N˚ | Question | Answers’s modalities | Code | |
I-PATIENT IDENTIFICATION | ||||
102 | Age group | 1 = 15 - 19; 2 = 20 - 24; 3 = 25 - 29; 4 = 30 - 34; 5 = ≥35 | /__/ | |
105 | Level of education | 1 = Analphabetic; 2 = Primary level; 3 = Secondary level; 4 = Graduate study; 5 = N.I | /__/ | |
106 | Marital status | 1 = Married; 2 = Single; 3 = Divorced; 4 = Widowed 5 = Concubine; 6 = N.I. | /__/ | |
107 | Occupation | 1 = Housewife; 2 = Government employee; 3 = Pupil; 4 = Student; 5 = Trade; 6 = Dressmaker 7 = Hairdresser; 8 = Teacher; 9-Call box; 10 = Other..................... (Specify); 11 = N.I |
/__/ | |
II-ADMISSION CONTEXT | ||||
208 | Time of entry | /________/ |
| |
209 | Receiving structure | 1 = YGOPH; 2 = YCH | /__/ | |
210 | Referring structure | 1 = D.M.C; 2 = D.H; 3 = Private H.C; 4 = Reference hospital; 5 = Faith-based HC; 6 = N.I | /__/ | |
212 | Mode of admission | 1 = Self-referred; 2 = Family-referred; 3 = Referred; 4 = Deceased; 5 = 2 + 3; 6 = 2 + 3 + 4 | /__/ | |
214 | Transport conditions | 1 = Ambulance; 2 = Taxi; 3 = Personal car; 4 = Other:................... (Specify); 5 = N.I | /__/ | |
215 | Pre-transfer preparation | a-PVL; 1 = Yes; 2 = No | /__/ | |
h-No treatment received; 1 = Yes 2 = No 3 = N.D | /__/ | |||
III-OBSTETRIC AND PREGNANCY HISTORY | ||||
320 | Gravida | 1 = /__/; 2 = N.I (Not informed) | /__/ | |
321 | Parity | 1 = /__/; 2 = N.I (Not informed) | /__/ | |
324 | Term of current pregnancy | /____ /Week /_____/ Days |
| |
325 | ANCs | 1 = Yes; 2 = No | /__/ | |
326 | Number of ANCs | /____/ | /__/ | |
IV-CLINICAL DIAGNOSIS | ||||
430 | Diagnostic hypotheses and evolution | a-Hypovolemic shock; 1 = yes 2 = no | /__/ | |
b-Septic shock; 1 = yes 2 = no | /__/ | |||
c-Ruptured Ectopic Pregnancy; 1 = yes 2 = no | /__/ | |||
d-Disseminated Intravascular Coagulation (DIC); 1 = yes 2 = no | /__/ | |||
e-Stroke; 1 = yes 2 = no | /__/ | |||
f-Post partum haemorrhage; 1 = yes 2 = no | /__/ | |||
g-Placenta Abruptio; 1 = yes 2 = no | /__/ | |||
h-Haemorrhagic placenta previa | /__/ | |||
i-Severe pre-eclampsia; 1 = yes 2 = no | /__/ | |||
j-Eclampsia; 1 = yes 2 = no | /__/ | |||
k-Uterine rupture; 1 = yes 2 = no | /__/ | |||
l-Incomplete abortion; 1 = yes 2 = no | /__/ | |||
m-Septic abortion; 1 = yes 2 = no | /__/ | |||