Courtesy translation. Only the German version is binding. Zur

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November 2015
Courtesy translation. Only the German version is binding.
Zur Information; es gilt die deutsche Fassung.
IMPORTANT MESSAGE FOR PREGNANT WOMEN
Stamp (physician/hospital/midwife)
1
2
bi
nd
in
g.
Pregnancy and birth are perfectly natural processes and as such
not a disease. But sometimes they can be associated with a
greater risk of illness for both mother and child. Getting attentive
prenatal care can help you to avoid most of these risks, or to
spot them in time to prevent greater harm.
is
But that can only work if you go to your checkups regularly!
4
m
an
ve
rs
io
n
3
The clinical examinations offered in this document are based on
up-to-date medical knowledge and many years of experience in
obstetrics. They will help keep you and your baby healthy.
y
th
e
G
er
These maternity records contain the most important medical
findings of your pregnancy. Your doctor will give this document
back to you after each checkup. These records are important
information for your doctor and midwife to ensure the safety of
you and your child.
tio
n.
O
nl
These maternity records are your personal documents. You have
full control over who has access to them. No one else (e.g. an
employer or public authority) can demand to see them.
Date
Time
Date
Time
C
ou
rte
sy
tra
ns
la
So please:
● Take advantage of this opportunity to keep yourself and your
child safe.
● Remember to take this booklet with you to every medical
checkup during your pregnancy, as well as before and after
the birth of your child.
● If you have any concerns, seek help.
● Don‘t hesitate to ask your doctor questions you might have,
and follow his or her advice.
My next checkup is on:
2
3
Surname:
First name:
Date of birth:
Place of birth:
Test for chlamydia trachomatis DNA
in urine sample using nucleic acid
amplification test (NAT)
Screening for syphilis conducted
negativepositive
Log number:
on:
Examination date:
(Name changes here:)Surname:
Laboratory tests and rubella protection
negative
io
n
Antibody screening test
ABO
positive, titre 1:
(Results of other serological
examinations, if applicable:
see page 4)
Antibody screening retest
negative
negative
positive, titre 1:
positive, titre 1:
Examination date:
Examination date:
Laboratory
log number:
Laboratory
log number:
th
e
G
er
Laboratory
log number:
Physician signature and stamp
Antibody screening retest
m
an
Examination date: rhesus D status pos. (D pos.)
or neg. (D neg.) *)
g.
is
Physician signature and stamp
ve
rs
Blood group
nd
in
Place of residence:
bi
Laboratory
log number:
negative
positive, titre 1: orIU/ml:
Immunity can
be assumed:
yes
sy
Laboratory
log number:
tra
Examination date: rte
Examination date: C
ou
Laboratory
log number: Additional serological
examinations, if applicable:
Physician stamp
4
Physician signature and stamp
Physician signature and stamp
nl
O
n.
tio
Rubella antibody test
ns
la
The information entered here does not
release the physician from his or her
due diligence obligations (e.g.
cross-matching)
Proof of two rubella vaccinations has
been shown:
yes
no
y
Rubella vaccination
*) Enter words: Rh positive (or) Rh negative
Physician signature
no
Rubella antibody retest
(see Maternity Directive, section C, number 1)
negative
positive, titre 1:
or
IU/ml:
Examination date:
Test for HBs antigen in serum
negative
positive
Examination date:
Laboratory
log number:
Laboratory
log number:
Additional serological
examinations, if applicable:
Physician signature and stamp
Physician signature and stamp
5
Information on prior pregnancies
Age _________ years
Gravida _________
Height _________ cm
A. Medical history and overall findings/first checkup
Outcomes of pregnancies and births (vaginal delivery, Caesarean
section, assisted vaginal birth, abortion, miscarriage, ectopic
pregnancy, length of pregnancy in weeks, progress in labour,
complications, child‘s weight and gender):
1.Family history (e.g. of diabetes, hypertension, congenital anomalies,
yesno
genetic disorders, mental illnesses ______________________________ ) q
1.
q
2.Prior severe illnesses, (e.g. heart, lung, liver, kidneys, central nervous
system, mental), if so, which ___________________________________ q
2.
q
3.Susceptible to bleeding/thrombotic events
3.
q
q
4.Allergies, including to medications ______________________________ q
4.
q
5.Prior blood transfusions
5.
q
q
6.Special mental stress (e.g. family- or work-related)
6.
q
q
7.Special social stress (e.g. integration or financial issues)
7.
q
q
8.Rhesus incompatibility (in prior pregnancies)
8.
q
q
9.Diabetes mellitus
9.
q
q
10.Obesity
10.
q
q
11.Microsomia / small stature
11.
q
q
12.Skeletal abnormalities
12.
q
q
13.Under 18 years of age
13.
q
q
14.Over 35 years of age
14.
q
q
15.Multipara (more than 4 children)
15.
q
q
16.History of fertility treatment
16.
q
q
17.History of preterm birth (before the end of week 37)
17.
q
q
18.History of low-birth-weight infant
18.
q
q
19.History of 2 or more miscarriages/abortions
19.
q
q
20.History of previous stillbirth or neonatal death or baby with
20.
q
q
serious medical problems/impairment
21.Complications during prior births
if yes, which
21.
q
q
22.Complications post partum/in puerperium
if yes, which
22.
q
q
23.History of Caesarian section
23.
q
q
24.History of other uterine surgery
if yes, which
24.
q
q
25.Pregnancies in quick succession (less than 1 year)
25.
q
q
26.Other special circumstances
if yes, which
26.
q
q
nl
n.
O
q
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Medical advice provided
a) Nutrition (incl. iodine intake), medications,
consumption of alcohol, tobacco, and other drugs
b) Job/profession, sports, travel
c) Advice on special risks
d) Preparation for birth: exercise during pregnancy,
child birth preparation class
e) Cancer screening
f) HIV antibody test
• HIV antibody test administered: yes q no q
g) Oral hygiene
y
th
e
G
er
m
an
ve
rs
io
n
is
bi
nd
in
g.
Year
Weight before pregnancy _________ kg
Para _________
6
q
q
q
q
q
q
After medical assessment according to catalogue A,
a pregnancy risk is present at initial examination
q
Special findings
7
B. Special findings in the course of pregnancy
27. General illnesses requiring treatment, if yes, which
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28.Long-term medication
43.Urinary tract infection
29.Substance abuse
44.Antenatal antibody screening positive
30.Exceptional mental stress
45.Risk due to other serological findings
31.Exceptional social stress
46.Hypertension (blood pressure over 140/90)
32.Bleeding before 28th week
47.Urinalysis for protein 1%
33.Bleeding after 28th Week
(1000mg/l) or more
34.Placenta praevia
48.Moderate – severe oedema
35.Multiple pregnancy
49.Hypotension
36.Polyhydramnios
50.Gestational diabetes
• Pretest conducted:
yes/no abnormal: yes/no
37.Oligohydramnios
38.Uncertain expected date of delivery • Diagnostic test conducted: yes/no abnormal: yes/no
51.Abnormal engagement of fetal head
39.Placental insufficiency
52.Other special findings
40.Cervical insufficiency
if yes, which
41.Preterm labor
42.Anaemia
G
Due date/expected date of delivery
Last menstrual period (LMP)
Date of conception (if known):
nl
y
th
e
Cycle /
O
Pregnancy detected on:
tio
n.
Estimated due date (calculated):
rte
sy
tra
ns
la
Due date (if corrected later):
C
ou
Comments
8
in the
week
Ri
s
(c k n
at um
al b
og e
ue r
B)
io
n
lo
od
)
Va
gi
Ex nale
am
in
at
Urinalysis/urine
microscopy
(B
(N
itr
ite
n
ga
r
Su
Pr
ot
ei
t
co
un
syst./
diast.
Hb
gh
t
W
ei
lp
pr
e
al
Fo
et
te
Da
BP
)
Presented at maternity hospital on:
se
Fo
nt
et
at
io
so al h
n
un ea
r
d
t
Fo s/
r
et ate
a
O lm
ed
ov
e
Va ma em
en
ric
ts
os
is
Anti-D prophylaxis (week 28-30) on:
iti
on
Hepatitis B test (week 28-30) on:
os
Pr
eg
na
nc
W
y
ee
w
ee
k
if
k
co
r
re
Fu
ct
nd
ed
a
Pregnancy chart
2nd antibody screening test (week 28-30) on:
nd
in
g.
1.
Notes/treatment/measures
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bi
2.
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3.
m
an
4.
er
5.
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G
6.
O
nl
y
7.
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n.
8.
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9.
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rte
ou
12.
C
11.
tra
10.
13.
14.
9
10
Hospital
Diagnosis
Treatment
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G
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From/to
m
an
Inpatient treatment during pregnancy
ve
rs
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n
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nd
in
g.
Remarks on catalogues A and B
(including measures taken)
tra
In week
Assessment
C
ou
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sy
Date
ns
la
Cardiotocographical findings
11
ULTRASOUND EXAMINATIONS
Remarks:
I. Screening 8 + 0 to 11 + 6 week
Date
Week (acc.
Week
to LMP) corrected
II. Screening 18 + 0 to 21 + 6 week
m
an
a)Thorax:
Single pregnancy:
❍ yes
❍ no
Abnormal heart/thorax
Heartbeat:
❍ yes
❍ no
ratio (visual diagnosis)
Placenta location/structure: ❍ normal ❍ checkup
Heart on left side
er
Comments:
G
Persistent arrhythmia
during examination period
❍ no ❍ yes
BPD FOD/HC
❍ yes ❍ no
Checkup required for:
❍ yes ❍ no
Torso:
Contour interruptions on
the frontal abdominal wall
Consultative examination
arranged: ❍ no ❍ yes
nl
O
n.
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sy
❍ yes ❍ no
Urinary bladder visualized
❍ yes ❍ no
❍ yes
❍ no
Single pregnancy:
Foetal presentation:
Heartbeat:
❍ yes
❍ no
Placenta location/structure: ❍ normal❍ checkup
Amniotic fluid quantity:
Phys. development/foetal growth:
C
❍ yes ❍ no
Stomach visualized in the
upper left abdomen
Checkups required for
12
Remarks:
BPD FOD/HC
Remarks:
❍ checkup
Consultative examination arranged:
Biometry II
ATD
APD/AC
FL
❍ no ❍ yes
❍ no ❍ yes
Comments:
Development ❍ yes ❍ no
according to gestational age:
FL
Amniotic fluid quantity: ❍ no ❍ yes
Phys. development/foetal ❍ no ❍ yes
growth:
III. Screening 28 + 0 to 31 + 6 week
rte
Week (acc.
to LMP)
ou
Date
❍ no
tra
Neck and back:
Irregularities of the
❍ yes
dorsal skin contour
APD/AC
❍ yes ❍ no
y
b)
Head:
Ventricular system ❍ yes
❍ no
abnormalities
Abnormal head shape
❍ yes
❍ no
Cerebellum visualized ❍ yes
❍ no
ATD
Remarks:
Four chamber view visualized ❍ yes ❍ no
e
❍ checkup
th
Development ❍ yes ❍ no
according to gestational age:
Biometry I
❍ yes ❍ no
❍ checkup
Development according
to gestational age:
Consultative examination
arranged:
BPD
g.
no
no
no
yes
yes
checkup
nd
in
❍
❍
❍
❍
❍
❍
bi
yes
yes
yes
no
no
no
CRL
is
❍
❍
❍
❍
❍
❍
io
n
Intrauterine:
Embryo visualized:
Heartbeat:
Multiple pregnancy:
Monochorionic:
❍ yes
Abnormalities:
GS
ve
rs
Date
(e.g. results from prior ultrasound examinations)
Week (acc.
Week
to LMP) corrected
Biometry III
❍ no ❍ yes
13
Reference curves of foetal growth
mm
110
70
100
50
mm
95%
60
50
30
5%
20
bi
io
n
is
0
ve
rs
mm
BPD
m
an
95%
40
20
nl
O
90
10
80
0
70
y
th
e
G
er
100
5%
60
n.
tio
ns
la
tra
sy
rte
120
110
30
mm
40
50
ATD
40
30
30
SSL =crown-rump length (according to Rempen 1996)
BPD=biparietal head diameter (outside-outside)
(according to Hansmann 1976 and Merz/Wellek 1996)
ATD =abdominal transverse diameter (outside-outside)
(according to Merz/Wellek 1996)
20
10
C
ou
90
80
10
678910
1112
Week
110
100
40
5%
20
0
70
nd
in
80
10
50
CRL
40
30
60
95%
60
90
70
mm
g.
Ultrasound checkups according to appendix 1 b
of the Maternity Directive
(date, indication to be examined, findings, comments,
examiner/stamp)
20
10
0
12141618202224262830323436384042
1. US screening
14
2nd US screening
3rd US-Screening
week (compl.)
15
Final examination/discharge summary
Further ultrasound examinations to clarify and monitor
pathological findings according to appendix 1 c of the
Maternity Directive
(date, indication to be examined, findings, comments,
examiner/stamp)
Age
SingleGerman
other
First examination in
week
g.
nd
in
Number of
antenatal care examinations
Presented in
hospital before delivery
Hospitalized
ante partum
in weeks
bi
Most important risk numbers documented (catalogue A/B, pages 5 and 6)
week
Live birth
yes
Mode of birth
Assisted
V CS vag.
birth
m
an
er
Birth
G
e
th
y
yes
m
f
CP
no
m
BP
f
Assisted
V CS vag.
birth
TP
Weight
CP
BP
TP
g
g
Head length/ circumference
/
Apgar score 5’/10’
/
nl
yes
O
Congenital anomalies
/
cm
cm
/
no
yes
no
tio
n.
Special findings
ns
la
Puerperium normal
yes
no
HbBP
Anti-D prophylaxis
yes
Puerperium
tra
sy
rte
ou
no
Gender
Foetal presentation
yes
2. child (twin)
pH level (umbilical artery)
Doppler sonography examinations according to appendix 1 d
(date, indication to be examined, findings, comments,
examiner/stamp)
C
Out of hospital birth
1. child
ve
rs
Date
io
n
is
Pregnancy
PregnanciesBirths (including
(including this one)
this one)
Gyn. findings normal
/
yes
no
Mother advised on sufficient iodine
intake while nursing
no
Exceptional findings (also see p. 16)
1. child
Blood group
and subtype
(only for RH-neg.mother;
no official document!)
Direct Coombs test
2. child (twin)
A B O AB A B O AB
Rh pos. Rh neg.
neg.
pos.
Rh pos. Rh neg.
neg.
pos.
Child released (without problems) on
Child transferred on
Child died on
16
Date of release examination
Signature/stamp
17
Hb
Protein
pos.
Urinalysis
normal
m
an
Sugar
pos.
Urine
g%
io
n
no
/
RR
th
e
G
er
Special findings
Did not breastfeed
Has weaned child
nl
y
Mother is breastfeeding
O
2. examination after delivery
(6th-8th week)
yes
ve
rs
Gyn. findings normal
is
bi
nd
in
g.
Abnormalities during puerperium
tio
n.
Child: Examination U3 conducted
1. child
2. child (twin)
yes
no
yes
no
Is alive and healthy
yes
no
yes
no
Requires treatment after
pediatric examination U 3
yes
no
yes
no
tra
ns
la
C
ou
rte
sy
Died on
Examination date
18
Signature/stamp

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