Standards for Female and Male Sterilization Services - STATE ...

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58Standards for female and male Sterilization servicesFemale sterilizationExternal genitaliaPV examinationPS examinationUterus positionUterus sizeUterus mobilityCervical erosionAdnexaNormal..................................................... Abnormal....................................................Normal..................................................... Abnormal....................................................Normal..................................................... Abnormal....................................................A/V.......................................................... R/V..............................................................Mid position............................................ Not determined..........................................Normal..................................................... Abnormal...................................................Yes............................................................. No.................................................................Yes............................................................. No.................................................................Normal..................................................... Abnormal....................................................Comments........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Laboratory investigationsHaemoglobin level ...................................................................................................................................gm %Urine: Albumin Yes..........................................................1 No............................................................... 2Urine: Sugar Present...................................................1 Absent........................................................ 2Any other (specify) ..........................................................................................................................................................................................................................................................................................Name and signature of the examining doctor
Standards for female and male Sterilization services 59To be filled by the operating surgeon5. Checklist before conducting surgeryClient is within eligible ageClient is ever marriedClient has at least one child more than one year oldLab investigations (Hb, urine) undertaken are withinnormal limitsMedical status as per clinical observation is withinnormal limitsMental status as per clinical observation is normalLocal examination done is normalInformed consent is given by the clientExplained to the client that consent form has authorityas legal documentAbdominal/pelvic examination has been done in thefemale and the findings are within normal limits (WNL)Infection-prevention practices followed as per laid downstandardsYes...................................... No......................................Yes...................................... No......................................Yes...................................... No......................................Yes...................................... No......................................Yes...................................... No......................................Yes...................................... No.......................................Yes...................................... No......................................Yes...................................... No......................................Yes...................................... No......................................Yes...................................... No......................................Yes...................................... No......................................6. Preoperative preparationFastingYes................................................. No......................................................Passed urineYes................................................. No......................................................Any other (specify) ................................................................................................................................................................................................................................................7. Anaesthesia/analgesiaType of anaesthesia givenTimeDrug nameDosageRouteLocal only...............................................................................................................................Local and analgesia................................................................................................................*General, no intubation........................................................................................................*General, intubation..............................................................................................................*Any other (specify)......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................*Signature of anaesthetist in case of regional or general anaesthesia
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DR. (SMT.) M.S. JayalakshmiDeputy C
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