NT MIDWIVES’ COLLECTION DEPARTMENT OF HEALTH
PATIENT DETAILS
Given name Marital status Indigenous status
Surname ☐Married/Defacto Mother Baby
Suburb/Community ☐Never Married ☐ Aboriginal but not T.S.I ☐
State ☐Widowed ☐ T.S.I. but not Aboriginal ☐
Country of birth ☐Separated ☐ Aboriginal and T.S.I. ☐
Date of admission ☐Divorced ☐ Not Aboriginal or T.S.I. ☐
HRN ☐ Not Stated ☐ PREVIOUS PREGNANCIES
Is this the mothers' first pregnancy? Y ☐ N ☐ Outcome of last pregnancy
Specify outcome of the most recent pregnancy preceding this pregnancy i.e. NND Previous Pregnancy Outcomes
Number of pregnancy outcomes excluding current pregnancy
☐Livebirths ☐Spontaneous abortion
☐Stillbirths ☐Ectopic pregnancy Total number of previous caesareans
☐Termination of pregnancy ☐Neonatal deaths Was the last birth a caesarean? Y ☐ N ☐ CURRENT PREGNANCY
Gravida: Total number of pregnancies the mother has had regardless of outcome. Include the current pregnancy.
Parity: Total number of previous pregnancies that resulted in a live birth or stillbirth. (Twins = one) Exclude this pregnancy.
Antenatal Service Provider
☐Midwives clinic ☐ Shared care (GP) ☐Public Antenatal clinic ☐Other
☐Home birth service ☐Remote Health Centre ☐Private obstetrician/GP ☐None/no ANC
☐Community Health Centre
Complications of Present Pregnancy Maternal Medical Conditions Were the A/N records available during labour? Y ☐ N ☐
☐None ☐None
☐IUGR ☐Anaemia Any Smoking During Pregnancy?
☐Gestational diabetes ☐UTI At all in first 20 weeks Y ☐ N ☐ At all after 20 weeks Y ☐ N ☐
☐UTI ☐Chronic hypertension If smoked after 20 weeks, note the number of cigarettes per day
☐Antepartum haemorrhage ☐Past GDM (If the client did not smoke each day then enter 98)
☐Pre-term SROM ☐Syphilis req. treatment
☐Fetal death ☐Other STD Any Alcohol during Pregnancy?
☐Other ☐Cardiac disease At first visit Y ☐ N ☐ Around 36 weeks Y ☐ N ☐
☐Anaemia < 11g/L ☐Epilepsy
☐Multiple birth ☐Renal disease Date of 1st Antenatal Total No. of A/N visits
☐Threatened pre-term labour ☐Pre-existing DM Type 1 Care Visit (hint 1st bloods or U/S)
☐Eclampsia ☐Pre-existing DM Type 2
☐Pre-eclampsia ☐Pre-existing DM Other Date of 1st Ultrasound Gestational Age at 1st US
☐Gestational hypertension ☐Other
☐Unknown ☐Unknown EDB (due date) Rubella immune Y ☐ N ☐
Diabetes treatment Weight (1st visit) gms. Height cms.
☐None
☐N/A Intended place of birth during pregnancy
☐Diet & Exercise ☐Hospital ☐Remote Heath Centre
☐Oral ☐Birth Centre ☐Home
☐Hypoglycaemic ☐Free Birth ☐Other
☐Insulin
☐Unknown Specify
LABOUR & BIRTH
Onset of Labour Analgesia during labour 1st & 2nd Indications for F/V/C Method of birth
☐Spontaneous ☐None ☐ ☐Previous caesarean ☐SVB cephalic
☐Induced ☐Bath/shower ☐ ☐Fetal compromise ☐SVB breech
☐No labour ☐Nitrous oxide ☐ ☐Antepartum haemorrhage ☐Assisted vaginal (forceps)
Method of Induction ☐Epidural/caudal ☐ ☐Cord prolapse ☐Assisted vaginal (vac. extraction)
☐Not induced ☐Spinal/epidural ☐ ☐Lack of progress 2nd stage ☐Emergency caesarean (unplanned)
☐ARM ☐Spinal ☐ ☐Lack of progress =<3cm ☐Elective caesarean (planned)
☐Prostaglandins ☐Alternative methods ☐ ☐Lack of progress 1st stage State of perineum
☐Oxytocin ☐Systemic Opioids ☐ ☐Malpresentation ☐Intact
☐Balloon Catheter ☐Other ☐ ☐Maternal choice only ☐1st degree laceration/graze
☐Other Anaesthesia at F/V/C delivery ☐ ☐Failed forceps/ventouse ☐2nd degree laceration
Main indication of induction ☐None ☐ ☐Unsuccessful induction ☐3rd degree laceration
☐Hypertensive disorder ☐Epidural caudal ☐ ☐Placental abruption ☐4th degree laceration
☐IUGR ☐Epidural bolus ☐ ☐Vasa praevia ☐Other
☐Diabetes ☐Spinal/epidural ☐ ☐Multiple pregnancy Episiotomy Y ☐ N ☐
☐SROM <37GA ☐Spinal ☐ ☐Suspected macrosomia Blood loss volume in first 24 hours
☐Prolonged SROM ☐Gen. anaesthetic ☐ ☐Past shoulder dystocia mls
☐Fetal Death ☐Other ☐ ☐Past adverse neonatal outcome Blood transfusion for primary PPH
☐Postdated >= 40 weeks GA Complications of labour & birth ☐ ☐Past adverse fetal outcome Y ☐ N ☐
☐No MED/OBS reason ☐None ☐ ☐Past 3rd/4th/ degree tear Accoucheur Status
☐Unknown ☐APH ☐ ☐Other (OBS/MED/SURG/PSYCH) ☐Midwife
☐Other ☐Hypertension ☐ ☐Unknown ☐Student midwife
Method of augmentation ☐Pre eclampsia Presentation at birth ☐Consultant GP
☐None ☐Fetal distress ☐Vertex ☐Worker other
☐ARM ☐Cord prolapse ☐Face ☐Other
☐Prostaglandins ☐Meconium stained liquor ☐Brow
☐Oxytocin ☐PPH ☐Breech
☐Other ☐Retained placenta ☐Unknown
☐Manual removal of placenta ☐Other
☐Eclampsia in labour
☐Other
BABY
Date of Birth Sex HRN Agpar
Place of Birth ☐ Male 1 min 5 min
☐ Female Plurality
Gestation at Birth weeks ☐ Indeterminate Singleton ☐ Weight gm
Respiratory Resuscitation Birth status Multiple birth ☐ Length cm
☐None ☐Livebirth Total No. Babies Head cm
☐Tactile stimulation only ☐Stillbirth Birth order, this baby Discharge Date
☐Suction only Congenital anomaly Neonatal Death Y ☐ N ☐ Discharged to
☐Oxygen only ☐Obvious Date of death ☐Died
☐CPAP ☐Not obvious PSANZ Codes ☐Not admitted
☐IPPV by Mask ☐Under investigation ☐Home
☐IPPV by Intubation Describe anomaly ☐Transferred to
☐Ext cardiac massage & IPPV Request to Dr to complete the Congenital Anomaly Notifications form Admission to SCN Y ☐ N ☐
☐ Other Repeat this baby section if multiple birth MOTHER
Discharge Feeding Status Discharge date Perinatal Registry
☐AF only from birth to D/C Discharged to Health Gains Planning Branch
☐BF only from birth to D/C ☐Died Department of Health
☐BF initiated but fully AF at D/C ☐Not admitted http://www.health.nt.gov.au/Perinatal_Registry/
☐BF from start to D/C but >=1AF ☐ Home Ph: 08 898 58074
☐N/A Baby remains in SCN ☐Transferred to Complete form and email to:
☐Not Applicable [email protected]
