Alberta Prenatal Record by sdaferv


									                        Alberta Prenatal Record                        (Page 1)
                       Last Name of Mother                              First Name                             Middle Initial

                       Maiden Name                                                           Date of Birth                  Age                                  Affix patient label here
                       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
                                                                                     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
                                                        56. Abdomen
                      Current Weight
                                                        57. Spine
                                                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
                                                                                             Living     Stillbirths Neonatal
                                                                                                                                                       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)
     Pap Smear                                                ABO/Rh                                                   Varicella
    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
             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
                                                                                                                                                                         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
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)
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

•   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 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
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
                                  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

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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