Appendix S.3 L&D MR Form

Appendix S.3 L&D MR Form.doc

The National Centers for Autism and Developmental Disabilities Research and Epidemiology (CADDRE) Study

Appendix S.3 L&D MR Form

OMB: 0920-0741

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Study ID Number:














caddre


labor & delivery Chart


Abstraction Form






(11/14/2005)

A. IDENTIFYING INFORMATION No Info

  1. Mother’s name (Last, First, Middle)

2. Study ID#

3. Maiden Name

4. AKA

5. Mother’s Medical Record Number

6. SSN

7. Mother’s DOB

8. Baby’s Medical Record Number

9. Street Address (from L&D chart)

10. City

11. State

12. Zip Code


_ _ _ _ _-_ _ _ _

13. Delivery Hospital Name



14. Hospital Street Address

15. City

16. State

17. Zip Code


_ _ _ _ _-_ _ _ _

18. Date Abstracted


__ __/__ __ /__ __ __ __

19. Abstractor

20. Start Time


:

21. Stop Time


:

22. Start Time


:

23. Stop Time


:

24. Start Time


:

25. Stop Time


:

Comments:




B. ADMISSION THAT LED TO DELIVERY No Info

  1. Admit date


__ __/__ __ /__ __ __ __

99. unknown

2. Admit time

  1. Delivery date


__ __/__ __ /__ __ __ __

99. unknown

4. Delivery time


99. unknown

5. Discharge date


__ __/__ __ /__ __ __ __

99. unknown


6. Admitting Diagnoses

Comments:

C. Maternal Transport by Ambulance No Info

1. Transporting Facility

  1. Admit date


__ __/__ __ /__ __ __ __

3. Admit time

  1. Departure date


__ __/__ __ /__ __ __ __

5. Departure time

6.

1. Med record adequate

2. Order medical record

3. Record not available

7. Medical record number

8. Reason for transport

Comments:

D. INJECTIONS/VACCINATIONS DURING CURRENT PREGNANCY No Info

THROUGH 24 HOURS POSTPARTUM

Injection/vaccination

Rhogam (or other RH(D)) Immunoglobulin

Date


First__ __/__ __/ __ __ __ __

99. unknown



Second__ __/__ __/ __ __ __ __

99. unknown

Dose


First________

99. unknown



Second_______

99. unknown

Manufacturer


First________

99. unknown



Second_______

99. unknown

Product Name


First________

99. unknown



Second_______

99. unknown

Influenza vaccine

Date


__ __/__ __/ __ __ __ __

99. unknown

Manufacturer


99. unknown

Lot #


99. unknown

Other (specify):____________

Date


__ __/__ __/ __ __ __ __

99. unknown

Manufacturer


99. unknown

Lot #


99. unknown

Comments:

E. Cervical Exam on Admission No Info

  1. Date


__ __/__ __ /__ __ __ __

99. unknown

Time



99. unk

Dil (cm)



99. unk

Effac (%)



99. unk

Station



99. unk

1. SSE

2. SVE

3. US

4. Not noted

Comments:

  1. Date


__ __/__ __ /__ __ __ __

99. unknown

Time



99. unk

Dil (cm)



99. unk

Effac (%)



99. unk

Station



99. unk

1. SSE

2. SVE

3. US

4. Not noted

Comments:

Comments:



F. INDUCTION OR AUGMENTATION OF LABOR No Info

Method: 1= Prostaglandins for cervical ripening, 2= Artificial rupture of membranes (AROM), 3= Oxytocin/pitocin

4= Misoprostol 8= Other (specify), 9= Unknown

Reasons for induction/augmentation: 7= Premature ROM 11= Mature amnio

1= PIH 4= Chorionamnionitis 8= Prolonged premature ROM 12= Post date

2= Bleeding 5= Low biophysical profile 9= Prolonged ROM (term) 13= Fetal Distress

3= Polyhydramnios 6= Low AFI or oligohydramnios 10= Prolonged labor/uterine dystocia

88= Other (specify) ______ 99= Unknown

  1. Date initiated

__ __/__ __/__ __ __ __ __


Date stopped

__ __/__ __/__ __ __ __ __

Time Initiated

:


Time Stopped

:

Method

Purpose


1. Induction

2. Augmentation

3. No Info

Reason

Comments

  1. Date initiated

__ __/__ __/__ __ __ __ __


Date stopped

__ __/__ __/__ __ __ __ __

Time Initiated

:


Time Stopped

:

Method

Purpose


1. Induction

2. Augmentation

3. No Info

Reason

Comments

  1. Date initiated

__ __/__ __/__ __ __ __ __


Date stopped

__ __/__ __/__ __ __ __ __

Time Initiated

:


Time Stopped

:

Method

Purpose


1. Induction

2. Augmentation

3. No Info

Reason

Comments

  1. Date initiated

__ __/__ __/__ __ __ __ __


Date stopped

__ __/__ __/__ __ __ __ __

Time Initiated

:


Time Stopped

:

Method

Purpose


1. Induction

2. Augmentation

3. No Info

Reason

Comments

Comments:



G. RUPTURE OF MEMBRANES

If “yes” is indicated for medications, please fill out Section N. No Info

  1. Date


__ __/__ __/__ __ __ __ __

2. Time

1. at delivery

__ __ : __ __


2. at c-section

__ __ : __ __


3. other time

__ __ : __ __

Unknown

3. Length of time before delivery


1. <1 h 3. 12-24h

2. 1-12h 4. >24 h


Unknown

4. Method


  1. Spontaneous

  2. Artificial

9. Unknown

5. Confirming dx


  1. +Pooling

  2. +Nitrazine

  3. +Ferning

  4. +Indigo dye test

  5. +History

9. Unknown

  1. Description of fluid at time of rupture

7. Thin meconium 10. Terminal mec

1. Clear 3. Bloody 5. Foul odor 8 . Thick meconium 88. Other (specify)

2. Yellow 4. Purulent 6. Meconium NOS 9 . Moderate meconium 99. Unknown

7. Note any changes in fluid color/odor

8. Mother’s statement (include where, when, description)

9. Medication given during ROM

  1. Yes 9. Unknown

  2. No

Comments:


H. DELIVERY SUMMARY No Info


II = Singleton 20 = Twin NOS 30 =Triplet NOS 40 = Quadruplet NOS

21 =Twin A 31 =Triplet A 41 = Quadruplet A
22 = Twin B 32 = Triplet B 42 = Quadruplet B ENTER 99/99/9999 when date is unknown
33 =Triplet C 43 = Quadruplet C
44 = Quadruplet D


  1. Delivery date


__ __/__ __/__ __ __ __ __

2. Delivery time


:

3. Gender


1. Male

2. Female

3. Ambiguous

9. Unknown

4. Outcome


1. Live birth

2. Stillbirth

5. Plurality

6. Zygosity


1. Monozygotic (MZ)

  1. Dizygotic (DZ)

3. Unknown/No Info

Zygosity determined by:



7. Weight (gm)

8. Length (cm)

9. Head circumference (cm)

10. Apgar 1’ 5’ 10’ 15’

scores


11. Type of delivery


1. NSVD

2. Operative vaginal delivery

3. C-section

4. Breech extraction

9. Unknown

12. Presentation at delivery


1. Vertex

2. Transverse lie (shoulder presentation)

3. Face/brow

4. Breech

8. Other, (specify):_____

9. Unknown

13. Description of delivery

1. Normal

2. Precipitous

3. Prolonged 1st stage

4. Prolonged 2nd stage

9. Not Noted


14. Meconium staining of baby’s

1. Skin 4. Cord

2. Nails 5. No staining

3. Placenta 99. Unknown

15. Birth defects


None noted


16. Date onset labor


__ __/__ __/__ __ __ __ __

17. Time onset

:

18. If date/time unknown, mother’s statement


19. Analgesia in labor


1. Yes

2. No


Nubain

Stadol

Demerol

Fentanyl

Other: Specify:

_________________

_________________


List complications:

20. Anesthesia in labor


1. Epidural 6. Paracervical (saddle block)

2. Spinal 7. Pudendal

3. Local 8. Other (specify):____________

4. General 9. None

5. Perineal 99. Unknown/Not noted


List complications:



Spinal/Intrathecal start time: __ __:__ __ Date __________


Epidural start time: __ __ : __ __ Date: ____________

Epidural stop time: __ __ : __ __ Date: ____________

(when not stated use delivery time)

21. Estimated blood loss (EBL)


1. <500 cc’s (WNL)

2. >500 cc’s, (specify) __________


List complications


Comments/Discrepancies


22. Document any prep solutions used/where


99. unknown

23. Reason for preterm delivery per MD


99. unknown



24. Newborn Screening Accession Number: No Info


Comments:


I. PLACENTA AND CORD No Info

  1. Delivery date


__ __/__ __/__ __ __ __ __

2. Delivery time


:


No Info

3. 1. Spont.

2. Assisted

3. Manual

4. No Info

4. Nuchal cord 1. Tight

2. Loose

X_________ 3. NOS

4. Other: Specify_____________

5. Nuchal cord not noted

5. Cord length

1. Long

2. Short

3. Not stated

4. Stated length:________

6. Other cord abnormalities


1. True knot

2. Thin

3. Two vessels

4. Three vessels (normal)

5. Velamentous/marginal

insertion

6. Cord prolapse

9. No info

  1. Infarcts noted on OB/CNM exam

1. Old 3. NOS

Size ________ 2. New

8. Description of placenta on OB/CNM exam


Small placenta

Fetal papyraceous

Abruption _____%

Placenta accreta, increta or percreta

Placenta previa

Complete/total

Partial/marginal

Low lying

Missing lobes

Calcification

Vascular abnormalities

Clot noted

other: specify__________________

No Description

Comments:

J. PLACENTAL PATHOLOGY No Info

1. Pathology report copied

2. Placenta not sent to pathology (discarded)

3. Status unclear/report not in chart-contact path. Dept.

Comments:


K. DELIVERY INTERVENTIONS No Info

Codes: 1= Yes, 2= No, 9= Unknown

Code
Interventions
Comments



Version


Date: __ __/__ __/ __ __ __ __ 1. Successful 2. Failed



Amnio Infusion


Specify complications:



Vacuum


1. Successful 2. Failed Total time on ________min



Forceps


1. Successful 2. Failed Total time on ________min 1.Outlet 2. Low 3. Mid 4. Rotation



Cesarean Section



1.Elective 2. Unscheduled 3. Emergency

Comments:

Complications of Labor and Delivery

Check all that apply


No Complications Noted

Active Phase Arrest (APA)

Arrest of descent

Cephalopelvic Disproportion (CPD)

Cholestasis of pregnancy or intrahepatic cholestasis

Deep Transverse Arrest

Failed Trial of Labor

Failure to progress (FTP)

Failure to descend


Fetal distress or intolerance of labor (FIOL)

Herpes (genital), Active only

Intra-uterine Fetal Demise (IUFD)/ Stillbirth

Intra-uterine growth retardation (IUGR)

Low BPP or non-reassuring fetal testing

Macrosomia

Maternal death

Neonatal death

Oligohydramnios or Low AFI

Persistent OP


Polyhydramnios

Post-dates

Postpartum hemorrhage

Hemabate given

Methergine given

E&C

Uterine Artery Embolization

Prolonged latent stage

Retained placenta

Seizure

Shoulder dystocia

Slow Slope Active Phase

Uterine atony

Uterine rupture

Vasa previa

VBAC

Other (specify):_________________



L. MATERNAL INFECTIONS NOTED THIS ADMISSION

THROUGH 24H POSTPARTUM No Info

Dx codes : 1=Chorioamnionitis, 2= UTI, 3= Renal, 4= Vaginal, 5= STD, 6= GI, 7= URI, 8= Other (specify), 9=Unknown

If cultures were performed, note in Section M.

If “yes” is indicated for medications, please fill out Section N.

a. Dx

Date diagnosed


__ __/__ __ /__ __ __ __


9. unknown

GA

Tri

Certainty of Dx


1. Lab

2. Clinical

3. Suspect

9. Unknown

Duration


__ __ __ days


Unk

Highest temp


oC______


oF______


1. No temp

999. unknown

Cultures


  1. Yes

  2. No

9. Unknown

Medication Given


  1. Yes

  2. No

9. Unknown

b. Dx

Date diagnosed


__ __/__ __ /__ __ __ __


9. unknown

GA

Tri

Certainty of Dx


1. Lab

2. Clinical

3. Suspect

9. Unknown

Duration


__ __ __ days


Unk

Highest temp


oC______


oF______


1. No temp

999. unknown

Cultures


  1. Yes

  2. No

9. Unknown

Medication Given


  1. Yes

  2. No

9. Unknown

c. Dx

Date diagnosed


__ __/__ __ /__ __ __ __


9. unknown

GA

Tri

Certainty of Dx


1. Lab

2. Clinical

3. Suspect

9. Unknown

Duration


__ __ __ days


Unk

Highest temp


oC______


oF______


1. No temp

999. unknown

Cultures


  1. Yes

  2. No

9. Unknown

Medication Given


  1. Yes

  2. No

9. Unknown

d. Dx

Date diagnosed


__ __/__ __ /__ __ __ __


9. unknown

GA

Tri

Certainty of Dx


1. Lab

2. Clinical

3. Suspect

9. Unknown

Duration


__ __ __ days


Unk

Highest temp


oC______


oF______


1. No temp

999. unknown

Cultures


  1. Yes

  2. No

9. Unknown

Medication Given


  1. Yes

  2. No

9. Unknown

e. Dx

Date diagnosed


__ __/__ __ /__ __ __ __


9. unknown

GA

Tri

Certainty of Dx


1. Lab

2. Clinical

3. Suspect

9. Unknown

Duration


__ __ __ days


Unk

Highest temp


oC______


oF______


1. No temp

999. unknown

Cultures


  1. Yes

  2. No

9. Unknown

Medication Given


  1. Yes

  2. No

9. Unknown

Comments:






Codes: 1= Yes , 2= No(stated) , 3= Suspect, 9= not stated/Unknown

S/S on admission for delivery to 24 hrs postpartum

Date first noted

Time

Fever >37.7C or 100F on admission to 24hrs postpartum

Uterine tenderness

__ __/__ __ /__ __ __ __

:

5 highest fevers

Date

Time

Foul vaginal discharge noted (odor)


__ __/__ __ /__ __ __ __

:

1.



__ __/__ __ /__ __ __ __

:

Purulent amniotic fluid (color)


__ __/__ __ /__ __ __ __

:

2.



__ __/__ __ /__ __ __ __

:

WBC count >15,000/mL

__ __/__ __ /__ __ __ __

:

3.



__ __/__ __ /__ __ __ __

:

Persistent mat’l tachycardia (>100 bpm)

__ __/__ __ /__ __ __ __

:

4.



__ __/__ __ /__ __ __ __

:

Persistent fetal tachycardia (>160 bpm)


__ __/__ __ /__ __ __ __

:

5.



__ __/__ __ /__ __ __ __

:

Fetal Bradycardia


Periodic Changes

Other, (specify):

__ __/__ __ /__ __ __ __

Comments:


M. CULTURES OBTAINED THIS ADMISSION

(RECORD ALL CULTURES OBTAINED) No Info

Refer: Indicate the letter of the event from Section L. Use letter code in Section
L (e.g., La, Lb, Lc etc). If the culture does not correspond to an event in section L, insert “0”.


Source codes: 1= amniotic fluid, 2= placenta, 3= cervix, 4= vagina, 5=urine, 6=blood, 7= sputum, 8= stool,

88= other (specify), 99= unknown

Refer

Date cultured

Source

Results

Description (organisms, etc)

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

__ __/__ __ /__ __ __ __


99. unknown

1. No growth 3. NL Flora

2. Light growth 4. Positive

5. Growth noted, not specifed

9. Unknown

Comments:



N. ALL ANTI-INFECTIVES AND OTHER DRUGS TAKEN DURING THIS ADMISSION THROUGH 24 HOURS POSTPARTUM No Info

Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0‘.

Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, tylenol, methergine, labor and delivery anesthetics

Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid,

14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics (not labor and delivery), 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention, 88= other (specify), 99= unknown

Reason: 3 = lung maturity, 4= cervical ripening, 5= maternal disease, 6= prophylaxis 7= maternal fever 8= positive culture , 9= pain relief, 10= hyperemesis, 11= PIH, 88= other (specify), 99= unknown


Refer

Code

Drug name

Reason

Start Date

Duration

(in days)

Dose

Unit

Freq

Entire pregnancy



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info

N. ALL ANTI-INFECTIVES AND OTHER DRUGS TAKEN DURING THIS ADMISSION THROUGH 24 HOURS POSTPARTUM (cont’d)

Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0‘.

Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, tylenol, methergine, labor and delivery anesthetics

Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid,

14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics (not labor and delivery), 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention, 88= other (specify), 99= unknown

Reason: 3 = lung maturity, 4= cervical ripening, 5= maternal disease, 6= prophylaxis 7= maternal fever 8= positive culture , 9= pain relief, 10= hyperemesis, 11= PIH, 88= other (specify), 99= unknown

Refer

Code

Drug name

Reason

Start Date

Duration

(in days)

Dose

Unit

Freq

Entire pregnancy



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info



__ __/__ __/ __ __ __ __

TIME:


__ __ : __ __

9. Unknown



variable

1. gm 2. mg

3. mcg 4. mU

5. . cc/ml

8. . other

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

9. No Info

Comments:


Appendix S3 Page 12 of 12

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