Alberta Prenatal Record (Page 1)

Last name First name Middle initial Marital status

Maiden name DOB Age

Affix label here

YYYY/MM/DD
Address/Reserve name Phone (H) (W)

Postal Code Emergency contact Emergency number

Occupation Ethnicity Language spoken

Ethnicity baby’s father Partner’s name Partner’s occupation

Referring care provider Prenatal care provider Consultant Baby physician (in hospital) Baby physician (in community) Intended place of birth

Date Children
Site of Birth/Abortion Gest. Hrs in Delivery type Complications
yyyy/mm/dd age labour Sex Birth weight Present health
Indicate lbs/kgs
Obstetrical History

Family History Allergies  No  Yes Substance Use None Before During Quit
No Yes if yes, specify agent and reaction Preg Preg Date
  Diabetes Tobacco
  Heart disease # cigarettes / day
  Hypertension
  Malformation / birth defects Medications No Yes Nicotine replacement
  Mental illness / depression
  Multifetal gestation Folic acid at conception   Alcohol
Prenatal vitamins   # drinking days / wk
  Other (include obstetrical, anaesthetic)
List prescription, OTC, herbals
Max # drinks/drinking day

Hereditary / Ethnic Risk (refer to page 3) Rec drugs/solvents

# days / wk
Specify type:

Environmental / Occupational Topics Discussed

(second hand smoke, pets, toxins, daycare worker, etc)
Medical History
No Yes  Nutrition / calcium
  Asthma  Food quality / safety
  Autoimmune  Prenatal classes
  Bleeding / clotting disorder / DVT Social / Cultural (financial, support systems,  Breastfeeding
  Heart beliefs, relationship stability, domestic violence, etc)
  Hypertension  Routine tests / HIV screening (option to decline)
  Diabetes  Genetic screening
  Thyroid  Physical activity, rest & sleep
  GI disorder Preterm labour
  Epilepsy Physical Examination BP 
  Renal / urinary tract Wt Pre-Preg Ht BMI  Maternity leave
  Hepatitis / liver disease  Seat belt use
 Kg  Lbs  cm  ft/in
  HIV / AIDS  Pain relief in labour
  STI General nutritional status
 On call provider
  Tuberculosis
 Labour stages
  Chicken pox or vaccine Head & neck (teeth & gums)
  Mental illness / depression  Other (VBAC, Inductions, etc)
  Assisted conception Breasts / nipples
 Ovulation induction
 Invitro fertilization Comments / Referral
Heart
 Intracytoplasmic sperm injection
 Other, specify
Chest

  Anaesthetic problems Abdomen

  Transfusions
  Operations Spine / extremities
  Other, specify
Pelvic exam / uterine size _________________ weeks
Provider signature Date

HS0001-125 (Rev. 2009/09) Page 1

 Alberta Prenatal Record (Page 2) Affix label here
Gravida Term Preterm Number of abortions (by type) # of living Stillbirths Neonatal
Spon. Induced Ectopic children deaths

LMP Sure of dates Cycle EDB by LMP EDB confirmed by U/S Last name of mother First name Middle initial
 Yes  Regular
yyyy mm dd  No  Irregular yyyy mm dd yyyy mm dd

Investigations
Date Date Date
Test Result (yyyy/mm/dd) Test Result (yyyy/mm/dd) Test Result (yyyy/mm/dd)
Pap smear ABO/Rh HIV
Chlamydia & Blood Syphilis
gonorrhea screen antibodies serology
Urinalysis HBsAG Syphilis serology
2nd screen
Gestational
Urine C&S Rubella
diabetic screen mmol/L

Hemoglobin Varicella Group B

strep
Hemoglobin

Other investigations (laboratory, ultrasound) identify date, investigation and results

Prenatal genetic investigations Counseled Declined Rh-IG Counseled Influenza vaccine

1 Test Result YYYY/MM/DD Rh IG Ist dose: YYYY/MM/DD  Yes  No
2 YYYY/MM/DD Rh IG 2nd dose: YYYY/MM/DD (yyyy/mm/dd)
Date Weight Urine Gest. Fundus F.H. F.M. Cigs/ Next
(protein/ BP age Pres. Comments Init.
(yyyy/mm/dd) lbs glucose) (cms) rate 20 wks+ day Visit
kg wks/days

Fetal movement discussed Comments / Action plan

 Count chart given: Date _________________

Postpartum / Newborn Topics Newborn requires

Hepatitis B Prophylaxis
 Breastfeeding  Yes  No  Maybe
 Vitamin D supplement No Yes
 Back to sleep / SIDS prevention
 Postpartum depression
 Birth control
 Follow-up mother/baby Provider signature Date
 Other (circumcision)

HS0001-125 (Rev. 2009/09) Page 2

 Alberta Prenatal Record (Page 3)
The Alberta Prenatal Record guides the practitioner in obtaining Pregnancy Risk Profile for Specific Outcomes
the woman’s medical, obstetrical, and family history. It is a record This risk profile summarizes the likelihood of specific adverse
of the care provided. Refer to the Alberta Prenatal Care work sheet
on page 4. pregnancy outcomes (preterm, preterm SGA, SGA and LGA) in the
presence of risk factors. The numbers are evidence-based odds
The Healthy Mother, Healthy Baby Questionnaire Form HS0285 ratios, representing the likelihood of occurrence of the adverse
can be used to obtain additional information on lifestyle and social pregnancy outcomes in the presence of the specific risk factors.
history. Circle all that apply. Preterm Term Term
At 36 weeks of gestation the Alberta Prenatal Record should be Risk Factor Preterm SGA SGA LGA
given to the woman to carry with her or a copy sent to the intended
site for delivery. > 4000g
Demographic / Social
Hereditary/Ethnic Risk Assessment*
Aboriginal 3
Offer genetic counseling and/or carrier screening to biological Black 3
parents with a relevant personal or family history of the Single 2 2
following conditions, or to members of an at risk ethnic group.* Nulliparity 2 2
Multiparity (> G3) 3
Is there any blood relationship between the biological parents
No  Yes  Height < 152cm 3 2
Pre-pregnancy Wt <50kg 2
A. Is there a personal or family history (either side of the baby’s 2
Pre-pregnancy Wt >80kg
family) of the following:
Age >35 13 2 2
Thalassemia No  Yes  Cigarettes 2 2 2
Tay Sachs disease No  Yes  Substance Use 3 2
Sickle cell anemia or trait No  Yes 
Cystic fibrosis No  Yes  Pre-existing Illness
Hemophilia/bleeding disorder No  Yes 
Intellectual disability/developmental delay No  Yes 
Diabetes 4 2
Neuromuscular disease or muscular dystrophy No  Yes 
Fragile X syndrome No  Yes  Hypertension 2 2 2
Major birth defect (e.g. spina bifida, cleft lip/palate) No  Yes  Chronic renal disease 4 5
Metabolic disorder (e.g. PKU) No  Yes  Endocrine disorder 3
Other inherited disease or chromosome abnormality, No  Yes 
specify: Medical disorder 3 4
Cervical conization / surgery 7

B. Offer genetic counseling / carrier screening for ethnic risk or Obstetrical History
positive family history:
Previous SGA 2 12 8
Ethnic Group Carrier screening Previous preterm birth 4 2
Asian, African, Middle Eastern Thalassemia, hemoglobinopathy
Mediterranean, Hispanic (e.g. sickle cell) Prior > 3 abortions 2 2

Ashkenazi Jew Tay-Sachs disease, Canavan Current Pregnancy

Disease, familial dysautonomia Multifetal gestation 20 47
French Canadian, Acadian, Cajun Tay-Sachs disease Poly / oligohydramnios 4 13 3
Blood antibodies 4
* For additional information, contact Medical Genetics at: Acute medical disorder 4 5
Calgary Ph: 403-955-7373 or Edmonton Ph: 780-407-7333 PIH 2 6
Resource: Society of Obstetricians and Gynecologists of Canada PIH / proteinuria / HELLP 5 3 2
(SOGC) guidelines. www.sogc.org/guidelines Placenta abruptio 5 5
Placenta previa 10 12
Definitions and Abbreviations:
Vaginal bleeding >20 wks 5
Expected Date of Birth (EDB) - Calculated by date of LMP and
PPROM 80 69
confirmed by early ultrasound
Prenatal visits < 4 4
Small for Gestational Age (SGA) - birth weight of less than 10th percentile
Large for Gestational Age (LGA) - birth weight greater than 90th percentile Wt gain <0.5 kg per wk 3
PIH - Pregnancy Induced Hypertension (gestational hypertension) Gestational age > 41 wks 4
PPROM - Preterm Prelabour Rupture Of Membranes Net wt gain > 15 kg 3
HELLP - Hemolysis, Elevated Liver enzyme levels and a Low Risk Factor Preterm Preterm Term Term
Platelet count Circle outcome risk SGA SGA LGA
Page 3
 Prenatal Care Worksheet
This prenatal worksheet outlines the examinations, investigations and counseling the physician or midwife should consider in providing prenatal care.
Significant effort has been made to ensure the accuracy of information presented. This worksheet should not be considered a substitute for clinical judgement and clinical advice.
TIMING HISTORY & PHYSICAL INVESTIGATIONS TO CONSIDER COUNSELING
First prenatal visit  Complete history & physical, including preconception:  CBC Review (HMHB-Q) with mother and/or identify concerns
Wt, Ht, and BMI.  ABO/Rh & antibodies through interview
6 - 10 weeks
 Obtain environmental/occupational, social/cultural and  Rubella & varicella titre  Nutrition (including folic acid supplementation)
substance use history by interview or have mother complete  Hepatitis B antigen  Nausea & vomiting
Healthy Mother, Healthy Baby Questionnaire  HIV serology  Food quality / safety
(HMHB) HS0285.  Pap smear  Exercise / sleep
 Assess current medical status  Chlamydia & gonorrhea screen  Work / environmental concerns
 Smoking
 Determine hereditary / ethnic risk - page 3  Urinalysis & urine C&S
 Alcohol and drug use
 Review current medications / herbal / OTC  Genetic screening - schedule 1st
 Screening for infections in pregnancy
 Complete risk profile - page 3 trimester aneuploidy screen
 Genetic screening options
 Assign EDB (expected date of birth)  Carrier screening  Seatbelt use
 Complete Prenatal Testing - Initial Screen for Pregnant  Glucose testing  Domestic violence / relationship stability
Woman Lab Requisition  TSH Refer to SOGC - Intimate Partner Violence
 Schedule dating ultrasound consensus statement (2005) for screening questions.
 Viral serology (e.g. toxoplasmosis)  Prenatal classes
 Sexuality
 Breastfeeding
At each visit  Inquire as to general well-being  Urine for glucose  Counsel for common symptoms at this
(Schedule visits every 4  Assign gestational age  Urine for protein gestation
weeks up to 28-30 weeks,  Weight  Blood antibody titres every 4  Review results of investigations
every 2 weeks up to 36  Blood pressure weeks if Rh sensitized
weeks and then weekly after  Symphysis - fundal height in cm
36 weeks until birth or more  Fetal heart sounds
frequently if indicated)  Presence of fetal movements
11-14 Weeks  Discuss results of genetic screening  Genetic screening (1st trimester)  2nd trimester genetic screening
 Arrange for diagnostic investigations  Diagnostic genetic testing (CVS)  Diagnostic genetic testing aminocentesis
16-20 Weeks  Genetic screening (2nd trimester)
 Amniocentesis
18-20 Weeks  Ultrasound anatomical & fetal growth  Confirm EDB for entire pregnancy
24-28 Weeks  Commence fetal movement counts  Hemoglobin  Discuss importance of fetal movement awareness and
 Provide copy of Fetal Movement Chart Form HS0001-132  Diabetic screening maternal response to a decrease in fetal movement
 Complete Prenatal - Testing Universal Syphilis  Syphilis rescreening  Signs & symptoms of preterm labour
Rescreening Lab Requisition  HIV screening / rescreening  Obtain VBAC consultation / documentation
 ABO/Rh & antibodies (if Rh negative)  Offer HIV screening / rescreening
28-32 Weeks  Add fetal presentation to routine visit  Give Rh immune globulin (if Rh neg)  Importance of fetal movement awareness
30-36 Weeks  Importance of fetal movement awareness
 Labour & birth concerns
 Hospital admission procedures
 Newborn issues and testing
 Breastfeeding
 Postpartum planning
35-36 Weeks  Confirm presentation of fetus  GBS culture  Ensure record available to L&D unit
41-42 Weeks  Pelvic examination  Fetal assessment / NST Biophysical profile  Importance of fetal movement awareness
 Syphilis & HIV screening / re-screening  Induction plans
Birth & Postpartum  Pelvic examination  Give Rh immune globulin (if Rh neg)  Labour & birth concerns
Postpartum (6 weeks)  Breastfeeding evaluation  Pap smear  Sexuality & Contraception
 Assess for postpartum depression  Hemoglobin  Review immune status
 Arrange for newborn follow-up  Coping strategies
 Risk for postpartum depression
 Newborn well-being / follow-up
Page 4