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1. INITIAL PREGNANCY PROFILE IDENTIFICATION PATIENT Date: History since LMP Check and detail positive findings below. Precede findings with symptom number. 15. Nutritional Assessment: Adequate 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Headaches Nausea/vomiting Abdominal pain Urinary complaints Vaginal discharge Vaginal bleeding Oedema (specify area Febrile episode Rubella exposure Viral exposure Drug exposure Radiation exposure Other Last contraceptive: Type: Date last used: Inadequate Remarks…………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… 16. Medication since LMP (Rx, non-Rx, vitamins) None Describe…………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… Initial Physical Examination System 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Height Weight Pre-gravid weight BP Normal Check and detail all positive findings below 38. SS Notch Skin EENT Mouth Neck Chest Breast Heart Lungs Abdomen Muskuloskeletal Extremities Neurological Pelvic Examination 29 30 31 32 33 34 35 External genitalia Vagina Cervix Uterus (describe) Adnexa Rectum Other Bony Pelvis 36. Diagnostic Conj. 37. Shape Sacrum 40 40. Pubic arch 41. Trans. 39. Ischial Spines 42. Post sag. Outlet Exam by: 43. Coccyx diam 44. Classification Gynaecoid Android Anthropoid 45. Estimation: Adequate Borderline Contracted Platypelloid Pulse Optional 2. Health History PATIENT IDENTIFICATION Summary Date: Patient’s name………………………….. ………………………………… Age____Race______Religion______Marital Status_______Years Married____Education_____ Occupation_________ Home Home Work Adress_______________________________________________________tel.________________tel.______________ Nearest Relative’s Work Relative____________________________ Employer___________________________________Tel.______________ Referring Attending Physician___________________________ Physician________________________ Medical History Sensitivities 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Congenital anomalies Genetic diseases Multiple births Diabetes mellitus Malignancies Hypertension Heart disease Rheumatic fever Pulmonary disease GI problems Renal disease Other urinary tract problems Genitourinary anomalies Abnormal uterine bleeding 30. None known 31. Antibiotics 32. Analgesics 33. Sedatives Anaesthesia Other 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Infertility Venereal disease Phlebitis, varicosities Nervous/mental disorders Convulsive disorders Metabol./endocrine disorders Anaemia/haemoglobinopathy Blood dyscrasias Drug addiction Smoking/alcohol Infections diseases Operations/accidents Blood transfusions Other hospitalisations No known disease Menstrual Onset Cycle 34. 35. Pre-existing Risk Guide Indicates pregnancy/outcome at risk 36. Age 37. 8th Grade Education 38. Cardiac disease 39. Tuberculosis, active 40. Chronic pulmonary disease 41. Thrombophlebitis 42. Endocronopathy 43. Epilepsy 44. Infertility 45. Abortions 46. > 7 deliveries 47. Previous pre-term or SGA infants 48. Infants > 4,000 gms 49. Isoimmunisation (ABO etc) 50. Haemorrhage during previous preg. 51. Previous pre-eclampsia 52. Surgically scarred uterus 53. ____________________ Length Amount Indicates pregnancy/outcome at high risk 54. Age > 40 55. Diabetes mellitus 56. Hypertension 57. Cardiac disease (class III or IV) 58. Chronic renal disease 59. Congenital/chromosomal anomalies 60. Haemoglobinopathies 61. Immunisation 62. Drug addiction/alcoholism 63. Habitual abortions 64. Incompetent cervix 65. Prior fetal or neonatal death 66. Prior neurologically damaged infant 67. _____________________________ 3. PRENATAL FLOW RECORD PATIENT IDENTIFICATION Patient’s Name__________________________ Risk Guide for Pregnancy and Outcome LabFindings Preliminary Risk Assessment No risk factors Noted Hct/Hgb (1) At risk (2) High risk Initial Prenatal Mo day Test / / / / / / / / / Result Hct/Hgb Screen Additional Mo/day Test Patient’s blood type And Rh Father’s and RH/ blood type Antibody Serology Rubella titre Urinalysis micro Pap test G.C. / Hct/Hgb / / / / / Continuing Risk Guide (enter dates first noted and revisit RISK STATUS) Mo/day / / / / / / / / / / Potential risk factors 3. Preg. Without family support 4. Second pregnancy in 12 months 5. Smoking > 1 pack per day 6. Rh negative (non-sensitised) 7. Uterine/cervical malformation 8. Inadequate pelvis 9. Venereal disease 10 Anaemia(Hct < 30%:Hgb <10%) 11 Acute pyelonephritis 12 Failure to gain weight Mo/day / / / / / / / / / / / 13 Multiple pregnancy (term) / / / 14 Abnormal presentation 15 Post-term pregnancy / / High Risk factors 18. Diabetes mellitus 19. Hypertension 20. Thrombophlebitis 21. Herpes (type 2) 22. RH sensitisation 23. Uterine bleeding 24. Hydramnios 25. Severe pre-eclampsia 26. Fetal growth retardation 27. Premature rupt. Membranes 28. Multiple pregnancy preterm 29. Low/falling oestriols 30. Significant social problems Flow Chart: Weight this visit: Attends prenatal classes Blood Pressure: Caesarean Section Protein: For sterilisation Breast Circumcision Bottle Feeding Sugar: Est. weeks/gestation: Fundal Height: Anaesthesia: Fetal Heart Rate: Baby’s Physician Edema: Risk Status (0, 1, 2) Result / 4. PRENATAL FLOW PATIENT IDENTIFICATION RECORD (Supplemental) Patient’s Name………………… ………………………………………... Date: Weight this visit: Blood Pressure: Urine - Protein Sugar Est. weeks gestation: Fundal height: Fetal heart rate: Oedema: Risk status (0,1,2): Quickening Date: 5. OBSTETRIC ADMITTING RECORD Basic Admission Data – Significant Prenatal Data LMP: EDC: AGE: Ambulatory: Wheelchair: Stretcher: Next of Kin: Tel. No. None Prenatal Lab Tests Patient’s Blood type Father’s blood type Rh Titre Rubella titre Reasons for Admission – Onset of labour Spontaneous abortion Observation/Evaluation Caesarean Section Induction of Labour: elective indicated Medical Complication: Obstetric Complication Antibody Serology Fetal assessment tests None Date Test Result Other Patient Care Data Allergies/sensitivities None Contractions on admission None Frequency_________Duration__________Quality_________Latest risk assessment No risk factors noted at present Began on (date) ____________________ time___________ At risk 1._________________4._________________ Membranes on admission: Intact High risk2._________________5._________________ Ruptured (date)_________________ 3._________________6._________________ Fluid was clear Meconium Prenatal education Foul smelling Vaginal bleeding None Attended Classes Normal Show Bleeding (describe) Received prenatal care Patient has: Records available when admitted Recent URI Dentures Source of prenatal data: Exposed to infection Contact lenses Baby’s Physician: Vomiting Glasses Plans for anaesthesia None planned Admission Physical Examination Specify type: Ht. Wt. BP Temp. Pulse Resp. Last oral intake (date/time) Current medications: System WNL Abn. HEENT Patient Plans: Fetal evaluation Estimated weeks gest___________ Private Semi-private Rooming in Breasts Fundal height_______________ Presentation: Position: Smoker Non-smoker Husband in delivery Heart and Lungs Breast Bottle feeding Circumcision for boy Abdomen fetal wt.___________ vertex Estimated FHR______________________ Face/brow Other Extremities Station____________________ Breech (type)_______________ Reflexes Effacement________________ Transverse lie Procedures: Prep Enema (results) Dilatation_________________ Compound Physician’s name : Notified by: Date: Urine Alb. Glu. Blood sent: am/pm HCT Hgb Nurse attending __________________ 6. LABOUR PROGRESS CHART Admission date Admission time: Blood type and Rh Membranes are : Intact Baby’s Physician: Page Effacement % Examination by: Blood Pressure: FHR: Oxytocin Frequency: Duration Quality: TPR Medications and Key Events Ruptured Bulging 7. LABOUR DELIVERY AND SUMMARY Labour Summary G T P A L Type Presentation Position Vertex Face or brow Breech Transverse lie Unknown Complications Compound None No prenatal care Preterm labour (<37 weeks) Term (>42 weeks) anomalies Febrile (>100.4) when admitted PROM (>12 hrs preadmit) Meconium Foul smelling fluid Hyrdamnios Abruption Placenta previa Bleeding-site undetermined Toxaemia (mild) (severe) Seizure activity {Precipitous labour (<3hrs) Prolonged labour (>20 hrs) Prolonged latent phase Prolonged active phase Prolonged 2nd stage (>2.5 hrs) Secondary arrest of dilatation Cephalopelvic disproportion Cord prolapse Decreased FHT variability Extended fetal bradycardia Extended fetal tachycardia Multiple late decelerations Multiple variable decelerations Acidosis (pH<7.2) Anaesthetic complications _____________________________ Delivery Data Delivery Data Infant Data Method of Delivery Delivery Anaesthesia None Cephalic Local Epidural Spontaneous Type Pudendal Spinal Low forceps Paracervical General Mid-forceps No. Agent/drug Dose Rotation To Vacuum extraction No. Agent/Drug Dose Breech Delivery Room Meds. None Spontaneous Partial extraction (assisted) Agent/Drug Dose Route Total extraction Forceps to A.C. head Time: Sig: Caesarean (details in operation notes) Low cervical: transverse Agent/Drug Dose Route Low cervical: vertical Classical Caesarean Placenta Spontaneous Expressed Manual Adherent Curettage Configuration Normal Abn. Weighed (No) (Yes)_____gms Cord Cord Time: Sig. Agent/Drug Time: Dose Route Sig: Medications None Scalp care Volume expander Sodium bicarbonate Drug antagonists Umbilical catheter Other Initial Newborn Exam No observed abnormality Gross congenital Mec. Staining Trauma Petechiae Other Describe______________ Chronology Date _____________________ EDC: _____________________ Admitted: _____________________ Membranes Ruptured: _____________________ Onset of labour: Basic Data Nuchal cord COMPLETE CERVICAL DIL. True knot 2 3 Umbilical vessels DELIVERY OF INFANT: Cord blood to (lab) (refrig) (discard) ID Bracelet no. Hospital No. Male Episiotomy DELIVERY OF PLACENTA: None Infant Data Median Apgar Scores At 1 min: At 5 min: Mediolateral Heart rate Birth order Female Weight _____________________________ Length Vitamin K Induction None Other Respiration ARM Augmentation ARM Oxytoc None Oxytoc Laceration None 1 2 3 4 Degree perineal Vaginal Cervical Uterine rupture Other____________________ Muscle tone Surgical Procedures/None Resuscitation _________________ __________ Tubal ligation Oxygen _________________ __________ Other Bag and mask AgNo3 1% or__________ Monitor External Internal FHT Medications UC None Total dosage Sig: Reflex irritation Output Skin colour Spontaneous respiration Urine Meconium Gastric Living at transfer to: _____________________ _________________ __________ Intubation Time of last narcotic __________ Ext. cardiac massage Deceased Antepartum Intrapartum Neonatal Date Other Remarks_________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Assisting: Attending: Nurse Data 8. INITIAL NEWBORN PROFILE 1. Basic Data (entered by nursing personnel) G T P A L Mother’s name: LMP risk estimate EDC Delivery Date: Time: Apgar at: 1min. 5 min. Male Female Ambiguous 2. Physical Examination Date of exam: Time of exam Temperature Respiration rate Femoral pulse: Normal Absent Code: 1. 2. 3. 4. 5. = No abnormalities Reflexes Skin colour/lesions Head/Neck Eyes ENT Newborn Risk Indicators - Please review these along with the prior risk information available to you, in order to arrive at your Initial in part 3. Observations at birth Baby’s age at exam Pulse rate Weak Delayed = Abnormalities present 6. 7. 8. 9. 10. Thorax 11. Genitals Lungs 12. Anus Heart 13. Trunk/Spine Abdomen 14. Extremities/joints Umbilicus 15. Tone/Appearance Description of abnormal findings – please describe your findings objectively. Reserve your impressions or diagnoses for part 3 below. Please begin your Findings with the reference number preceding each category. ____________________________________________________________________ ____________________________________________________________________ within 24 hrs postpartum No risk factors noted Abnormal presentation Multiple birth Low birth weight Resuscitation at birth 1 min. Apgar < 5 5 min. Apgar < 7 Placental abnormalities Two cord vessels Difficult catheterisation >20ml. Of gastric aspirate Small mandible cleft palate Grunting Deep retractions Imperforate anus Pallor Jaundice Plethora Conclusions Decreased tone Congenital malformations No risk factors noted Abdominal distension Vomiting Failure to pass meconium (if skin not stained) Melena Apneoic episodes Tachypneoea(transient) See-saw breathing Cyanosis Petechiae/Ecchymoses Jaundice Pallor Plethora Fever Hypothermia Arrhythmia’s Murmur Lethargy Tremors Convulsions ____________________________________________________________________ ____________________________________________________________________ 4. ____________________________________________________________________ Gest. age by dates Gest. age by exam 3. Impressions and Diagnosis This infant is classified as: Initial Risk Estimate No risk factors noted Medium risk Low risk High risk 5. Maturity Evaluation Weight Length Chest circ. Head circ. pre-term <37 weeks term 37 – 42 weeks Post-term >42 weeks SGA AGA LGA Plans: diagnostic and therapeutic ____________________________________________________________________ ____________________________________________________________________ ________________________________________________ ____________________________________________________________________ ________________________________________________ ____________________________________________________________________ ________________________________________________ ____________________________________________________________________ ________________________________________________ ____________________________________________________________________ ________________________________________________ 9. NEWBORN DISCHARGE SUMMARY Physical Examination Name: last Basic Data Date of Exam Time of Exam Baby’s age at Exam Discharge weight: Temperature: Respiration Rate: Pulse rate: Tests (Code: Infant’s first No abnormalities Abnormalities present) Mother’s record No. Results Date Infant’s record No. Blood Type: Infant’s ID No. 1. Reflexes 6. Thorax 11. Genitals Coombs Serology Sex: 2. Skin colour, lesions 7. Lungs 12. Anus PKU blood/urine Race: 3. Head/Neck 8. Heart 13. Trunk/Spine Thyroid DoB 4. Eyes 9. Abdomen 14. Extremities/Joints Place of Birth: Hospital 5. ENT 10. Umbilicus 15. Tone/Appearance Description of Abnormal findings – Please describe your findings objectively. Reserve your impressions or diagnosis for the Discharge section below. Please Begin your findings with the reference number preceding the circled category. If baby died note: Age at death: __________________________________________________________________ With mother __________________________________________________________________ To another service __________________________________________________________________ To another hospital __________________________________________________________________ Against advice __________________________________________________________________ Follow-up appointment: __________________________________________________________________ With private physician Discharge Status – Use this section to summarise the baby’s present condition. At clinic Describe briefly existing and resolved neonatal problems. If the baby is deceased Note: Explain the reasons for death. Date: Problem(1)_________________________________________________________ T4/TSH Home En route Other Autopsy: Y/N Newborn discharged on: Signature: Developed: At birth In nursery Course of treatment and impressions – Please refer to the Problem 1, 2, 3, or 4 in your summary. Note also your final impression of the baby at discharge. Status: Resolved Stable ________________________________________________ Diminished Accelerated ________________________________________________ Problem (2)_________________________________________________________ ________________________________________________ Developed: At birth In nursery ________________________________________________ Status: Resolved Stable ________________________________________________ Diminished Accelerated ________________________________________________ Problem (3)_________________________________________________________ ________________________________________________ Developed : At birth In nursery ________________________________________________ Status: Resolved Stable ________________________________________________ Diminished Accelerated ________________________________________________ Problem (4)________________________________________________________ ________________________________________________ Developed: Status: ________________________________________________ Date: At birth Resolved Diminished In nursery Stable Accelerated Physician’s signature:___________________________ ________________________________________________