Perinatal Paperwork

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Contents


Cost-effective and efficient electronic systems depend on getting the paperwork right first.

This section of EEPDwiki concerns documents where the master copy is held by the healthcare providers.

For documents where the master copy is held by the woman, please see Hand Held Records

Please see also the links to generic work on healthcare paperwork on our WISDAM Wiki.



Reproductive Medicine and Preconception

Fertility


Source(s): Perinatal Paperwork


Genetic Screening and Counselling

see also Cytogenetics for antenatal laboratory test requisition forms and results

Document Date Source
Dartmouth-Hitchcock Prenatal & Preconception Appointment Request Form 2010 USA: Wentworth Health Partners, Dover, New Hampshire
Prenatal Genetic Screening Questionnaire 2010 USA: St Anthony's Medical Center Perinatal Center, St. Louis, MO
Prenatal Genetic Screening Questionnaire 2008 USA: Stanford University Medical Center Lucile Salter Packard Children's Hospital
Prenatal Screening Questionnaire USA: American Medical Association
PFCPMC Prenatal Genetic Screening Questionnaire USA: California Pacific Medical Center
Prenatal Diagnosis Screening Questionnaire USA: University of Maryland Medical Center Ob/Gyn Department
Appointment Referral Form for Genetic Counseling and Testing USA: University of South Carolina


Source(s): Perinatal Paperwork


Contraception


Source(s): Perinatal Paperwork


Termination of Pregnancy


Source(s): Perinatal Paperwork


General Perinatal

to be moved to appropriate sections in due course Admin 13:29, 4 September 2012 (BST)
  • WHO World Health Organization
Illustrative Maternal Health Card
Making Pregnancy Safer Assessment tool for the quality of hospital care for mothers and newborn babies


Source(s): Perinatal Paperwork


Antenatal

Go to the Antenatal Documentation section


Source(s): Perinatal Paperwork


Investigations

Go to Laboratory Investigations


Source(s): Perinatal Paperwork


Ultrasound

Document Date Source
Request for Ultrasound Scan in Pregnancy 2011 University Hospitals Bristol NHS Foundation Trust: St Michael's Hospital
Pathway for fetal anomaly scan

Pathway for raised nuchal translucency (NT) ≥3.5mm

Knowing about the woman before the scan. Includes minimum core information that should be documented in the hand-held notes and a link to video of sonographer and midwife discussing importance of hand-held notes.

2010 NHS Screening Programmes: Fetal Anomaly
Request for Routine Obstetric Ultrasound Examination see Appendix 1 (p.9 of the PDF)  ? Wiltshire Community Health Services
Women's Imaging Request  ? AUSTRALIA: Royal Brisbane and Women’s Hospital
Prenatal Screening for Down Syndrome, Trisomy 18 and Neural Tube Defects 2012 CANADA: Children's Hospital of Eastern Ontario
Obstetrics & Gynecology Ultrasound Request 2011 CANADA: McGill University Health Centre, Royal Victoria Hospital, Montreal
Requisition 2011 CANADA: Pureform Ultrasound & X-Ray, Sherwood Park Clinic, Alberta
Obstetrical Ultrasound Centre requisition form 2010 CANADA: Sunnybrook Health Sciences Centre
SOGC Committee Opinion 103: Content of a Complete Obstetrical Ultrasound Report 2001 CANADA: Society of Obstetricians & Gynaecologists of Canada
Perinatal Ultrasound Referral Form  ? IRELAND: Coombe Hospital, Dublin
Procedures, guidelines and reports - includes sample reports & templates for first trimster ultrasound 2012 NEW ZEALAND: National Screening Unit
Prenatal Diagnosis / Ultrasound Service Request 2011 USA: UNC Health Care
MD.8 Obstetric Ultrasound Prior Authorization Request Form 2011 USA: Texas Medicaid Program
Sample obstetric ultrasound report 2006 USA: Medical Image Enhancement Technology, Inc. (MIET)
Ultrasound Order Form  ? USA: Krislan Ultrasonix Imaging Center, Concord, NH
Ultrasound Request Form  ? USA: ROSH Maternal-Fetal Medicine, New York
Requisition form  ? USA: Vanderbilt Center for Women's Imaging, Nashville, Tennessee


Source(s): Perinatal Paperwork


Hydatidiform Mole

Also called Molar Pregnancy; Gestational Trophoblastic Disease

Registration in the UK is normally done online.

Document Date Source
Registration form for patients having hydatidiform mole - for use when online registration is not possible - send to one of the UK registration centres 2011 UK
Registration form for patients having hydatidiform mole 2005 Sheffield
Gestational Trophoblastic Unit registration documentation 2009 AUSTRALIA: Royal Brisbane & Women's Hospital
Gestational Trophoblastic Disease Registration Form and Physician Information 2006 CANADA: Nova Scotia Gestational Trophoblastic Disease Registry
Patient Registration Form

in English in French

2012 CANADA: Quebec Trophoblastic Disease Registry / Registre des Maladies Trophoblastiques du Québec (RMTQ)


Source(s): Perinatal Paperwork


Group B Streptococcus


Source(s): Perinatal Paperwork


Venous Thromboembolism

VTE, Venous Thrombosis, Deep Vein Thrombosis, DVT, Pulmonary Embolism

Document Date Source
Clinical guideline for the risk assessment of venousthromboembolism (VTE) during pregnancy, labour and post natal period. Contains several proformas:
p.3 Appendix 1: Antenatal VTE risk assessment and management at booking (to be completed by community midwife)
p.4 Appendix 2: Referral form to combined obstetric and haematology clinic
p.5 Appendix 3: Antenatal VTE assessment and management on admission (Excluding labour/induction of labour). (To be completed on any admission by Doctor / Midwife)
p.6 Appendix 4: VTE assessment and management on admission - outcome (to be filled by the Doctor clerking the woman)
p.7 Appendix 5: Postnatal VTE assessment (To be completed after delivery by person conducting the delivery)
p.8 Appendix 6: VTE assessment and management after delivery - outcome (to be filled by the Middle grade/ SHO/ Consultant on call on delivery suite)
2012 Royal Cornwall Hospitals NHS Trust


Source(s): Perinatal Paperwork


Home Birth

  • Worcestershire Acute Hospitals NHS Trust (2012) Home Birth Guideline. See p.9-10 Appendix A Home Birth Checklist and p.11 Appendix B. Notification of Home Birth to Midwifery Manager / Supervisor of Midwives.


  • North Cumbria University Hospitals NHS Trust (2011) Homebirth. See p.15-29 Appendix 2. Homebirth forms.


  • Halton and St Helens PCT (2009) Guideline for Planned Home Births. See p.13 Appendix 1. Home Confinement Form ; p.14-15 Appendix 2. Notice that a home birth has taken place ; p.16-17 Appendix 3. Notification to G.P. of Home Delivery.


  • Northampton General Hospital NHS Trust (2009) Homebirth Guideline. Includes several forms: p.14 Appendix 2. Referral form to homebirth team for women (regardless of gestation) requesting a homebirth ; p.18-19 Appendix 4. Homebirth Risk Assessment Form ; p.20-21 Appendix 5. Booked Homebirth Form.


Source(s): Perinatal Paperwork


Intrapartum

Document Date Source
Birth Notes 2011 Perinatal Institute
WHO Surgical Safety Checklist for maternity cases only 2010 NPSA and Royal College of Obstetricians and Gynaecologists
Intrapartum Scorecard and Guide to using the Intrapartum Scorecard - issue 4 2010 NHS Patient Safety
Intrapartum Record 2011 AUSTRALIA: Queensland Government
Maternity Inpatient's Register  ? NIGERIA: Aminu Kano Teaching Hospital
National Maternity Case Record - record made for every pregnant woman entering a maternity unit. See also the Guidelines for completing the National Maternity Case Record 2001? SOUTH AFRICA: Department of Health


Source(s): Perinatal Paperwork


Fetal Monitoring

Document Date Source
Maternal / Cord Blood Investigation Request Form in use 2012 University Hospitals Coventry & Warwickshire NHS Trust Transfusion Department
Parer & Ikeda Five-tier classification of intrapartum fetal heart rate patterns 2007-2011 read more on perinatology.com


Source(s): Perinatal Paperwork


Obstetric Anaesthesia

Document Date Source
Obstetric Anaesthetic Sheet 2010 St Thomas' Hospital
Analgesia Record 2010 St Thomas' Hospital
Obstetric Regional Analgesia - Consent and Procedure 2008 Brighton and Sussex University Hospitals NHS Trust
Suggested items to be included in obstetric anaesthesia records 2006 Obstetric Anaesthetists' Association
Ballarat Analgesia Infusion Chart 2007 AUSTRALIA: Victorian Quality Council
Sample c-section chart USA: Stony Brook Medical Department of Anesthesia


Source(s): Perinatal Paperwork


Epidural

Document Date Source
Epidural Analgesia Prescription and Observation Chart  ? East Cheshire NHS Trust
Epidural Observation & Pain Assessment Chart  ? Great Ormond Street Hospital NHS Trust
Epidural Monitoring 2008 Brighton & Sussex University Hospitals NHS Trust
Patient Controlled Epidural Analgesia (PCEA) Birthing Suite CH-0152 2008 AUSTRALIA: Calvary Health Care ACT
Sample epidural chart USA: Stony Brook Medical Department of Anesthesia


Source(s): Perinatal Paperwork


Modified Obstetric Early Warning Score (MEOWS)

go to our MEOWS resources page


Source(s): Perinatal Paperwork


Labour

Document Date Source
Use of a Partogram clinical guideline 2011 AUSTRALIA: King Edward Memorial Hospital, Perth, WA
A Companion Guide for Completion of the Nova Scotia Labour Partogram 2007 CANADA: Reproductive Care Program of Nova Scotia
Hania Sholkamy, Nevine Hassanein, Mohamed Cherine, Amr Elnoury, Miral Breebaart and Karima Khalil An Observation Checklist for Facility-Based Normal Labor and Delivery Practices: The Galaa Study (Monographs in Reproductive Health: 5 see Appendix A p.29 for the observation checklist 2003 EGYPT: Population Council Regional Office for West Asia and North Africa
Paperless Partogram - needs no special partograph paper and is appropriate for low-resource settings. See also Google search results for "paperless partogram" 2010 INDIA: Dr. A.K. Debdas MD FRCOG FRCS
Labour Records  ? NIGERIA: Aminu Kano Teaching Hospital
Form OB-32 Labor Room Record 1959-1962 USA: Johns Hopkins School of Public Health
Preventing Prolonged Labour. The Partograph Part II: User's Manual 1994 WHO: World Health Organization
Resource A: Observation Tool—Caring Behaviours in Labour and Delivery Family Care International


Source(s): Perinatal Paperwork


consent forms

see Consent Forms: Labour


Source(s): Perinatal Paperwork


Induction of Labour


Source(s): Perinatal Paperwork


Caesarean Section

Go to the Caesarean Section section


Source(s): Perinatal Paperwork


Vaginal Birth After Caesarean (VBAC)

Document Date Source
VBAC Proforma 2011 unknown
Guidelines for the Management of Vaginal Birth after Caesarean Section. Pages unnumbered in this document. See Appendix 2 for a letter template to be used by booking midwife to request information about previous Caesarean if it took place in a different organisation. See Appendix 3 for Audit Tool 2010 Ashford & St Peter's Hospitals NHS Trust


Source(s): Perinatal Paperwork


consent forms

see Consent Forms: Vaginal Birth After Caesarean (VBAC)


Source(s): Perinatal Paperwork


Delivery

Document Date Source
Clinical Guideline for Operative Vaginal Delivery. See p.6-7 for Instrumental Delivery Proforma 2012 Royal Cornwall Hospitals NHS Trust
Management of Multiple Pregnancy. See p.7-8 for Twin Vaginal Delivery Proforma 2012 Royal Cornwall Hospitals NHS Trust
Maternity Record: Delivery 2005 Brighton & Sussex University Hospitals NHS Trust
Delivery Record - Part One

Delivery Record - Part Two

2009-10 CANADA: Alberta Perinatal Health Program (APHP)


Source(s): Perinatal Paperwork


Complications

Obstetric Haemorrhage

Document Date Source
Clinical guideline for massive obstetric haemorrhage. See p.5-6 Appendix 1: Major/massive obstetric Haemorrhage Summary Proforma 2012 Royal Cornwall Hospitals NHS Trust
Postpartum haemorrhage. See p.18-20: Management of Obstetric Haemorrhage Proforma 2012 East Cheshire NHS Trust
Intrapartum Guidelines No. 18. Management of Major Obstetric Haemorrhage: antenatal & intrapartum. See p.5-6 Appendix 2: Obstetric Haemorrhage Proforma

Postnatal Guidelines No. 9. Post Partum Haemorrhage (PPH). See p.7-8 Appendix 1: Obstetric Haemorrhage Proforma

2012 Plymouth Hospitals NHS Trust
Toolkit for the management of major haemorrhage. See p.10-12: North West RTC Audit of Massive Haemorrhage Proforma 2010 North West Regional Transfusion Committee incorporating North Wales


Source(s): Perinatal Paperwork


Perineal Trauma

Document Date Source
Recognition and management of perineal and genital tract trauma. See p.6 Appendix 1: Perineal Suturing Proforma 2012 Royal Cornwall Hospitals NHS Trust
3rd & 4th degree tear proforma 2009 Salisbury NHS Foundation Trust


Source(s): Perinatal Paperwork


Obstetric Fistula


Source(s): Perinatal Paperwork


Shoulder Dystocia

Document Date Source
Shoulder Dystocia guideline. See p.14 Appendix 1: Shoulder Dystocia Proforma. 2012 East Cheshire NHS Trust
Shoulder Dystocia Maternity Guideline See p.9 Appendix 2: Shoulder Dystocia Reporting Form 2012 Imperial College Healthcare NHS Trust
Intrapartum Guidelines No. 28 Shoulder Dystocia See p.5 Appendix 1: Shoulder Dystocia Proforma 2012 Plymouth Hospitals NHS Trust
Guideline for the management of a shoulder dystocia See p.7 Appendix 1: Shoulder Dystocia Documentation 2012 Royal Cornwall Hospitals Acute Trust
Management of Shoulder Dystocia v5 See p.8-9 Shoulder Dystocia Proforma 2012 Worcestershire Acute Hospitals NHS Trust
Proforma - Shoulder Dystocia (QMC campus)  ? Nottingham University Hospitals NHS Trust


Source(s): Perinatal Paperwork


Perinatal Death

please go to Perinatal_Mortality


Source(s): Perinatal Paperwork


Postnatal

Document Date Source
Postnatal Notes for mother and baby 2011 Perinatal Institute
Scottish Birth Record ISD Scotland
Maternity Record Maternal Postnatal 2009 Brighton & Sussex University Hospitals NHS Trust
British Columbia Postpartum Clinical Path (PSBC 1592)

A Guide for Completion of the British Columbia Postpartum Clinical Path (PSBC 1592)

2011 CANADA: Perinatal Services BC
Rourke Baby Record resources & downloads, including forms in English & French 2009 - CANADA: Drs. L Rourke, D Leduc and J Rourke
Child Health Resource Package Clinical Records - collection of forms for neonatal and paediatric record keeping. 2nd edition. The neonatal records are ‘flow patterned’, with chronology emphasised, and forms that may be required throughout an admission are available. The neonatal guidelines are also cross-referenced to the forms. 2007 SOUTH AFRICA: KwaZulu-Natal Department of Health


Source(s): Perinatal Paperwork


Neonatal Intensive Care

NICU, Neonatal Critical Care Unit, Special Care Baby Unit, SCBU

Document Date Source
Chatinkha Nursery Admission Sheet 1997-2010 MALAWI: Queen Elizabeth Central Hospital, College of Medicine, Paediatric Department, Box 360, Blantyre
Neonatal critical care pathway for days 1-5. The reverse side of the CCP can be used to record days 6-10 similar to the front page, or can be used to record drug doses etc. 1997-2010 MALAWI: Queen Elizabeth Central Hospital, College of Medicine, Paediatric Department, Box 360, Blantyre


Source(s): Perinatal Paperwork


Neonatal Screening

Blood Spot

Heel prick, Guthrie Test, Neonatal capillary blood sampling

Document Date Source
Blood Spot Card 2011 NHS Screening
Procedure for Performing Heel Prick for Newborn Blood Spot Screening. See Appendix 2 p.12-13 for Health Visitor Neonatal Screening Information Form. 2009 NHS Wirral


Source(s): Perinatal Paperwork


Drug and Prescription Charts

Document Date Source
Neonatal Vitamin K Prescription and Administration Chart (Maternity Only) 2006 Brighton and Sussex University Hospitals NHS Trust
Paediatric and Neonatal Drug Prescription and Administration Chart 2003 Brighton and Sussex University Hospitals NHS Trust


Source(s): Perinatal Paperwork


Birth Notification


Source(s): Perinatal Paperwork


Birth Certificate


Source(s): Perinatal Paperwork


Discharge

see also Handover


Source(s): Perinatal Paperwork


Immunization


Source(s): Perinatal Paperwork


Paediatric Growth Charts

  • AUSTRALIA: Victoria Department of Education and Early Childhood Development. Growth Charts


Source(s): Perinatal Paperwork


Maternal Child Health Surveys

  • USA: California Department of Public Health. Maternal and Infant Health Assessment (MIHA) Survey
2010 questionnaire - English ; 2010 questionnaire - Versión en español
Archive of questionnaires 2000-2009 (English & Spanish)


Source(s): Perinatal Paperwork


PRAMS

PRAMS (Pregnancy Risk Assessment Monitoring System) is a surveillance project of the United States Centers for Disease Control and Prevention (CDC) and individual state health departments. PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. (adapted from information on the PRAMS website)


Source(s): Perinatal Paperwork


Document Date Source
PRAMS Questionnaires 2004 - present USA: Centers for Disease Control Pregnancy Risk Assessment Monitoring System (PRAMS)
PRAMS Utah Questionnaire USA: Utah Department of Health


Source(s): Perinatal Paperwork


Child Protection

Document Date Source
Health version of Standard Child Concern Form - with additional check-list 2009 NHS Highland
Child abuse notification form AUSTRALIA: Townsville Mackay Medicare Local


Source(s): Perinatal Paperwork


Postnatal Depression

Document Date Source
Edinburgh Postnatal Depression Scale (EPDS) 1987 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987 Jun;150:782-6. PMID 3651732
Postnatal Risk Questionnaire 2005 AUSTRALIA: MP Austin, Black Dog Institute


Source(s): Perinatal Paperwork


Administrative


Source(s): Perinatal Paperwork


Handover

See Handover for examples of paperwork and guidance relating to handover and transfers.


Source(s): Perinatal Paperwork


Financial

Document Date Source
Statutory Maternity Pay - forms for employers 2011 HM Revenue & Customs
Application form for maternity birth grant (in Greek) - must be submitted along with baby's birth certificate within 12 months of baby's birth. 2011 CYPRUS Government
Claim form for maternity allowance (in Greek) 2007 CYPRUS Government
Guidelines for Implementation of Janani Suraksha Yojana (JSY) Card - the JSY scheme offers poor women cash incentives for institutional delivery 2006 INDIA: Government of West Bengal
various benefit forms in English, including Maternity ISRAEL: National Insurance Institute
SSS Form MAT2 Maternity Reimbursement 2000 PHILIPPINES: Republic of the Philippines Social Security System


Source(s): Perinatal Paperwork



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