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

/__/