Appendix_S

Study ID Number _____________________

Labor and Delivery Medical Record Abstraction Form

This form should be used for abstraction of medical records from all labor and delivery care providers seen during index pregnancy.

A single abstraction form should be used for all relevant providers.

Below list all providers that contributed data to this form.

OF NOTE: It is NOT necessary to indicate the specific provider record source for each individual data item on this form. It will be too cumbersome to try and detail exactly which record(s) provided which data. Hopefully, in most cases if the same information is provided in multiple different provider records, it will be consistent and complimentary. However, there might be cases in which conflicting information is presented in 2 different records. Use the data available to make your best judgment about the correct information and then add a comment providing details of the conflict between provider sources.

CONTRIBUTING PROVIDERS
A.1. Name of Provider/Hospital
A.2. Street Address
A.3. City		A.4. State		A.5. Zip Code
ABSTRACTION LOG
A.6. Date __ __/__ __/__ __ __ __	A.7. Date __ __/__ __/__ __ __ __		A.8. Date __ __/__ __/__ __ __ __
A.6.1 to A.6.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	A.71 to A.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		A.8.1 to A.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
A.9. Date __ __/__ __/__ __ __ __	A.10. Date __ __/__ __/__ __ __ __		A.11. Date __ __/__ __/__ __ __ __
A.9.1 to A.9.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	A.10.1 to A.10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		A.11.1 to A.11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

B.1. Name of Provider/Hospital
B.2. Street Address
B.3. City		B.4. State		B.5. Zip Code
ABSTRACTION LOG
B.6. Date __ __/__ __/__ __ __ __	B.7. Date __ __/__ __/__ __ __ __		B.8. Date __ __/__ __/__ __ __ __
B.6.1 to B.6.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	B.71 to B.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		B.8.1 to B.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
B.9. Date __ __/__ __/__ __ __ __	B.10. Date __ __/__ __/__ __ __ __		B.11. Date __ __/__ __/__ __ __ __
B.9.1 to B.9.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	B.10.1 to B.10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		B.11.1 to B.11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

A. IDENTIFYING INFORMATION

No information for any item in section

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

2. Study ID#

3. Maiden Name

4. AKA

5. Mother’s DOB

6. Street Address (from L&D chart)

7. City

8. State

9. Zip Code

_ _ _ _ _-_ _ _ _

10.Place of Delivery

1. Hospital (enter Name in 11)

2. Car (Skip to )

3. Ambulance (Skip to )

4. Parking Lot (Skip to )

5. Home (Skip to )

6. Work (Skip to )

7. Other, specify ________

88 IL

99 NR

11. Delivery Hospital Name

12. Hospital Street Address

13. City

14. State

15. Zip Code _ _ _ _ _-_ _ _ _

Comments:

Sections B-N: How to Document Various Types of Missing Information

A. No information -- entire section

Each section of each form will include either one or two universal missing check boxes. If either are checked, no further data are recorded for the entire section.

1. No information for any item in section

Checked if:

No relevant tests or procedures appear to have been ordered by any contributing medical care providers; and/or

No information was recorded for relevant health status, medical conditions, medications.

2. Test/procedure for one or more items in section indicated but no information on dates, results, etc.

(will only apply to certain sections as indicated)

B. Information available for one or more items within a section BUT no information for selected items

If there is information in the chart for one or more items in a given section on a given abstraction form, all pertinent data should be recorded. However, there is still the possibility that there will be missing data within these sections. Three types of missing data codes are recognized:

NA – NOT APPLICABLE (for use with certain items such as those with skip patterns and those for which multiple tests/procedures/etc. might have been performed and all are requested in abstraction form. After last relevant item is recorded, the subsequent item on abstract form is NA to indicate the end of reporting).

IL -- NOT LEGIBLE (self-explanatory)

NR – NO info in RECORD (“true missing” There should be information for an item, but it cannot be located.)

The following coding schemes will be applied to code these 3 types of missing:

Categorical variables with a finite coding scheme

77. NA

88. IL

99 NR

Dates and times – these may be completely missing or partially missing.

Data entry format is __ __/__ __/__ __ __ __ and __ __:__ __

For dates and time (military hours and minutes)

For day, month, hours, and minutes, enter 77, 88, or 99 as appropriate

For year the enter 7777, 8888, or 9999 as appropriate

Thus, these can be completely missing or mixed with valid data such as:

03/99/2003 and 10:88

Continuous/open ended data items: Since it will be overly burdensome to develop and employ a missing data scheme which individually considers each data item and the appropriate number of digits for missing values use the alpha codes for missing in these instances:

NA, IL, or NR

B. ADMISSION THAT LED TO DELIVERY No information for any item in section
Admit date __ __/__ __ /__ __ __ __	2. Admit time _ _ : _ _	3. Delivery date __ __/__ __ /__ __ __ __	4. Delivery time _ _ : _ _	5. Discharge date __ __/__ __ /__ __ __ __
6. Admitting Diagnoses 6a. DX1: __________________________________________________ 77 NA 88 IL 99 NR 6b. DX2: __________________________________________________ 77 NA 88 IL 99 NR 6c. DX3: __________________________________________________ 77 NA 88 IL 99 NR 6d. DX4: __________________________________________________ 77 NA 88 IL 99 NR 6e. DX5: __________________________________________________ 77 NA 88 IL 99 NR
Comments:

C. Maternal Transport by Ambulance No information for any item in section
1. Transporting Facility	Admit date __ __/__ __ /__ __ __ __	3. Admit time _ _ : _ _	4. Departure date __ __/__ __ /__ __ __ __	5. Departure time _ _ : _ _	6. 1. Med record adequate 2. Order medical record 3. Record not available 88 IL 99 NR
7. Reason for transport
Comments:

D. INJECTIONS/VACCINATIONS NOTED THIS ADMISSION THROUGH 24 HOURS POSTPARTUM No information for any item in section
Injection/Vaccination
1. Rhogam (other RH(D)) Immunoglobulin 1 Yes 2 No 88 IL 99 NR	Date (1.dt1, 1.dt2) 1st _ _ / _ _ / _ _ _ _ 2nd _ _ / _ _ / _ _ _ _	Dose (1.ds.1, 1.ds.2) 1st __________ 2nd ________	Manufacturer (1.m.1, 1.m.2) 1st _________ 2nd ________	Product Name (1.p.1, 1.p.2) 1st _________ 2nd ________	Lot # (1.lot.1, 1.lot.2) _________ __________
2. Influenza Vaccine 1 Yes 2 No 88 IL 99 NR	2.dt Date _ _ / _ _ / _ _ _ _	2.m Manufacturer ______________		2.lot Lot # ___________
3. Other 1 Yes 2 No 88 IL 99 NR 3a.sp (specify) _________________	3a.dt Date _ _ / _ _ / _ _ _ _	3a.m Manufacturer ______________		3a.lot Lot # ___________
3b.sp Other (specify) _________________	3b.dt Date _ _ / _ _ / _ _ _ _	3b.m Manufacturer ______________		3b.lot Lot # ___________
3c.sp Other (specify) _________________	3c.dt Date _ _ / _ _ / _ _ _ _	3c.m Manufacturer ______________		3c.lot Lot # ___________
3d.sp Other (specify) _________________	3d.dt Date _ _ / _ _ / _ _ _ _	3d.m Manufacturer ______________		3d.lot Lot # ___________
3e.sp Other (specify) _________________	3e.dt Date _ _ / _ _ / _ _ _ _	3e.m Manufacturer ______________		3e.lot Lot # ___________
3f.sp Other (specify) _________________	3f.dt Date _ _ / _ _ / _ _ _ _	3f.m Manufacturer ______________		3f.lot Lot # ___________
Comments:

E. Cervical Exam on Admission Note: Dilation may be noted as complete, please record as 10cm; Effac may be noted as complete, please record as 100% No information for any item in section
1a. Date __ __/__ __ /__ __ __ __	1b. Time _ _ : _ _	1c. Dil (cm) 88 IL 99 NR	1d. Effac (%) 88 IL 99 NR	1e. Station 88 IL 99 NR	1f. 1. SSE 2. SVE 3. US 88 IL 99 NR	Comments:
2a. Date __ __/__ __ /__ __ __ __	2b. Time _ _ : _ _	2c. Dil (cm) 88 IL 99 NR	2d. Effac (%) 88 IL 99 NR	2e. Station 88 IL 99 NR	2f. 1. SSE 2. SVE 3. US 88 IL 99 NR	Comments:
Comments:

F. INDUCTION OR AUGMENTATION OF LABOR No information for any item in section
Method: 1= Prostaglandins for cervical ripening, 2= Artificial rupture of membranes (AROM), 3= Oxytocin/pitocin 4= Misoprostol 6= Other (specify), 88=Not Legible 99=Not Recorded 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 66= Other (specify) ______ 77=NA 88=Not Legible 99=Not Recorded
1a1. Date initiated __ __ / __ __ / __ __ __ __ 1b1. Date stopped __ __ / __ __ / __ __ __ __	1a2.Time Initiated __ __ : __ __ 1b2. Time Stopped __ __ : __ __	1c. Method	1d. Purpose 1. Induction 2. Augmentation 88 IL 99 NR	1e. Reason	1f. Comments
2a1. Date initiated __ __ / __ __ / __ __ __ __ 2b1. Date stopped __ __ / __ __ / __ __ __ __	2a2.Time Initiated __ __ : __ __ 2b2. Time Stopped __ __ : __ __	2c. Method	2d. Purpose 1. Induction 2. Augmentation 88 IL 99 NR	2e. Reason	2f. Comments
3a1. Date initiated __ __ / __ __ / __ __ __ __ 3b1. Date stopped __ __ / __ __ / __ __ __ __	3a2.Time Initiated __ __ : __ __ 3b2. Time Stopped __ __ : __ __	3c. Method	3d. Purpose 1. Induction 2. Augmentation 88 IL 99 NR	3e. Reason	3f. Comments
4a1. Date initiated __ __ / __ __ / __ __ __ __ 4b1. Date stopped __ __ / __ __ / __ __ __ __	4a2.Time Initiated __ __ : __ __ 4b2. Time Stopped __ __ : __ __	4c. Method	4d. Purpose 1. Induction 2. Augmentation 88 IL 99 NR	4e. Reason	4f. Comments
Comments:

G. RUPTURE OF MEMBRANES If “yes” is indicated for medications, please fill out Section N. No information for any item in section
Date __ __/__ __/__ __ __ __ __	2. Time 1. at delivery __ __ : __ __ 2. at c-section __ __ : __ __ 3. other time __ __ : __ __	3. Length of time before delivery 1. <1 h 2. 1-12h 3. 12-24h 4. >24 h 88 IL 99 NR	4. Method 1. Spontaneous 2. Artificial 88 IL 99 NR			5. Confirming dx (select all that apply) 1. +Pooling 2. +Nitrazine 3. +Ferning 4. +Indigo dye test 5. +History 88 IL 99 NR
6. Description of fluid at time of rupture (select all that apply) 1. Clear 2. Yellow 3. Bloody 4. Purulent 5. Foul odor 6. Meconium NOS 7. Thin meconium 8. Thick meconium 9. Moderate meconium 10. Terminal mec 88 IL 99 NR				7. Note any changes in fluid color/odor 1. No Change Noted 88 IL 99 NR
8. Mother’s statement (include where, when, description)					9. Medication given during ROM 1. Yes 2. No 88 IL 99 NR
Comments:

H. DELIVERY SUMMARY No information for any item in section
Plurality: 11 = 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 33 =Triplet C 43 = Quadruplet C 44 = Quadruplet D
1. Gender 1. Male 2. Female 3. Ambiguous 88 IL 99 NR	2. Plurality 77 NA 88 IL 99 NR		3. Zygosity 1. Monozygotic (MZ) 2. Dizygotic (DZ) 77 NA 88 IL 99 NR 3a. Zygosity determined by:		4. Weight (gm) 88 IL 99 NR	5. Length (cm) 88 IL 99 NR		6. Head circumference (cm) 88 IL 99 NR
7. Apgar 1’ 5’ 10’ 15’ scores      88 IL 99 NR
8. Type of delivery 1. NSVD 2. Operative vaginal delivery 3. C-section 4. Breech extraction 88 IL 99 NR		9. Presentation at delivery 1. Vertex 2. Transverse lie (shoulder presentation) 3. Face/brow 4. Breech 6. Other, (specify):_____ 88 IL 99 NR					10. Description of delivery 1. Normal 2. Precipitous 3. Prolonged 1st stage 4. Prolonged 2nd stage 88 IL 99 NR
11. Meconium staining of baby’s (select all that apply) 1. Skin 4. Cord 2. Nails 5. No staining 3. Placenta 88 IL 99 NR		12. Birth defects (use codes from medical conditions list; write out verbatim any conditions not on list) 12a. Dx1 code________ Text_____________________ 77 NA 88 IL 12b. Dx2 code________ Text_____________________ 77 NA 88 IL 12c. Dx3 code________ Text_____________________ 77 NA 88 IL 12d. Dx4 code________ Text_____________________ 77 NA 88 IL 12e. Dx5 code________ Text_____________________ 77 NA 88 IL 12f. Dx6 code________ Text_____________________ 77 NA 88 IL
13. Date onset labor __ __ / __ __ / __ __ __ __		14. Time onset __ __ : __ __		15. If date/time unknown, mother’s statement
16. Analgesia in labor 16a. Agent (select all that apply) Nubain Stadol Demerol Fentanyl Other: Specify: _________________ _________________ None 88 IL 99 NR		16b. Complications: 16b1 Complication 1 __________________________________ 77 NA 88 IL 16b2 Complication 2 __________________________________ 77 NA 88 IL 16b3 Complication 3 __________________________________ 77 NA 88 IL 16b4 Complication 4 __________________________________ 77 NA 88 IL 16b5 Complication 5 __________________________________ 77 NA 88 IL 16b6 Complication 6 __________________________________ 77 NA 88 IL
16c. Method (when not stated use delivery time) 1. Epidural Epidural start time: __ __ : __ __ Date: ____________ 2. Spinal Spinal/Intrathecal start time: __ __:__ __ Date __________ 3. Local 4. General 5. Perineal 6. Paracervical (saddle block) Spinal/Intrathecal start time: __ __:__ __ Date __________ 7. Pudendal Spinal/Intrathecal start time: __ __:__ __ Date __________ 8. Other (specify):____________ 88 IL 99 NR
19a. Prep solutions used 1. Yes 2 No 77 NA 88 IL 99 NR 19b. Location: ____________ ________________________ ________________________ ________________________ ________________________		20. Preterm delivery 1. Yes 2 No 88 IL 99 NR			21. Reason for preterm delivery per MD 88 IL 99 NR
21. Newborn Screening Accession Number: 88 IL 99 NR
Comments:

I. PLACENTA AND CORD No information for any item in section
Date of Placenta Delivery __ __/__ __/__ __ __ __ __	2. Time of Placenta Delivery ____:____		3. 1. Spont. 2. Assisted 3. Manual 88. IL 99. NR	4. Nuchal cord 4.b. 1. Tight 2. Loose 3. NOS 4. Other: Specify_____________ 5. Nuchal cord not noted 88. IL 99. NR 4a. Times wrapped around neck X_________ 88. IL 99. NR		5. Cord length 1. Long 2. Short 4. Stated length:_______ 88. IL 99. NR
6. Other cord abnormalities (select all that apply) 1. True knot 2. Thin 3. Two vessels 4. Three vessels (normal) 5. Velamentous/marginal insertion 6. Cord prolapse 88. IL 99. NR		7. Infarcts noted on OB/CNM exam 1. Old 2. New 3. NOS 4. None noted 88. IL 99. NR 7a. Size ________ 88. IL 99. NR			8. Description of placenta on OB/CNM exam (select apply that apply) 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__________________ 88. IL 99. NR
Comments:

J. PLACENTAL PATHOLOGY

No information for any item in section

1. Pathology report copied

2. Placenta not sent to pathology (discarded)

3. Status unclear/report not in chart

Comments:

K. DELIVERY INTERVENTIONS No information for any item in section
	Interventions	Comments
	1a. Version 1. yes 2. no 77 NA 88 IL 99 NR	1b. Date: __ __/__ __/ __ __ __ __				1c. 1. Successful 2. Failed 88 IL 99 NR
	2a. Amnio Infusion 1. yes 2. no 77 NA 88 IL 99 NR	2b. Specify complications: 2b1 Complication 1 ___________________________________ 77 NA 88 IL 2b2 Complication 2 ___________________________________ 77 NA 88 IL 2b3 Complication 3 ___________________________________ 77 NA 88 IL 2b4 Complication 4 ___________________________________ 77 NA 88 IL 2b5 Complication 5 ___________________________________ 77 NA 88 IL 2b6 Complication 6 ___________________________________ 77 NA 88 IL
	3a. Vacuum 1. yes 2. no 77 NA 88 IL 99 NR	3b. 1. Successful 2. Failed 88 IL 99 NR			3c Total time on ________min 88 IL 99 NR				3d. Number of Pulls _________ 88 IL 99 NR
	4a. Forceps 1. yes 2. no 77 NA 88 IL 99 NR	4b. 1. Successful 2. Failed 88 IL 99 NR		4c. Total time on ________min 88 IL 99 NR				4e. 1. Outlet 2. Low 3. Mid 4. Rotation 88 IL 99 NR
				4d. Number of Pulls _________ 88 IL 99 NR
	5a. Cesarean Section 1. yes 2. no 77 NA 88 IL 99 NR	5b. 1. Elective 2. Unscheduled 3. Emergency, 5b1. Specify: _____________________________________________________ 88 IL 99 NR
Comments:
Section K Part 2: Complications of Labor and Delivery Check all that apply
No Complications Noted (Skip to section L) 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 growth retardation (IUGR) Low BPP or non-reassuring fetal testing Macrosomia Maternal death Oligohydramnios or Low AFI Persistent OP				Polyhydramnios Post-dates Postpartum hemorrhage Hemabate given Methergine given Uterine Artery Embolization Prolonged latent stage Retained placenta Seizure, infant Shoulder dystocia Slow Slope Active Phase Uterine atony Uterine rupture Vasa previa VBAC Other (specify):_________________

L (part 1). MATERNAL INFECTIONS NOTED THIS ADMISSION THROUGH 24 HOURS POSTPARTUM Extra sheet provided in Appendix A if needed Dx: Use codes from infection list (Appendix D) If cultures were performed, note in section M. If “yes” is indicated for medications, please fill out Section N. No information for any item in section
1a Dx	1b.1 Date diagnosed _ _ / _ _ / _ _ _ _ OR 1b.ga GA _____ wks OR 1b.tri Trimester _____	1c Duration ______ days	1d Certainty of Dx 1. Lab/Test 2. Clinical 3. Suspect 9. unknown	1e.1 Highest Temp _______ 1e.2 Unit 1. oC 2 oF 88 IL 99 NR	1f.1 Lowest Temp _______ 1f.2 Unit 1. oC 2 oF 88 IL 99 NR	1g Cultures/Rapid Screen done? 1 Yes 2 No 88 IL 99 NR	1h Meds given? 1 Yes 2 No 88 IL 99 NR
2a Dx	2b.1 Date diagnosed _ _ / _ _ / _ _ _ _ OR 2b.ga GA _____ wks OR 2b.tri Trimester _____	2c Duration ______ days	2d Certainty of Dx 1. Lab/Test 2. Clinical 3. Suspect 9. unknown	2e.1 Highest Temp _______ 2e.2 Unit 1. oC 2 oF 88 IL 99 NR	2f.1 Lowest Temp _______ 2f.2 Unit 1. oC 2 oF 88 IL 99 NR	2g Cultures/Rapid Screen done? 1 Yes 2 No 88 IL 99 NR	2h Meds given? 1 Yes 2 No 88 IL 99 NR
3a Dx	3b.1 Date diagnosed _ _ / _ _ / _ _ _ _ OR 3b.ga GA _____ wks OR 3b.tri Trimester _____	3c Duration ______ days	3d Certainty of Dx 1. Lab/Test 2. Clinical 3. Suspect 9. unknown	3e.1 Highest Temp _______ 3e.2 Unit 1. oC 2 oF 88 IL 99 NR	3f.1 Lowest Temp _______ 3f.2 Unit 1. oC 2 oF 88 IL 99 NR	3g Cultures/Rapid Screen done? 1 Yes 2 No 88 IL 99 NR	3h Meds given? 1 Yes 2 No 88 IL 99 NR
4a Dx	4b.1 Date diagnosed _ _ / _ _ / _ _ _ _ OR 4b.ga GA _____ wks OR 4b.tri Trimester _____	4c Duration ______ days	4d Certainty of Dx 1. Lab/Test 2. Clinical 3. Suspect 9. unknown	4e.1 Highest Temp _______ 4e.2 Unit 1. oC 2 oF 88 IL 99 NR	4f.1 Lowest Temp _______ 4f.2 Unit 1. oC 2 oF 88 IL 99 NR	4g Cultures/Rapid Screen done? 1 Yes 2 No 88 IL 99 NR	4h Meds given? 1 Yes 2 No 88 IL 99 NR
Comments: Specify any other DX (code=600) as 1a.sp, 2a.sp, 3a.sp, 4a.sp Also list other comments.

L (PART 2) SIGNS AND SYMPTOMS (S/S) FOR DELIVERY TO 24 HOURS POSTPARTUM No information for any item in section
S/S	Date first noted	Time
1. Uterine Tenderness Yes No Suspect IL NR	1a. __ __ / __ __ / __ __ __ __	1b. __ __ : __ __
2. Foul vaginal discharge note (odor) Yes No Suspect IL NR	2a. __ __ / __ __ / __ __ __ __	2b. __ __ : __ __
3. Purulent amniotic fluid (color) Yes No Suspect IL NR	3a. __ __ / __ __ / __ __ __ __	3b. __ __ : __ __
4. WBC count > 15,000/mL Yes No Suspect IL NR	4a. __ __ / __ __ / __ __ __ __	4b. __ __ : __ __
5. Persistent mat’t tachycardia (>100 bpm) Yes No Suspect IL NR	5a. __ __ / __ __ / __ __ __ __	5b __ __ : __ __
6. Persistent fetal tachycardia (>160 bpm) Yes No Suspect IL NR	6a. __ __ / __ __ / __ __ __ __	6b. __ __ : __ __
7. Fetal bradycardia Yes No Suspect IL NR	7a. __ __ / __ __ / __ __ __ __	7b. __ __ : __ __
8. Periodic Changes Yes No Suspect IL NR	8a. __ __ / __ __ / __ __ __ __	8b. __ __ : __ __
9. Other, 9a. Specify _______________________ Yes No Suspect IL NR	__ __ / __ __ / __ __ __ __	__ __ : __ __
Comments:

L (part 3). Fever >37.7 oC or 100 oF ON ADMISSION TO 24 HOURS POSTPARTUM No information for any item in section
	5 highest fevers	Date	Time
1.	1a.1 Highest Temp _______ 1a.2 Unit 1. oC 2 oF 88 IL 99 NR	1b _ _ / _ _ / _ _ _ _	1c (military time) ___ ___ : ___ ___
2.	2a.1 Highest Temp _______ 2a.2 Unit 1. oC 2 oF 88 IL 99 NR	2b _ _ / _ _ / _ _ _ _	2c (military time) ___ ___ : ___ ___
3.	3a.1 Highest Temp _______ 3a.2 Unit 1. oC 2 oF 88 IL 99 NR	3b _ _ / _ _ / _ _ _ _	3c (military time) ___ ___ : ___ ___
4.	4a.1 Highest Temp _______ 4a.2 Unit 1. oC 2 oF 88 IL 99 NR	4b _ _ / _ _ / _ _ _ _	4c (military time) ___ ___ : ___ ___
5.	5a.1 Highest Temp _______ 5a.2 Unit 1. oC 2 oF 88 IL 99 NR	5b _ _ / _ _ / _ _ _ _	5c (military time) ___ ___ : ___ ___
Comments:

M. CULTURES/RAPID STREP SCREENS OBTAINED THIS ADMISSION (RECORD ALL CULTURES /STREP SCREENS OBTAINED) Extra sheet provided in Appendix A if needed Indicate the number of the event from section L or ‘0’ If culture does not correspond to an event in section L. No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded
1a – 20a REF	1b – 20b Date Cultured	1c–20c 1c.sp-20c.sp (specify) Source	1d – 20d (1d.6.sp – 20d.6.sp and 1d.9.sp – 20d.9.sp for specify fields) Results	1e – 20e Description (organisms, etc.)
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR

M.CULTURES/RAPID STREP SCREENS (continued)
Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded
1a – 20a REF	1b – 20b Date Cultured	1c–20c 1c.sp-20c.sp (specify) Source	1d – 20d (1d.6.sp – 20d.6.sp and 1d.9.sp – 20d.9.sp for specify fields) Results	1e – 20e Description (organisms, etc.)
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
Comments:

N. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES, STEROIDS, HORMONES, AND OTHER MEDICATIONS) TAKEN THIS ADMISSION THROUGH 24 HOURS POSTPARTUM Extra sheet provided in Appendix A if needed No information for any item in section
Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’. Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 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 agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 88 = other (specify); 99 = unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine, labor and delivery anesthetics (recorded in Section F)
1a - 30a Refer	1b - 30b Code	1c - 30c Drug Name	1d - 30d Start Date	1e - 30e 1e.ep – 30e.ep Stop Date	1f - 30f 1f.sp – 30f.sp Dose	1g - 30g 1g.sp – 30g.sp Unit	1h - 30h 1h.sp – 30h.sp Freq
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR

N. ALL MEDICATIONS (continued)
Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’. Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 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 agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 88 = other (specify); 99 = unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine, labor and delivery anesthetics (recorded in Section F)
1a - 30a Refer	1b - 30b Code	1c - 30c Drug Name	1d - 30d Start Date	1e - 30e 1e.ep – 30e.ep Stop Date	1f - 30f 1f.sp – 30f.sp Dose	1g - 30g 1g.sp – 30g.sp Unit	1h - 30h 1h.sp – 30h.sp Freq
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR

N. ALL MEDICATIONS (continued)
Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’. Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 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 agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 88 = other (specify); 99 = unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine, labor and delivery anesthetics (recorded in Section F)
1a - 30a Refer	1b - 30b Code	1c - 30c Drug Name	1d - 30d Start Date	1e - 30e 1e.ep – 30e.ep Stop Date	1f - 30f 1f.sp – 30f.sp Dose	1g - 30g 1g.sp – 30g.sp Unit	1h - 30h 1h.sp – 30h.sp Freq
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR
			_ _ / _ _ / _ _ _ _	_ _ / _ _ / _ _ _ _ OR Entire pregnancy or ongoing	8. variable	1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____ 88. Illegible 99. NR	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 88. Illegible 99. NR