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OBGY OPD in an Indian District Hospital - Complete Practical Guide

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WHO COMES TO OBGY OPD - Patient Categories

1. ANC (Antenatal Care) cases - registered or new
2. PNC (Postnatal Care) cases - post-delivery follow-up
3. Gynaecology cases - menstrual problems, prolapse, discharge, infertility, lumps, pain
4. Family Planning - IUCD insertion/removal, counselling, sterilization counselling
5. MTP cases - first and second trimester, medical or surgical
6. Adolescent / Reproductive Health - dysmenorrhoea, PCOS, puberty issues
7. Cancer screening - Pap smear, VIA/VILI, Colposcopy referrals
8. MLC (Medico-Legal Cases) - rape, sexual assault - handled separately

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SECTION 1: PATIENT REGISTRATION AT COUNTER

• OPD ticket with unique OPD number and date
• If new ANC: MCP card (Mother and Child Protection Card) issued free under JSSK
• If new gynaec: OPD case paper (yellow/white slip depending on state format)

• Name, age, address, husband's name
• Chief complaint (brief)
• RCH ID number (if previously registered on RCH portal/ANMOL app)

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SECTION 2: BEFORE YOU SEE THE PATIENT - Nursing Station Work

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SECTION 3: TAKING HISTORY

3A - For ANC Patients (New Registration)

• LMP (Last Menstrual Period) - calculate POG (Period of Gestation): Naegele's Rule = LMP + 9 months + 7 days = EDD
• Cycle regularity, duration, flow before pregnancy
• Any bleeding per vaginum in this pregnancy

• G = Gravida (total pregnancies including current)
• P = Para (deliveries after 28 weeks)
• L = Living children
• A = Abortions (spontaneous or induced)
• For each previous pregnancy: mode of delivery, complications, birth weight, outcome

• Diabetes, hypertension, thyroid, heart disease, epilepsy, TB, asthma
• Previous surgeries, blood transfusions
• Drug allergies

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3B - For Gynaecology Patients

• Age of menarche
• Cycle: regular/irregular, duration (e.g., 3-4/28-30 days)
• Flow: normal/excess (menorrhagia)/scanty
• Intermenstrual bleeding (IMB), post-coital bleeding (PCB) - always ask
• Dysmenorrhoea: primary or secondary
• LMP

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SECTION 4: CLINICAL EXAMINATION

4A - General Examination (All Patients)

• Built and nourishment
• Pallor (conjunctivae, nailbeds) - grade as mild/moderate/severe
• Icterus (sclera)
• Oedema (pedal - graded +/++/+++)
• Cyanosis, lymphadenopathy, clubbing
• BP, Pulse, Temperature, Respiratory rate
• Thyroid palpation
• Breast examination (especially in gynaec cases - look for lumps, nipple discharge, skin changes)

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4B - Abdominal Examination (ANC)

• Shape, size, scars (previous LSCS scar), striae gravidarum, linea nigra

1. Fundal palpation - note fundal height in weeks (should match POG within ±2-3 cm in cm)
   • Rule of thumb: at 12 wks just above symphysis; 20 wks at umbilicus; 36 wks at xiphisternum
2. Lateral palpation (Lateral grip) - feel for back (firm, smooth) vs limbs (irregular, knobby) - determines lie (longitudinal/transverse/oblique)
3. First pelvic grip (Pawlik's grip) - feel presenting part above pelvis
4. Second pelvic grip - assess engagement (head 5/5 = free, 0/5 = fully engaged)

• Fetal Heart Sound (FHS) with Pinard fetoscope or Doppler
• Normal: 120-160 bpm
• Document: FHS heard/not heard, rate

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4C - Per Vaginum (PV) Examination

• Not routine in all ANC cases (but do at first visit for cervical assessment in high risk)
• Indicated: suspected labour, bleeding, discharge, assessment for post-dates, cervical incompetence

• Note: cervix (healthy/unhealthy/erosion/polyp/growth), discharge (colour, consistency), any bleeding
• Do Pap smear if due (every 3-5 years in women 21-65, or as per state protocol)
• Do VIA/VILI for cervical cancer screening (part of national cancer screening program)

• Uterine size, consistency, mobility, tenderness
• Adnexa (ovaries, tubes) - any mass, tenderness
• Cervix: os (closed/open), cervical excitation tenderness (if PID suspected)

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SECTION 5: INVESTIGATIONS TO ORDER

Routine ANC Investigations (All at First Visit)

Routine Gynaec Investigations

• USG pelvis (trans-abdominal ± transvaginal)
• Hb, CBC
• Pap smear (if not done in last 3 years)
• VIA/VILI
• Urine routine
• Additional as per case: hormonal profile (FSH, LH, prolactin for infertility/PCOS), thyroid, CBNAAT for TB, colposcopy referral

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SECTION 6: HIGH-RISK PREGNANCY - IDENTIFICATION AND COLOUR CODING

• Referred to FRU/District Hospital if at PHC level
• Followed up more frequently
• Birth plan discussed and documented

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SECTION 7: SPECIFIC PROTOCOLS

7A - First Visit ANC (New Registration)

1. History (full as above)
2. General + Abdominal + PV examination
3. Issue MCP card, fill all details
4. Register in ANC Register
5. Give RCH ID / register on ANMOL
6. Order all baseline investigations
7. Prescribe:
   • IFA tablets (Iron Folic Acid): 1 tab OD after meals from 2nd trimester, continue for 6 months postpartum (180 tablets minimum)
   • Folic acid 500 mcg OD in first trimester
   • Calcium 500 mg BD from 2nd trimester onwards
   • TT vaccination: TT1 on registration, TT2 after 1 month (or booster if vaccinated within 3 years) - now Td (Tetanus + diphtheria) under national programme
8. Counselling on: nutrition, rest, danger signs, institutional delivery, JSSK entitlements, JSY incentive
9. Fix next appointment (next visit at 14-26 weeks if first visit was before 12 weeks)

7B - Follow-up ANC Visit

1. Review complaints since last visit
2. Check all parameters: weight, BP, oedema, FHS
3. Review investigation reports from last visit
4. Abdominal examination: fundal height, presentation, FHS
5. PV if indicated
6. Update MCP card
7. Refill IFA, calcium tablets
8. Update ANC Register and HMIS data
9. Identify any new risk factors - upgrade colour sticker if needed

7C - Gynaecology Case

1. Full history and examination
2. Provisional diagnosis
3. Order investigations
4. Prescribe treatment / refer if needed
5. Fill OPD prescription slip (drug name, dose, duration - legibly)
6. Cancer screening: offer VIA/VILI and Pap smear (under NPCDCS - National Programme for Cancer, Diabetes, Cardiovascular Disease and Stroke)

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SECTION 8: MTP (MEDICAL TERMINATION OF PREGNANCY)

• Form C (Consent Form): Written, informed consent from the woman herself (not husband/family). For minors (<18 yrs) or mentally ill: guardian consent. Format is fixed - do not use a general consent form.
• Form I (Doctor's Certificate): Opinion of the RMP stating the reason for termination
• Form II (Monthly Statement): Head of hospital sends to CMO of district every month - number of MTPs performed
• Follow-up card: must be given to every patient receiving medical MTP (Mifepristone + Misoprostol)
• Confidentiality is mandatory - records kept secure for 5 years

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SECTION 9: FAMILY PLANNING OPD

IUCD (Copper T / CuT 380A)

• Consent (written)
• Menstrual history to confirm not pregnant, assess for PID
• Rule out contraindications: active PID, STI, unexplained vaginal bleeding, uterine anomaly
• Insert under aseptic technique
• Document in: FP Register, OPD paper, issue IUCD card to patient
• Counsel on: thread check after first period, when to return (pain, missed period, fever)

Sterilization Counselling

• Explain permanent nature
• Options: tubectomy (mini-lap / laparoscopic) vs vasectomy (husband)
• Written consent from the individual (not spouse) - mandatory
• Motivator is not to be involved in obtaining consent
• Register in FP register, HMIS data entry

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SECTION 10: PAPERWORK AND REGISTERS - COMPLETE LIST

Mandatory Registers at District Hospital OBGY OPD:

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Documents You Give the Patient:

• MCP card (for ANC patients) - patient keeps this always
• OPD prescription slip - signed, dated, legible
• Lab investigation request slips (free under JSSK)
• Referral slip (if referring to higher center) - duplicate: one with patient, one in register
• IUCD card (if IUCD inserted)
• Follow-up card (MTP medical method)
• Birth preparedness counselling booklet / danger signs pamphlet

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SECTION 11: HMIS REPORTING (Monthly)

• Number of ANC registrations (1st trimester, 2nd trimester, 3rd trimester)
• Number of ANC 4+ check-ups completed
• Number of TT1, TT2, Booster vaccinations given
• Number of IFA tablets distributed
• Number of Hb estimations done, number with Hb <11, <7
• Number with hypertension detected
• Number of high-risk pregnancies identified
• Number of MTPs (medical + surgical, trimester-wise)
• Number of IUCDs inserted/removed
• Number of sterilizations
• Number of Pap smears / VIA-VILI done
• Number of cancer screening referrals
• Number of deliveries (in the delivery register section)
• Number of maternal deaths (if any) + MDR initiated

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SECTION 12: DANGER SIGNS - ALWAYS COUNSEL AND DOCUMENT

• Severe headache, visual disturbances - suggests PIH/eclampsia
• Bleeding per vaginum at any time
• Fever with chills
• Severe abdominal pain
• Reduced or absent fetal movements after 28 weeks
• Facial/hand puffiness (oedema)
• Convulsions
• Labour before 37 weeks (preterm labour)

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SECTION 13: JSSK ENTITLEMENTS - KNOW AND COMMUNICATE

• Free ANC check-ups and investigations
• Free drugs and consumables
• Free diet during admission
• Free blood (if needed)
• Free transport: home to facility, inter-facility referral, drop back home
• Free delivery (normal + caesarean)
• Zero user charges

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SECTION 14: QUICK REFERENCE - PRESCRIPTION ESSENTIALS IN OBGY OPD

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SUMMARY WORKFLOW: ONE PATIENT IN OBGY OPD

Patient arrives → Registration counter (OPD slip, MCP card issued)
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Nursing station: weight, BP, urine dipstick, pulse
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You see patient: History → Examination → Working Diagnosis
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Investigations ordered (free slips for JSSK patients)
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Prescription written (legibly, signed, dated)
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Registers filled: OPD Register + ANC/FP/MTP Register (as applicable)
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Counselling: danger signs, JSSK, nutrition, next visit date
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MCP card updated and returned to patient
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Data entered in HMIS at end of day/week (or by data entry operator)

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• Keep a rubber stamp with your name/designation for prescriptions - saves time
• Write diagnosis and management clearly - medico-legal cases happen, your OPD note is evidence
• For every MLC, even if minor, immediately inform the MO-IC or CMO and fill the MLC register before any treatment
• Incomplete documentation in MTP register is a criminal offence under MTP Act
• If you suspect domestic violence, note it, offer referral to District One Stop Centre (OSC/Sakhi Centre)
• For Pap smears done at OPD, maintain a tracking register for results and follow-up - many centres lose samples