Professional Documents
Culture Documents
Health
Service
:
Pregnancy
Summary:
Gravida
Parity
EDD:
/
/
by
Blood
group:
HIGH
RISK?
GBS
status
at
36/40:
For
Delivery
at
:
Hospital
Maiden
name:
Surname:
Support
person:
Support
person
contact
details:
MRN:
Given
name:
DOB:
Address
Phone:
Partners name:
Alternate phone:
Gest
Alive.SB
NND
Sex
Birth
wt
Type
of
Delivery
Place
of
Delivery
EXAMINATION
Epilepsy:
Post
Natal
Depression:
Psychiatric:
Thyroid:
Anaemia:
Thrombosis:
FAMILY HISTORY
Diabetes:
BP:
Twins:
Genetic
Disorder:
Cigarettes:
Alcohol:
Marijuana:
Other
drugs:
36/40:
Yes/No;
How
much?
Cycle
length:
Regular:
Yes
No
Performed
by
2
3
4
Placental
Location:
Contraception:
Notes:
Date
EDD
by
LMP
/
/
EDD
by
USS
/
/
/
/
/
/
/
/
Final
EDD:
/
/
MRK70A
Author: Multi Agency Project Group; Authorised by; Kimberley MAC and Patient Safety Network; Version 2 (November 2010); Review: November 2012
Year
Page No 1
Surname:
MRN:
Given
names:
Medicare
no:
Address:
DOB:
Phone:
st
1 VISIT
Date
Results
14 -17 Weeks
Date Results
FBC
Rubella
Varicella
Hep B
28 Weeks
Hep C
FBC
HIV
Syphilis
Iron studies
Vitamin D*
Random glucose
34 Weeks
SOLVS MCS
36 Weeks
FBC
Edinburgh
Postnatal
Depression
Score
(EPDS)*
*See
local
protocols
BMI
>
35
at
Booking
:
See
Local
Site
Instruction
for
Exclusion
Criteria
KNX:
refer
to
anaesthetist
if
BMI>32.
Broome:
refer
if
BMI
>
35.
Derby
if
BMI
>
35.
SOCIAL
HISTORY
No.
of
people
in
your
house?
Do
all
your
children
live
with
you?
If
not,
who
is
the
carer?
Do
you
have
a
supportive
partner/family?
Antenatal Education
Date
Antenatal Education
Date
Nutrition
Oral Health
Breastfeeding
When to go to hospital
Support person/s
Contraception
SIDS information
PATS arrangements
Page No 2
Surname:
Given
names:
Medicare
no:
MRN:
DOB:
Address:
Phone:
PREGNANCY
SUMMARY
Gravida
Parity
BMI:
Booking
32/40
EDD:
/
/
by
Blood
group:
GBS
36/40
Date
Wks
Fundal
Height
Wt
BP
Urine
Oedema
Presentation
Position
FHR
FM
Next
visit
Sign
Dr/MW
Page No 3
Surname:
Given
names:
Medicare
no:
MRN:
DOB:
Gravida Parity
Address:
Phone:
EDD:
ANTENATAL
VISITS
Date
Wks
Fundal
Height
Wt
BP
Urine
Oedema
Presentation
Position
FHR
FM
Next
visit
Sign
Dr/MW
COMMENTS
REVIEWS
Anaesthetic
Review
Date
/
/
Signed
___________________
Approved
for
delivery
at
___________________
Hospital
Obstetric
Review
Date
/
/
Signed
___________________
Approved
for
delivery
at
___________________
Hospital
DELIVERY
OUTCOME
DOB
Gestation
Sex
Birth Weight
Type of birth
Apgars
Name
Signature
SIGNATURE
REGISTER
Name
Signature
Name
Signature
Page
No
4
MRK70A
MRK70A
Surname:
Given
names:
Medicare
no:
MRN:
DOB:
Gravida Parity
Address:
Phone:
EDD:
ANTENATAL
VISITS
Date
Wks
Fundal
Height
Wt
BP
Urine
Oedema
Presentation
Position
FHR
FM
Next
visit
Sign
Dr/MW
MRK70A
Page No ___