Affix label here Alberta Prenatal Record (Page 1)
Affix label here Alberta Prenatal Record (Page 1)
Affix label here Alberta Prenatal Record (Page 1)
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<strong>Alberta</strong> <strong>Prenatal</strong> <strong>Record</strong> (<strong>Page</strong> 1)<br />
Last name First name Middle initial Marital status<br />
Maiden name DOB Age<br />
YYYY/MM/DD<br />
Address/Reserve name Phone (H) (W)<br />
<strong>Affix</strong> <strong>label</strong> <strong>here</strong><br />
Postal Code Emergency contact Emergency number<br />
Occupation<br />
Ethnicity<br />
Language spoken<br />
Ethnicity baby’s father<br />
Partner’s name<br />
Partner’s occupation<br />
Referring care provider<br />
<strong>Prenatal</strong> care provider<br />
Consultant<br />
Baby physician (in hospital)<br />
Baby physician (in community)<br />
Intended place of birth<br />
Obstetrical History<br />
Date<br />
yyyy/mm/dd<br />
Site of Birth/Abortion<br />
Gest.<br />
age<br />
Hrs in<br />
labour<br />
Delivery type<br />
Complications<br />
Sex<br />
Children<br />
Birth weight<br />
Indicate lbs/kgs<br />
Present health<br />
Family History<br />
No Yes<br />
Diabetes<br />
Heart disease<br />
Hypertension<br />
Malformation / birth defects<br />
Mental illness / depression<br />
Multifetal gestation<br />
Other (include obstetrical, anaesthetic)<br />
Allergies<br />
No Yes<br />
if yes, specify agent and reaction<br />
Medications No Yes<br />
Folic acid at conception <br />
<strong>Prenatal</strong> vitamins <br />
List prescription, OTC, herbals<br />
Substance Use<br />
Tobacco<br />
# cigarettes / day<br />
Nicotine replacement<br />
Alcohol<br />
# drinking days / wk<br />
Max # drinks/drinking day<br />
None<br />
Before During<br />
Preg Preg<br />
Quit<br />
Date<br />
Hereditary / Ethnic Risk (refer to page 3)<br />
Rec drugs/solvents<br />
# days / wk<br />
Specify type:<br />
Medical History<br />
No Yes<br />
Asthma<br />
Autoimmune<br />
Bleeding / clotting disorder / DVT<br />
Heart<br />
Hypertension<br />
Diabetes<br />
Thyroid<br />
GI disorder<br />
Epilepsy<br />
Renal / urinary tract<br />
Hepatitis / liver disease<br />
HIV / AIDS<br />
STI<br />
Tuberculosis<br />
Chicken pox or vaccine<br />
Mental illness / depression<br />
Assisted conception<br />
Ovulation induction<br />
Invitro fertilization<br />
Intracytoplasmic sperm injection<br />
Other, specify<br />
Environmental / Occupational<br />
(second hand smoke, pets, toxins, daycare worker, etc)<br />
Social / Cultural (financial, support systems,<br />
beliefs, relationship stability, domestic violence, etc)<br />
Physical Examination<br />
Wt Pre-Preg<br />
Ht<br />
Kg Lbs<br />
cm ft/in<br />
General nutritional status<br />
Head & neck (teeth & gums)<br />
Breasts / nipples<br />
Heart<br />
Chest<br />
BP<br />
BMI<br />
Topics Discussed<br />
Nutrition / calcium<br />
Food quality / safety<br />
<strong>Prenatal</strong> classes<br />
Breastfeeding<br />
Routine tests / HIV screening (option to decline)<br />
Genetic screening<br />
Physical activity, rest & sleep<br />
Preterm labour<br />
Maternity leave<br />
Seat belt use<br />
Pain relief in labour<br />
On call provider<br />
Labour stages<br />
Other (VBAC, Inductions, etc)<br />
Comments / Referral<br />
Anaesthetic problems<br />
Transfusions<br />
Operations<br />
Other, specify<br />
Abdomen<br />
Spine / extremities<br />
Pelvic exam / uterine size _________________ weeks<br />
Provider signature<br />
Date<br />
HS0001-125 (Rev. 2009/09) <strong>Page</strong> 1
Gravida Term Preterm Number of abortions (by type)<br />
Spon. Induced Ectopic<br />
<strong>Alberta</strong> <strong>Prenatal</strong> <strong>Record</strong> (<strong>Page</strong> 2)<br />
# of living<br />
children<br />
Stillbirths<br />
Neonatal<br />
deaths<br />
<strong>Affix</strong> <strong>label</strong> <strong>here</strong><br />
LMP Sure of dates Cycle EDB by LMP EDB confirmed by U/S<br />
Yes Regular<br />
yyyy mm dd No Irregular<br />
yyyy mm dd yyyy mm dd<br />
Investigations<br />
Test<br />
Pap smear<br />
Date<br />
Date<br />
Result (yyyy/mm/dd) Test Result (yyyy/mm/dd) Test<br />
ABO/Rh<br />
HIV<br />
Last name of mother First name Middle initial<br />
Result<br />
Date<br />
(yyyy/mm/dd)<br />
Chlamydia &<br />
gonorrhea screen<br />
Urinalysis<br />
Urine C&S<br />
Hemoglobin<br />
Blood<br />
antibodies<br />
HBsAG<br />
Rubella<br />
Varicella<br />
Syphilis<br />
serology<br />
Syphilis serology<br />
2nd screen<br />
Gestational<br />
diabetic screen<br />
Group B<br />
strep<br />
mmol/L<br />
Hemoglobin<br />
Other investigations (laboratory, ultrasound) identify date, investigation and results<br />
<strong>Prenatal</strong> genetic investigations Counseled Declined Rh-IG Counseled<br />
1 Test<br />
Result<br />
YYYY/MM/DD Rh IG Ist dose:<br />
YYYY/MM/DD<br />
2 YYYY/MM/DD Rh IG 2nd dose:<br />
YYYY/MM/DD<br />
Date Weight Urine<br />
Gest. Fundus F.H. F.M. Cigs/<br />
(yyyy/mm/dd)<br />
lbs (protein/ BP age Pres.<br />
kg glucose)<br />
(cms) rate 20 wks+ day<br />
wks/days<br />
Comments<br />
Influenza vaccine<br />
Yes No<br />
(yyyy/mm/dd)<br />
Next<br />
Visit<br />
Init.<br />
Fetal movement discussed<br />
Count chart given: Date _________________<br />
Comments / Action plan<br />
Postpartum / Newborn Topics<br />
Breastfeeding Yes No Maybe<br />
Vitamin D supplement<br />
Back to sleep / SIDS prevention<br />
Postpartum depression<br />
Birth control<br />
Follow-up mother/baby<br />
Other (circumcision)<br />
Newborn requires<br />
Hepatitis B Prophylaxis<br />
No<br />
Yes<br />
Provider signature<br />
Date<br />
HS0001-125 (Rev. 2009/09) <strong>Page</strong> 2
<strong>Alberta</strong> <strong>Prenatal</strong> <strong>Record</strong> (<strong>Page</strong> 3)<br />
The <strong>Alberta</strong> <strong>Prenatal</strong> <strong>Record</strong> guides the practitioner in obtaining<br />
the woman’s medical, obstetrical, and family history. It is a record<br />
of the care provided. Refer to the <strong>Alberta</strong> <strong>Prenatal</strong> Care work sheet<br />
on page 4.<br />
The Healthy Mother, Healthy Baby Questionnaire Form HS0285<br />
can be used to obtain additional information on lifestyle and social<br />
history.<br />
At 36 weeks of gestation the <strong>Alberta</strong> <strong>Prenatal</strong> <strong>Record</strong> should be<br />
given to the woman to carry with her or a copy sent to the intended<br />
site for delivery.<br />
Hereditary/Ethnic Risk Assessment*<br />
Offer genetic counseling and/or carrier screening to biological<br />
parents with a relevant personal or family history of the<br />
following conditions, or to members of an at risk ethnic group.*<br />
Is t<strong>here</strong> any blood relationship between the biological parents<br />
No Yes <br />
A. Is t<strong>here</strong> a personal or family history (either side of the baby’s<br />
family) of the following:<br />
Thalassemia<br />
Tay Sachs disease<br />
Sickle cell anemia or trait<br />
Cystic fibrosis<br />
Hemophilia/bleeding disorder<br />
Intellectual disability/developmental delay<br />
Neuromuscular disease or muscular dystrophy<br />
Fragile X syndrome<br />
Major birth defect (e.g. spina bifida, cleft lip/palate)<br />
Metabolic disorder (e.g. PKU)<br />
Other inherited disease or chromosome abnormality,<br />
specify:<br />
No <br />
No <br />
No <br />
No <br />
No <br />
No <br />
No <br />
No <br />
No <br />
No <br />
No <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Yes <br />
Pregnancy Risk Profile for Specific Outcomes<br />
This risk profile summarizes the likelihood of specific adverse<br />
pregnancy outcomes (preterm, preterm SGA, SGA and LGA) in the<br />
presence of risk factors. The numbers are evidence-based odds<br />
ratios, representing the likelihood of occurrence of the adverse<br />
pregnancy outcomes in the presence of the specific risk factors.<br />
Circle all that apply.<br />
Risk Factor<br />
Demographic / Social<br />
Aboriginal<br />
Black<br />
Single<br />
Nulliparity<br />
Multiparity (> G3)<br />
Height < 152cm<br />
Pre-pregnancy Wt 80kg<br />
Age >35<br />
Cigarettes<br />
Substance Use<br />
Pre-existing Illness<br />
Diabetes<br />
Hypertension<br />
Chronic renal disease<br />
Endocrine disorder<br />
Medical disorder<br />
Cervical conization / surgery<br />
Preterm<br />
3<br />
2<br />
13<br />
2<br />
3<br />
4<br />
2<br />
4<br />
3<br />
3<br />
7<br />
Preterm<br />
SGA<br />
2<br />
2<br />
3<br />
2<br />
2<br />
2<br />
2<br />
5<br />
4<br />
Term<br />
SGA<br />
2<br />
2<br />
2<br />
2<br />
2<br />
2<br />
Term<br />
LGA<br />
> 4000g<br />
3<br />
3<br />
2<br />
2<br />
B. Offer genetic counseling / carrier screening for ethnic risk or<br />
positive family history:<br />
Ethnic Group<br />
Asian, African, Middle Eastern<br />
Mediterranean, Hispanic<br />
Carrier screening<br />
Thalassemia, hemoglobinopathy<br />
(e.g. sickle cell)<br />
Obstetrical History<br />
Previous SGA<br />
Previous preterm birth<br />
Prior > 3 abortions<br />
2<br />
4<br />
2<br />
12<br />
2<br />
2<br />
8<br />
Ashkenazi Jew<br />
French Canadian, Acadian, Cajun<br />
Tay-Sachs disease, Canavan<br />
Disease, familial dysautonomia<br />
Tay-Sachs disease<br />
* For additional information, contact Medical Genetics at:<br />
Calgary Ph: 403-955-7373 or Edmonton Ph: 780-407-7333<br />
Resource: Society of Obstetricians and Gynecologists of Canada<br />
(SOGC) guidelines. www.sogc.org/guidelines<br />
Definitions and Abbreviations:<br />
Expected Date of Birth (EDB) - Calculated by date of LMP and<br />
confirmed by early ultrasound<br />
Small for Gestational Age (SGA) - birth weight of less than 10th percentile<br />
Large for Gestational Age (LGA) - birth weight greater than 90th percentile<br />
PIH - Pregnancy Induced Hypertension (gestational hypertension)<br />
PPROM - Preterm Prelabour Rupture Of Membranes<br />
HELLP - Hemolysis, Elevated Liver enzyme levels and a Low<br />
Platelet count<br />
Current Pregnancy<br />
Multifetal gestation<br />
Poly / oligohydramnios<br />
Blood antibodies<br />
Acute medical disorder<br />
PIH<br />
PIH / proteinuria / HELLP<br />
Placenta abruptio<br />
Placenta previa<br />
Vaginal bleeding >20 wks<br />
PPROM<br />
<strong>Prenatal</strong> visits < 4<br />
Wt gain 41 wks<br />
Net wt gain > 15 kg<br />
Risk Factor<br />
Circle outcome risk<br />
20<br />
4<br />
4<br />
4<br />
2<br />
5<br />
5<br />
10<br />
5<br />
80<br />
4<br />
Preterm<br />
47<br />
13<br />
5<br />
6<br />
3<br />
5<br />
12<br />
69<br />
Preterm<br />
SGA<br />
3<br />
2<br />
3<br />
Term<br />
SGA<br />
4<br />
3<br />
Term<br />
LGA<br />
<strong>Page</strong> 3
<strong>Prenatal</strong> Care Worksheet<br />
This prenatal worksheet outlines the examinations, investigations and counseling the physician or midwife should consider in providing prenatal care.<br />
Significant effort has been made to ensure the accuracy of information presented. This worksheet should not be considered a substitute for clinical judgement and clinical advice.<br />
TIMING<br />
First prenatal visit<br />
6 - 10 weeks<br />
At each visit<br />
(Schedule visits every 4<br />
weeks up to 28-30 weeks,<br />
every 2 weeks up to 36<br />
weeks and then weekly after<br />
36 weeks until birth or more<br />
frequently if indicated)<br />
11-14 Weeks<br />
16-20 Weeks<br />
HISTORY & PHYSICAL<br />
INVESTIGATIONS TO CONSIDER<br />
Complete history & physical, including preconception: CBC<br />
Wt, Ht, and BMI.<br />
ABO/Rh & antibodies<br />
Obtain environmental/occupational, social/cultural and Rubella & varicella titre<br />
substance use history by interview or have mother complete Hepatitis B antigen<br />
Healthy Mother, Healthy Baby Questionnaire<br />
HIV serology<br />
(HMHB) HS0285.<br />
Pap smear<br />
Assess current medical status<br />
Chlamydia & gonorrhea screen<br />
Determine <strong>here</strong>ditary / ethnic risk - page 3<br />
Urinalysis & urine C&S<br />
Review current medications / herbal / OTC<br />
Genetic screening - schedule 1st<br />
Complete risk profile - page 3<br />
trimester aneuploidy screen<br />
Assign EDB (expected date of birth)<br />
Carrier screening<br />
Complete <strong>Prenatal</strong> Testing - Initial Screen for Pregnant Glucose testing<br />
Woman Lab Requisition<br />
TSH<br />
Schedule dating ultrasound<br />
Viral serology (e.g. toxoplasmosis)<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Inquire as to general well-being<br />
Assign gestational age<br />
Weight<br />
Blood pressure<br />
Symphysis - fundal height in cm<br />
Fetal heart sounds<br />
Presence of fetal movements<br />
Discuss results of genetic screening<br />
Arrange for diagnostic investigations<br />
Urine for glucose<br />
Urine for protein<br />
Blood antibody titres every 4<br />
weeks if Rh sensitized<br />
<br />
<br />
<br />
<br />
Genetic screening (1st trimester)<br />
Diagnostic genetic testing (CVS)<br />
Genetic screening (2nd trimester)<br />
Amniocentesis<br />
COUNSELING<br />
Review (HMHB-Q) with mother and/or identify concerns<br />
through interview<br />
Nutrition (including folic acid supplementation)<br />
Nausea & vomiting<br />
Food quality / safety<br />
Exercise / sleep<br />
Work / environmental concerns<br />
Smoking<br />
Alcohol and drug use<br />
Screening for infections in pregnancy<br />
Genetic screening options<br />
18-20 Weeks<br />
Ultrasound anatomical & fetal growth<br />
Confirm EDB for entire pregnancy<br />
24-28 Weeks<br />
Commence fetal movement counts<br />
Hemoglobin<br />
Discuss importance of fetal movement awareness and<br />
Provide copy of Fetal Movement Chart Form HS0001-132 Diabetic screening<br />
maternal response to a decrease in fetal movement<br />
Complete <strong>Prenatal</strong> - Testing Universal Syphilis<br />
Syphilis rescreening<br />
Signs & symptoms of preterm labour<br />
Rescreening Lab Requisition<br />
HIV screening / rescreening<br />
Obtain VBAC consultation / documentation<br />
ABO/Rh & antibodies (if Rh negative)<br />
Offer HIV screening / rescreening<br />
28-32 Weeks Add fetal presentation to routine visit<br />
Give Rh immune globulin (if Rh neg)<br />
Importance of fetal movement awareness<br />
30-36 Weeks Importance of fetal movement awareness<br />
Labour & birth concerns<br />
Hospital admission procedures<br />
Newborn issues and testing<br />
Breastfeeding<br />
Postpartum planning<br />
35-36 Weeks Confirm presentation of fetus<br />
GBS culture<br />
Ensure record available to L&D unit<br />
41-42 Weeks Pelvic examination Fetal assessment / NST Biophysical profile Importance of fetal movement awareness<br />
Syphilis & HIV screening / re-screening Induction plans<br />
Birth & Postpartum Pelvic examination<br />
Give Rh immune globulin (if Rh neg)<br />
Labour & birth concerns<br />
Postpartum (6 weeks) Breastfeeding evaluation<br />
Pap smear<br />
Sexuality & Contraception<br />
Assess for postpartum depression<br />
Hemoglobin<br />
Review immune status<br />
Arrange for newborn follow-up<br />
Coping strategies<br />
Risk for postpartum depression<br />
<strong>Page</strong> 4<br />
Newborn well-being / follow-up<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Seatbelt use<br />
Domestic violence / relationship stability<br />
Refer to SOGC - Intimate Partner Violence<br />
consensus statement (2005) for screening questions.<br />
<strong>Prenatal</strong> classes<br />
Sexuality<br />
Breastfeeding<br />
Counsel for common symptoms at this<br />
gestation<br />
Review results of investigations<br />
2nd trimester genetic screening<br />
Diagnostic genetic testing aminocentesis
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