Medical Assessment Questionnaire

Maternal Variables

1. Maternal Age

2. Maternal Parity

3. Number of Previous Pregnancies

4. Current Gestational Age in Weeks

5. Previous IUD/Stillbirth?

6. Previous IUGR/SGA?

7. History of Pregnancy Loss?

8. Hypertension in Pregnancy?

9. Diabetes in Pregnancy?

10. Maternal Autoimmune Disorders?

11. PAPP-A Level

12. What was the woman's blood pressure at booking?

Not performed

13. Race / Ethnicity

14. Antenatal Problems (Specify)

15. Smoking in pregnancy?

17. Any history of Any Respiratory Problems?

18. Any history of the following Inherited Disorders?

19. Any history of any cardiac problems?

20. Any history of hypertension?

21. Any history of anaemia or other haematological problems?

22. Is there any history of thromboembolic or clotting disorders?

23. Any history of jaundice or liver problems?

24. Reduced fetal movements in pregnancy?

25. Any history of any gastrointestinal problems?

26. Any history of any endocrine problems?

27. Any history of fits, epilepsy or neurological problems?

28. Is there any history of autoimmune disease in family?

29. Any history of any of the following infections?

30. Was this pregnancy a result of fertility treatment?

31. What is the LMP?

32. Has there been any vaginal bleeding during pregnancy?

33. Was any medication taken during this pregnancy?

34. Has the woman ever smoked?

35. What is the CO reading at booking (ppm)?

Not taken

36. Does anyone else in the household smoke?

37. How many units of alcohol per week are consumed now?

None

38. Did the woman use any substance before pregnancy?

39. What is the woman's height?

Not performed

40. What was the woman's weight?

Not weighed

41. BMI

42. Was an abnormality detected at the anomaly scan?

43. At Booking are there any known risk factors for fetal growth restriction, or stillbirth?

44. What is the FGR risk status at booking?

45. At booking are there any known risk factors for pre-term birth?

46. Has an Aspirin Risk Assessment been completed at booking?

47. Has Vitamin D been recommended?

48. Maternal sepsis in labor (Confirmed/Suspected)?

49.Induction of labor?

50. Date and time of rupture of membranes

51. Color of liquor

52. Smell of liquor

53. Slow progress?

54. Epidural?

55. Oxytocin augmentation?

56. IVF Details

57. Maternal fever in labor?

58. Gynaecological history ?

59. Any other maternal condition?

60. Maternal medications in labor

Placental Variables

1. APLA Syndrome/Placental Pathology?

2. Previous/Current Pre-eclampsia?

3. Placental Abnormality

Fetal Variables

1. Current IUGR?

2. Abnormal Dopplers?

3. Multiple Pregnancy?

4. Presentation

5. Birth Weight (grams)

6. Baby's Sex

7. APGAR Scores

8. Oligohydramnios?

9. Mode of delivery

10. Cord around neck?

11. Placental abruption?

12. Time and date of birth

13. Baby cried at birth?

14. Neonatal resuscitation required?

15. Suspected neonatal congenital malformations?

16. Neonatal ICU admission?

17. Any other birth related findings

Cord Blood Analysis

Arterial

Base Excess

Lactate

Fetal Hb

pO2

pCO2

HCO3

Venous

Base Excess

Lactate

Fetal Hb

pO2

pCO2

HCO3

WebPlotDigitizer - File Upload

Select first FHR and then UC and MP files for proper analysis.

Attach Files (only images)

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Final CTG Data

Final merged CTG data file from FHR and UC analysis.

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Hospital Information

Hospital

Medical Assessment

Maternal Variables

Placental Variables

Fetal Variables

Cord Blood Analysis

Arterial

Venous

WebPlotDigitizer - File Upload

Final CTG Data

Hospital Information

Select Hospital

Add New Hospital

Select Race / Ethnicity

Pregnancy Loss Details

Select Respiratory Problems

Select Inherited Disorder(s)

Select Cardiac Problem(s)

Select Hypertension Option

Select Haematological Problem(s)

Select Thromboembolic Disorder(s)

Select Hepatic Problem(s)

Select Gastrointestinal Problem(s)

Select Endocrine Problem(s)

Select Neurological Problem(s)

Select Autoimmune Disease(s)

Select Infection(s)

Select Fertility Treatment

Select LMP Option

Select Bleeding During Pregnancy

Select Medication(s)

Select Substance(s)

Select Abnormality Detected

Select FGR Risk Factors

Select Pre-term Birth Risk Factors

APGAR Scores

Previous Pregnancies Details

Induction of Labor Details

Oxytocin Augmentation

IVF Details

Neonatal Resuscitation

Congenital Malformations

Neonatal ICU Admission

Multiple Pregnancy Details

Specify Details