SAMPLE CASE Royal College of Obstetricians and Gynaecologists UK Obstetric Surveillance System Extreme Obesity Study 03/07 Data Collection Form - CASE Please report all women delivering after 1st September 2007 and before 1st November 2008 Case Definition: EITHER any woman weighing over 140Kg at any point during pregnancy OR any woman with a Body Mass Index (BMI) greater than 50 at any point during pregnancy OR any woman estimated to be in either of the previous categories but whose weight exceeds the capacity of hospital scales. Please return the completed form to: UKOSS National Perinatal Epidemiology Unit University of Oxford Old Road Campus Oxford OX3 7LF Fax: 01865 289701 Phone: 01865 289714 Case reported in: ID Number:
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Extreme Obesity Study 03/07€¦ · CASE Royal College of Obstetricians and Gynaecologists UK Obstetric Surveillance System Extreme Obesity Study 03/07 Data Collection Form - CASE
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SAMPLE
CASE
Royal College of Obstetricians and Gynaecologists
UK Obstetric Surveillance System
Extreme Obesity Study 03/07
Data Collection Form - CASE
Please report all women delivering after 1st September 2007 and before 1st November 2008
Case Definition:
EITHER anywomanweighingover140KgatanypointduringpregnancyOR anywomanwithaBodyMassIndex(BMI)greaterthan50atanypoint
If no previous pregnanciespleasegotosection3.If the woman has had previous pregnancies pleaseindicatewhetheranyofthefollowingwerepresent:2.2 Pregnancy problems2* Yes No
IfYes,pleasespecify2.3 What was the maximum weight in immediately preceding pregnancy? .
ORtickifnotknown
Section 3: Previous Medical HistoryPleaseindicatewhetheranyofthefollowingwerepresentpriortocurrentpregnancy:
3.1 Diabetes mellitus Yes No IfYes,isthisinsulindependent? Yes No
3.2 Essential hypertension requiring treatment Yes No 3.3 Previous abdominal surgery Yes No
IfYes,pleasespecify
3.4 Sub-fertility or problems with conception Yes No 3.5 Other previous or pre-existing medical problems3* Yes No
IfYes,pleasespecify
*Forguidancepleaseseebackcover
Section 4: This Pregnancy4.1 Final Estimated Date of Delivery (EDD)4* / /D M Y YMD
4.2 Was antenatal care undertaken in the usual hospital for this woman’s area of residence? Yes No
6a.1 Was the woman admitted to ITU/HDU Yes NoIfYes,durationofstay(days)OrTickifwomanisstillinITU/HDUOrTickifwomanwastransferredtoanotherhospital
6a.2 Did any major maternal morbidity occur6*? Yes NoIfYes,pleasespecify
6a.3 Did the woman die? Yes NoIfYes,pleasespecifydateofdeath / /D M Y YMDWhat was the primary cause of death as stated on the death certificate?
5.6 Please indicate below what high weight capacity equipment was available for labour and delivery (tickallthatapply)
Availableasstandard
Availablebyspecial
arrangementNotavailable
Bed
Operatingtable
Hoist
Chair
Other
IfOther,pleasespecify
5.7 Was equipment made available by special arrangement? Yes No If Yes, please give date arrangements were first made / /D M Y YMD
5.8 Was shoulder dystocia documented? Yes NoIfYes,pleasedescribewhatmanagementtechniqueswereused
5.9 Were thromboprophylactic measures used after delivery? Yes NoIfYes,pleasespecify TEDstockings Antiplateletagent(e.g.aspirin)Lowmolecularweightheparin Unfractionatedheparin Warfarin Other
Section 6b: Infant 1NB:If more than one infant,foreachadditionalinfant,pleasephotocopytheinfantsectionoftheform(before filling it in)andattachextrasheet(s)ordownloadadditionalformsfromthewebsite:www.npeu.ox.ac.uk/ukoss
6b.1 Date and time of delivery / /D M Y YMD :h m mh24hr
6b.2 Mode of deliverySpontaneousvaginal ventouse lift-outforceps rotationalforceps breech pre-labourcaesareansection caesareansectionafteronsetoflabour
6b.3 Birthweight (g) 6b.4 Was the infant stillborn? Yes No
IfYes,pleasegotosection7
6b.5 5 min Apgar 6b.6 Was the infant admitted to the neonatal unit? Yes No
4. Estimated date of delivery (EDD):Usethebestestimate(ultrasoundscanordateoflastmenstrualperiod)basedona40weekgestation
5. RCA/RCOG/CEMACH/CNST Classification for urgency of caesarean section:ImmediatethreattolifeofwomanorfetusMaternalorfetalcompromisewhichisnotimmediatelylife-threateningNeedingearlydeliverybutnomaternalorfetalcompromiseAtatimetosuitthewomanandmaternityteam
6. Major maternal medical complications, including: