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					                                   MOTHER                                                                                                                                                                   Hospital:
                                                                                                                                                                                                            Intended Place of Birth:                                               Actual Place of Birth:
                                   Mother UR number:
                                                                                                                                                                                                            Hospital (specify)............................. x                      Hospital (specify)............................. x
                                   Admission date:                                                                           20                                                                             Birth Centre     x                 Home x                              Birth Centre     x               Home             x
                                   Suburb: ............................................................................................. Postcode                                                           Other (specify).................................. x                    Other (specify).................................. x
                                   Public/Private Patient:                                    Country of Birth: (Mother)                                                                                    If place of birth changes, specify if change occurred:
                                                                                                                                                                                                            Before onset of labour           x     During labour                                                                                  x
                                   Public x     Private x                                     .........................................................................
                                                                                                                                                                                                            Reason for change:
                                   Indigenous Status (Mother): (circle one or more) Aboriginal x                                                                          TSI x          No x               Recognition of higher risk                                    x        Unintended/unplanned                          x
                                   Indigenous Status (Baby): (circle one or more)   Aboriginal x                                                                          TSI x          No x               Complication of pregnancy                                     x        Not stated                                    x
                                   Marital Status (Mother):                                   Married                                 x                                                                     Social or geographic                                          x        Other (specify).............................. x .
                                   Single         x                                           Widowed                                 x                  Defacto                                  x         Smoking <20 weeks:                                                              >
                                                                                                                                                                                                                                                                                   Smoking _ 20 weeks:
                                   Divorced       x                                           Separated                               x                  Unknown                                  x         Non-smoker                                                    x        Non-smoker                                                     x
                                                                                                                                                                                                            Quit                                                          x        Smoked (n/day)
                                   Birthdate                                                                      Height:                                    Weight:
                                   (Mother):                                                                      (cm)                                       (kg)                                           Smoked                                                        x        Occasional (<1/day)                                            x

                                              REPRODUCTIVE HISTORY                                                                               LABOUR, BIRTH & POSTNATAL                                                                         BABY                UR:

                                   G:                            P:                                                                        Onset labour:                                   Date                Time                                (Complete a separate form in full for each baby of a multiple birth)

                                   Total number: (Excluding this pregnancy)
                                                                                                                                                                           20                                                :                     Birthdate:                                     Date              Time
                                                                                                                                           Onset 2nd stage:                                Date                Time                                                               20                                                :
                                   Livebirth                       _
                                                          – (lived > 28 days) ...................
                                                          – (died < 28 days)....................
                                                                                                                                                                           20                                                :                     Estimated gestation at birth: (weeks)
                                                                                                                                           Rupture of membranes: Date                                          Time
                                   Stillbirth ................................................................                                                                                                                                     Sex:   Male x Female x Indeterminate x
                                   Abortion – spontaneous ...........................
                                                                                                                                                                           20                                                :                     Plurality: (eg. Single 1 , Twins 2 )
                                                                                                                                           Labour:
                                                    – induced .....................................                                        Spontaneous            x    Augmented            x                                                      (this record refers to    born)
                                   Ectopic ..................................................................                              Induced – medical      x    No labour            x                                                      Condition: Liveborn        x
                                   Unknown ..............................................................                                               surgical  x                                                                                Stillborn (before labour) x     (during labour)                                                x
                                   Date of completion of                                                                                   If labour induced or augmented: (circle one or more)                                                    Birthweight: (grams)
                                   last pregnancy: (mth/yr)                                                                                Oxytocin               x    ARM                  x
                                                                                                                                                                  x                         x                                                      Apgar: 1 minute                                            5 minutes
                                   Outcome of last pregnancy:                                                                              Prostaglandins              Other (specify)
                                   Livebirth               Abortion                                                                         ....................................................................................................   Time to established respiration: (mins.)
                                            _
                                   - lived >28 days   x    - spontaneous                                                         x                                                                                                                 Resuscitation – mechanical:
                                                                                                                                           Specify indication for induction:
                                   - died <28 days    x    - induced                                                             x                                                                                                                 None            x   ETT with air                                                               x
                                                                                                                                            ....................................................................................................
                                   Stillbirth         x    Ectopic                                                               x         Fetal monitoring in labour: (circle one or more)                                                        Suction         x   ETT with O2                                                                x
                                   Unknown            x                                                                                    Intermittent Ausc    x Internal CTG            x                                                        O2 therapy      x   CPAP with air                                                              x
                                                                                                                      Y           N        Admission CTG        x Fetal blood sampling x                                                           IPPR with air   x   CPAP with O2                                                               x
                                   Was last birth a caesarean section?:
  PERINATAL DATA




                                                                                                                                           Intermittent CTG     x None                    x                                                        IPPR with O2    x   Cardiac massage                                                            x
                   COLLECTION




                                   Total no. of previous caesarean sections:
                                                                                                                                           Cont. external CTG x                                                                                    Other (specify)............................................................... x
                                   Plan for VBAC: (if prev CS)                                                        Y          N
                                                                                                                                           Presentation:
                                                                                                                                                                                                                                                   Resuscitation - drugs: (specify) ..................................
                                                                                                                                           Vertex x Brow            x     Shoulder        x
                                                         THIS PREGNANCY                                                                                                                                                                            ........................................................
                                                                                                                                           Breech x Compound x            Unknown         x
                                   Agreed due date:                                                                                        Face      x Cord         x     Other (specify) x                                                        Congenital anomalies:                                                Y           N
                                                                                                                                            ....................................................................................................   CVS / CNS / MS / GI / UG / Resp / Skin / Other
                                   Estimated gest. age at 1st A/N visit:
                                                                                                                                           Method of birth:                                                                                        Circle & Specify ....................................................................
                                   Maternal medical conditions:                                                                            Unassisted vaginal x Forceps x Vacuum x
                                                                                                                                                                                                                                                   ....................................................................................................
                                   Pre-existing                                                                                            Planned C/S      - No labour x   Labour x
                                                                                                                                                                                                                                                   ....................................................................................................
                                   Diabetes Type 1                      x       Diabetes Type 2                                   x        Unplanned C/S - No labour x      Labour x
                                                                                                                                                                                                                                                   ....................................................................................................
                                   Circulatory                          x       Hypertension                                      x        Indications for operative birth:
                                                                                                                                                                                                                                                   ....................................................................................................
                                   Renal (specify)                      x       Psychosocial (specify)                            x         ....................................................................................................
                                                                                                                                                                                                                                                   Paediatrician: ......................................................................
                                                                                                                                            ....................................................................................................
                                   Other (specify) .......................................................................
                                                                                                                                           Analgesia for labour:                                                        Y           N              Neonatal morbidity:                                                          Y          N
                                   ....................................................................................................
                                                                                                                                           Specify .....................................................................................           Specify .....................................................................................
                                   Obstetric complications:                                                                                 ................................................................                                       ....................................................................................................
                                   Gestational diabetes      Diet x                                            Insulin            x        Anaesthesia for operative delivery:                                          Y           N
                                                                                                                                                                                                                                                   ....................................................................................................
                                                   x              x                                                               x        Specify .....................................................................................
                                   Pre-eclampsia        IUGR                                                   GBS+                                                                                                                                ....................................................................................................
                                                                                                                                            ................................................................
                                   Placenta praevia - with haemorrhage                                                            x                                                                                                                ....................................................................................................
                                                                                                                                           Complications/events of labour and birth:
                                   Placenta praevia - without haemorrhage                                                         x                                              Shoulder                        Water                                                                                  x                                         x
                                                                                                                                           Antibiotics              x            dystocia                x birth                    x              Admitted:                              SCN                                     NICU
                                   Placental abruption x         Other APH                                                        x
                                                                                                                                           Specify .....................................................................................           Hepatitis B vaccine received:
                                   Other (specify) .......................................................................                  ....................................................................................................   < 7 days x
                                                                                                                                                                                                                                                   _               > 7 days x                                           Not given                 x
  HOSPITAL/MEDICAL PRACTITIONER/




                                   ....................................................................................................     ....................................................................................................
                                                                                                                                                                                                                                                   Breastfeeding attempted:                                                             Y         N
                                                                                                                                            ....................................................................................................
                                   A/N care provider:                                                                                                                                                                                              Formula given in hospital:                                                           Y         N
                                                                                                                                            ....................................................................................................
                                   Obstetrician x Midwife x                                       GP x             None x                                                                                                                          Last feed taken exclusively from breast: Y                                                     N
                                                                                                                                           Lead intrapartum care provider:
           MIDWIFE COPY




                                   Procedures and operations:                                                                              Obstetrician x Midwife x GP x                                                     None x                                                DISCHARGE
                                   Ultrasound 10 - 14 weeks (specify no.)                                                                  Prophylactic oxytocin 3rd stage:                                Y         N
                                                                                                                                                                                                                                                   Date of discharge from place of birth:
                                   Ultrasound 15 - 26 weeks (specify no.)                                                                  Manual removal of placenta: (excl c/s) Y                                  N
                                                                                                                                                                                                           Y         N                             Mother date                                                              20
                                   Ultrasound > 27 weeks (specify no.)
                                              _                                                                                            Perineal status: Episiotomy
                                   Cervical suture                                                                                x        Laceration:                                                     Y          N                            Baby date                                                                20
                                   IM Steroids (2 doses)......................................                                    x        Degree/type: (specify) ........................................................                         Discharge status:                                      Mother                        Baby
                                                                                                                                           Repaired:                                                      Y           N                            Discharged                                               x                             x
                                   ART (specify)...................................................... Y                          N
                                                                                                                                           Blood loss: (mls)                                                                                       Died                                                     x                             x
                                   Other (specify) .......................................................................                                                                                                                                                                                  x                             x
                                                                                                                                           Transfusion:                                                                 Y           N              Transferred to (specify)
                                   Occasional data:                                                                                        Postpartum complications:                                                                               Mother ..................................................
OCT                                    ...................................................................                                 Specify .....................................................................................
                                                                                                                                                                                                                                                   Baby ......................................................
2008                                   ...................................................................                                  ....................................................................................................

                                       ...................................................................                                 Admitted to HDU/ICU: (Mother)                                                         Y         N       Date                                                                     20

				
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