Antenatal Booking Referral Form

ANTENATAL BOOKING REFERRAL FORM PLEASE EMAIL TO: [email protected]

This information is confidential and will only be shared with other professionals in discussion with you

Surname: Date of Birth: Forename: GP Name: PCT code: Address: GP Address & Postcode:

GP Telephone No: Telephone Number: NHS No: Home: Mobile: Hospital Number: Work (optional): Previous Name: Partners Name: Date of Birth: Previous Address: Address:

Postcode: Telephone Number: Smoker Yes ☐ No ☐ How many per day: Smoker Yes ☐ No ☐ How many per day:

LMP: Menstrual Cycle: EDD: Regular / Irregular Folic Acid Taken: Yes ☐ No ☐

Height: Weight: BMI:

Obstetric History (parity, previous deliveries) Gender of last baby: M ☐ F ☐ Weight:______

Gestation:______

Place of Birth:______

RISK INDICATORS FOR SAFEGUARDING CHILDREN (CONSIDER LIFE EVENTS AND SIGNIFICANT EPISODES THIS WOMAN MAY HAVE HAD PRIOR TO PREGNANCY WHICH MAY IMPACT ON THE ABILITY TO PARENT)

Drug/alcohol misuse YES ☐ NO ☐ Mental health problems YES ☐ NO ☐ Previous or current contact with Social Care YES ☐ NO ☐ Any children subject to a child protection plan now or in the past? YES ☐ NO ☐ 1 Are previous children living with mother YES ☐ NO ☐ If any concerns, have they been discussed with woman YES ☐ NO ☐ Referral to social care department YES ☐ NO ☐ Information sharing form required YES ☐ NO ☐ Other Agency referral YES ☐ NO ☐ Other agency known to be involved YES ☐ NO ☐ (please specify if yes)

Ethnic origin: ${Ethnicity} Learning difficulties YES ☐ NO ☐ English first language YES ☐ NO ☐ Is interpreter required YES ☐ NO ☐

ARE ANY OF THE FOLLOWING PRESENT? Please tick as appropriate

Maternal request for initial 40 years or over at booking Booking BP diastolic > 90mm/Hg consultation systolic > 140 mm/hg or any known hypertensive disorder. Women who are particularly BMI > 35 or < 18 Women with current or past vulnerable (see risk factors history of mental illness previous page). Any other existing or previous medical problems which may complicate pregnancy e.g. diabetes thromboembolic disorders epilepsy. Please refer to booking guideline. Specify below:

PREVIOUS OPERATIONS THAT MAY COMPLICATE PREGNANCY

Cone biopsy (under GA) Pelvic floor repair Other

Surgery for urinary or faecal Hysterectomy incontinence

OBSTETRIC HISTORY

Previous 3rd or 4th degree Pre-term delivery < 37 weeks Low birth weight <2.5Kg perineal laceration High birth weight > 4.5Kg Grand multiparity> 6 pregnancies LSCS Previous HELPP syndrome Eclampsia or severe pre Previous IUGR eclampsia Previous foetal abnormality 3 or more consecutive Red cell antibodies miscarriages Previous stillbirth, neonatal Puerperal psychosis Previous APH causing death or late miscarriage maternal/foetal compromise PPH > 1 litre or requiring blood transfusion

It is advised that these women have an Obstetric review in antenatal clinic to plan appropriate care pathways

Please indicate most appropriate location for booking appointment LISTER ☐ QEII ☐ Hertford County ☐

Please indicate if Consultant appointment required Y ☐ N ☐ Planned place of birth: CLU ☐ MLU ☐ HOME ☐

MIDWIVES BOOKING ASSESSMENT

Assessment completed by ______Named Midwife______

Midwifery Team______2 Discussion of Choices

Shared GP/Midwifery Care Consultant Care Dating Scan

Combined Screening Anomaly Scan Appointment with AN screening co-ordinator Appointment with Consultant Previous Consultant if known: Midwife

HOSPITAL USE ONLY:

APPOINTMENT: Consultant:☐ Midwives booking: ☐

Date: Time: Location: