □ Yes □ No oIf Yes, Duration: __________ hours Meconium-Stained Liquor: □ Yes □ No Per Vaginal Findings: _____________________ CTG Indication: _____________________ D. CARDIOTOCOGRAPHY (CTG) FINDINGS Date & Time of CTG: Duration of CTG Monitoring: ______ min Baseline FHR: __________ bpm Variability: □ Absent □ Minimal □ Moderate □ Marked Accelerations: □ Present □ Absent Decelerations: □ None □ Early □ Variable □ Late □ Prolonged Sinusoidal Pattern: □ Yes □ No Saltatory Pattern: □ Yes □ No Overall CTG Interpretation: □ Reassuring □ Non-reassuring □ Ominous E. MANAGEMENT DECISIONS BASED ON CTG Intervention: o□ Emergency LSCS o□ Induction of Labor o□ Augmentation o□ Expectant Management Indication for Delivery: _____________________ Time from CTG to Delivery: __________ hrs F. DELIVERY DETAILS Date and Time of Delivery: ___________________ Mode of Delivery: □ Normal Vaginal Delivery □ Assisted Vaginal (Forceps/Vacuum) □ Cesarean Section Indication for Cesarean (if applicable): _____________________ Duration of Labor: __________ hrs Use of Oxytocin: □ Yes □ No G. MATERNAL OUTCOME Intrapartum Complications: □ PPH □ Fever □ Eclampsia □ Sepsis □ Other: __________ ICU/HDU Admission: □ Yes □ No Blood Transfusion Required: □ Yes □ No Length of Hospital Stay: __________ days Maternal Outcome: □ Stable □ Complicated □ Mortality H. NEONATAL OUTCOME Baby Sex: □ Male □ Female Birth Weight: __________ gm APGAR Score: o1 minute: _____ o5 minutes: _____ Meconium Aspiration: □ Yes □ No Resuscitation Required: □ Yes □ No NICU Admission: □ Yes □ No oIf Yes, Reason: ____________________ Neonatal Complications: □ Asphyxia □ Sepsis □ Hypoglycemia □ IUGR □ Death Neonatal Outcome: □ Alive □ Stillbirth □ Early Neonatal Death FINAL REMARKS Final Diagnosis: ____________________________ Summary of Fetomaternal Outcome: Signature Section Investigator’s Name & Signature: __________________________ Date of Entry Completion: _____________________