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15. Date & time of membrane rupture: __ __ /__ __ /__ __ __ __
month
day
__ __ __ __
Unknown (1)
time
year (4 digits)
16. Was duration of membrane rupture >18 hours?
Yes (1)
No (0)
Unknown (9)
17. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?
Yes (1)
No (0)
Unknown (9)
18. Type of rupture:
Spontaneous (1)
Artificial (2)
19. Type of delivery: (Check all that apply)
Vaginal (1)
Vaginal after previous C-section (1)
Primary C-section (1)
Forceps (1)
Vacuum (1)
Unknown (1)
If delivery was
by C-section:
Did labor begin before C-section?
Yes (1)
No (0)
Unknown (9)
Did membrane rupture happen before C-section?
Yes (1)
No (0)
Unknown (9)
20. Intrapartum fever (T > 100.4 F or 38.0 C):
Yes (1)
No (0)
Unknown (9)
IF YES, 1st recorded T > 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month
day
year (4 digits)
IF YES, answer a-b and Questions 22-23
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __
b) Antibiotic 1: ___________________________
Start date: __ __ /__ __ /__ __ __ __
22.
month
IV (1)
Antibiotic 2: ___________________________
Start date: __ __ /__ __ /__ __ __ __
IV (1)
IV (1)
IV (1)
IV (1)
time
Unknown (9)
PO (3) # doses given before delivery: ______
IM (2)
PO (3) # doses given before delivery: ______
IM (2)
PO (3) # doses given before delivery: ______
IM (2)
PO (3) # doses given before delivery: ______
IM (2)
PO (3) # doses given before delivery: ______
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 6: ___________________________
Start date: __ __ /__ __ /__ __ __ __
__ __ __ __
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 5: ___________________________
Start date: __ __ /__ __ /__ __ __ __
IM (2)
year (4 digits)
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 4: ___________________________
Start date: __ __ /__ __ /__ __ __ __
day
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 3: ___________________________
Start date: __ __ /__ __ /__ __ __ __
Unknown (9)
Stop date (if applicable): __ __ /__ __ /__ __ __ __
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
Stop date (if applicable): __ __ /__ __ /__ __ __ __
I nterval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)
*Day variable should only be completed if the number of hours >24
2/2012
No (0)
Unknown (1)
time
Were antibiotics given to the mother intrapartum?
Yes (1)
__ __ __ __
21.
Repeat C-section (1)
Page 2 of 4
___ ___ (minutes) ___ ___ (days)*
23. What was the reason for administration of intrapartum antibiotics? (Check all that apply)
GBS prophylaxis (1)
Suspected amnionitis/
chorioamnionitis (1)
Prolonged latency (1)
C-section prophylaxis (1)
Mitral valve prolapse prophylaxis (1)
Other (1)
Unknown (1)
24. Did mother have chorioamnionitis or suspected chorioamnionitis?
Yes (1)
No (0)
***Questions 25–33 should only be completed for early- and late-onset GBS cases***
25. Did mother receive prenatal care?
Yes (1)
No (0)
Unknown (9)
26. Please record the following: the total number of prenatal visits AND the first and last visit dates to the prenatal provider
as recorded in the labor and delivery chart
No. of visits: __ __ First visit: __ __ /__ month
__ /__ __
visit: __ __ /__month
__ /__ __
day__ __
yearLast
(4 digits)
day__ __
year (4 digits)
27. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
28. GBS
bacteriuria during this pregnancy?
Yes (1)
No (0)
Unknown (9)
IF YES, what order of magnitude was the colony count?
0 (1)
<10,000 (2)
10k–<25,000 (3)
25k–<50,000 (4)
50k–<75,000 (5)
>100,0000 (7)
Unknown (9)
29. Previous infant with invasive GBS disease?
Yes (1)
No (0)
Unknown (9)
30. Previous pregnancy with GBS colonization?
Yes (1)
No (0)
Unknown (9)
75k–<100,000 (6)
31a. Was maternal group B strep colonization screened for BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, list dates, test type, and test results below:
Test date (list most recent first):
1. __ __ /__ __ /__ __ __ __
2. __ __ /__ __ /__ __ __ __
Test type:
Rapid antigen (3)
Test Result
(Do not include urine here!)
Culture (1)
PCR (2)
Positive (1)
Other (4)
Unknown (9)
Unknown (9)
Culture (1)
PCR (2)
Other (4)
Unknown (9)
Positive (1)
Unknown (9)
Rapid antigen (3)
Negative (0)
Negative (0)
31b. If the most recent test was GBS positive was antimicrobial susceptibility performed BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
32a. Was maternal group B strep colonization screened for AFTER admission (before delivery)?
IF YES, list date of most recent test, test type and test results below:
Test date (list most recent first):
__ __ /__ __ /__ __ __ __
Test type:
Culture (1)
PCR (2)
Other (4)
Unknown (9)
Rapid antigen (3)
Yes (1)
No (0)
Test Result
(Do not include urine here!)
Positive (1)
Unknown (9)
32b. If the most recent test was GBS positive, was antimicrobial susceptibility performed AFTER admission?
Yes (1)
No (0)
Unknown (9)
IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
2/2012
Yes (1)
Yes (1)
Page 3 of 4
No (0)
No (0)
Unknown (9)
Unknown (9)
Unknown (9)
Negative (0)
33.
Were GBS test results available to care givers at the time of delivery?
Yes (1)
No (0)
Unknown (9)
34. COMMENTS: ______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
35. Neonatal Infection Expanded Form Tracking Status:
Complete (1)
Partial (2)
Chart unavailable (3)
2/2012
Page 4 of 4
Edited & corrected (4)
| File Type | application/pdf |
| File Modified | 2013-06-28 |
| File Created | 2013-05-21 |