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XY310440 Government of Western Australia Department of Health 6152 4301 6152 4012 Armadale 9391 2497 9391 2901 Bentley 9334 3627 9365 3529 Rockingham 9599 4740 HCCZXBKSWHPS *Booking midwife to highlight relevant hospital / contacts NWHPR 04/15 Australian Health Ministers’ Advisory Council South Metropolitan Health Service Version 1 April 2015 Other NATIONAL WOMAN-HELD PREGNANCY RECORD Fiona Stanley Sa South Metropolitan Area Health Service HOSPITAL Maternal Fetal Assessment Unit or Maternity ward Antenatal Clinic MR70 SERVICE m pl e National Woman-Held Pregnancy Record WHEN TO SEEK ADVICE Contact your lead maternity provider or hospital if you are worried or experience any of the following: Abdominal pain or sudden onset of back pain If you think labour has started Baby is moving less than usual Vaginal bleeding Fainting Swelling in your hands, feet and face first thing in the morning Fever Unusual headaches [severe/persistent] If your 'waters' (liquor) break; watery vaginal discharge Constant itching Urinary problems, including frequency or burning when passing urine Blurred vision Uncontrollable vomiting or diarrhoea, severe nausea You are worried e • Your Birth Registration, Centrelink and Medicare documents will be given to you following the birth of your baby • Discharge home after a vaginal birth is usually within 4 - 24 hours after birth pl • Women experiencing a caesarean section are planned for discharge 48 - 72 hours following birth • Occasionally, women may be transferred to another hospital for their continued care • Occasionally, women and babies who become unwell may be transferred to a tertiary hospital m • If you go home within 4 days of your birth your care will continue either by the hospital visiting midwifery service (if they have one), at another maternity hospital, as a hospital outpatient or with a community midwife or GP. Sa If care is transferred between hospitals then the receiving hospital is to place their phone contact details sticker here Department of Health & Ageing Australian Health Ministers’ Advisory Council This document was prepared under the auspices of the Australian Health Ministers’ Advisory Council. 2 Affix unique patient identification label in this box National Woman-Held Pregnancy Record Confidential Medical Record U.R: Surname: Given Name: Second Given Name: DOB Please take care of this Record as it may be the only official record of your pregnancy. You should bring this Record with you when you visit any health care professional and when you go into labour. It is best to carry the Record with you at all times. (If you don’t want to carry your Record, tell your midwife or doctor). The Record will be stored by the hospital or your lead maternity provider at the end of your pregnancy (you may request a copy). For URGENT Telephone advice call: Please remember in an EMERGENCY call: 000 (maternity provider should complete) Intended place of birth Midwife GP Shared care MGP Other Hospital Obstetric Team describe / m / Nominated lead maternity provider/team: Contact Details for lead maternity provider: Sa Change of Model of care, new Model/team Date of change: Alert for sensitive information Private obstetrician Collaborative care describe Date agreed: / / pl Model of Care ( ) / / e Intended place of birth: Intended place of birth changed to: Reason: / / Reason for change of Model: Management Plan Preferences for labour and/or birth to be noted here for discussion with your maternity provider. Can be left blank. GP Contact Details (if different to lead maternity provider) Name GP: GP Address: GP Phone: Phone Numbers & Websites Pregnancy, Birth & Baby Helpline 1800 88 24 36 DV Hotline 1800 200 526 DV WA Hotline 1800 007 339 QUIT Smoking Helpline 131 848 beyondblue Info 1300 22 4636 Lifeline 13 11 14 Alcohol & Drug Centre 1800 888 236 Australian Breastfeeding Association (ABA) 1800 6 8 6 2 6 8 6 1800 MUM 2 MUM Telephone Interpreter Services 13 14 50 Kimberley Aboriginal Interpreter Services 08 9192 3981 Pregnancy and Medication Helpline KEMH 08 9340 2723 8:30am – 5:00pm Mon to Fri www.health.wa.gov.au/havingababy www.breastfeeding.asn.au www.beyondblue.org.au 3 Affix unique patient identification label in this box ANTENATAL APPOINTMENTS, INCLUDING EDUCATION AND SPECIALIST REFERRAL U.R: Surname: Given Name: Second Given Name: DOB Time Where With Notes Sa m pl e Date 4 Affix unique patient identification label in this box U.R: PERSONAL HISTORY Surname: Given Name: Second Given Name: DOB Some questions about baby’s mother and father, and additional maternal contact person. Tick ( ) as appropriate (complete as applicable) Mother Marital Status Name: Reside with baby’s father? Yes No Relationship to baby’s mother: Relationship to baby’s mother: Yes Language: Business Hours: Mobile: Any workplace hazards? Born in Australia ( both if appropriate) N/A Yes No N/A Language: Single Defacto Married Separated / Divorced Business Hours: Business Hours: Mobile: Mobile: To be contacted in emergency: To be contacted in emergency: Yes No Yes No No Yes No Yes No Yes No N/A Aboriginal Torres Strait Islander (TSI) Not Aboriginal or TSI N/A Aboriginal Torres Strait Islander (TSI) Not Aboriginal or TSI N/A N/A Yes Sa Indigenous status No Single Defacto Married Separated / Divorced m Emergency contacts Yes Language: Single Defacto Married Separated / Divorced Occupation: Phone contact details No Name: e Interpreter needed? If Yes, specify language: Name: pl Preferred Name Additional maternal contact person Partner If born overseas, name of country: N/A Ethnicity Religious, ethnic or cultural considerations important to antenatal care (dietary, blood products, etc.) Details/NA N/A Tobacco use and exposure to passive smoking [current and recent past] (refer to screening tool) Have you ever smoked? Yes No Does anyone at home smoke? Yes No Alcohol, other drug use [current and recent past] (refer to screening tool) (Complete if living in maternal household) (Complete if living in maternal household) Completed by: (print name/designation) Date: / / 5 Affix unique patient identification label in this box Summary Booking BP: Pre-pregnancy (or 1st visit) weight: Weight at 28 week: Age: U.R: Height (cm): Surname: BMI: BMI at 28 week: Gravida Parity (20 or more weeks) Stillbirths Blood Group Neonatal Deaths Rhesus Alive now Antibodies Given Name: Second Given Name: DOB Prepregnancy 1st Score 2nd Score 3rd Score Date Significant History Audit-C EPDS ANAESTHETIC & SURGICAL HISTORY Tick () as appropriate if applicable Surgical History ❑ Cervix: (cone biopsy, Lletz procedure) ❑ Uterus: myomectomy ❑ Lower uterine segment caesarean ❑ Classical caesarean ❑ Ovaries/tubes – give details Breast: ❑ Reduction ❑ Implants ❑ Lumpectomy ❑ Mastectomy Pelvis: ❑ Prolapse repair ❑ Other pl Medications (inc. over-the-counter) Allergies e Medications / Substance Use (use assessment tool) Medical History q q q q q q q q q q q q q q q q q q m Folate: ❑ Preconception ❑ In pregnancy Alcohol (specify) Refer to Audit C Other: Anaesthetic History Marijuana/Speed/Heroin/Other ❑ Never ❑ Spinal ❑ Epidural ❑ Combined spinal and epidural ❑ Previous ❑ General ❑ Regional (i.e. pudendal block) ❑ Current ❑ Other – give details Sa Autoimmune conditions Blood disorders or clots Cancer Endocrine - diabetes, thyroid etc Gastrointestinal / liver conditions Genetic conditions q Past Heart disease q Present High blood pressure q Severe Mental Illness q Anxiety Incontinence q Schizophrenia Immunisations up to date q Bipolar Infectious diseases q Postnatal (PND) q Psychosis Kidney disease / UTI q Depression MRSA Screening Musculoskeletal or fractures Neurological conditions / epilepsy Psychiatric illness Respiratory disease Other Gynaecological Conditions (please circle) endometriosis, fibroids, polycystic ovarian syndrome, abnormal Pap test, Fertility problems/treatment, Involuntary fertility > 1 year ❑ Never had Pap Last Pap test / / Result: FGM: ❑ No ❑ Yes Type: ❑ 1 ❑ 2 ❑ 3 ❑ 4 Name: 6 Desig: Any anaesthetic problems or any problems relating to surgery? [e.g. back/jaw problems, adverse reaction to drugs] ❑ No ❑ Yes If yes, give details: History of blood transfusion(s)? ❑ No ❑ Yes ❑ Refused If so, give reason: Were there any problems with the blood transfusion? ❑ No ❑ Yes If yes, give relevant details: Will you accept a blood transfusion? ❑ No ❑ Yes Details: Have you ever had any dental care? ❑ Yes ❑ No In past 12 months: ❑ Yes ❑ No Have you any current dental problems? ❑ Yes ❑ No It is recommended you see a dentist at least once a year. Family History Blindness Blood disorders/clots Endocrine/diabetes Disability Deafness Genetic disorders Heart problems High BP/preeclampsia Perinatal loss, miscarriages Psychiatric illness Respiratory problems History Partner q q q q q q q q q q q q q q q q q q q q q q Other ..................................................................... Signature: Date / / TRIM Details of Past Pregnancies (in chronological order) Wks Outcome Sex Name Birth Type Weight Place Complications Peri Feeding Postnatal Pregnancy Screening Routine Blood Group/Rhesus Pregnancy Screening 36 wks Ferritin Red Cell Antibodies Ferritin Results Full Blood Picture Group B Strep swab m pl e No. Date Tick this box if sensitive information has not been documented q Yes q No q Yes q No q Yes q No Full Blood Picture As Required Hepatitis B Hepatitis C HIV (pre/post test counselling) Rubella Antibody Chlamydia q Yes q No Anti-D given q Not required q 28 weeks q 36 weeks Repeat Chlamydia STI screen q 36 weeks Haemoglobinopathy screening q Midstream Urine Varicella Vit D Screening Thyroid function Sa MRSA risk Syphilis 28 wks Full Blood Picture Red Cell Antibodies (Rh negative only) Diabetes Screen GTT @ Results Influenza Vaccine Date given: Pertussis Vaccine Date given: q Yes q No q Yes q No Other (specify) wks date Routine GTT @ 26 - 28 wks date 80-136 weeks 110-136 weeks 17-22 weeks Scan Date Gestation (wks) Indication Gestational age assessment & detection of multiple pregnancy Nuchal translucency screening Fetal anatomy (morphology) Results & Follow-Up q Low risk q High risk q Counselling q Amniocentesis/CVS considered q Referral Placenta q Anterior q Posterior q Fundal q Low lying q Other Fetus q Normal morphology q Referral q Other Other 7 TRIM Physical Examination Abdomen: Cardiovascular: Respiratory: Thyroid: Other: Mother c Hearing c Speech c Literacy c Other Infant Feeding Discussion c Vision c Mobility B/F duration c Vision c Mobility c Breast feeding c Breast feeding Other Supporting Person c Hearing c Vision c Mobility c Speech c Literacy c Other c Formula feeding c Formula feeding m Baby feeding choice this pregnancy Previous infant feeding methods Partner c Hearing c Speech c Literacy c Other pl Assistance needed with: e Referral to medical specialist/other N/A Yes No (e.g. dietician, diabetes educator, housing officer, mental health, physiotherapist, social worker, other [Refer to page 4]) Previous feeding issues Referral to Lactation Consultant offered Date sent c Declined c Offered breastfeeding class c Yes c No Provided with written information on breastfeeding and Baby Friendly Health Initiative c Yes c No Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name 8 Signature Next visit in: Designation weeks TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: pl m Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Next visit in: weeks Designation Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name Signature Next visit in: weeks Designation 9 TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: m pl Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Oedema Next visit in: weeks Designation Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name 10 Signature Next visit in: Designation weeks TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: pl m Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Next visit in: weeks Designation Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name Signature Next visit in: weeks Designation 11 TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: m pl Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Oedema Next visit in: weeks Designation Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name 12 Signature Next visit in: Designation weeks TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: pl m Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Next visit in: weeks Designation Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name Signature Next visit in: weeks Designation 13 TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: m pl Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Oedema Next visit in: weeks Designation Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name 14 Signature Next visit in: Designation weeks TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: pl m Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Next visit in: weeks Designation Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name Signature Next visit in: weeks Designation 15 TRIM Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: m pl Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Oedema Next visit in: weeks Designation Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name 16 Signature Next visit in: Designation weeks Please ( ): Natural or Assisted conception First day of Last Menstrual Period (LMP) Length of cycle days / LMP Estimated Date of Birth (EDB) / Agreed EDB / Calculated by (please print) / Certain Yes Regular: Uncertain Ultrasound Scan (USS) Date of scan / / No / / Name Changed EDB / Changed by (please print) Reason Name Designation / / Weeks pregnant USS Estimated Date of Birth (EDB) / / Date Contraception method/ceased / /40 / / Date / / Designation Calculating Estimated Date of Birth (EDB) The information above is needed to calculate the approximate date of your baby’s birth. This can be called estimated date of birth (EDB), estimated due date/estimated date of delivery (EDD), or estimated date of confinement (EDC). Most babies are born in the two weeks before or after their estimated date of birth. Because both the menstrual cycle and ultrasound result can be used to calculate the estimated date of birth, the date can change. However, the change should only be made by a health professional with considerable experience in antenatal care (NHMRC ANC Guidelines 2011). Date Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) e Notes: pl m Print name Signature Urine test Blood Registered Weeks Fundal Weight kg interpreter pregnant height cm Prot Gluc pressure Sa Date Next visit in: weeks Designation Oedema Fetal Presentation Engagement movements Fetal heart Y / NA Brief intervention offered for: Smoking: c Yes c NA c Declined Alcohol: c Yes c NA c Declined Other: c Yes c NA c Declined (i.e. substance misuse) Notes: Print name Signature Next visit in: weeks Designation 17 EDINBURGH EDINBURGH POSTNATAL POSTNATAL DEPRESSION DEPRESSION SCALE SCALE (EPDS) (EPDS) The The EPDS EPDS is is recognised recognised as as a a very very valuable valuable screening test to assist you and screening test to assist you and your your carers carers in in the detection of possible depression, the detection of possible depression, both both in in pregnancy pregnancy and and the the postnatal postnatal period. period. The The EPDS EPDS is is a a set set of of questions questions which which can can tell tell you you whether whether you you have have symptoms symptoms that that are are common common in in women women with with depression depression and anxiety during pregnancy and in the year following the and anxiety during pregnancy and in the year following the birth birth of of a a child. child. This This is is not not intended intended to to provide provide a a diagnosis diagnosis – – only only trained trained health health professionals professionals should should do do this. this. To To complete complete this this set set of of questions, questions, mothers mothers should should circle circle the the number next to the response which comes closest number next to the response which comes closest to to how how they they have have felt felt in in the the PAST PAST SEVEN SEVEN DAYS. DAYS. DATE DATE DATE (at (at 12 12 weeks weeks or or first first visit): visit): .................................................... .................................................... DATE (at (at 28 28 -- 30 30 weeks):............................................. weeks):............................................. st st 1 28 30 1 28 st 1 28 30 1st 28 -- 30 30 IN THE PAST 7 DAYS IN THE PAST 7 DAYS visit wks visit wks IN THE PAST 7 DAYS IN THE PAST 7 DAYS visit wks visit wks 6. 6. Things Things have have been been getting getting on on top top of of me: me: 1. 1. II have have been been able able to to laugh laugh and and see see the the funny side of things: funny side of things: •• As As much much as as II could could •• Yes, Yes, sometimes sometimes II haven’t haven’t been been coping coping as well as usual as well as usual •• Not Not quite quite so so much much now now •• Definitely Definitely not not so so much much now now •• No, No, most most of of the the time time II have have coped coped well well •• Not Not at at all all e •• No, No, II have have been been coping coping as as well well as as ever ever 7. 7. II have have been been so so unhappy unhappy that that II have have had difficulty sleeping: had difficulty sleeping: •• As As much much as as II always always did did •• Rather Rather less less than than II used used to to •• Definitely Definitely less less than than II used used to to 3. 3. II have have blamed blamed myself myself unnecessarily unnecessarily when things go when things go wrong: wrong: •• Yes, Yes, most most of of the the time time •• Yes, Yes, some some of of the the time time Sa •• Not Not very very often often •• Yes, Yes, sometimes sometimes •• Not Not very very often often •• No, not at at all all No, not m •• Hardly Hardly at at all all •• Yes, Yes, most most of of the the time time pl 2. 2. II have have looked looked forward forward with with enjoyment enjoyment to things: to things: •• No, No, never never 8. 8. II have have felt felt sad sad or or miserable: miserable: •• Yes, Yes, most most of of the the time time •• Yes, Yes, quite quite often often •• Not Not very very often often •• No, No, not not at at all all 4. 4. II have have been been anxious anxious or or worried worried for for no no good reason: good reason: 9. 9. II have have been been so so unhappy unhappy that that II have have been crying: been crying: •• Hardly Hardly ever ever •• Yes, Yes, quite quite often often •• No, No, not not at at all all •• Yes, Yes, sometimes sometimes •• Yes, Yes, very very often often •• Yes, Yes, most most of of the the time time •• Only Only occasionally occasionally •• No, No, not not at at all all 5. 5. II have have felt felt scared scared or or panicky panicky for for no good reason: no good reason: 10. 10. The The thought thought of of harming harming myself myself has has occurred to me: occurred to me: •• Yes, Yes, sometimes sometimes •• Sometimes Sometimes •• Yes, Yes, quite quite a a lot lot •• No, No, not not much much •• No, No, not not at at all all •• Yes, Yes, quite quite often often •• Hardly Hardly ever ever •• Never Never Cox, J.L., Holden, J.M., and Sagovsky, R. (1987). “Detection of postnatal depression: Development of the Cox, J.L., Holden, J.M., and Sagovsky, R. (1987). “Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale”. British Journal of Psychiatry 150:782-786 10-item Edinburgh Postnatal Depression Scale”. British Journal of Psychiatry 150:782-786 TOTAL: TOTAL: TOTAL ANXIETY SUBSCALE: 18 EDINBURGH POSTNATAL POSTNATAL DEPRESSION DEPRESSION SCALE SCALE (EPDS) (EPDS) MR312B MR312B EDINBURGH •• Yes, Yes, most most of of the the time time II haven’t haven’t been been able to cope at all able to cope at all 23 23 Affix unique patient identification label in this box U.R: ASSESSING ALCOHOL USE DURING PREGNANCY Surname: Given Name: Second Given Name: DOB Ask your client the following questions about their alcohol use to assess the level of risk. Add the scores for each question to get a total score and match the total score to the level of risk below. Score Q: Since becoming pregnant / last appointment, how often have you had a drink containing alcohol? 1 2 3 4 Never Monthly or less 2-4 times a month 2-3 times a week 4+ a week PrePregnancy Date: Date: Date: Gestation Gestation Gestation e 0 Date: Q: How many standard drinks containing alcohol do you have in a day when you are drinking? 1 2 1or 2 3 or 4 5 or 6 3 4 pl 0 7-9 10+ Q: How often do you have five or more standard drinks in one sitting? 1 2 Never Monthly or less Monthly Total Score: 4 Weekly Daily / almost daily Sa Level of Risk 3 m 0 Low risk of harm to women (total score 0-3) Medium risk of harm to women (total score 4-7) High risk of harm to women (total score 8+) Actions: a) Discuss score and provide feedback for low risk drinking for women. b) Assist by providing alcohol harm prevention and reduction resources. c) Offer to arrange a follow up session if needed. a) Discuss score and give feedback a) Discuss score and provide for risky drinking. feedback for high risk drinking. b) Discuss positives and negatives of taking action. c) Discuss tips, strategies and plan for taking action. d) Assist by providing alcohol harm prevention and reduction resources. e) Offer to arrange referral and follow-up session if needed. WARNING: People who score in the high risk range (8+) should not be told to stop drinking alcohol or cut down without seeing a doctor. b) Discuss the positives and negatives for taking action. c) Provide contact information for alcohol and other drug services, ADIS and a doctor. d) Assist by providing alcohol harm prevention and reduction resources. e) Offer to arrange referral and a follow-up session. Table continued over page 19 Affix unique patient identification label in this box U.R: ASSESSING ALCOHOL USE DURING PREGNANCY Surname: Given Name: Second Given Name: DOB Continuation of 'Level of Risk' table Lower risk of fetal harm (total score <1) Risk of fetal harm (total score 1-4) Higher risk of fetal harm (total score >5) • Advise that the safest choice is not to drink alcohol during pregnancy. • Advise that the safest choice is not to drink alcohol during pregnancy. Key messages: • Advise that the safest choice is not to drink alcohol during pregnancy. e • Advise that a score of 0 indicates • Advise that a score of 0 indicates • Advise that a score of 0 indicates no risk of alcohol-related harm to no risk of alcohol-related harm to no risk of alcohol-related harm to the developing fetus. the developing fetus. the developing fetus. • Commend women who have not consumed alcohol since becoming pregnant. • Commend women who have not consumed alcohol since becoming pregnant. • Advise women who have consumed small amounts (e.g. one or two standard drinks) of alcohol prior to or during pregnancy, that the risk to the developing fetus is low. • Advise women who have consumed small amounts (e.g. one or two standard drinks) of alcohol prior to or during pregnancy, that the risk to the developing fetus is low. • Advise women who have consumed small amounts (e.g. one or two standard drinks) of alcohol prior to or during pregnancy, that the risk to the developing fetus is low. m pl • Commend women who have not consumed alcohol since becoming pregnant. • Advise that the risk to the • Advise that the risk to the • Advise that the risk to the developing fetus is influenced by developing fetus is influenced by developing fetus is influenced by maternal and fetal characteristics maternal and fetal characteristics maternal and fetal characteristics and is difficult to predict. and is difficult to predict. and is difficult to predict. • Advise that the risk of harm to the developing fetus increases with increasing the amount and frequency of alcohol consumption. • Advise that the risk of harm to the developing fetus increases with increasing the amount and frequency of alcohol consumption. • Offer to arrange a follow-up session if needed. • Offer to arrange a follow-up session if needed. • Offer to arrange a follow-up session if needed. Sa • Advise that the risk of harm to the developing fetus increases with increasing the amount and frequency of alcohol consumption. People with health problems such as diabetes or are on medication that interacts with alcohol should seek advice from their doctor. The Alcohol and Drug Service (ADIS) is a free 24-hour, confidential, telephone counselling, information and referral service available state-wide on: (country toll-free) 1800 198 024 or (metro) 08 9442 5000. 20 Affix unique patient identification label in this box U.R: Med Rec. Rec. No: No:............................................................................. ............................................................................. Med Surname: TOBACCO SMOKING TOBACCO SMOKING SMOKING ASSESSMENT ASSESSMENT ASSESSMENT ERREE E H H L BBEEL Second Given Name: A A L L Given Names: ............................................................................. X Given Names: ............................................................................. IX DOB AAFFFFI Surname: .................................................................................... Given Name: Surname: .................................................................................... Sex:.............................. ..............................D.O.B. D.O.B................................................... .................................................. Sex: smoked? 1. Have you ever smoked? home smoke? smoke? 2. Does anyone at home Yes Yes Yes Yes No No No No to both both of of these these questions questions you you don’t don’t need needto toanswer answerany anymore morequestions questionsabout aboutsmoking. smoking. If you answered no to to either either 11 or or 22 above above please please answer answer the the following followingquestions. questions. If you answered yes to You will be offered information information about about the the benefits benefits of of quitting quitting and andthe thepossible possiblerisks risksto toyour yourhealth healthofofsmoking smoking smoking. and passive smoking. Within Within 55 min min 5-30 5-30 min min 31-60 31-60 min min 60+ 60+ min min 10 10 or or less less 11 11 –– 20 20 21 21 –– 30 30 31 31 or or more more 33 22 11 00 00 11 22 33 Dependence Dependence Nicotine NicotineReplacement Replacement Level Therapy Level Therapy(NRT) (NRT)Dosage Dosage pl How soon after waking waking do do you you smoke your first cigarette? cigarette? Offer Offerappropriate appropriatelevel levelofofNRT NRTaccording accordingtotolevel levelofofdependence dependence Consider ate Considercontraindications contraindications&&precautions precautions- -refer refertotoMO MOif ifappropri appropri ate High High or or Moderate Moderate Patches: Patches:21mg/24 21mg/24oror15mg/16hr 15mg/16hrPatches: Patches:21mg/24hr 21mg/24hr Inhaler: oror15mg/16hr Inhaler:6-12 6-12cartridges/day cartridges/day 15mg/16hr AND AND Lozenge: Lozenge:4mg 4mg Gum: Gum:44mg mg Lozenge/gum: Lozenge/gum:2mg 2mg Low Lowto to moderate moderate Patches: Patches:14mg/24 14mg/24oror10mg/16hr 10mg/16hrPatches: Patches:14mg/24hr 14mg/24hr Inhaler: oror10mg/16hr Inhaler:6-12 6-12cartridges/day cartridges/day 10mg/16hr AND AND Lozenge: Lozenge:2mg 2mg Gum: Gum:22mg mg Lozenge/gum: Lozenge/gum:2mg 2mg m How many cigarettes cigarettes aa day day do do you you smoke? Low Low Total Total Score Score Dependence 1-2 1-2 == very very low low Score 3 == low low to to mod mod Combination Combination Therapy Therapy May Maynot notneed needNRT NRTMonitor Monitorfor for withdrawal withdrawalsymptoms symptoms Patches: Patches:7mg/24hr 7mg/24hroror5mg/16hr 5mg/16hr Lozenge: Lozenge:2mg 2mg Gum: Gum:2mg 2mg 44 == moderate moderate 55 ++ == high high Health Health Care Care Workers Workers to to assess assess your your plan plan and andsuccess successat atall allopportune opportunevisits. visits. Sa Assessment by Health Health Care Care Worker Worker Date Date // // // // // // // // // / / // // // // // // Gestation Gestation in in weeks weeks II am am an an ex ex smoker smoker // II quit quit since since finding finding out out II was was pregnant pregnant Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Interested Interested in in quitting quitting Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Planning Planning to to quit quit date date // // // // // // // // // / / // // // // // // Recently Recently quit quit -- date date // // // // // // // // // / / // // // // // // Number Number of of cigarettes cigarettes smoked per smoked per day day Support Support literature literature given given or or offered / Advice given offered / Advice given Yes Yes No No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Intermediate Intermediate support support given given Yes Yes No No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Other Other comments comments Seen by: Seen by: (name & designation) (name & designation) TOBACCO SMOKING SMOKING ASSESSMENT ASSESSMENT TOBACCO Please Please tick tick one one box box for for each each question question MR215.10 MR215.10 Fagerstrom Test for Nicotine Nicotine Dependence Dependence e following statements statements best best describes describes your your smoking smokinghabits? habits? Which of the following Yes No I smoke daily Yes No have recently recently cut cut down down Yes No I smoke daily, but have Yes No in aa while while Yes No I smoke every once in Yes No 19 21 19 Affix unique patient identification label in this box U.R: Surname: TIPS TO HELP YOU QUIT SMOKING Given Name: Second Given Name: DOB All health professionals agree that pregnant women should not smoke. When a pregnant women smokes the toxic chemicals in cigarettes cross the placenta to the baby. To help with quitting many smokers need support. You may feel confused about quitting. Most people know it’s bad for them, but enjoy smoking, while others are frightened and don’t have the confidence to quit. Below are a few suggestions that might help you. There are many benefits to quitting (e.g. improved health for you and your baby, saves money). It helps to write a list of your reasons for quitting: e My quit date: pl My quitting methods (tick one): FF Cold turkey (stopping completely) FF Cutting down or postponing (gradually reducing the number of cigarettes smoked each day or delaying your fist cigarette by an hour each day) Strategies I can use to avoid smoking (tick one or more): FF Substitution (drink water, eat a healthy snack, deep breath) m FF Distraction (go for a walk, read a book, watch a movie, call a friend) FF Break the association – be aware of why you smoke and break the link between smoking, feelings and habit (after a meal go for a walk instead of smoking) FF Positive self-talk (keep a list of why your quitting, remember your baby’s health, visualise yourself as a non-smoker) Sa Think of situations where you may want a cigarette and take the time now to write down some strategies to deal with the cravings. Situation Strategy These may also help: • Make your home and car smoke free • Try doing things where you cannot smoke (e.g. go to the movies, sit in smoke free areas in restaurants, go to the library, go for a swim) • Practice relaxation exercise (e.g. visualisation, meditation) • Keep your hands busy (e.g. stress ball) • Put something in your mouth instead of a cigarette (e.g. healthy snacks) • Remember the 4D’s (delay, drink water, deep breath, do something else) • Call the Quitline 131 848, see your doctor or midwife, find a support group/friend • Be kind to yourself and reward yourself for progress • Read the information in your “Care for my air” pack • Stay positive – you can do it! All Public Metropolitan Hospitals are non smoking facilities. Smoking is prohibited anywhere on site. If you feel this will be an issue for you when you come into hospital please discuss this with your midwife or doctor so they can arrange some nicotine replacement therapy. 22 Affix unique patient identification label in this box INFORMATION & CONSENT FOR NEWBORN CARE Women and Newborn Health Service U.R: Surname: RE E H Second Given Name: Surname: ................................................................. (Vitamin K, Hepatitis B, and InFORMAtIOn & COnsEnt EL B Newborn Blood Spot Screening) A DOBForename: FOR nEwBORn CARE ............................................................... XL I F AF D.O.B. ................................ (Vitamin K, Hepatitis B & newborn screening test) Gender: ...................... King Edward Memorial Hospital Rec. No: .......................................................... GivenMed Name: this form is to be completed giving due consideration to the “Consent to Treatment Policy for the Western Australian Health System” Vitamin K Consent Declaration of Health Practitioner (to be completed by the clinician obtaining consent) e F I have recommended the administration of Vitamin K. I have discussed the proposed procedure, benefits, risks and outcomes with the parent / guardian. I have also explained the risks of not having Vitamin K to the parent / guardian. The parent / guardian and Medical Research information F The guardian has has been beenprovided providedwith withthe theNational WomenHealth and Newborn Health ServiceCouncil information leaflet leaflet specific to Vitamin K. He or she has been asked to read the information provided and to advise the specific to Vitamin K. He or she has been asked to read the information provided and to advise me, theme, health health practitioner obtaining consent for the procedure if further information is required. practitioner obtaining consent for the procedure if further information is required. Full Name (print) _____________________________________________________ Position / Title __________________________ m Please read the information carefully and tick the following to indicate that you have understood and agree with the information provided to you. Any specific concerns should be discussed with your health practitioner prior to signing the consent form. F The health practitioner has explained the benefits, risks and outcomes of Vitamin K with me, including the risks of not having Vitamin K. F II have received, received, read readand andunderstand understandthe the information provided to me in the Women and Newborn Health written information provided to me. Service Vitamin K information leaflet. Parent / Guardian Consent Sa F I consent to the baby having a single intramuscular Vitamin K dose. OR F I wish for the baby to receive an oral dose of Vitamin K. I therefore undertake to accept the responsibility of ensuring that the baby receives a total of 3 oral doses of Vitamin K and will arrange this with my family doctor or Child Health Nurse. OR F I DO nOt wish the baby to receive Vitamin K following birth. Parent / Guardian Full Name _________________________________________ Relationship to patient __________________ Parent / Guardian Signature__________________________________________ Date KE022 09/11 ___________________________________ 23 MR216 InFORMAtIOn & COnsEnt FOR FOR nEwBORn CARE MR30.9 INFORMATION & CONSENT NEWBORN CARE Parent / Guardian Declaration pl Signature ____________________________________________________________ Date ____________________________________ Affix unique patient identification label in this box INFORMATION & CONSENT Women and Newborn Health Service Women and Newborn Health Service King Edward Memorial Hospital FORKing NEWBORN Edward Memorial CARE Hospital In FORMAt IOn & C Ons Ent In FORMAt IOn & C Ons Ent FOR nEK,w BORn ARE (Vitamin Hepatitis B, C and FOR nE w BORn C ARE Newborn Blood Spot Screening) U.R: E ER E H R L E E H AB EL L B X A I FIX L AF F A F Med Rec. No: .......................................................... Surname: Med Rec. No: .......................................................... GivenSurname: Name: ................................................................. Surname: ................................................................. Second Given Name: Forename: ............................................................... Forename: ............................................................... (Vitamin K, Hepatitis B & n ewborn s creening t est) DOB Gender: ...................... D.O.B. ................................ (Vitamin K, Hepatitis B & n ewborn s creening t est) Gender: ...................... D.O.B. ................................ Birth Hepatitis B Immunisation Consent Birth Hepatitis B Immunisation Consent Declaration of Health Practitioner (to be completed by the clinician obtaining consent) m pl e Declaration of Health Practitioner (to be completed by the clinician obtaining consent) I have recommended the administration of the Birth Hepatitis B immunisation. I have discussed the proposed I have recommended the administration of the Birth Hepatitis B immunisation. I have discussed the proposed the Birth Hepatitis B immunisation to the parent / guardian. the Birth Hepatitis B immunisation to the parent / guardian. The parent / guardian has been provided with the National Health and Medical Research Council information The parent / guardian has been provided with the National Health Medicalprovided Research Council information leaflet specific to Hepatitis B. He or she has been asked to read the and information and to advise me, the leaflet specific to Hepatitis B. He or she has been asked to read the information provided and to advise me, the health practitioner obtaining consent for the procedure, if further information is required. health practitioner obtaining consent for the procedure, if further information is required. Full Name (print) _____________________________________________________ Position / Title __________________________ Full Name (print) _____________________________________________________ Position / Title __________________________ Signature ____________________________________________________________ Date ____________________________________ Signature ____________________________________________________________ Date ____________________________________ Parent / Guardian Declaration Parent / Guardian Declaration Please read the information carefully and tick the following to indicate that you have understood and agree with Please read the information carefully and tick the following to indicate that you have understood and agree with prior to prior to signing the consent form. signing the consent form. with me, including the risks of not having the Birth Hepatitis B immunisation. me,received, includingread the risks not havingthe the information Birth Hepatitis B immunisation. with I have and of understand provided to me in the National Health and Medical Research I have received, and B understand information provided to me in the National Health and Medical Councilread Hepatitis informationthe leaflet. Research Council Hepatitis B information leaflet. Newborn Blood Spot Screening Consent Parent / Guardian Consent Newborn Blood Spot Screening Consent Parent / Guardian Consent I consent to the baby having the intramuscular Birth Hepatitis B immunisation. I consent to the baby having the intramuscular Birth Hepatitis B immunisation. I DO NOT wish the baby to receive the Birth Hepatitis B immunisation. I DO NOT wish the baby to receive the Birth Hepatitis B immunisation. Parent / Guardian Full Name _________________________________________ Relationship to patient __________________ Parent / Guardian Full Name _________________________________________ Relationship to patient __________________ Parent / Guardian Signature__________________________________________ Date ___________________________________ Parent / Guardian Signature__________________________________________ Date ___________________________________ Newborn Blood Spot Screening Consent Newborn Blood Spot Screening Consent Declaration of Health Practitioner (to be completed by the clinician obtaining consent) Sa Declaration of Health Practitioner (to be completed by the clinician obtaining consent) I have discussed the purpose, procedure and outcomes of the Newborn Blood Spot Screening with the parent I have /discussed purpose, procedure outcomes of according the Newborn Bloodcriteria: Spot Screening with the guardian. Ithe have discussed the needand for repeat testing to weight Day 14 (<1500gm) parent I have discussed the need for repeat testing according to weight criteria: Day 14 (<1500gm) and Day/ guardian. 28 (<1000gm) 28 /(<1000gm) and The Day parent guardian has been provided with the WA Screening Program information leaflet specific to the The parent / guardian has beenHe provided the WA Screening information leaflet to me, the Newborn Blood Spot Screening. or she with has been asked to read Program the information provided andspecific to advise Newborn Blood Spot Screening. He or she has been asked to read the information provided and to advise me, the health practitioner obtaining consent for the procedure, if further information is required. the health practitioner obtaining consent for the procedure, if further information is required. Full Name (print) _____________________________________________________ Position / Title __________________________ Full Name (print) _____________________________________________________ Position / Title __________________________ Signature ____________________________________________________________ Date ____________________________________ Signature ____________________________________________________________ Date ____________________________________ Parent / Guardian Declaration Parent / Guardian Declaration Please read the information carefully and tick the following to indicate that you have understood and agree with Please read the information carefully and tick the following to indicate that you have understood and agree with prior to prior to signing the consent form. signing the consent form. Newborn Blood Spot Screening including the risks of not having the test carried out. Newborn Blood Spot Screening including the risks of not having the test carried out. I have received, read and understand the information provided to me in the WA Screening Program information Ileaflet have have specific received, read and understand understand the information written information me. received, and the providedprovided to me intothe WA Screening Program information toread the Newborn Blood Spot Screening. leaflet specific to the Newborn Blood Spot Screening. Parent / Guardian Consent Parent / Guardian Consent I consent to the baby being given the Newborn Blood Spot Screening. the the baby being given thethe Newborn Blood Spot Screening. II consent DO NOT to wish baby to be given Newborn Blood Spot Screening. I DO NOT wish the baby to be given the Newborn Blood Spot Screening. Parent / Guardian Full Name _________________________________________ Relationship to patient __________________ Parent / Guardian Full Name _________________________________________ Relationship to patient __________________ Parent / Guardian Signature__________________________________________ Date ___________________________________ Parent / Guardian Signature__________________________________________ Date ___________________________________ 24 22 Affix unique patient identification label in this box U.R: Surname: NEWBORN HEARING SCREEN Given Name: Second Given Name: DOB Parent consent and screening record It is strongly recommended that all newborn babies are screened for hearing loss at birth. Information brochure received c (please tick) Please sign the following authority so that your baby can be screened. I (please print full name) would like my baby to be screened for hearing loss and understand that if there are any concerns about my baby’s hearing, a referral will be made to a paediatric audiologist. e I have read and understood the information about the hearing screening program. My questions have been answered to my satisfaction. I understand that I may decline further hearing screening at any stage and this will not interfere with access to routine care. pl I agree to health professionals such as my GP, child health nurse and paediatrician being notified of the results if there are concerns about my baby’s hearing. I understand that the results of the screen will be stored in an approved Newborn Hearing database. I agree that the research data generated by the program may be published, provided that names are not used. Parent m Signed Guardian (please circle) Date Sa Aboriginal or Torres Strait Islands status: Aboriginal TSI Unknown NEWBORN SCREENING TEST CONSENT For data collection purposes please provide the following information: (please circle) OR I (please print full name) DO NOT agree to my baby being screened for hearing loss. I understand that if my baby has a hearing loss, delayed detection and treatment may result in poor language and learning outcomes. Signed Parent Guardian (please circle) Date INTERPRETERS DECLARATION Specific language requirements (if any) Interpreter service used (please tick service used): c on-site c telephone I declare that I have interpreted the dialogue between the parent / guardian / proceduralist to the best of my ability and have advised them of any concerns about my performance. MR30.7 Full name (please print) NAATI number Signature Date 25 Affix unique patient identification label in this box U.R: Surname: NEWBORN HEARING SCREEN RESULTS Given Name: Second Given Name: DOB Newborn Details Surname First Name DOB Birth Hospital Time of Birth Gest. Age Screening Hospital Birth Weight c Yes c No Cultural and Linguistically Diverse (CALD) c Yes c No Consent signed Early Discharge Transferred Screen performed: Result Left Refer Pass Refer Pass Refer Pass Refer Left Pass Refer Right Pass Refer Left Unknown Screener Other Comments/ Risk Factors Inpatient Discharge F/U Screen Audiology Inpatient Discharge F/U Screen Audiology Inpatient Please complete this section for infants who require follow-up screen or referral Appointment Date & Time Appointment Location Parent Name/Guardian Phone/Address Parent Name/Guardian Phone/Address GP/Paediatrician Phone/Address Child Health Centre Comments Risk factors noted: 26 Screen Location Discharge F/U Screen Sa Right Deceased Action Pass Right TSI m Date & Time Aboriginal pl Declined c No Language Spoken Aboriginal or Torres Strait Islands status (please circle) Screen not performed: Please circle c Yes e Information brochure given Outpatient Outpatient Outpatient ‘Sleep Safe, Safe, ‘Sleep My Baby’ Baby’ My safe sleeping sleeping message message aa safe safe sleeping e Sixways waystotosleep sleepbaby babysafely safelyand and Six reducethe therisk riskofofsudden suddenunexpected unexpected reduce deathinininfancy: infancy: death Keephead head Keep andface face and uncovered uncovered Sa m pl Sleep Sleep babyon on baby back back Keepbaby baby Keep smokefree free smoke beforeand and before afterbirth birth after Sleepbaby baby Sleep safecot cot inin safe parents’ inin parents’ room room FIND OUT MORE FIND OUT MORE Safe Safe sleeping sleeping environment environment nightand and night day day Breastfeed Breastfeed BABY BABY FIND US ON FIND US ON FACEBOOK FACEBOOK Visit www.sidsandkids.org for more information Visit www.sidsandkids.org for more information 27 ‘Sleep Safe, My Baby’ a safe sleeping message safe wrapping e Infant wrapping is a safe and effective strategy that can be used to help babies sleep on their back during the first 6 months of life. Discontinue wrapping when baby can roll from back to tummy to back again during play (usually 4-6 months). Sa m pl Infant must be placed on their back Infant must not be bed-sharing if wrapped Infant must not be overdressed under the wrap FIND OUT MORE Infant’s face and head must not be covered wrap should beWrap firm but allow baby's should hands to be be free; firm but legs to stretch from hips; not the tight chest to breathe Wrap should be of muslin or light cotton material FIND US ON FACEBOOK Visit www.sidsandkids.org for more information 28 Affix unique patient identification label in this box SUGGESTIONS Suggestions For BIRTH Your Birth Plan FOR YOUR PLAN U.R:complete by 34 weeks after talking with your GP, midwife or Please obstetrician. You may tick more than one box These plans are flexible and Surname: can be complete changed at time , even labour and Please byany 34 weeks after through talking with your GP,birth midwife or obstetrician. You may tick more than one box These plans are flexible and Given Name: Birthing aids can be complete changed at time , even labour and Please byany 34 weeks after through talking with your GP,birth midwife or Bean bag Bath Shower TENS obstetrician. You may tick more than one box These plans are flexible and Second Given Name: Birthing aids can be changed at time , even through labour and Please complete byany 34 weeks after talking with your GP,birth midwife or Mirror Birth stool Gym ball obstetrician. You may tickBath more than one box These plans are flexible and Bean Shower TENS DOB bag Other: Birthing aidsat any time , even through labour and birth can be changed Suggestions For Your Birth Plan Mobility and positions forafter labour Please complete by 34 weeks talking with your GP, midwifeWalking or obstetrician. You may tick moreSquatting than one box These Suggestions For Your Birth Plan Standing Mobility and positions for plans are flexible and can(bed/floor be labour changed at any Fitball time, even Kneeling L ying mat) Suggestions For YourSquatting Birth Plan Walking Standing through labour birth Mobility andand positions for labour Mobility Other: and positions for labour Kneeling Lying (bed/floor mat) Walkingand positions Standing Mobility for labourSquatting Fitball m pl e Other: Kneeling and personal L ying (bed/floor Relaxation comfort mat) Walking Standing Squatting Fitball Other: Massage Oils Heat pack Other: Kneeling Lying (bed/floor Fitball Relaxation and personal comfort mat) Music-relaxation CD/Tapes Relaxation techniques Other: Massage Oils Heat pack Relaxation Other: and Relaxation and personal personal comfort comfort Music-relaxation CD/Tapes Relaxation techniques Massage Heat Massage Oils Oils Heat pack pack Relaxation and personal personal comfort comfort Relaxation and Other: Music-relaxation CD/Tapes Relaxation techniques BeMassage aware Oils Music-relaxation CD/Tapes Relaxation techniques Heat Massage Oils Heat pack pack Circumstances can change due to a long and/or difficult labour Other: Music-relaxation CD/Tapes CD/Tapes Relaxation techniques Other: Music-relaxation techniques BeRelaxation aware baby. or preterm You may require: Other: Circumstances can change due to a long and/or difficult labour Other: BeMore aware pain relief than you anticipated Bepreterm aware or baby. Youchange may require: Circumstances can due to a long and/or difficult labour Assisted birthcan [i.e.change forceps,due ventouse (vacuum)] Circumstances to a long and/or difficult labour Be aware Be aware or More preterm baby. may pain reliefYou than yourequire: anticipated or preterm baby. You may require: Circumstances can change due to a long and/or difficult labour Caesarean section (operative birth) Circumstances can change due to a long and/or difficult labour More pain relief than yourequire: anticipated birth [i.e. forceps, ventouse (vacuum)] or Assisted preterm baby. You may More pain relief than you anticipated or Episiotomy preterm baby. You may require: Assisted [i.e. forceps, ventouse Caesarean section (operative birth) (vacuum)] More painbirth relief than you anticipated Assisted birth [i.e. forceps, ventouse (vacuum)] Continuous monitoring More pain relief than you anticipated Caesarean section (operative birth) (vacuum)] Episiotomy Assisted birth [i.e. forceps, ventouse Caesarean section (operative birth) (vacuum)] Assisted birth [i.e.needs forceps, ventouse Episiotomy Support / Cultural Continuous monitoring Caesarean section (operative birth) Episiotomy Caesarean section (operative birth) Name of main support person: Name of second support person: Continuous monitoring Episiotomy Support / Cultural needs Continuous monitoring Episiotomy Continuous monitoring Support / Cultural needs Name of main support person: Name of second support person: Continuous monitoring Support / Cultural needs Name of main support person: Name of second support person: Comments: Support / Cultural Name of main supportneeds person: Name of second support person: Support / Cultural Name of main supportneeds person: Name of second support person: Comments: Name of main support person: Name of second support person: Comments: Comments: Comments: Comments: Mirror Birth stool Gym ball Bean bag Bath Shower TENS Birthing aids Other: Mirror Birth stool Gym ball Pharmacological pain Bean bag Bathrelief Shower TENS Other: Nit rous Oxide and Birth Oxygen Other: Mirror stool Gym ball Pharmacological pain relief Opiod Other: intramuscular injection Nit rous Oxide and Oxygen Pharmacological pain Epidural Pharmacological pain relief relief Opiod injection Nitrous rousintramuscular Oxide and and Oxygen Oxygen Nit Oxide Pharmacological pain relief Non-pharmalogical pain relief Pharmacological pain relief Epidural Opiod intramuscular injection Opiod intramuscular injection Nit rous Oxide and Oxygen Nitrous Oxide and Oxygen TENS Epidural Non-pharmalogical pain relief Opiod intramuscular Epidural Water Opiod immersion intramuscular injection injection TENS Non-pharmalogical pain Epidural Non-pharmalogical pain relief relief Shower Epidural Water TENS immersion TENS Non-pharmalogical pain relief Sterile water injections Non-pharmalogical Shower Water immersion pain relief TENS Water immersion TENS - 3rd stage management Placenta Shower Sterile water injections Water Shower Active immersion - oxytocic injection given to mother following baby’s Water immersion Sterile water Placenta -reduce 3rd injections stage management Shower birth towater the risk of bleeding as recommended by Sterile injections Shower Active water --oxytocic injection given to mother following baby’s Placenta 3rd injections stage management hospital guideline Sterile Placenta -reduce 3rd injections stage management Sterile birth towater the risk of bleeding as recommended by Active oxytocic injection given to mother following baby’s Modified active Placenta 3rd stage management Active --reduce oxytocic injection given to mother following baby’s hospital guideline birth to the risk of bleeding as recommended by Placenta - 3rd stage management Active oxytocic injection given to mother following baby’s birth to- reduce riskclamping of bleeding as recommended by Discuss delayedthe cord hospital guideline Active oxytocic injection given to mother following baby’s Modified active the birth to- reduce risk of bleeding as recommended by hospital guideline Physiological - as discussed with care givers (comments): birth to reduce the riskclamping of bleeding as recommended by Modified active hospital guideline Discuss delayed cord Modified active hospital guideline Discuss clamping Modifieddelayed active Physiological - ascord discussed with care givers (comments): Discuss delayed cord clamping Modified active Physiological as discussed with care givers (comments): Discuss delayed cord clamping Physiological - ascord discussed with care givers (comments): Discuss delayed clamping Physiological - as discussed with care givers (comments): Physiological - as discussed with care givers (comments): Plans for home discussed Sa I have discussed with my health provider Plans for home discussed Plans for home discussed Vaginal birth, expected discharge 4-24 hours I have discussed with my health provider Plans for home discussed IPlans have discussed with my health providerwithin 48-72 hours Caesarean birth, expected discharge for home discussed Vaginal birth, expected discharge 4-24 hours IPlans have discussed with my health provider Vaginal birth, expected discharge 4-24 hours24 hours, mother for homedischarge discussed My discussed preferred time. May be within I have with my health provider Caesarean birth, expected discharge within 48-72 hours Vaginal birth, expected discharge 4-24 hours48-72 hours and baby condition permitting Caesarean birth, expected discharge I have discussed with my health provider Vaginal birth, expected discharge 4-24within hours My preferred discharge time. May be within 24 hours, mother Caesarean birth, expected discharge 48-72 hours Visiting midwifery service My preferred discharge time. May be within hours, mother Vaginal birth, expected discharge 4-24 hours24 Caesarean birth, expected discharge within 48-72 hours and baby condition permitting andpreferred baby home condition permitting postnatal visiting /time. phone contact up to 5hours, days mother My discharge May be within 24 Caesarean birth, expected 48-72 hours My preferred discharge time. May be within 24 hours, mother Visiting midwifery service -- discharge Visiting midwifery and baby condition permitting Community Child service Health Services and baby condition permitting My preferred discharge time. May be within 24 hours, mother postnatal home // phone contact postnatal home visiting visiting phone contact up up to to 5 5 days days Visiting midwifery service --with GP 3 weeks postnatal check and baby condition permitting Visiting midwifery service Community Child Health Community Childvisiting Health// Services Services postnatal home contact postnatal home visiting phone contact up up to to 5 5 days days 6 weeksmidwifery postnatal check phone GP Visiting service -with 3 weeks postnatal check with GP 3 weeks postnatal check with GP Community Child Health Services Community Child Health Services postnatal home visiting / phone contact up to 5 days Postnatal depression information 6 weeks postnatal check with GP 6 3 weeks postnatal check with GP 3 weeks postnatal check withpre-existing GP Community ChildupHealth Services Postnatal follow regarding medical condition(s) Postnatal depression information Postnatal depression information weeks postnatal check with GP GP 6 weeks 3 postnatal check with Safe sleeping and SIDS information Postnatal follow up pre-existing Postnatal follow up regarding regarding pre-existing medical medical condition(s) condition(s) Postnatal depression information 6 weeks postnatal check with GP Discharge time is by 10am Safe sleeping and SIDS information Postnatal follow aup regarding pre-existing condition(s) Postnatal depression information How to register compliment or complaintmedical about the service Discharge timeand is by 10am Safe sleeping SIDS information Postnatal and followquestions up regarding pre-existing medical condition(s) Comments How to register a by compliment or complaint about the service Discharge timeand is 10am Safe sleeping SIDS information Comments and How to register a by compliment or complaint about the service Discharge timequestions is 10am Meals I will require normal hospital food Meals I will require a special diet: Meals I will require normal hospital food require normal hospital I will Meals Vegetarian Veganfood Diabetic Meals I will require a special diet: require normal hospital food I will a special diet: Halal Gluten free require normal hospital I will Meals Vegetarian Veganfood Diabetic II will require a special diet: Vegetarian Veganfood Diabetic require hospital Other: I will will require normal a special diet: Halal Gluten free Vegetarian Vegan Diabetic Halal Gluten free I will require a special diet: Vegetarian Vegan Diabetic DoOther: not bring in food to be reheated or stored on the ward Halal Gluten free Other: Vegetarian Vegan Diabetic Halal Gluten free Discuss care Other: Do not bring in food to be reheated or stored Halal Gluten free Other: Do not bring in food to be reheated or stored on on the the ward ward Involvement of student doctors Other: Discuss care Do not bring in food to be reheated or stored on the Discuss Do notcare bring of in student food to be reheated stored onofthe ward ward Involvement midwives andorcontinuity Involvement of student doctors Involvement of student doctors carer experience Do not bring in food to be reheated or stored on the ward Discuss care care Discuss Involvement of student midwives and continuity of Involvement of student midwives and continuity of Involvement of student doctors Parent education classes Involvement Discuss care of student doctors carer carer experience experience Involvement of Hospital tours Involvement of student student midwives doctors and continuity of Parent education Parentexperience education classes classes carer Skin-to-skin with baby at birth and continuity of Involvement of student midwives Hospital tours Parent education classes carer experience Skin-to-skin with baby at birth Hospital tours Parent education classes Skin-to-skin with baby at birth Hospital tours Skin-to-skin with baby at birth How to register a compliment or complaint about the service Comments and questions Comments and questions Awareness Statement Safety for you and your baby will be paramount in any decision making. I understand that this is a guide to my preferences and acknowledge that circumstances can change, sometimes suddenly. I Awareness Statement Safety for your will be in any decision making. Awareness Statement Safety for you youasand and your baby baby willprimary be paramount paramount anywill decision understand that if things do not happen indicated then the maternity in carer discuss making. options with me in consultation with II understand that this is a guide to my preferences and acknowledge that circumstances can change, sometimes suddenly. I understand that a Safety guide tofor myyou preferences and acknowledge thatmy circumstances can change, suddenly. the specialist Statement teamthis onisduty. I have information about and have indicated choices for decision screening and sometimes vaccinations followingI birth. Awareness and your baby will be paramount in any making. Awareness Statement Safety for youas your baby willprimary be paramount anywill decision understand that that if things things do do not happen happen asand indicated then the the primary maternity in carer will discuss making. options with with me me in in consultation consultation with with understand if not indicated then maternity carer discuss options IIMother’s understand that this is a to my and acknowledge that circumstances can sometimes suddenly. II birth. signature: Doctor’s/Midwife’s signature: Doctor’s/Midwife’s name: Date understand that this isduty. a guide guide to information my preferences preferences and acknowledge thatmy circumstances can change, change, sometimes suddenly. the specialist team on II have about and have indicated choices for screening and vaccinations following the specialist team on duty. have information about and have indicated my choices for screening and vaccinations following birth. Awareness Statementdo Safetyhappen for youasand your babythe willprimary be paramount in any decision making. understand that carer options in understand that ifif things things do not not happenDoctor’s/Midwife’s as indicated indicated then then the primary maternity maternity carer will will discuss discussname: options with with me me Date in consultation consultation with with signature: signature: Doctor’s/Midwife’s IMother’s understand that a guide to information my preferences and acknowledge thatmy circumstances can change, suddenly. the specialist teamthis onisduty. I have about and have indicated choices for screening and sometimes vaccinations following Mother’s signature: Doctor’s/Midwife’s signature: Doctor’s/Midwife’s name: Date / I birth. / the specialist team on duty. I have information about and have indicated my choices for screening and vaccinations following birth. understand that if things do not happenDoctor’s/Midwife’s as indicated then the primary maternity carer will discussname: options with me Date in consultation with Mother’s signature: signature: Doctor’s/Midwife’s // birth. // Mother’s signature: Doctor’s/Midwife’s signature: Doctor’s/Midwife’s name: the specialist team on duty. I have information about and have indicated my choices for screening and vaccinationsDate following Mother’s signature: Doctor’s/Midwife’s signature: Doctor’s/Midwife’s name: Date // // 29 Affix unique patient identification label in this box U.R: SUGGESTED SCHEDULE OF ROUTINE ANTENATAL CARE Surname: Given Name: Second Given Name: DOB Weeks Content e 1st Visit Woman centred care (comprehensive history including physical, social and emotional aspects of health, including alcohol consumption, smoking and exposure to second-hand smoke) Clinical assessment (including BP, BMI, ultrasound scan for gestational age 8-12 weeks pregnancy) Screening (blood and urine tests), including screening for diabetes risks and chromosomal abnormalities (11-14 weeks pregnancy) Offer psychosocial assessment Discuss maternity care options available; identify women who may need additional care; plan pattern of care for pregnancy Provide general advice on pregnancy symptoms, supplements, nutrition, weight management, exercise, dental visits and vaccinations checks Invite women to discuss concerns/issues since last visit, offer verbal and written information Review, discuss, record test results Assess EPDS If indicated, arrange follow-up investigations, referrals, reassess plan of care Measure BP, weight if influences management, test urine for protein for women at high risk of pre-eclampsia Offer fetal anomaly ultrasound scan for between 18-20 weeks 18-20 If the woman chooses, a morphology ultrasound scan should be performed. If the placenta is found to extend across the internal cervical os, another scan at 32 weeks should be offered Offer diabetes screening between 24- 28 weeks 24 Invite women to discuss concerns/issues since last visit, offer verbal and written information, including antenatal education Offer screening for anaemia, blood group and antibodies Discuss fetal movements (timing, normal patterns of behaviour) Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of pre-eclampsia Sa m pl 16 28 Invite women to discuss concerns/issues since last visit, offer verbal and written information, including antenatal classes, infant feeding including breastfeeding and skin-to-skin Offer Anti-D to rhesus negative women, investigate Hb less than 10.5g/100ml & consider iron supplements, if indicated Offer screening for anaemia, blood group and antibodies (if there was no 25 week visit) Reassess EPDS at 28-30 weeks Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of pre-eclampsia, discuss fetal movements (timing, normal patterns of behaviour) Measure BMI if this is likely to influence clinical management 32 Invite women to discuss concerns/issues since last visit, offer verbal and written information, infant feeding including breastfeeding and skin-to-skin Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of preeclampsia, discuss fetal movements Review, discuss and record test results Reassess plan of care; identify women who require additional care 30 Affix unique patient identification label in this box U.R: SUGGESTED SCHEDULE OF ROUTINE ANTENATAL CARE (cont) Surname: Given Name: Second Given Name: DOB Weeks Content Invite women to discuss concerns/issues since last visit, offer verbal and written information, including labour & birth, birth plan, recognising active labour, coping with labour, breast feeding (including skinto-skin) or formula feeding if chosen Discuss and provide written information on Group B strep and the screening test at 36 weeks Discuss repeat full blood picture and Rhesus screening test at 36 weeks Offer 2nd Anti-D to Rhesus negative women Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of preeclampsia, discuss fetal movements Offer Ultrasound Scan to women if morphology scan suggested repeat to assess location of placenta Reassess plan of care; identify women who require additional care 36 Invite women to discuss concerns/issues since last visit Offer verbal and written information, including care of the new baby, infant feeding, including breastfeeding, safe sleeping, newborn screening tests and vitamin K prophylaxis, the postnatal period including distress; provide an opportunity to discuss issues and ask questions; offer ongoing support Offer Group B strep screening test Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of pre-eclampsia, discuss fetal movements Check position of baby, for women with breech presentation, discuss options and offer external cephalic version (ECV) Review ultrasound scan report if performed at last visit 38 Review screening /diagnostic test results undertaken at 36 weeks and develop plan of care if required Invite women to discuss concerns/issues since last visit, offer verbal and written information, including normal length of pregnancy (two weeks before or after expected due date), onset of labour, any fears/ worries; provide an opportunity to discuss issues and ask questions Measure and plot symphysis-fundal height, BP, weight, test urine for protein for women at high risk of pre-eclampsia, discuss fetal movements Sa m pl e 34 40 For women having their first baby Invite women to discuss concerns/issues since last visit, offer verbal and written information, including options for prolonged pregnancy; provide an opportunity to discuss issues and ask questions Measure symphysis-fundal height BP, weight, test urine for protein for women at high risk of preeclampsia, discuss fetal movements 41 For women who have not yet given birth Invite women to discuss concerns/issues since last visit , offer information, including further discussion about options for prolonged pregnancy; provide an opportunity to discuss issues and ask questions Measure symphysis-fundal height BP, weight, test urine for protein for women at high risk of preeclampsia, discuss fetal movements Offer membrane sweep, induction of labour Advise to be vigilant of a reduction in fetal movements 31 GLOSSARY OF TERMS Sa m pl e Antenatal Before birth of the baby Antibodies Proteins in blood Measurement of the baby’s skull used to assess growth of the baby Biparietal Body Mass Index – a calculation gained from height and weight BMI BP Blood Pressure Blood Glucose LevelMeasurement of the amount of glucose in blood, usually measured with a blood test, and usually for women who have - BGL/BSL diabetes Braxton Hicks Contractions or tightenings which are irregular, relatively painless and not associated with labour Breech The unborn baby laying with it’s bottom down in the uterus Caesarean Birth The delivery of the baby by surgical incision through the abdominal wall and uterus Cephalic The unborn baby laying with it’s head down in the uterus Cervix The narrow, lower end of the uterus that extends into the vagina EDB Estimated date of baby’s birth EPDS Edinburgh Postnatal Depression Scale – a screening test to assist in the detection of possible depression, both in pregnancy and postnatal period FH Fetal Heart - normal heart rate 110 to 160 beats per minute FHH Fetal Heart Heard FMF Fetal Movement Felt Fetal movements Muscular motions produced by the fetus in utero, felt by the mother from approx 20 weeks gestation. Fetal presentation The part of the baby lying closest to the cervix. Most often referred to as “cephalic” or “breech” Fetus The unborn baby in the uterus after the completion of the eighth gestational week until birth. “Embryo” may be the term used to describe your baby prior to 8 weeks gestation FGM Female Genital Mutilation (female circumcision) Fifths above brim Level of the unborn baby’s head in relation to the mother’s pelvis expressed as a fraction e.g. 3/5 Fundal height The distance (in cm) from the top of the pubic bone to the top of the uterus - generally equals gestational age in weeks GBS Group B Streptococcus – part of a normal flora of the gut and genital tract. It may be harmful to baby causing an infection Gestation Number of weeks pregnant measured from the first day of the last menstrual period. GP General Practitioner - your family doctor Gravidity/Gravida The number of times that a woman has been pregnant GTT Glucose tolerance test - a blood test to diagnose gestational diabetes, a condition which may develop during pregnancy Haemoglobin An iron-containing protein in red blood cells Hb Haemoglobin – these cells contain iron and carry oxygen. HIV Human Immunodeficiency Virus. The virus which may lead to AIDS (Auto Immune Deficiency Syndrome) Hypertension High Blood Pressure Instrumental birth A vaginal delivery of the baby using either a vacuum cap or forceps to assist the delivery In utero Inside the uterus (womb) Regular painful contractions of the uterus (womb) that open the cervix (neck of the uterus) for the baby to pass through Labour Labour - Induction Labour that is started artificially by a health professional before the natural onset Labour - SpontaneousA labour that starts without any induction procedure Last menstrual period LMP MRSA Methicillin-Resistant Staphylococcus Aureus – a bacteria responsible for several difficult-to-treat infections and resistant to some antibiotics MSU Mid-stream specimen of urine Multigravida A woman who is pregnant for at least the second time Multipara A woman who has given birth more than once Neonate Infant from birth to 28 days of age NAD No abnormality detected OedemaSwelling A sample of cells is removed from the cervix and examined to detect any early changes that warn of cancer Pap Smear Parity/Para The number of times a woman has given birth after 20 weeks gestation. (Livebirths and stillbirths are included) Pre-eclampsia High blood pressure complicating pregnancy. There may also be protein in the urine, oedema or other symptoms. Postnatal After the baby is born Presentation The part of the baby that is positioned to come first ie head, bottom Primigravida A woman pregnant for the first time Rh Refers to Rhesus which is a protein on blood cells. Will be either negative or positive for Rhesus factor Rubella A mild contagious disease caused by a virus and capable of producing congenital defects in infants born to mothers infected SUDI A sudden death of an infant that is unexpected and remains unexplained after an autopsy Stillbirth A baby who did not breathe after birth or show any other signs of life Term The gestational period between 37 and 42 weeks Transverse Lie The unborn baby lies across the uterus Trimester A period of 3 months. In pregnancy, the first trimester is usually until 12 weeks gestation, second trimester until 24 weeks and the third trimester from 25 weeks until the birth of the baby Uterus The womb UTI Urinary Tract Infection (usually in the bladder or kidneys) Vaginal birth The delivery of the baby through the vagina VBAC Vaginal Birth After Caesarean VE Vaginal examination - an internal pelvic examination usually performed to determine pelvic size, cervical change and fetal presentation VMS Visiting Midwifery Service – midwives who visit women at home during pregnancy or postnatally 32
