Attach 11. Postpartum Abstraction Form

Measurement of Maternal Life Experience Study

Postpartum Medical Record Abstraction

1. Study ID Number: ______________

2. Delivery Date: ______________

3. Gestational Age at Delivery: ______________

4. Maternal weight at delivery or last prenatal visit: ______________

5. Gestational Age at Last Recorded Maternal Weight: ______________

6. Sex of Baby

1…….Female

2…….Male

Pregnancy complications:

7. Preeclampsia / eclampsia

1……..Yes

2……...No

8. Gestational hypertension

1…….Yes

2…….No

9. Spontaneous preterm delivery

1……..Yes (continue to 10)

2……..No (skip to 12)

• If yes:

10. Spontaneous Preterm Labor (sPTL)

1……..Yes

2……..No

11. Preterm Premature Rupture of Membranes (PPROM)

1……..Yes

2……..No

12. Abruption leading to delivery

1……..Yes

2……..No

13. Intrauterine Fetal Demise

1……..Yes

2……..No

14. Maternal Diabetes

1……Yes (continue to 15)

2……No (skip to 16)

• If yes:

15.Was it:

1…….Pregestational Diabetes

a…….Type 1

b…….Type 2

2…….Gestational Diabetes

a……Insulin required

b……No insulin required

16. Reasons for delivery

1…….Spontaneous term labor or term rupture of membranes (skip to 18)

2…….Induced term labor

3…….Spontaneous preterm labor or ppprom

4…….Medically Indicated / Induced Preterm Labor

5…….Scheduled term cesarean section

6…….Medically indicated scheduled preterm cesarean section

17. If not spontaneous labor (scheduled c-section or induced labor), why?

1…….Repeat cesarean (prior low transverse)

2…….Placenta Previa

3…….History of classical cesarean section

4…….Preeclampsia

5…….Non-reassuring fetal status

6…….Intrauterine growth restriction

7…….Elective

8…….Post Dates

9…….Other _____________________

18. Delivery

1…….NSVD (vaginal delivery)

2…….Operative delivery (forceps, vacuum)

3…….Cesarean Section

19. Perineal Laceration

1…….None

2…….1st degree

3…….2nd degree

4…….3rd degree

5…….4th degree

20. Postpartum Hemorrhage (> 500 cc vag, > 1000cc C/S)

1……..Yes (continue to 21)

2……..No (skip to 23)

• If yes:

21. Amount __________

22. Were they transfused?

1……..Yes

2……..No

23. Evidence of infection peripartum (in labor or around the time of delivery) (code yes if fever)

1…….Yes (continue to 24)

2…….No (skip to 27)

• If yes:

24. Chorioamnionitis

1……..Yes

2……..No

24. Endometritis

1……..Yes

2……..No

24. Other prior to delivery

1……..Yes _______________

2……..No

27. Birth weight (grams) ________

28. Birth length (in)

29. Head circumference ________

30. Congenital Anomaly

1……..Yes (continue to 31)

2……..No (skip to 32)

• 31. If yes, what: _________________________

APGARS

32. At 1 min 0-10 ________

33. At 5 min 0-10 ________

34. At 10 min 0-10 ________

35. Meconium

1…….Yes

2…….No

36. Special Care Nursery admission

1…….Yes (continue to 37)

2…….No (skip to 45)

• If yes, was it due to:

37. Prematurity

1……..Yes

2……..No

37. Hypoglycemia

1……..Yes

2……..No

37. TTN (transient tachypnea of the newborn)

1……..Yes

2……..No

37. Infection suspected

1……..Yes

2……..No

37. Infection proven

1……..Yes

2……..No

37. HIE (hypoxic ischemic encephalopathy)

1……..Yes

2……..No

37. Hyperbilirubin

1……..Yes

2……..No

37. Other ____________

45. Neonatal Intubation

1…….Yes

2…….No

46. Neonatal death

1…….Yes

2…….No

47. Placenta sent to path for analysis:

1……..Yes (continue to 48)

2……..No (skip to 49)

48. If yes, results:

1…….Normal

2…….Abruption

3…….Acute inflammation

4…….Chronic inflammation

5…….Thrombosis

6…….Small for gestational age

7…….Other

49. Total Days Mom in hospital at the time of delivery ___________

50. Total Days Baby in hospital after delivery ___________

51. Initial feeding method (specify all used in the first 24 hours of life):

1……. IV (skip to 54)

2…..Tube (continue to 52)

3…..Breast (skip to 54)

4……Bottle (skip to 53)

52. If tube, was it:

1…….Formula

2…….Breast milk

53. If Bottle, was it (SELECT ALL THAT APPLY):

1…….Formula

2…….Breast milk

54. Feeding Method at discharge (specify all used in last 24 hours in hospital):

1…..Breast (skip to 56)

2…..Bottle (continue to 55)

55. If Bottle, was it (SELECT ALL THAT APPLY):

1…….Formula

2…….Breast milk

56. Birth trauma:

1…..Yes (continue to 57)

2…..No (skip to 58)

57. Specify trauma _________________

58. Hearing screen—LEFT EAR:

1…..Pass

2…..Fail

3….Refer

58. Hearing screen-- RIGHT EAR:

1….Pass

2…..Fail

3…..Refer

Date_____________ Initials of person collecting data_____