Alberta Prenatal Record (Page 1) Last Name of Mother First Name Middle Initial Maiden Name Date of Birth Age Affix patient label here YYYY/MM/DD Address/Reserve Name Phone Number Postal Code Marital Status Highest Education Mother’s Occupation Name of Father of Child/Partner of Mother Father’s Date of Birth Father’s/Partner’s Occupation Level YYYY/MM/DD Emergency Contact Phone Number Mother’s Ethnicity Father’s Ethnicity Language Spoken at Home Interpreter Required Yes No Referring Physician/Midwife/Nurse Prenatal Care Provider Consultant Physician for Baby Date Gest. Hrs in Details/Comments Children Site of Birth/Abortion Delivery Type yyyy/mm/dd Age Labour (Pregnancy, Delivery, Postpartum, Neonatal, Congenital Anomalies) Sex Birth Weight Indicate lbs/kgs Obstetrical History Extended No Yes Medical History No Mother Father Family 28. Assisted Conception If yes: Life Style, Psychosocial and Environmental History 1. Auto-immune disorder Concerns Action/Referral Ovulation induction No Yes 2. Bleeding/Clotting disorder Intrauterine insemination 31. Nutrition/calcium 3. Diabetes Invitro fertilization 32. Nausea/vomiting 4. Developmental delay Intracytoplasmic sperm injection 33. Food safety 5. Hereditary conditions Other, specify 34. Physical activity 6. Consanguinity 35. Sleep/rest 7. Malformation/Birth Defects 36. Dental hygiene/care 8. Cardiac 29. Medications and Alternate Therapies 37. Environment/occupation 9. Psychiatric/depression Folic acid at conception No Yes 38. Culture/religion 10. Anaesthetic problems If yes, dose 39. Social support 11. Hypertension Prenatal Vitamins No Yes 40. Stress factors 12. HIV If yes, specify 41. Emotional/depression 13. Hepatitis B 42. Relationship stability 14. Hepatitis C Prescription Medications, specify 43. Seat belt in pregnancy 15. STI 44. Personal safety/violence 16. Tuberculosis 45. Parenting readiness 17. Chickenpox immune 46. Sexuality 18. Asthma 19. Epilepsy Substance Use During Pregnancy 20. Major trauma 47. Tobacco Never Yes Quit YYYY/MM/DD ___________________ 21. GI disorder Average # of cigs per day ___________________ 22. Renal/Urinary tract Non-prescription/Herbal/Alternate Medications, specify Nicotine replacement No Yes 23. Thyroid Second hand smoke No Yes 24. Operations 48. Alcohol Never Yes Quit YYYY/MM/DD ___________________ 25. Transfusions 30. Allergies No Yes Average # of drinks per drinking day 1-2 3-4 5 or more 26. Other, specify If yes, specify agent and reaction Number of days per week that you drink 1-2 3-4 5-7 How often do you have 3 or more drinks per day _______________ 49. Recreational drugs/solvents 27. Data unavailable YYYY/MM/DD Never Yes Quit ___________________ Type and Frequency: __________________________________________ Physical Examination Date Normal Abnormal Comments (Indicate the item number) YYYY/MM/DD 50. General condition Height 51. Head & neck cm 52. Teeth & gums ft/in 53. Breasts/nipples/axilla Prepregnancy Weight 54. Chest kg 55. Heart lbs 56. Abdomen Current Weight 57. Spine kg lbs 58. Reflexes Pre-pregnancy BMI 59. Varicosities/Extremities WT (kg) 60. Perineal/pelvic exam HT(m2) Uterine size _______ wks BP Pulse Care Provider’s Signature Date X YYYY/MM/DD HS0001-125 (Rev. 2007/02) Alberta Prenatal Record (Page 2) Last Name of Mother First Name Middle Initial Gravida Term Preterm Number of Abortions (by type) # of live births Living Stillbirths Neonatal deaths Affix patient label here Spon. Induced Ectopic LMP Sure of dates Cycle EDD by LMP EDD confirmed Yes Regular yyyy mm dd No Irregular yyyy mm dd yyyy mm dd Date Date Date Test Result (yyyy/mm/dd) Test Result (yyyy/mm/dd) Test Result (yyyy/mm/dd) Immune Pap Smear ABO/Rh Varicella Non-immune Vaginal/Cervical Blood Negative Negative Swabs Antibodies Positive HIV Positive Urinalysis HBsAG Negative Positive Declined Culture & Sens. Syphilis Non-reactive Gestational of Urine Serology Reactive Diabetic Screen mmol/L 1 g/L Immune Group B Negative Hemoglobin Rubella 2 g/L Non-immune Strep Positive Other investigations - Identify date, investigation, results and action: (Laboratory, Ultrasound, consultations, etc.) Prenatal Genetic Screening Counseled Declined Rh-IG Counseled Newborn needs 1 Test Result YYYY/MM/DD Rh IG Ist dose: YYYY/MM/DD Hep B Prophylaxis 2 YYYY/MM/DD Rh IG 2nd dose: YYYY/MM/DD Yes No Date Weight Urine Gest. Fundus F.H. F.M. Cigs/ Next lbs (protein/ BP Age Pres. Comments Visit Init. (yyyy/mm/dd) (cms) Rate 20 wks+ day kg glucose) wks/days Topics Discussed Breastfeeding Comments / Plan of action for problems in current pregnancy (including medications): 61. Routine testing Intend to breastfeed 62. Maternal vaccinations/influenza Yes No Maybe 63. Prenatal education 64. Preterm labour Breastfeeding support 65. Fetal movement Yes No YYYY/MM/DD Count chart given ________________ 66. Hospital admission Feeding plan on return to work: 67. On Call Provider 68. Labour stages/support/interventions 69. Pain relief in labour 70. Postpartum support 71. Newborn screening/immunization Risk Scores Initial Visit 36 Weeks 72. See the Risk Assessment form Circumcision (Total A+B+C+D) 73. Baby care/infant seat to calculate the Risk Scores. Care Provider’s Signature Date X YYYY/MM/DD Affix patient label here Risk Profile: Odds Ratio (OR) for Specific Pregnancy Outcomes The risk profile is based on the best available evidence with odds ratios for pregnancy outcomes for preterm delivery, preterm-SGA (<10%), Term SGA (<10%), LGA >4000 g and LGA >or equal 4500 g. Factors associated with these outcomes that have an OR of 1.5 or greater are included. Use the risk profile to assist in counseling, scheduling of prenatal visits, and in management decisions (diagnostic tests and specialist referral). Circle the Odds Ratio for each risk factor. Review and update at each prenatal visit. RISK PROFILE ODDS RATIO (Rounded to the whole number ) Risk Factor Preterm Preterm Term LGA LGA Delivery SGA SGA >4000g 4500g Demography/Social Race Aboriginal 3 3 Race Black 3 Single 2 2 Nulliparity 2 2 Multiparity (gr 3 or >) 3 2 Height <152 cm. 3 2 Low pre pregnancy wt (<110lbs or <50kg) 2 High pre pregnancy wt (>175 lbs or >80kg) 2 2 Age >35 13 2 2 Cigarettes 2 2 2 Substance use 3 2 Pre-existing Illness Diabetes 4 2 3 Hypertension 2 2 2 Chronic renal disease 4 5 Endocrine disorder 3 Medical disorder 3 4 Cervical conization/surgery 7 Obstetrical History Previous SGA 2 12 8 Previous preterm delivery 4 2 Prior 3+ abortions 2 2 Current Pregnancy Multiple gestation 20 47 Poly/oligohydramnios 4 13 3 Blood antibodies 4 Acute medical disorder 4 5 Pregnancy induced hypertension 2 6 Toxemia 5 3 2 Placenta abruptio 5 5 Placenta praevia 10 12 Vaginal bleeding >20 wks undetermined cause 5 Preterm rupture of membranes 80 69 Prenatal visits </=4 4 Wt gain <0.5 kg per wk 3 Gestational age 41 wk + 4 4 Net wt gain >15 kg or 25% weight gain 3 Affix patient label here Antenatal Risk Assessment Add up the risk factors in the current pregnancy on the initial visit and at 36 weeks, and record the score on Page 2 of the Alberta Prenatal Record. Part A - Pre-Pregnancy Part C - Problems in Current Pregnancy Score Score 1 Age < 17 at delivery 2 Diagnosis of large for dates 2 Age > 35 at delivery 3 Diagnosis of small for dates 1 Weight > 91 kg 2 Polyhydramnios or oligohydramnios 1 Weight < 45 kg 3 Multiple pregnancy Height < 152 cm 3 Malpresentation(s) Diabetes 2 Membranes ruptured before 37 weeks 1 Controlled by diet only 1 Bleeding < 20 weeks 3 Insulin used 3 Bleeding > 20 weeks 3 Retinopathy documented 2 Gestational hypertension Heart Disease 1 Proteinuria > 1+ 1 Asymptomatic (no affect on daily living) 1 Gestational diabetes documented 3 Symptomatic (affects daily living) 3 Blood antibodies (Rh, Anti C, Anti K, etc.) Hypertension 1 Anaemia (Hgb < 100gm per L) 2 140/90 or greater 1 Pregnancy > 41 weeks 3 Antihypertensive drugs 1 Poor weight gain (26-36 weeks < 0.5 kg/week or 2 Chronic Renal Disease Documented weight loss) 1 OTHER medical disorders e.g. epilepsy 1 Smoker - anytime during pregnancy Part B - Past Obstetrical History Part D - Other Risk Factors (Note: Scores to be validated) Score 3 Neonatal death(s) Score 3 Stillbirths(s) 3 Major fetal anomaly 1 Abortion between 12 to 20 weeks 3 Acute Medical Disorder (acute Asthma, Thyrotoxicosis, and under 500 grams birth weight UTI, etc.) 1 Delivery at 20 - 37 weeks 3 Cervical surgery 2 Cesarean section Substance Use: 1 Small for dates - 5th percentile 3 Alcohol > 3 drinks on any one occasion during pregnancy 1 Large for dates - 95th percentile 3 Alcohol > 1 drink per day throughout pregnancy 1 RH Isoimmunization - unaffected infant 3 Drug dependent 3 RH Isoimmunization - affected infant 1 Major congenital anomaly e.g. chromosomal, heart, CNS defects *Low Risk 0-2, Moderate Risk 3-6, High Risk > 7 Please enter the Risk Score on Page 2 of the Alberta Prenatal Record Alberta Prenatal Record Information for Prenatal Care Providers The Alberta Prenatal Record is available to all prenatal providers in Alberta. The prenatal record guides the practitioner in obtaining the woman’s health and obstetrical history, and documents investigations, and care provided during pregnancy. A copy of the form should be provided to the site of delivery for practitioners providing care to the woman and baby during labour, delivery and postpartum. At 36 weeks gestation the form should be given to the woman to carry with her or a copy sent to the intended site for delivery. Enhancements to the Alberta Prenatal Record (HS0001-125 Rev.2007/02) include the following: • Risk profile that identifies odds ratio for preterm delivery, preterm - SGA, Term - SGA, LGA • Antenatal risk assessment with risk scoring which can be used as a work sheet • Healthy Mother, Healthy Baby Questionnaire HS0285 - to be completed by the mother or used as an interview guide. Information links to the Alberta Prenatal Record Supporting documents available from the Alberta Perinatal Health Program website www aphp.ca or contact (780) 735-1000. • Desk reference for Alberta Prenatal Record completion guidelines and Healthy Mother, Healthy Baby Questionnaire • Pregnancy and Baby Health Community Resource Directory • Healthy Mother, Healthy Baby User Guide with information on development of the form including evidence and links to other assessment tools. To order more forms The Alberta Prenatal Record (HS0001 -125) and the Healthy Mother, Healthy Baby Questionnaire (HS0285) can be ordered on-line at https://secure5.datagroup.ca/ acsc/request_ext.asp or by faxing your request to: (780) 422-1695. To provide comments on the forms or request assistance with implementation contact: Alberta Perinatal Health Program, Quality Improvement Coordinator at (780) 735-1000 or email firstname.lastname@example.org. Definitions of terms Highest Education Level – the highest grade/education level completed by the mother. less than high school high school completed trade/business school college/university other Ethnicity – describes family heritage as distinct from where the mother/father was born. Refer to HMHB-Q (HS0285). Mother – refers to biological mother of fetus. Father – refers to biological father of fetus. Partner – refers to woman’s support person if other than biological father. Pre-pregnancy weight – most accurate weight pre-pregnancy as determined by actual measurement or self-reported by the mother. Reporting in kilograms preferred. Gravida – Total number of pregnancies for this mother, including this pregnancy. Term – Total number of babies born to this mother at > or = to 37 weeks gestation. Preterm – Total number of babies born to this mother at < 37 weeks gestation. Abortions by type – total number of pregnancy losses (fetal deaths) prior to 20 weeks gestation and birth weight of less than 500 grams. Livebirths – Total number of babies born alive regardless of birth weight or gestational age. Stillbirths – Total number of fetal deaths born to this mother at or after 20 weeks pregnancy or after birth weight of 500 grams or greater if gestational age is not known. Neonatal deaths – Total number of neonatal deaths prior to 28 days of age. Living – Total number of living children born to this mother. LMP – Last menstrual period. EDD – Expected date of delivery calculated by date of LMP and confirmed by Ultrasound.
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