Illustrative Maternal Health Card

ANC No.______Date enrolled in HIV care______Unique HIV care/ART No.______Health facility ______Preferred site of delivery______Name______Age______Mode of transportation______Address: ______District:______Village______Notes ______Marital Status______Gravida______Para______LMP______EDD ______Contact person/next of kin ______

History of previous pregnancy and outcome of current pregnancy

No. Year Place of Gestational age at History of Mode of Birth weight Sex Birth outcome: Serious obstetric delivery delivery/abor-tion prolonged delivery complications labour Alive/Stillbirth (Y/N) Fresh/macerated

1 Antenatal (ANC) → Delivery (circle date) → Postpartum (PP)

1st 2nd visit 3rd visit 4th visit 5th visit 6th visit 7th visit 8th 9th 10th visit visit visit visit Date Date (dd/mm/yy) of visit, current pregnancy TT1 Gestation in weeks (ANC)/Weeks postpartum TT2 Weight

LabourBlood Pressure and Delivery (transfer from labour record) TT3 InfantFundal feedinght (ANC) intention:  EBF RF MF TT4 DateFetal ofPresentation delivery______(ANC) TT5 Uterus firm (PP) Place of delivery: Home Hospital Health Centre Other ______Clinical Notes/Additional Postnatal Visits ConductedHIV test result by: (Positive, Nurse/Midwife Negative, Known positive, Doctor Unknown) TBA Other WHO clinical stage Condition of mother______ART Eligible?  ______CD4 (record Sent; result, result given to Conditionmother) of baby______Infant feeding: Counselling (Y/N) ______Mode of delivery (indication if operative delivery)______Additional Date PostpartumFP: Counselling complications:; PP write method orPPH? No FP  ______interventions ARV adherence counselling (Y/N) ARV given during delivery: Sd- NVP  AZT+3TC  ART  None  ______ITN ARV adherence (Good, Fair, Poor) ARV tail (AZT 300 mg +3TC 150 mg twice daily x 7 days) dispensed:  CTX started Hgb (record result) ______Postpartum- mother- outpatient visit INH Blood group and RH (record result) prophylaxis/TB ProblemSyphilis test with result breast (Positive, feeding Negative, ______Unknown) RX started ______PerineumSyphilis treatment ______given/No. doses given (IM Lochia______PCN 1st, 2ndor 3rd) Mebendazol

BreastsUrine protein ______Vit A(Units) ______InfantIron folate feeding dispensed practice: (Y/N) and EBF No. dispensed  RF  MF  Malaria IPT (1st, 2nd, 3rd dose) Infant Slept under ITN the previous night(Y/N) Birth weight ______Sex: Female Male ARVs dispensed mother (AZT, Sd- NVP, AZT+ 3TC; or ART) BabyNext appointmentImmunization: (dd/mm/yy )BCG OPV 0 Vitamin K: Yes No Referral site______ARV prophylaxis: Given at delivery:  Sd-NVP  AZT first dose Reason for referral______

AZT dispensed to baby:  None  1 week  4 weeks 2  3