Subject MRN
GA at delivery
Record ID
Date of Delivery
Term deliveries
Pre-Term Deliveries
Living children
Age at Delivery
Height (cm)
Admit weight (kg)
Pre-pregnancy weight (kg)
BMI (pre-preg)
preg wt gain (kg)
IOM wt cat
GA weeks at delivery
GA days at delivery
Marital Status
Drug Abuse
Alcohol Abuse
Chronic Medical Problems
Type of Medical Problem
Meds other than PNV
Type of Medication
Reason for Admission
Other Reason for Admission
Reason for IOL
Early GCT
Date of Early GCT
Result of Early GCT
Gestational Age at Time of Early GCT
GCT Date
Gestational Age at GCT
GCT Result
Gestational Diabetic?
GTT Date
Gestational Age at GTT
GTT fasting
GTT 1 hour
GTT 2 hr
GTT 3 hr
EFM for last 30 mi
Mode of delivery
Vacuum used?
Forceps used?
Shoulder Dystocia?
3rd or 4th degree laceration?
PPH (>500 cc for vag delivery, >1000 cc for c/s)?
Uterine atony documented in chart?
Estimated Blood Loss
Indication for c/s
Dilation (in cm)
Other:
Type of Pregnancy
Meconium?
Apgars 1 min
Apgars 5 min
Apgars 10 min
Complete?
Infant sex
Infant weight (grams)
BW percentile
Infant Discharged
NICU admission?
Length of NICU stay
Infant sepsis?
Infant NEC?
Infant ICH?
Infant intubated?
Findings on placental pathology?
What were the findings?
Cord gas (art)?
Base Excess of umbilical cord
pH of umbilical cord
Anomaly?
Type of anomaly identified
Neonatal death?
Infant neurological complications?
Infant respiratory distress?
Infant PNA?
Placenta < 10% for weight?
Complete?1
Date and time of sono
1st Sono Location
1st BPD
1st HC
1st AC
1st FL
1st F Weight
Overall %tile
Overall percentile
HC %tile
AC %tile
FL %tile
Date and time of 2nd sono
2nd Sono Location
2nd BPD
2nd HC
2nd AC
2nd FL
2nd F Weight
2nd Overall %tile
2nd Overall percentile
2nd HC %tile
2nd AC %tile
2nd FL %tile
2nd scan wt cat?
2nd Best GA
Complete?2
2nd scan cat
change inwt%
increase>=20%
within20%
decrease>=20%