Postpartum Iucd Insertion Register Format

POSTPARTUM IUCD INSERTION REGISTER FORMAT

S. No / Indoor Reg No / Name / Age / Postal Address / Phone No / No. of Living Children / Date of PPIUCD Insertion / Counseled during(Tick appropriate column) / Name of Provider who inserted PPIUCD / Type of PPIUCD insertion
(Tick appropriate column) / Instrument used for insertion
(Tick appropriate column) / Due date for FU / Remarks
Antenatal Care / Early Labor / Postpartum Period / Post placental (within 10 min) / Immediate PP (within 48 hrs.) / Intra Caesarean / Manual / Long Placental Forceps (Kelly) / Sponge/ Ring Forceps

POSTPARTUM IUCD FOLLOW-UP(FU) REGISTER FORMAT

S. No / Indoor Reg No / Name / Age / Phone No / Date of PPIUCD insertion / Type of PPIUCD insertion
(Tick appropriate column) / Name of provider who inserted PPIUCD / Due date of FU / Actual date of FU / Type of FU
(Tick appropriate column) / Time of FU
(Tick appropriate column) / Finding of FU
(Tick appropriate column) / Action taken for complica-tions / Reason for removal / Remarks
Postpartum (within 10 min.) / Immediate PP (within 48 hrs.) / Intracesarean / Clinic Visit / Telephonic / Up to 6 weeks / After 6 weeks / Expulsion / Infection / Missing Strings / Other complaints (Specify) / No complaint

MONTHLY PPFP/PPIUCD SERVICES REPORT

Name of the Facility ______

Type of Facility-  Medical college District Hospital  FRU CHC 24x7 PHC

 Pvt Hospital Pvt Clinic

District ______State______

Reporting Period – From______(dd/mm/yyyy) to______(dd/mm/yyyy)

Item / Number
1)No. of women attending the ANC clinic
2)No of clients counseled for PPFP at ANC clinic
3)No. of deliveries conducted in the facility
a)Normal Deliveries
b)Caesarean
c)Assisted
TOTAL
4)No. of women counseled for PPFP during early labor (EL) and postpartum (PP) period
5)No. of deliveries with use of utero-tonic drug for AMTSL
a)Oxytocin
b)Misoprostol
c)Other (Specify)
TOTAL
6)No. of postpartum female sterilization performed
7)No. of PPIUCD Insertion
a)Postplacental (within 10 min)
b)Postpartum (within 48 hrs)
c)Intracesarean
TOTAL
8)No. of PPIUCD clients followed up
a)At Clinic
b)By Telephone
TOTAL
9)No of clients coming for Follow-up
a)Upto 6 weeks
b)After 6 weeks
10)No. of clients reporting
a)Expulsion
b)Infection
c)Missing Strings
d)Other Complaints (Specify)
e)No complaint
11) No. of PPIUCD removed(please specify the reasons for each removal in the space below)

Signature of the Head of Department

Seal and Date