Microsoft word - dataform version 5. 09.12.10.docx

IMUK Statistics Form
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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
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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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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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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