Affix Patient Label Here - Alberta Perinatal Health Program

Affix patient label hereRisk Profile: Odds Ratio (OR) for Specific Pregnancy OutcomesThe risk profile is based on the best available evidence with odds ratios for pregnancy outcomes for preterm delivery, preterm-SGA(or equal 4500 g. Factors associated with these outcomes that have an OR of 1.5or 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 PROFILERisk FactorDemography/SocialRace AboriginalRace BlackSingleNulliparityMultiparity (gr 3 or >)Height 35CigarettesSubstance usePre-existing IllnessDiabetesHypertensionChronic renal diseaseEndocrine disorderMedical disorderCervical conization/surgeryObstetrical HistoryPrevious SGAPrevious preterm deliveryPrior 3+ abortionsCurrent PregnancyMultiple gestationPoly/oligohydramniosBlood antibodiesAcute medical disorderPregnancy induced hypertensionToxemiaPlacenta abruptioPlacenta praeviaVaginal bleeding >20 wks undetermined causePreterm rupture of membranesPrenatal visits 4000gLGA4500g3 3324 43

Affix patient label hereAntenatal Risk AssessmentAdd up the risk factors in the current pregnancy on the initial visit and at 36 weeks, and record thescore on Page 2 of the Alberta Prenatal Record.Part A - Pre-PregnancyScore1 Age < 17 at delivery2 Age > 35 at delivery1 Weight > 91 kg1 Weight < 45 kgHeight < 152 cmDiabetes1 Controlled by diet only3 Insulin used3 Retinopathy documentedHeart Disease1 Asymptomatic (no affect on daily living)3 Symptomatic (affects daily living)Hypertension2 140/90 or greater3 Antihypertensive drugs2 Chronic Renal Disease Documented1 OTHER medical disorders e.g. epilepsyPart B - Past Obstetrical HistoryScore3 Neonatal death(s)3 Stillbirths(s)1 Abortion between 12 to 20 weeksand under 500 grams birth weight1 Delivery at 20 - 37 weeks2 Cesarean section1 Small for dates - 5th percentile1 Large for dates - 95th percentile1 RH Isoimmunization - unaffected infant3 RH Isoimmunization - affected infant1 Major congenital anomaly e.g. chromosomal,heart, CNS defectsPart C - Problems in Current PregnancyScore2 Diagnosis of large for dates3 Diagnosis of small for dates2 Polyhydramnios or oligohydramnios3 Multiple pregnancy3 Malpresentation(s)2 Membranes ruptured before 37 weeks1 Bleeding < 20 weeks3 Bleeding > 20 weeks2 Gestational hypertension1 Proteinuria > 1+1 Gestational diabetes documented3 Blood antibodies (Rh, Anti C, Anti K, etc.)1 Anaemia (Hgb < 100gm per L)1 Pregnancy > 41 weeks1 Poor weight gain (26-36 weeks < 0.5 kg/week orweight loss)1 Smoker - anytime during pregnancyPart D - Other Risk Factors (Note: Scores to be validated)Score3 Major fetal anomaly3 Acute Medical Disorder (acute Asthma, Thyrotoxicosis,UTI, etc.)3 Cervical surgerySubstance Use:3 Alcohol > 3 drinks on any one occasion during pregnancy3 Alcohol > 1 drink per day throughout pregnancy3 Drug dependent*Low Risk 0-2, Moderate Risk 3-6, High Risk > 7Please enter the Risk Score on Page 2 of the Alberta Prenatal Record

Alberta Prenatal RecordInformation for Prenatal Care ProvidersThe Alberta Prenatal Record is available to all prenatal providers in Alberta.The prenatal record guides the practitioner in obtaining the woman’s health andobstetrical history, and documents investigations, and care provided during pregnancy.A copy of the form should be provided to the site of delivery for practitioners providingcare to the woman and baby during labour, delivery and postpartum. At 36 weeksgestation the form should be given to the woman to carry with her or a copy sent to theintended site for delivery.Enhancements to the Alberta Prenatal Record (HS0001-125 Rev.2007/02) include thefollowing:• 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 bythe mother or used as an interview guide. Information links to the AlbertaPrenatal RecordSupporting documents available from the Alberta Perinatal Health Program websitewww aphp.ca or contact (780) 735-1000.• Desk reference for Alberta Prenatal Record completion guidelines and HealthyMother, Healthy Baby Questionnaire• Pregnancy and Baby Health Community Resource Directory• Healthy Mother, Healthy Baby User Guide with information on development of theform including evidence and links to other assessment tools.To order more formsThe Alberta Prenatal Record (HS0001 -125) and the Healthy Mother, Healthy BabyQuestionnaire (HS0285) can be ordered on-line at https://secure5.datagroup.ca/acsc/request_ext.asp or by faxing your request to: (780) 422-1695.To provide comments on the forms or request assistance withimplementation contact:Alberta Perinatal Health Program, Quality Improvement Coordinator at (780) 735-1000or email graceguyon@cha.ab.ca.

Definitions of termsHighest Education Level – the highest grade/education level completed by the mother. less than high school high school completed trade/business school college/university otherEthnicity – 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 actualmeasurement 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 weeksgestation 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 weekspregnancy 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.