OBI DATA ABSTRACTION FORMS DEMOGRAPHICS

Last Name: First Name:

Patient MRN: Maternal Birthdate: Ethnicity: Hispanic or Latino

/ / Not Hispanic or Latino Race (select all that apply): Postal Zip Code: American Indian or Alaskan Native

Asian Patient's Insurance Type: Black Medicaid Self Pay/None Native Hawaiian or Other Pacific Islander Private Other White

ADMISSION

Admission Date: Admission Time: Provider admitting patient to Labor & Delivery: / / Service/Practice patient admitted to: Admitting nurse: Certified Nurse Family Practice Gravidity on admission: Parity on admission: Maternal Fetal Medicine Obstetrics Physician Height at admission: Weight at admission: Pre- weight: IN LBS LBS CM KG KG Did patient receive ? Date prenatal care started: Transfer of care from an intended ? Yes No Unable to determine / / Yes No

MATERNAL COMORBIDITIES PRESENT ON ADMISSION

Pre-pregnancy diabetes (Type I or Type II Yes Was the patient using opioids during this Yes diabetes diagnosed prior to this pregnancy) No pregnancy? No

Gestational diabetes (diagnosis in this Yes What was the status of the patient's opioid use during this pregnancy with or without medication tx) No pregnancy? Select all that apply: Yes In treatment for opioid use disorder during pregnancy Pre-pregnancy hypertension (chronic) No Ongoing opioid/heroin use disorder (without current tx)

Gestational hypertension (PIH, preeclampsia, Yes Opioid use for acute pain eclampsia, HELLP syndrome) No Opioid use for chronic pain

Alcohol Use During Pregnancy? Yes Unknown No Tobacco Use Before or During Pregnancy? Yes Did the patient receive Medication Assisted Therapy (MAT) No for Opioid use disorder during this pregnancy? If yes, did Mother quit Yes, before pregnancy Yes, MAT with Buprenorphine smoking? Yes, during pregnancy Yes, MAT with Methadone No, did not stop Yes, MAT with Naltrexone Unable to Determine No MAT Previous diagnosis of asthma? Yes Unknown No PLANNED MODE OF DELIVERY

Planned mode of delivery at time of admission: Planned labor for vaginal delivery Planned cesarean delivery What was the primary indication for the planned cesarean delivery?

Abdominal cerclage Maternal Request Abnormalities of the – e.g. accreta, previa Malpresentation (any noncephalic presentation) Active HSV Prior uterine surgery (myomectomy) Fetal Conditions, Specify: ______Maternal Conditions, Other Specify: ______HIV with viral load >1000 Other, Specify:______

ADMISSION WITH LABOR FOR PLANNED VAGINAL BIRTH

Labor status at admission: Induction, membranes intact Spontaneous onset of labor, membranes intact Induction, pre-labor Spontaneous onset of labor, membranes ruptured

Select the primary indication for induction: If additional indications for induction, enter up to three:

Cholestasis of pregnancy Cholestasis of pregnancy Chorioamnionitis Chorioamnionitis Diabetes Diabetes Elective (39+0+40+6 weeks, no medical indication) Elective (39+0+40+6 weeks, no medical indication) Fetal anomalies Fetal anomalies Fetal demise Fetal demise Fetal growth restriction Fetal growth restriction Fetal macrosomia Fetal macrosomia Fetal indication, other- Specify: ______Fetal indication, other -Specify: ______Hypertensive disorder of pregnancy (preeclampsia, Hypertensive disorder of pregnancy (preeclampsia, gestational hypertension) gestational hypertension) Isoimmunization Isoimmunization Non reassuring fetal testing, decreased fetal movement, Non-reassuring fetal testing, decreased fetal, non- non-reassuring fetal heart tones reassuring fetal heart tones Obesity Obesity Oligohydramnios Oligohydramnios Placental abruption Placental abruption Postdate (greater than or equal to 41 weeks) Postdate (greater than or equal to 41 weeks) PROM PROM Maternal indication, other- Specify: ______Maternal indication, other- Specify: ______None

Were cervical ripening methods undertaken prior to If yes, select all methods that were used prior to admission: admission (i.e Outpatient)? Transcervical catheter Yes Prostaglandin agent No

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Ripening/induction intervention during admission, select method(s) used:

Amniotomy alone Transcervical catheter with misoprostol Membrane stripping alone Cervidil alone Transcervical catheter Pitocin Pitocin alone Misoprostol alone Transcervical catheter alone Unable to determine within the 72 hours prior to admission, were there any How many visits in Hours between discharge of last triage unscheduled triage/ED not leading to an admission? those 72 hours? visit and delivery admission? Yes No

Cervical exam at time of admission? Yes at admission: No ______. ______cm

If cervical dilation less than 4, what was the reason for early admission for spontaneous labor? Select all that apply: Abnormal FHTs No Prenatal or Late Prenatal Care Difficulty with coping/pain management Shared decision making pt. request for admission Distance from home is too far Transportation challenges Hypertension Time to provide GBS preventative therapy Maternal Fatigue Other, Specify: ______Membranes Ruptured

Cervical effacement at admission: % Fetal station at admission: Group B Strep status during this pregnancy: Fetal monitoring type at admission, select all that apply: Positive Continuous Electronic Fetal Monitoring (CEFM) Negative Intermittent Auscultation (IA) Not documented Not documented Rupture of membranes: Rupture of Membranes Date and time: Cervical dilation at rupture of membranes: Amniotomy / / ______. ______cm Spontaneous (any time during labor)

Unable to determine Unknown

Was Pitocin used at any time prior to Date and time when Pitocin started: Cervical dilation when Pitcoin started: delivery? ______. ______cm Yes / / No

Fetal monitoring type for Active Labor (≥ 6cm) , select all Nurse supporting active labor (≥ 6cm): that apply:

Continuous Electronic Fetal Monitoring (CEFM) Intermittent Auscultation (IA) Not documented Provider supporting active labor (≥ 6cm):

Dx of Clinical Chorioamnionitis? Yes No

Attempted forceps delivery? Yes If yes, was forceps attempt successful? Successful No Unsuccessful

Attempted vacuum delivery? Yes If yes, was vacuum attempt successful? Successful No Unsuccessful

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PAIN, DISCOMFORT, AND COPING DURING LABOR

Method(s) to assess pain/discomfort/ Non-pharmacologic pain management Select Pharmacologic pain management coping during labor? all that apply: Select all that apply: Select all that apply: Aroma Therapy Comfort/Coping scale Birthing balls / peanut balls IV narcotics Pain scale (faces, numeric, etc.) Massage Nitrous oxide Other, specify: Tens Unit Oral narcotics ______Walking Pudendal block None Water / Shower / Tub Other, specify: ______Other, specify: ______None None

Did the patient have regional anesthetic? Yes If yes, type: Epidural No Combined spinal/epidural Unable to determine

Was there a patient controlled administration of additional When in labor was the epidural placed? boluses? 1st stage < 6cm 2nd stage Yes No Unable to determine 1st stage ≥ 6cm Unable to determine

LABOR SUPPORT

Shared Decision Making methods reviewed upon admission or during labor, select all that apply:

Document or tool scanned into chart (e.g. Birth plan, Preferred plans documented by nursing labor partnership) Not documented/Unable to determine CNM/Physician statement in H&P or admission note Was a present? Was a support person (family, friend, partner) present? Yes No/Not documented Yes No/Not documented

DELIVERY

Date/Time cervix completely dilated: Date/Time pushing started:

Provider attending birth: Which service/practice delivered this patient? Certified Nurse Midwife Nurse attending birth: Maternal Fetal Medicine Family Practice / Family Medicine Mode of delivery: Obstetrics Physicians Spontaneous (unassisted) vaginal Delivery from an OP (occiput posterior) Yes Forceps vaginal ? No Vacuum vaginal Episiotomy was performed? Yes Cesarean during labor No Planned cesarean delivery admitted in labor or after spontaneous rupture of membranes 3rd Degree Laceration? Yes Planned cesarean section without labor No 4th Degree Laceration? Yes No at delivery (weeks/days): Infant Date/Time of birth: Birth weight in grams: / /

Count of Registered Nurses from time of admission to time Count of OB providers from time of admission to time of of delivery: delivery:

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CESAREAN DELIVERY Cervical Dilation, exam closest to Cesarean Delivery: Cervical Exam closest to Cesarean Delivery Date/Time: / / Primary indication for Cesarean Delivery: *If arrest of dilation <6cm: Failed induction of labor (< 6cm)* Were moderate or strong contractions palpated for > 12 hours without cervical change? Arrest of dilation < 6cm* Yes No UTD Arrest of dilation ≥ 6cm** Arrest of descent*** Was an intrauterine pressure catheter (IUPC) used? Arrest of descent due to persistent OP or deep Yes No UTD transverse*** Abnormal of indeterminate fetal heart rate tracing (Fetal Was there documentation of ≥ 200 Montevideo units (MVU) intolerance of labor, or non-reassuring fetal heart for ≥ 12 hours? tracings) Yes No UTD Malpresentation (any noncephalic presentation) **If arrest of dilation≥ 6cm Macrosomia – Suspected based on ultrasound or clinical Adequate uterine contractions (e.g moderate or strong to estimate palpation for ≥ 4 hours) without improvement in dilation, Preeclampsia – includes preeclampsia, eclampsia, and effacement, station or position? hemolysis, elevated liver enzymes, and low platelet syndrome (HELLP) Yes No UTD Maternal Request Were there inadequate uterine contractions (e.g. <200 MVU) Maternal Conditions-Other, specify: ______for ≥ 6 hours of oxytocin administration without improvement in dilation, effacement, station or position? Fetal Conditions, Specify: ______Yes No UTD Abnormalities of the placenta (e.g. placental abruption, accreta, previa) Was an intrauterine pressure catheter (IUPC) used? Cord prolapse Yes No UTD Failed Assisted Delivery HIV with viral load > 1000 ***If Arrest of descent Active HSV Prior uterine surgery (myomectomy) Date and Time of Dx of Second Stage Arrest:

Abdominal cerclage / / Other, Specify: ______

Additional indications for cesarean delivery:

Failed induction of labor (< 6cm) Maternal Request Arrest of dilation < 6cm* Maternal Conditions, Other: Specify:______Arrest of dilation ≥ 6cm** Fetal Conditions, Specify: ______Arrest of descent*** Abnormalities of the placenta (e.g. placental abruption, accreta, previa) Arrest of descent due to persistent OP or deep transverse Cord prolapse Abnormal of indeterminate fetal heart rate tracing (Fetal Failed Assisted Delivery intolerance of labor, or non-reassuring fetal heart tracings) HIV with viral load > 1000 Malpresentation (any noncephalic presentation) Active HSV Macrosomia – Suspected based on US or clinical Prior uterine surgery (myomectomy) eestimate Abdominal cerclage Preeclampsia – includes preeclampsia, eclampsia, and Other, Specify: ______hemolysis, elevated liver enzymes, and low platelet syndrome (HELLP) None

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Were prophylactic IV antibiotics given before or during the cesarean delivery? Yes No

If yes, were the prophylactic antibiotics given before incision? Yes No Unable to Determine

Select all prophylactic antibiotic(s) given before or during the cesarean delivery:

Ampicillin Clindamycin Piperacillin/Tazobactam Azithromycin Gentamicin Vancomycin Cefazolin Metronidazole Other, Specify:______

DISCHARGE

Maternal Discharge Date/Time: / / Maternal transfer to Yes another hospital? No

Was the patient discharged with an opioid prescription? Yes No Not documented

Type of Opioid Prescribed:

Buprenorphine patch Fentanyl buccal or SL Levorphanol tartrate Oxycodone PO Buprenorphine tab/film Fentanyl film/oral spray Meperidine Oxymorphone Butorphanol Fentanyl nasal spray Methadone Pentazocine Codeine Fentanyl patch Morphine Tapentadol Dihydrocodeine Hydrocodone Nalbuphine Tramadol Hydromorphone PO Other, specify:______

Opioid dose prescribed: Opioid dose prescribed unit: Quantity prescribed:

mg mg/ml mL Not documented mcg/hr

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NEONATAL OUTCOMES

1-Minute APGAR: 5-Minute APGAR: Arterial cord pH:

Shoulder dystocia? Yes If Yes, documented length of the No shoulder dystocia in minutes:

Assisted ventilation (intubation, CPAP, or nasal cannula) required immediately following delivery? Yes No Select type of Assisted Intubation Was assisted ventilation required for Yes Ventilation Required: CPAP more than six hours? No Nasal cannula Antibiotics received by the newborn for suspected neonatal sepsis or other Yes infection? No Did the neonate require a NICU (or other Intensive Care Unit) Admission? Yes No

If yes, indicate primary reason:

Neonatal infection (With Sepsis without sepsis, with Neonatal seizures respiratory distress syndrome, wit Birth asphyxia Congenital Anomaly requiring ICU Care (heart disease, diaphragmatic hernia, etc) Respiratory distress (Transient tachypnea of the newborn, meconium aspiration syndrome) Observation (feeding issues, Meconium stained fluid, Neonatal Jaundice other) IUGR Other, Specify: ______Infant of Diabetic Mother

Did the neonate require a Special Care/ Intermediate Care Nursery Admission? Yes No

Was the neonate transferred to another hospital for a higher level of care? Yes, unexpected Yes, expected for prenatally diagnosed congenital anomaly No Was neonatal hypothermia therapy used? Yes No Our hospital does not provide this intervention Was there a significant neonatal birth injury which required intervention? Yes No If yes, select the injury/injuries requiring intervention:

Skeletal fracture(s), humerus OR clavicle Soft tissue injury Skeletal fracture(s), other than humerus OR clavicle Solid organ injury Hemorrhage, intracranial Intrapartum demise Hemorrhage, not intracranial (includes sub-dural and Neonatal demise sub-galeal bleed) Other. Specify: ______Nerve injury, peripheral brachial plexus injury Nerve injury, peripheral facial nerve Neurologic injury, central

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MATERNAL OUTCOMES

Maternal admission to intensive care unit? Date and Time of ICU admission: / /

Select any Severe Maternal Morbidity (SMM) Procedures that occurred during delivery through the 30-day post delivery period: Date Date

Blood Transfusion / / Temporary Tracheostomy / /

Conversion of Cardiac Rhythm / / Ventilation / /

Hysterectomy / / None of the above / /

Did the patient experience any other procedures NOT reported in Severe Maternal Morbidity? Yes No

If Yes, enter procedure(s) or ICD-10 code(s) and corresponding dates:

Select any Severe Maternal Morbidity (SMM) Complications that occurred during delivery through the 30-day post delivery period: Date Date

Acute myocardial infarction / / Heart failure/arrest during surgery or procedure / /

Acute renal failure / / Pulmonary edema/acute heart failure / /

Adult respiratory distress syndrome / / Puerperal cerebrovascular disorders (stroke) / /

Air and thrombotic embolism / / Sepsis / /

Aneurysm / / Severe anesthesia complications / /

Cardiac arrest/Ventricular fibrillation / / Shock / /

Disseminated intravascular coagulation / / Sickle cell disease with crisis / /

Eclampsia / / None of the above / /

Did the patient experience any other complications NOT reported in Severe Maternal Morbidity (SMM)? Yes No

If Yes, enter the complication(s) Dx or ICD-10 code and corresponding dates:

Was there a readmission within 30 days of discharge date? Yes No

If yes, enter date of readmission and primary indication(s) /ICD-10 code(s):

Was there an ED or Labor and Delivery Triage visit within 30 days of discharge date? Yes No

If yes, enter the date of visit and primary indication (ICD-10 code):

Was there a maternal death within 30 days of delivery? Yes No

If yes, enter date of maternal death:

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