The virtual birthing unit project/Resource pack/Woman's pregnancy notes

Personal details
NHI: ABC1234

Surname or family name: Jones

First name(s): Lisa

Previous surname: Smith

Address: 6 Linley Drive, Littleton, 8012

Phone: 023 876543

Work: 03 123456 Date of birth: 13/6/1982

Occupation: Manager – The Storehouse

Partner: Jack Smith

Woman’s residence: City

Woman referred by: Self

Community services card: No

Woman’s ethnic group: NZ Pakeha

Religious beliefs: Catholic

Next of kin: Jack Smith (husband)

Same address

GP: Dr Bill Conway

Diet: normal

Smoking: Gave up 4 years ago

Marijuana: No

Other substances: No

Obstetric history summary
Gravida: 2 Parity: 0 Number of spontaneous abortions: 1 at 8/52

Number of elective abortions: 0 LMP: (Make up your own dates) Sure about dates

EDD: (Make up your own dates) Menstrual cycle Regular every 30 days

Length: 5 days

Oral contraceptives: No

Last cervical smear: 1 year ago

On National Register: Yes

Past pregnancies: NA

Maternal medical and surgical history
Height: 163 cm Pre pregnancy weight: 68 kg

Previous uterine surgery(excl. cesarean): no Previous infertility: no

History of depression/psychosis: Got a little sad when she had her miscarriage but needed no treatment

Essential hypertension: no Diabetes: no

Pulmonary disease/asthma: no Heart disease: had a heart murmur at birth which came right after a few days

STD: no, but gets thrush sometimes

Thyroid disease: no

Neurological disorder (epilepsy etc): no Drug/or alcohol abuse: no

Breast surgery: had a small breast abscess when 15 years old but treated with antibiotics

Musculoskeletal disorder: no

Renal/urinary disorder:gets UTIs occasionally-last one 3 years ago

Allergies: gets hayfever for a couple of months in the summer

HIV risk: low MRSA risk: low

Medication supplements: nil Blood transfusion: no

Maternal family history
Diabetes: grandmother has late-onset Hypertension: mother has just been diagnosed & started on meds

Intellectual disability: second cousin had downs syndrome but died when she was 10 years old Congenital abnormalities: Brother had congenital dislocated hips & was in plaster for a few months when he was little -OK now

Paternal family history
Cousin had cleft lip

Birth plan
Place of birth: Birth unit

Early labour: Would like to stay at home as long as possible but at the same time, would like to be at the birth unit when things get going because I would hate to be stuck at home alone when giving birth

Monitoring in labour: I don’t want to be tied to my bed and stuck on a machine but I want baby to be safe & for midwife to keep a close eye on baby’s health

Positions for labour and birth: I want to be free to do what I find most comfortable. I want the midwife to suggest things to me if I am not sure what to do

Birth environment: Warm and cosy. I want Jack to feel welcome and comfortable

Pain management: I don’t want any medication if possible. Would like to try labouring in warm water. I don’t plan to give birth in water but would like to wait and see how I feel at the time

Third stage: No medication unless midwife feels it is necessary

Plans for placenta: Take home to bury in garden

Immediate care of baby: Please wipe off all the ‘gunk’. Would like to breastfeed as soon as possible after the baby has been born. Please can Jack cut the cord

Vitamin K: Not sure at this stage

Guthries test: Yes

Immunization: Worried about baby catching swine flu

Contraception: Condom

Ante natal record
Click on this link to see the woman's pregnancy notes.

Laboratory results
Booking:

HB 152 g/dL, Ferritin 66 ng/mL, Blood Group O+, Antibodies neg, HBsAG neg, VDRL neg, Rubella neg, Glucose not done, MSU neg, Cx Smear not required, vaginal swabs - not done

28 weeks:

HB 123 g/dL, Ferritin 42 ng/mL, Antibodies neg

36 weeks:

HB 120 g/dL, Ferritin 33 ng/mL, Antibodies neg, MSU neg, Strep B. neg

Scan results
12 weeks: NT: risk: 1:1099 No follow up

20 weeks: Singleton pregnancy, posterior placenta, anatomy appears normal, normal liquor volume, EDD agrees with dates. No follow up.