The New-Brunswick Perinatal Health Program · 2019-03-25 · The Antenatal Record Part 4 - Post Partum Assessment, should be done at her 6 -8 week post-partum visit at the OBS clinic

APPENDIX

A Completion Guide of the Antenatal Record

The New-Brunswick Perinatal Health Program

Administrative Address:

221 West Lane, 3rd Floor

Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

(A) Body Mass Index Graph. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Section 6 : Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . .8

Section 2 : Present Pregnancy/ Allergies and Medications. . . . .5

Section 4 : Medical History and Family History. . . . . . . . . . . . . . .6

Table Of Contents

Section 1 : Demographic and Backround Information. . . . . . . . . 4

Recommendations/ Important Information. . . . . . . . . . . . . . . . . 3

Working Tool for Healthcare Providers

Moncton, NB, E1C 6V3

135 MacBeath Avenue

Moncton, NB, E1C 6Z8

Section 3 : Obstetrical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Section 5 : Lifestyle and Social. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

May 2015

Section 7 : Laboratory and Diagnostic Testing. . . . . . . . . . . . . . . .8

Obtaining Copies of the Antenatal Record . . . . . . . . . . . . . . . . .10

(B) TWEAK scoring guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

(C)Maternal Drinking Guide/How to ask the question. . . . . . . . 13

(D) Edinburgh Postnatal Depression Scale (EPDS). . . . . . . . . . . . 14

Mailing Address:

A Completion Guide of the Antenatal Record

The New-Brunswick Perinatal Health Program

Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

(A) Body Mass Index Graph. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Section 6 : Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . .8

Section 2 : Present Pregnancy/ Allergies and Medications. . . . .5

Section 4 : Medical History and Family History. . . . . . . . . . . . . . .6

Table Of Contents

Section 1 : Demographic and Backround Information. . . . . . . . . 4

Recommendations/ Important Information. . . . . . . . . . . . . . . . . 3

Working Tool for Healthcare Providers

Section 3 : Obstetrical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Section 5 : Lifestyle and Social. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

May 2015

Section 7 : Laboratory and Diagnostic Testing. . . . . . . . . . . . . . . .8

Obtaining Copies of the Antenatal Record . . . . . . . . . . . . . . . . .10

(B) TWEAK scoring guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

(C)Maternal Drinking Guide/How to ask the question. . . . . . . . 13

(D) Edinburgh Postnatal Depression Scale (EPDS). . . . . . . . . . . . 14

The NB Perinatal Health Program Antenatal record part 1 and 2 is a tool developed to facilitate the assessment and

documentation of relevent information about the woman’s health and pregnancy care in a standardized matter. It

is a tool to aid in the communication between healthcare providers and facilities and provides a guide for evidence-

based components of prenatal and maternal care. Specific fields in the Antenatal record will be coded and

collected as a part of the NB Perinatal Health Program database. Having good documentation is the key to

maintain a consistent, acurate and reliable database. Every facility that offers maternal/newborn services will be

collecting data for this program. The collection of data will help identify and promote standards, best practices,

health care initiatives and evidence informed policies that support maternal and perinatal health outcomes across

the province.

INTRODUCTION

In conjunction with the Antenatal record part 1 and 2, there is several additional tools provided to asssist with the woman's assessment : ● Body Mass Index Graph ● TWEAK (Tolerence, Worry, Eye-opener, Amnesia, Cut down) for assessing the risk of alcohol use ● Maternal drinking guide along with "How to ask the question" is a tool to guide you through a series of appropriate introductory statements about alcohol consumption during pregnancy ● Edinburgh Postnatal Depression Scale (a self-adminstered questionnaire) is used to assess a woman's risk of perinatal depression in the antenatal and postnatal period

NB Perinatal Health Program 2

* Please Note that the Antenatal Record will have 3 copies made upon discharge from the hospital.

The original copy will be place in the mother's clinical chart, a copy for the baby's clinical chart and a

copy for the attending physician.

RECOMMENDATIONS / IMPORTANT INFORMATION

According to Horizon Health Network policies, the date should be entered as dd/mm/yyyy.

According to Vitalite Health Network policies, the date should be entered as yyyy-mm-dd.

Follow the correct policy that reflects your network.

The Antenatal Record Part 3 - Subsequent Assessments , is used for ongoing documentation at each

prenatal visit. If this sheet is completed, additional sheets may be added as needed.

The Antenatal Record Part 4 - Post Partum Assessment , should be done at her 6 -8 week post-partum

visit at the OBS clinic in the hospital, as well as the 1st family doctor visit. This will ensure the

information of the full pregnancy will be available for the Perinatal Program to report on.

We Recommend that a copy of the Antenatal Record be sent to the intented hospital of birth between

34-36 weeks gestation. This will insure that important information will be available if the woman is

admitted to the hospital unexpectedly in the antepartum period. Family doctors - please keep a copy

for your own records if desired. The original copy must follow the woman.

If the woman has been referred to the OBS clinic before the 34 weeks gestation mark, we recommend

that the antenatal record be sent to the clinic to make sure the healthcare providers will have all

pertinent information about the pregnancy.

The Antenatal Record must always follow the woman.


A Completion Guide of the Antenatal Record Part 1 and 2

Section 1 Demographic and backround Information

Physician/midwife/OBS

Ethnic/ racial backrounds of biological

Mother

The age of the partner/father

Education Level

Medicare Number

Occupation/Work Status

Occupation

Hospital chart number where she plans on giving birth (or home)

Newborn care

Family physician

Partner involved in pregnancy Will the partner be involved in the pregnancy ? Check 'yes' or 'no'

Last name of the partner/father

First name of the partner/father

Woman's date of birth

Hospital Chart Number

Woman's marital status. Indicate wether she is married, single, common-law,

separated/divorced or widowed

Partner/Father's occupation. This can identify if his work exposes him to any

environmental or occupational risks (e.g. chemicals, asbestos, radiation,

hazardous waste,etc.) This data will help identify any factors linked to

congenital anomalies, and is collected in our database for further investigation

in provincial and national reporting.

Last name of the mother

First name of the mother

Place of residence of woman (include postal code)

Woman's phone number (include home/cell and work numbers)

Language that the woman prefers and understands

Age

Partner/father's education level: Indicate the appropritate box on form

Description

Name of the primary care provider that will be giving the newborn care

Name of the primary care provider giving pregnancy care

Name of the family physician

Item

Patient's Last name

Patient's first name

Address

Phone number

Language

Date of birth

Age

Marital Status

Partner/Father's information :

Last name

First name

Woman's medicare number with expiry date

Woman's occupation. This can identify if her work exposes her to any

environmental or occupational risks (e.g. chemicals, asbestos, radiation,

hazardous waste,etc.) This data will help identify any factors linked to

congenital anomalies, and is collected in our database for further investigation

in provincial and national reporting. Also Indicate her she works full-time, part-

time or doesn't work.The woman's level of education. Indicate: no high school diploma, high school

diploma, some post-secondary education (includes working on college or

university degree, college or trade certification, university degree)

Ethnic or cultural identity. Indicate whether she/he are: Acadian, African

–Canadian, Asian, Caucasian, First Nations, Hispanic, Jewish, Mediterranean,

Middle Eastern, Quebecois, Other (specify). Our goal in collecting this data is to

be able to identify patients with increased risk of congenital anomalies linked

to certain ethnicities, racial backround. Please note that if the pregnancy

results from artificial insemination or surrogacy - we would like to know the

donor's ethnicity and not necessarily that of the partner who will be involved in

the pregnancy.

Woman's age at estimated date of delivery

Education Level



Section 2 Present Pregnancy/ Allergies and Medications

Section 3 Obstetrical History

Final EDD Date of final estimate date of delivery, check the appropriate box for dating

method (last menstrual period, ultrasound, artificial insemination)

Opportunity to document details of previous pregnancies and birth outcomes

including, date, place of birth/abortion, hours in labour, gestational age, type of

birth(spontaneous vaginal, forceps,vaccum, C/S), perinatal complications, sex

of the baby, birth weight, breastfed and present health status.

Abortion - induced

Abortion - Spontaneous

Living

Previous births, Details and Outcomes

If you desire more space for this

section, please use the progress notes

and attach with this form

The total number of previous induced terminations of pregnancies ending prior

to 20 completed weeks gestation. This includes unwanted pregnancies

The total number of previous spontaneous terminations of pregnancies ending

prior to 20 completed weeks gestation. This includes missed abortions, ectopic

pregnancies, termination of a non-viable fetus

The total number of children the women has given birth to, and are presently

living. Does not include present pregnancy

Term

Preterm

Description

The total number of prior plus present pregnancies regardless of gestational

age, type, time or method of termination outcome. Twins or multiple are

counted as one pregnancy

The total number of previous pregnancies with birth occuring at greater than or

equal to 37 completed weeks gestation

The total number of previous pregnancies with birth occuring between 20-36

completed weeks gestation

Item

Gavida

Allergies or sensitivities

Bleeding, nausea, vomiting

Infections or fever

Preconceptual folate

Medications/herbals/OTC

If the woman experienced any bleeding, nausea or vomiting during the current

pregnancy check 'yes' or 'no'

List allergies or sensitivities along with their reactions

If the woman experienced any infections or fever during the current pregnancy,

check 'yes' or 'no'If the woman has taken any pre-conceptual folate, check 'yes' or 'no' . If 'Yes"

please indicate the date the woman started to take the folic acid.

List of medications/herbals/OTC - please use the medications forms or progress

notes if you need more space to list the medications

Folate Acid Dose Indicate the dose of preconceptual folate the woman has taken.

Contraceptive type (pill, patch, IUD, ring) before knowing she is pregnant, with

date last used dd/mm/yyyy

Expected Delivery Date dd/mm/yyyy

Date of positive pregnancy test dd/mm/yyyy

Last menstrual period (LMP)

Menses Cycle

Contraceptive type

Expected Delivery Date (EDD)

Positive pregnancy test

The last menstrual period in dd/mm/yyyy - check 'yes' or'no' for wether or not

she is certainIndicate the menses cycle length; if the menses cycle is regular, check 'yes' or

'no'

DescriptionItem



Section 4 Medical History and Family History

Maternal / Paternal family history

Genetic disorders

Description

* Includes medical history/family history that may influence the management or outcome of the current pregnancy.

Check the 'no' box if the condition is not present. If 'yes' please document/explain. If there is insufficient space, please

use progress notes and attach to this form.

Item

Thromboembolic/Hematologic

Diabetes/thyroid/endocrine

Depression/psychiatric

Breast Surgery

Abdominal surgery

Anesthesia

Blood transfusions

Medical History

Family history of any congenital anomalies, chromosome abdnormalities or any

ethnic disorders (sicklecell, Tay Sachs, Thalassemia, Ashkenazi). Include any

other disorders that could affect the outcome of the pregnancy

Family History

Uterine/ Cx Procedure

Respiratory Significant respiratory disorder

Preeclampsia/eclampsia Any history of previous Preeclampsia or eclampsia during pregnancy

Gestational Hypertension Any history of previous gestational hypertension during pregnancy

STIs/infections

Chickenpox/Varicella

Endocrine disoders (diabetes, thyroid)

Significant neurological disorder (epilepsy, seizures, multiple sclerosis)

Significant cardiovascular disorder

Previous chronic hypertension, hypertension currently on medication,

hypertension with previous pregnancies

History of Gastrointestinal disease or hepatic disease

Pre-existing disorders, history of recurrent UTI, pyelonephritis, ARF, CRF or

those complicating a previous pregnancy

Significant gynecological history or cervical procedures such as fibroids,

endometriosis, abnormal Pap tests which required treatment or further

investigationHistory of STIs (Sexual Transmitted Infections) or other infection and their risk

to the pregnancy

History of varicella infection or immunization

Previous problems with varicose veins, Deep Vein Thrombosis, pulmonary

embolism or coagulation disorders

Neurologic

Cardiovascular

Hypertension

Gastrointestinal/ hepatic

Urinary / renal

Present or past history of mental illness and treatments

History of any breast surgery (reductions, augmentations, lumpectomies)

History of any abdominal surgery (appendectomy, cholecystectomy,

polypectomy, liposuction, gastrectomy)

Complications from any previous anesthetics

Any history of blood transfusions

Indicate any other medical condition that may affect pregnancy management Other

Includes heart disease, hypertention, diabetes, thryoid,

thromboembolic/hematologic or any other disease that may affect the

outcome of the pregnancy. Also include if there is history of Multiple births

Item Description



Section 5 Lifestyle and Social* Check the 'discussed' box of the item and document any concerns noted.

* Check the 'referred' box if the women is referred for further follow-up/treatment

Diet/nutrition/prenatal vitamins

* The TWEAK tool is attached with the completion guide. The tool has been validated to screen for alcohol risk with

pregnant women. The TWEAK (self-administed) can be intergrated into discussions with the woman.

Document the maximum number of drinks before pregnancy and the

maximum number of drinks during the current pregnancy

Please refer to sample questions that are available on the attached appendix C

"Maternal drinking guide and How to ask the question"

Document the TWEAK score for all women. Refer to the scoring guide on

Appendix B attached.

Indicate 'no' or 'yes' for substance use during pregnancy. Specify in the 'notes'

section the type of substance. Can include marijuana, cocaine, methadone,

heroine, solvents or other. If other, Please specify

Alcohol, Substance abuse

Item

Please ask to woman the following questions (and note) :

How many weeks were you when you found out you were pregnant ?

Tell me a bit about your drinking patterns before you were pregnant ?

Have you been able to stop or cut down since you found out ?

Maximum drinks before pregnancy

Maximum drinks during the current

pregnancy

Indicate if the woman has never smoked. Or indicate a quit date if she is a

former smoker

Item Description

Cig/ day before pregancy

Cig/ day current

Exposure to 2nd hand smoke Check 'no' or 'yes' if exposed to tobacco use. (if the mother lives with a smoker

or works in a environment with smokers)

Alcohol Indicate 'no' or 'yes' for wether the woman has consumed alcohol

Description

Adequacy of nutrition during present pregnancy. A restricted diet may indicate

an eating disorder or other types of diet (vegan,vegeterian). Referral may be

needed for women with Diabetes, obesity or a restricted diet

Physical activity, rest and the woman's work schedule

Tobacco use (smoking)

Item

Physical activity

Smoking

Document the average number of cigarettes per day during the current

pregnancy (Please note 1/2 pack is 13 cigs, 1 pack is 25 cigs)

Description

Document the average cigarettes per day before the pregnancy. (Please note

1/2 pack is 13 cigs, 1 pack is 25 cigs)

Subtances Use

TWEAK score



Section 5 Lifestyle and Social continued…

Section 6 Physical Examination

Section 7 Laboratory and Diagnostic Testing

9 - 13 +6 WEEKS

15 - 20 +6 WEEKS

Item

Indicate 'no' or 'yes' for occupational or environmental risk to the woman.

Refers to predisposur to any chemicals, asbestos, radiation, hazardous

waste,etc... (refer to 'woman's occupation' in the demographic section)

Discuss who will provide support to the woman during and after pregnancy

Document the height of the woman in centimeters

Document the pre-pregnant weight of the woman in kilograms

Document the pre-pregnant BMI. Refer to the BMI on the attached appendix A

Refers to any sexual abuse

First Prenatal Visit

Item

Results and Comments

Pre-pregnancy BMI (Body Mass Index)

Pre-pregnancy weight

Height

BP

Exam date

Document any financial concerns, housing stability

Support System

Interpersonal violence Indicate any pattern or history of physical, sexual and/or emotional

interpersonal violence

Item Description

Indicate if the maternal Serum Testing was 'discussed', 'declined' or 'accepted'

with the date (Screen's for Down Syndrome, Trisomy 18)

Indicate if the maternal Serum Testing was 'discussed', 'declined' or 'accepted'

with the date (Screen's for Down Syndrome, Trisomy 18)

Indicate if the woman has attended any prenatal classes

Description

Indicate when the physical examination took place

Document the blood pressure taken during the exam

Sexual abuse

Financial/housing/prenatal benefits

Prenatal classes

Occupational/Environmental risks

Document results and comments for the physical examination findings in the

space provided for the headings: Head & neck, abdomen, varices & skin, pelvic

exam, heart & lungs, Musculoskeletal, Breasts & nipples, swab/cervix cytology

Description

Date of the 1st prenatal visit. Indicate the results of the following testst offered

to all women: CBC, HbsAg, Rubella, Syphilis/VDRL, ABO/Rh, HIV, Chlamydia,

Gonorrhea, Urine C&S, PAP date

Indicate the results of the following test that is offered to some women :

Varicella, Diabetic screen, Father's RH, TSH, Hepatitis C and any other tests that

was performed. If this was done pre-visit, enter the results and dates.



Section 7 Laboratory and Diagnostic Testing

35 - 37 WEEKS

18 - 21 WEEKS

Indicate any other procedures or testing the woman received and is relevent to

her current pregnancy

Special Procedures/ Tests Indicate if the seasonal flu Shot was 'disscused', 'declined' or 'given'. If it was

administered, indicate the date

Indicate the date of the Ultrasound, and any other lab or DI results

Indicate if an Amniocentesis was done along with the date and the results

Indicate if a CVS was done along with the date and the results

Indicate the results of the following tests offered to all women: CBC, Diabetic

screen, Antibody ScreenIndicate if the Rho (D) Immuno Globulin is given, along with the date

Indicate the score of Edingburg Postnatal depression scale, along with 'yes' or

'no' for a follow-up. This screening is required for women between 28-32

weeks gestation and again at 6-8 weeks postpartum. Refer to the EPDS

screening tool attached on appendix D

Indicate the positive or negative result of the GBS (Group Strep B) if screening

was done along with the date. Or Check 'declined' box if the women refuses

Indicate wether the GTT was done 'yes' or 'no' along with the date and the

28 WEEKS

28 - 32 WEEKS

24 - 28 WEEKS


Obtaining Copies of the Antenatal Record

Contact Information

For any feedback or questions regarding any of the perinatal forms, please contact : Natalie Fay, CHIM/CGIS, Informatics Coordinator of the NB Perinatal Health Program Phone : (506) 870-2454 Email : [email protected]

Copies of the form will be uploaded onto Skyline and Boulevard for healthcare providers to print it from their offices, clinics or facilities. Copies will also be available on the Perinatal Programs website: http://en.horizonnb.ca/facilities-and-services/provincial-programs/nb-perinatal-health-program/for-health-professionals.aspx

NB Perinatal Health Program Page 11

Appendix A

Calculating Pre-Pregnancy Body Mass Index (BMI)

UNDERWEIGHT (BMI<18.5)

Increased Risk

NORMAL (BMI 18.5-24.9)

Least Risk

OVERWEIGHT (BMI 25.0-29.9) Increased Risk

OBESE CLASS I (BMI 30.0-34.9)

High Risk

OBESE CLASS II (BMI 35.0-39.9) Very High Risk

OBESE CLASS III (BMI >=40.0)

Extremely High Risk

Pre-Pregnancy Weight

Height in Feet/Inches and Meters

LB KG 4’8”

1.42m 4’10”

1.47m 5’0”

1.52m 5’2”

1.57m 5’4”

1.63m 5’6”

1.68m 5’8”

1.73m 5’10”

1.78m 6’0”

1.83m 6’2”

1.88m 6’4”

1.93m 6’6”

1.98m

100 45.4 22.5 21.0 19.7 18.4 17.1 16.1 15.2 14.3 13.6 12.8 12.2 11.6

105 47.6 23.6 22.0 20.6 19.3 17.9 16.9 15.9 15.0 14.2 13.5 12.8 12.1

110 49.9 24.7 23.1 21.6 20.2 18.8 17.7 16.7 15.7 14.9 14.1 13.4 12.7

115 52.2 25.9 24.2 22.6 21.2 19.6 18.5 17.4 16.5 15.6 14.8 14.0 13.3

120 54.4 27.0 25.2 23.5 22.1 20.5 19.3 18.2 17.2 16.2 15.4 14.6 13.9

125 56.7 28.1 26.2 24.5 23.0 21.3 20.1 18.9 17.9 16.9 16.0 15.2 14.5

130 59.0 29.3 27.3 25.5 23.9 22.2 20.9 19.7 18.6 17.6 16.7 15.8 15.0

135 61.2 30.4 28.3 26.5 24.8 23.0 21.7 20.4 19.3 18.3 17.3 16.4 15.6

140 63.5 31.5 29.4 27.5 25.8 23.9 22.5 21.2 20.0 19.0 18.0 17.0 16.2

145 65.8 32.6 30.5 28.5 26.7 24.8 23.3 22.0 20.8 19.6 18.6 17.7 16.8

150 68.0 33.7 31.5 29.4 27.6 25.6 24.1 22.7 21.5 20.3 19.2 18.3 17.3

155 70.3 34.9 32.5 30.4 28.5 26.5 24.9 23.5 22.2 21.0 19.9 18.9 17.9

160 72.6 36.0 33.6 31.4 29.5 27.3 25.7 24.3 22.9 21.7 20.5 19.5 18.5

165 74.8 37.1 34.6 32.4 30.3 28.2 26.5 25.0 23.6 22.3 21.2 20.1 19.1

170 77.1 38.2 35.7 33.4 31.3 29.0 27.3 25.8 24.3 23.0 21.8 20.7 19.7

175 79.4 39.4 36.7 34.4 32.2 29.9 28.1 26.5 25.1 23.7 22.5 21.3 20.3

180 81.6 40.5 37.8 35.3 33.1 30.7 28.9 27.3 25.8 24.4 23.1 21.9 20.8

185 83.9 41.6 38.8 36.3 34.0 31.6 29.7 28.0 26.5 25.1 23.7 22.5 21.4

190 86.2 42.7 39.9 37.3 35.0 32.4 30.5 28.8 27.2 25.7 24.4 23.1 22.0

195 88.5 43.9 41.0 38.3 35.9 33.3 31.4 29.6 27.9 26.4 25.0 23.8 22.6

200 90.7 45.0 42.0 39.3 36.8 34.1 32.1 30.3 28.6 27.1 25.7 24.3 23.1

205 93.0 46.1 43.0 40.3 37.7 35.0 33.0 31.1 29.4 27.8 26.3 25.0 23.7

210 95.3 47.3 44.1 41.2 38.7 35.9 33.8 31.8 30.1 28.5 27.0 25.6 24.3

215 97.5 48.4 45.1 42.2 39.6 36.7 34.5 32.6 30.8 29.1 27.6 26.2 24.9

220 99.8 49.5 46.2 43.2 40.5 37.6 35.4 33.3 31.5 29.8 28.2 26.8 25.5

225 102.1 50.6 47.2 44.2 41.4 38.4 36.2 34.1 32.2 30.5 28.9 27.4 26.0

230 104.3 51.7 48.3 45.1 42.3 39.3 37.0 34.8 32.9 31.1 29.5 28.0 26.6

235 106.6 52.9 49.3 46.1 43.2 40.1 37.8 35.6 33.6 31.8 30.2 28.6 27.2

240 108.9 54.0 50.4 47.1 44.2 41.0 38.6 36.4 34.4 32.5 30.8 29.2 27.8

245 111.1 55.1 51.4 48.1 45.1 41.8 39.4 37.1 35.1 33.2 31.4 29.8 28.3

250 113.4 56.2 52.5 49.1 46.0 42.7 40.2 37.9 35.8 33.9 32.1 30.4 28.9

255 115.7 57.4 53.5 50.1 46.9 43.5 41.0 38.7 36.5 34.5 32.7 31.1 29.5

260 117.9 58.5 54.6 51.0 47.8 44.4 41.8 39.4 37.2 35.2 33.4 31.7 30.1

265 120.2 59.6 55.6 52.0 48.8 45.2 42.6 40.2 37.9 35.9 34.0 32.3 30.7

270 122.5 60.8 56.7 53.0 49.7 46.1 43.4 40.9 38.7 36.6 34.7 32.9 31.2

275 124.7 61.8 57.7 54.0 50.6 46.9 44.2 41.7 39.4 37.2 35.3 33.5 31.8

280 127.0 63.0 58.8 55.0 51.5 47.8 45.0 42.4 40.1 37.9 35.9 34.1 32.4

285 129.3 64.1 59.8 56.0 52.5 48.7 45.8 43.2 40.8 38.8 36.6 34.7 33.0

290 131.5 65.2 60.9 56.9 53.3 49.5 46.6 43.9 41.5 39.3 37.2 35.3 33.5

295 133.8 66.4 61.9 57.9 54.3 50.4 47.4 44.7 42.2 40.0 37.9 35.9 34.1

300 136.4 67.5 63.0 58.9 55.2 51.2 48.2 45.5 43.0 40.6 38.5 36.5 34.7

305 138.3 68.6 64.0 59.9 56.1 52.1 49.0 46.2 43.6 41.3 39.1 37.1 35.3

310 140.6 69.7 65.1 60.9 57.0 52.9 49.8 47.0 44.4 42.0 39.8 37.7 35.9

315 142.9 70.9 66.1 61.9 58.0 53.8 50.6 47.7 45.1 42.7 40.4 38.4 36.5

320 145.1 72.0 67.1 62.8 58.9 54.6 51.4 48.5 45.8 43.3 41.1 39.0 37.0

325 147.4 73.1 68.2 63.8 59.8 55.5 52.2 49.2 46.5 44.0 41.7 39.6 37.6

330 149.4 74.2 69.3 64.8 60.7 56.3 53.0 50.0 47.2 44.7 42.4 40.2 38.2

335 152.0 75.4 70.3 65.8 61.7 57.2 53.9 50.8 48.0 45.4 43.0 40.8 38.8

340 154.2 76.5 71.4 66.7 62.6 58.0 54.6 51.5 48.7 46.0 43.6 41.4 39.3

345 156.5 77.6 72.4 67.7 63.5 58.9 55.4 52.3 49.4 46.7 44.3 42.0 39.9


Appendix B

TWEAK SCORING GUIDE

T Tolerance:

“How many drinks does it take to make you feel high?” (or this can be modified to “How many drinks can you hold?”) Record number of drinks

3 or more drinks = 2 points

W Worry:

“Have close friends or relatives worried or complained about your drinking in the past year?”

Yes = 2 points

E Eye-Opener:

“Do you sometimes have a drink in the morning when you first get up?” Yes = 1 point

A Amnesia (Blackout):

“Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?”

Yes = 1 point

K (c) Cut Down:

“Do you sometimes feel the need to cut down on your drinking?”

Yes = 1 point A score of 2 or more points indicates a risk of drinking problem. Source: Russell, M (1994). New Assessment tools for risk drinking during pregnancy: T-ACE, TWEAK and others. Alcohol Health and Research World.


Appendix C

How to ask “the question”? Based on Maternal Drinking Guide of the National FASD Screening Tool Development Project Effective introductory statements:

For women of childbearing age: “I want to ask you a series of questions today about your lifestyle. I ask all my patients these questions because it helps me to get a better understanding of what your day-to-day life is like (in terms of diet, exercise and other lifestyle issues). It will help me to know you, and that will help me to provide better care.”

For pregnant women:

“I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child/children (or name of child, if preferred).”

Following the above introductory statements, providers are recommended not to begin with alcohol-related questions as listed below, but rather, following a series of innocuous questions related to lifestyle (e.g. Do you take any prescription meds or over-the-counter meds? Do you take any vitamin supplements? How often do you get a chance to exercise, if at all? How often do you use herbal/homeopathic products?). It has been demonstrated in the literature that most accurate responses are derived when questions pertaining to alcohol are embedded among questions regarding other lifestyle behaviors and practices. When did you know you were pregnant? Examples of Practice-based questions proven effective: The following options of questioning have been validated by different experts:

“When was the last time you had a drink?” “Do you ever enjoy a drink or two?” “Do you sometimes drink beer, wine or other alcoholic beverages?” “Do you ever use alcohol?” “In the past month or two have you ever enjoyed a drink or two?”

Questions specific to pregnancy?

“Can you tell me a bit about your drinking patterns before you knew you were pregnant?”

“Have you been able to stop or cut down since you found out?” Questions specific to teens/youth:

“How do you party?” OR “How do your friends party?”

Helpful Suggestions:

To encourage more accurate reporting, one can suggest high levels of alcohol/drug consumption:

“And on those days, would it be something like 3 to 4 drinks or about 8 to 10 drinks?”

In cases of confirmed or suspected history of past alcohol dependency/abuse, the

following questions are suggested:

Have you ever had a drinking problem?” “When was your last drink?”

Questions to avoid and alternatives:

Avoid questions such as: “Do you drink often?” “How much are you drinking?”

Avoid questions that require a “yes” or “no” response. It is preferable to ask open-

ended questions to open dialogue, such as: “What do you know about the effects of drinking in pregnancy?”

Avoid statements that increase guilt in women who admit to continued alcohol use:

“You may have already hurt your baby"

Instead, an example of a statement that may be more constructive is:

“You can have a healthier baby if you stop drinking for the rest of the pregnancy.”


Appendix C

In cases of confirmed or suspected history of past alcohol dependency/abuse, the

following questions are suggested:

Have you ever had a drinking problem?” “When was your last drink?”

Questions to avoid and alternatives:

Avoid questions such as: “Do you drink often?” “How much are you drinking?”

Avoid questions that require a “yes” or “no” response. It is preferable to ask open-

ended questions to open dialogue, such as: “What do you know about the effects of drinking in pregnancy?”

Avoid statements that increase guilt in women who admit to continued alcohol use:

“You may have already hurt your baby"

Instead, an example of a statement that may be more constructive is:

“You can have a healthier baby if you stop drinking for the rest of the pregnancy.”


Appendix D

Edinburgh Perinatal / Postnatal Depression Scale (EPDS)

SCORING GUIDE

In the past 7 days:

1. I have been able to laugh and see the funny side of things 0 As much as I always could 1 Not quite so much now 2 Definitely not so much now 3 Not at all

2. I have looked forward with enjoyment to things 0 As much as I ever did 1 Rather less than I used to 2 Definitely less than I used to 3 Hardly at all

3. I have blamed myself unnecessarily when things went wrong 3 Yes, most of the time 2 Yes, some of the time 1 Not very often 0 No, never

4. I have been anxious or worried for no good reason 0 No, not at all 1 Hardly ever 2 Yes, sometimes 3 Yes, very often

5. I have felt scared or panicky for no very good reason 3 Yes, quite a lot 2 Yes, sometimes 1 No, not much 0 No, not at all

6. Things have been getting on top of me 3 Yes, most of the time I haven’t been able to cope at all 2 Yes, sometimes I haven’t been coping as well as usual 1 No, most of the time, I have coped quite well 0 No, I have been coping as well as ever

7. I have been so unhappy that I have difficulty sleeping 3 Yes, most of the time 2 Yes, sometimes 1 Not very often 0 No, not at all

8. I have felt sad or miserable 3 Yes, most of the time 2 Yes, quite often 1 Not very often 0 No, not at all

9. I have been so unhappy that I have been crying 3 Yes, most of the time 2 Yes, quite often 1 Only occasionally 0 No, never

10. The thought of harming myself has occurred to me 3 Yes, quite often 2 Sometimes 1 Hardly ever 0 Never

A score of 1 – 3 to item 10 indicating a risk of self-harm, requires immediate mental health assessment and intervention as appropriate.

Scoring of 11 – 13 range, monitor, support and offer education. Scoring of 14 or higher, follow-up with comprehensive bio-psychosocial diagnostic assessment for depression. Source: Cox, JL, Holden, JM, Sagosvsky, R (1987). Department of Psychiatry, University of Edinburgh


The New-Brunswick Perinatal Health Program · 2019-03-25 · The Antenatal Record Part 4 - Post Partum Assessment, should be done at her 6 -8 week post-partum visit at the OBS clinic

Documents