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Microsoft word - dataform version 5. 09.12.10.docx

IMUK Statistics Form
reply, PLEASE PUT ? FOR “DON’T
KNOW’ AND N/A FOR NOT
Client Code . . . . . . . . . . . Practice Code (optional) . . . . . . . . Date of Baby’s birth/early end d d m m y y y y
Answer in this column please
1. Pregnancy, General and Booking
1.1.1 Client consent
1= received; 2= not received; 3=client declined to have data entered 1.1.2 Log entry received prior to woman’s birth? 1=city/large town; 2=small town; 3=rural 0=no; 1=diagnosed twins; 2=undiagnosed twins; 1.2 Woman’s
1.2.1 Age at booking
Write woman’s occupation: 1 answer only please Please circle Part time
1=white; 2=mixed; 3=Asian; 4=black; 5=Chinese; 6=not stated; 1 answer 7
only please
0=married; 1=unmarried couple; 2=female partner; 3=separated/divorced; 4=single; 5=(explain): only please
1.3 Father’s/Partner’s
1.3.1 Father’s age at booking:
1.3.2 Father’s ethnic origin
Categories as in woman’s ethnic origin 1.2.3 (1 answer only please) 1 answer only please
1.3.3 Partner’s occupation
1.4 Personal Factors
1.4.1 Woman’s height
1=coitus; 2=artificial insemination; 3=in vitro; 4= (explain) 0=no; 1=yes before puberty; 2=yes after puberty; 3=before & after puberty; 4=woman prefers not to answer; 5=midwife did not ask 1.5 Previous Pregnancy and Birth History
Pregnancies
including this one
Number of previous
Number of previous
Previous medical
0=none; 1=heart disease; 2=kidney disease; 3=diabetes; 4=epilepsy; explain other:
5=thromboembolic disorder; 6=essential hypertension; 7=thyroid
history (circle
numbers)
/endocrine disorder; 8=mental health problems requiring treatment; 9=other Other previous
0=none; M=multiple birth; 1=gestation<37wks; 2=gestation>42wks; explain other:
(circle numbers)
6=IUGR/SGA; 7=birth defect; 8=shoulder dystocia; 9=(explain) Previous cervical investigation/surgery? If yes details please
(circle) Yes
IMUK Statistics Form
reply, PLEASE PUT ? FOR “DON’T
KNOW’ AND N/A FOR NOT
Client Code . . . . . . . . . . . Practice Code (optional) . . . . . . . . Answer in this column please
1.6 Present Pregnancy
1.6.1
0=none; E=eclampsia; 1=mild pre-eclampsia; 2=severe pre-eclampsia; explain other:
3=diabetes; 4=uterine/cervical scar; 5=mental health problems (circle numbers)
requiring treatment; 6=obstetric cholestasis; 7=anaemia Hb <9g/dl; 8=Rh antibodies; T=thromboembolism; 9=other (explain) 0=none; 1=genital herpes; 2=chlamydia; 3=UTI; 4=thrush; 5=genital explain other:
(circle numbers)
warts; 6=group B streptococcus; 7=HIV; 8=other (explain) 0=none; 1=suspected IUGR; 2=fetal abnormality (explain); 3=IUD; explain other:
(circle numbers)
4=oligohydramnios; 5=polyhydramnios; 6=complication of multiple gestation; 7=other (explain) Woman has 1=never smoked; 2=stopped smoking >1yr ago; 3=smoked prior to but not during pregnancy; 4=smoked prior to and only please
during pregnancy; 5=commenced smoking during this pregnancy Before pregnancy: 0=none; 1=1-5; 2=6-10; 3=11-20; 4=>20 During pregnancy: 0=none; 1=1-5; 2=6-10; 3=11-20; 4=>20 Woman 1=does not drink alcohol; 2=drank alcohol prior to but not during pregnancy; 3=drank alcohol prior to and during pregnancy only please
Before pregnancy: 0=none; 1=1-5; 2=6-10; 3=11-20; 4=>20 During pregnancy: 0=none; 1=1-5; 2=6-10; 3=11-20; 4=>20 1=excellent; 2=good; 3=fair; 4=poor 5=other (explain) If yes, please give details here:
1.7 Antenatal Care
Estimated Date of Birth (if several, please use scan adjusted) (circle) Yes
0=none; 1=routine blood tests; 2=triple test; 3=amniocentesis; 4=CTG or Doppler scan; 5=glucose tolerance test; 6=group B strep; 7=extra blood tests (explain); 8=nuchal fold; 9=other (explain) Inpatient antenatal admissions Woman missed hospital/clinic/IM appointments (DNA) Number missed (0=none)
0=none; 1=antibiotics; 2=antifungals; 3=antiemetics; 4=analgesia; 0=none; 1=once; 2=intermittent; 3= regular; 4=regular with Epi-no 0=none; 1=breech; 2=transverse; 3=oblique lie; 4=unstable lie; Gestation (wks) when malpresentation first noted 2.1 Client care ended early? (before 37/40)
(circle) Yes
M=miscarriage; P= preterm birth; 1=IUD; 2=referral for complications; Reasons for early end 3=client moved away; 4=client chose NHS community care; 5=client chose hospital; 6=changed IM; 7=cost; 8=unknown; 9=other (explain) NB: Please fill in date of baby’s birth/miscarriage/termination at top of page 1;
If preterm birth please continue data entry
IMUK Statistics Form
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KNOW’ AND N/A FOR NOT
Client Code . . . . . . . . . . . Practice Code (optional) . . . . . . . . Answer in this column please
Labour and birth
1=home; 2=birth centre; 3=hospital; 4=undecided; 5=other (explain) 1=home; 2=NHS birth centre; 3=NHS GP unit; 4=NHS consultant unit; 5=private hospital; 6=on route to hospital; 7=other (explain) Reason for change of 0=no change; 1=change of address in pregnancy; 2=clinical reasons Main reason only
in pregnancy; 3=other pregnancy reasons (explain); 4=clinical reasons in labour; 5=other labour reasons (explain) 3.2 Hospital care in labour/postpartum
(circle) Yes
1=planned; 2=unplanned but not urgent; 3=emergency 1=1st stage; 2=2nd stage; 3=3rd stage; 4=immediately postpartum; 5=not in labour; 6=in 1st postnatal month H=planned hospital birth; P=pain relief; 1=lack of progress; 2=fetal distress; 3=malpresentation; 4=thick meconium; 5=placental abruption; 6=haemorrhage; 7=retained placenta; 8=maternal exhaustion; S=baby’s condition (explain); 9=other (explain) 0=not present; 1=primary caregiver; 2=assistant midwife; 3=supporter/advocate only; 4=other (explain) only please
3.3 Labour – If birth was C/S please answer al relevant questions
If multiple birth, complete separate pp3-5 answering all
1 answer 17
asterisked questions for each baby
only please
0=singleton; 1=twins, both spontaneous; 2=twins, one assisted;
3=twins, both assisted; 4=twins, 1 spontaneous 1 by C/S; 5=twins 1
assisted, 1 by C/S; 6= twins, both by C/S;
0=no; 1=ARM<5cm; 2=ARM>or=5cm; 3=prostaglandin; 4=oxytocin;
5=cx stretch & sweep; 6=castor oil; 7=other (explain) 1=intermittent hand-held; 2=intermittent CTG; 3=continuous CTG; 4=fetal scalp monitor; 5=other (explain) Labour plateau>30mins 0=no; 1=1st stage; 2=2nd stage; 3=3rd stage 0=nothing; 1=only fluids; 2=solid food; 3=both pain 0=none; P=paracetamol; F=ibuprofen; 1=epidural; 2=spinal; relief in labour/for birth 3=pethidine/meptid; 4=local anaesthetic; 5=nitrous oxide; 6=general anaesthetic; 7=morphine; 8=voltarol; 9=other (explain) Number of vaginal examinations in 1st and 2nd stage 0=clear; 1=old meconium; 2=thick fresh mec; 3=other (explain) 0=none; 1=1st degree tear; 2=2nd degree; 3=3rd degree; 4=4th Perineal/vaginal trauma degree; 5=episiotomy; 6=labial tear; 7=other (explain) 0=not repaired; 1=by IM; 2=hosp m/w; 3=obstetrician 4=explain Other labour complication (explain here please)
IMUK Statistics Form
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Client Code . . . . . . . . . . . Practice Code (optional) . . . . . . . . Answer in this column please
1=IM; 2=hospital m/w; 3=obstetric registrar; 4=obstetric consultant; Person conducting birth 5=woman herself; 6=other (explain) only please *
3.4 Third Stage
3.4.1
Estimated blood loss in mls
0=none; 1=before problems (prophylactic); 2=after problems; 1=under water; 2=maternal effort; 3=CCT; 4=oxytocic drugs; (circle options used)
5=manual removal; 6=D&C; 7=other (explain) Baby’s birth and postnatal care
1=anterior vertex; 2=posterior vertex; 3=breech; 4=transverse lie; 1 answer 21
position at labour
5=head deflexed; 6=asynclitic; 7=OT; F=face; 8=brow; 9=other only please *
1=anterior vertex; 2=persistent OP; 3=frank breech; 4=footling 1 answer 21
position at birth
breech; 5=complete breech; 6=transverse lie; 7=face; 8=brow; only please *
C=compound presentation; 9=other (explain) Woman’s position for
1=semi-sitting; 2=kneeling; 3=al fours; 4=squatting; 5=standing; 6=on side; 7=on back; 8=stirrups; 9=birthing stool; only please *
4.2 Labour times
4.3 Birth
4.3.1
1=before pulsing stopped; 2=after pulsing stopped; 3=after placenta delivered; 4=not clamped; 5=other (explain) 0=no; 1=ventouse; 2=forceps; 3=ventouse fol owed by forceps; 4=breech extraction; 5=assistance failed only please
0=no; 1=C/S planned; 2=C/S in labour nonurgent; 3=emergency C/S Reasons for caesarean 1=lack of progress; 2=fetal distress; 3=meconium; 4=non-vertex presentation; 5=woman’s wish; 6=other (explain) Difficulty with shoulders 0=none; 1=minor; 2=moderate; 3=severe 0=no; 1=<10 minutes; 2= 11-29 minutes; 3= >29 minutes Other birth
IMUK Statistics Form
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KNOW’ AND N/A FOR NOT
Client Code . . . . . . . . . . . Practice Code (optional) . . . . . . . . Answer in this column please
4.4 Postnatal Health
0=good; 1=mild jaundice; J=jaundice requiring treatment; 2=infection; 3=RDS; 4=hypoglycaemia; 5=failure to thrive; 6=seizures; 7=problems of prematurity; 8=medical referral; 9=other (explain) 0=none; 1=minor; 2=serious; 3=life-threatening 0=no; 1=intensive care baby unit; 2=special care baby unit; 0=no; 1=IUD before labour; 2=death during labour; 3=within 28 days of birth; 4=>28 days but <6 weeks postnatal; 5=other (explain) 0=baby not breastfed; 1=breastfed 1wk or less; 2=2wks; 3=3wks; Did the baby have breastmilk supplements? Postnatal week when supplements first introduced 0=good, no problems; 1=minor residual problems (give details); 2=serious, requiring paediatric follow-up (explain reason) 0=good; U=bladder/urinary problem; 1=wound infection; 2=breast Woman’s health in first infection; 3=hypertension; 4=prolapse; 5=anaemia <10g/dl; 6=secondary PPH after 24 hrs; E=eclampsia; 7=medical referral; 8=anaesthetic complication; 9=other (explain) 0=no; 1= moderate, no treatment; 2=severe, required treatment (circle) Yes
0=good, no problems; 1=minor residual problems (give details); 2=serious, requiring medical fol ow-up (explain reasons) 4.5 Postnatal care
0=no p/n care; 1=1 p/n visit; 2=2 p/n visits; 3=3 p/n visits etc

Source: http://www.independentmidwives.org.uk/files/database_form.pdf

Microsoft word - asthma plan.doc

Asthma Plan Aim This plan has been developed to increase awareness of asthma and to actively support the whole school community in the effective management of asthma. Target group School Staff, Students and Parents Education for School Staff / Parents • An information session will be held biannually to update all school staff on asthma and its • New staff will

Sommario labirinti

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