Appendix 3

 

APPENDIX 3

The Third Patient Record Chart.

A chart of patient history derived from interrogation of mother about progress of the child during pregnancy.

Mother's Surname___________First Name_________________

Date:_____________

Pregnancy:

1.Duration:

2.Toxicosis:

1st trimester

a) Yes

b) Is not present

2nd trimester

a) Yes

b) Is not present

3rd trimester

a) Yes

b) Is not present

3. Aggravated tonus of uterus:

a) Yes

b) Is not present

4.. Threat of interruption of pregnancy:

a) Yes

b) Is not present

5. Retardation or cessation of development of fetus intrauterine?

a) Yes

b) Is not present

6. Accompanying diseases of mother:

7. Other pertinent information:

Birth and Delivery:

1. Duration of labor: _____hrs_____mins

2. Labor inducing medications or stimulations administered?

a) Yes

b) Not used

c) Spinal block used

3. Childbrith - labor complications: -

a) uterine neck failed to dialate?

b) Fetus would not pass through birth canal?

c) Use of doctor's hands to squeeze baby out of mother?

d) Other - such as forceps used?

4. Cesarian section performed?

a) Scheduled

b) Emergency

5. Entangled umbilical cord around neck/body?

a) Yes

b) No

6. Began crying:

a) At once

b) After some time - ____seconds____minutes

c) Artificial ventilation of lungs

7. Hypoxia detected?

a) During childbirth

b) Intra-uterine

8. Color of liquid when water broke?

a) Normal

b) Green

c) Feces in water

d) Large amount of water

e) Small amount of water

9. Other pertinent information:

10. Was mother warned about the consequences for the child concerning difficult pregnancy or childbirth?

a) Yes

b) No

c) Other