2020 OBI DATA ABSTRACTION FORMS DEMOGRAPHICS

Hospital Name: Patient Last Name: Patient First Name:

Medical Record Number (MRN): Maternal Birthdate (MM/DD/YY): Postal Zip Hispanic Ethnicity: Code: Hispanic or Latino Not Hispanic or Latino Race (select all that apply): Unknown American Indian or Alaskan Native

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

LABOR MANAGEMENT: Admission

L&D Admission Date: L&D Admission Time: Provider admitting patient to Labor & Delivery (Last Name, First Name):

Service/Practice patient admitted to: Admitting Nurse (Last name, First name):

Certified Nurse Family Practice / Family Medicine Gravidity on admission: Parity on admission: Maternal Fetal Medicine Obstetrics Physician Maternal Height at admission: Maternal Weight at admission: Pre- Weight:

IN LBS LBS

CM K G KG Did the patient receive ? If yes, date prenatal care Transfer of care from an intended ? started: Yes No Unable to determine Yes No

LABOR MANAGEMENT: 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 pregnancy Yes What was the status of the patient's opioid use during this with or without medication tx) No pregnancy? (select all that apply): In treatment for opioid use disorder during pregnancy Pre-pregnancy chronic hypertension Yes No Ongoing opioid/heroin use disorder (without current tx) Opioid use for acute pain Gestational hypertension (PIH, preeclampsia, Yes eclampsia, HELLP syndrome) No Opioid use for chronic pain

Previous diagnosis of asthma? Yes Unknown No

Alcohol use during pregnancy? Yes Did the patient receive Medication Assisted Therapy (MAT) No for opioid use disorder during this pregnancy?

Tobacco use before or during pregnancy? Yes No Yes, MAT with Buprenorphine (or Buprenorphine/Naloxone) If yes, did Mother quit smoking? Yes, MAT with Methadone Yes, MAT with Naltrexone Yes, before this pregnancy No MAT Yes, during this pregnancy Unknown No, did not stop smoking Unable to Determine LABOR MANAGEMENT: 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 Conditions, Other Abnormalities of the – e.g. accreta, previa Maternal Request Active HSV Prior uterine surgery (myomectomy) Fetal Conditions, Other HIV with viral load >1000

LABOR MANAGEMENT: 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 Non-reassuring fetal testing, decreased fetal, non- movement, 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 clinic)? Transcervical catheter (Foley balloon, Cook catheter, etc.) Yes Prostaglandin agent No

Page 2 of 9 Select the ripening/induction intervention(s) used any time during admission:

Amniotomy Misoprostol Transcervical catheter with Misoprostol Cervidil Oxytocin Transcervical catheter with Oxytocin Membrane stripping Transcervical catheter 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

Was a cervical exam done at the time Yes at admission: of 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 Time to provide GBS preventative therapy Hypertension Transportation challenges Maternal fatigue Other, Specify: ______Membranes ruptured

Cervical effacement at admission: % Fetal station at admission:

Group B Strep status during this pregnancy: Fetal monitoring type ordered 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 Not documented

Was Oxytocin used at any time prior Date and time Oxytocin started: Cervical dilation when decision to to delivery? initiate Oxytocin: Yes . cm

No

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

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

Dx of Clinical Chorioamnionitis (Triple Yes I) during labor? 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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Method(s) to assess pain/discomfort/ Non-pharmacologic pain management (select Pharmacologic pain management coping during labor (select all that all that apply): (select all that apply): 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 receive regional anesthetic? Yes If yes, type: Epidural No Combined spinal/epidural Unable to determine

Was there an order for patient-controlled epidural When in labor was the epidural placed? analgesia? 1st stage < 6cm 2nd stage Yes No Unable to determine 1st stage ≥ 6cm Unable to determine

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 (Last name, First name): Maternal Fetal Medicine Family Practice / Family Medicine Actual mode of delivery: Obstetrics Physicians Spontaneous (unassisted) vaginal Was the delivery from an OP (Occiput Yes Forceps vaginal Posterior) fetal ? No Vacuum vaginal Was an episiotomy performed? Yes Cesarean during labor No Planned cesarean delivery admitted in labor or after spontaneous rupture of membranes Did the patient Yes experience a 3rd degree Planned cesarean section without labor perineal laceration? No Did the patient Yes experience a 4th degree perineal laceration? No

Page 4 of 9 CESAREAN DELIVERY Cervical Dilation, exam closest to Cesarean Delivery: Cervical Exam closest to Cesarean Delivery Date/Time: ______. ______cm Primary indication for Cesarean Delivery: *If arrest of dilation <6cm: Failed induction of labor (< 6cm) Were moderate or strong contractions present for > 12 hours without cervical change? Latent phase arrest of dilation (< 6cm)* Yes No Unable to determine Active phase arrest of dilation (≥ 6cm)** Arrest of descent – First stage*** Was an intrauterine pressure catheter (IUPC) used? Arrest of descent – Second stage*** Yes No Unable to determine

Abnormal or 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 without cervical change? tracings) Yes No Unable to determine Malpresentation (any noncephalic presentation) **If arrest of dilation ≥ 6cm Macrosomia – Suspected based on ultrasound or clinical estimate Were there adequate uterine contractions (e.g. moderate or strong on palpation for ≥ 4 hours) without improvement in Preeclampsia – includes preeclampsia, eclampsia, and dilation, effacement, station, or position? hemolysis, elevated liver enzymes, and low platelet syndrome (HELLP) Yes No Unable to determine 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 Unable to determine Abnormalities of the placenta (e.g. placental abruption, accreta, previa) Was an intrauterine pressure catheter (IUPC) used? Cord prolapse Yes No Unable to determine Failed assisted delivery HIV with viral load > 1000 ***If Arrest of descent Active HSV Prior uterine surgery (myomectomy) Date and Time of Dx of arrest of descent:

Abdominal cerclage Other, Specify:

Additional indications for cesarean delivery:

Failed induction of labor (< 6cm) Maternal Request Latent phase arrest of dilation (< 6cm)* Maternal Conditions, other, specify: Active phase arrest of dilation (≥ 6cm)** Fetal Conditions, specify: Arrest of descent – first or second stage*** Abnormalities of the placenta (e.g. placental abruption, accreta, previa) Persistent OP or deep transverse position 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 incision for cesarean delivery? Yes No Unable to determine

Select all prophylactic antibiotic(s) given before incision for cesarean delivery:

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

ALL DELIVERIES at Date/Time of infant birth: Birth weight in grams: Estimated blood loss or delivery (weeks/days): quantified blood loss during delivery: _____mL EBL QBL

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

Page 6 of 9 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:

Was there documentation that the neonate required assisted Yes ventilation (intubation, CPAP, or nasal cannula) with 2 hours following delivery? No If yes, select type of Intubation Was assisted ventilation required for Yes Assisted Ventilation CPAP more than six hours? No Required: Nasal cannula Were antibiotics administered to the newborn for suspected neonatal Yes sepsis or other infection during the delivery encounter? No Did the neonate require a NICU (or other Intensive Care Unit) Admission Yes during the delivery encounter? No

If yes, indicate the primary reason:

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

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

Was the neonate transferred to another hospital for a higher level of care during the delivery encounter? 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 that 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

Page 7 of 9 MATERNAL OUTCOMES

Was the mother admitted to an Intensive Care Unit? If yes, date and Time of ICU admission: Yes No

Maternal Discharge Date/Time: Was the patient discharged with an Was the mother transferred to another opioid prescription? hospital? Yes No Yes No

MATERNAL OUTCOMES (During Delivery through 30 Days Postpartum)

Select any procedures that occurred during delivery through the 30-day post delivery period: Date Date

Blood Transfusion / / Removal of retained products of conception with / / suction device Conversion of Cardiac Rhythm / / / /

Drainage of abscess / / Repair of complex vagina trauma / /

Drainage of tube placement / / Repair of dehiscence / /

Evacuation of hematoma / / Temporary Tracheostomy / / Exploratory laparotomy / / Uterine artery embolization / /

Hysterectomy / / Ventilation / /

Manual removal of placenta / / None Select any complications that occurred during delivery through the 30-day post delivery period: Date Date

Acute myocardial infarction / / Pelvic abscess (organ space SSI) / /

Acute kidney injury / acute renal failure / / Postpartum depression and/or Anxiety / /

Adult respiratory distress syndrome / / / Pulmonary edema / / acute respiratory failure Air or thrombotic embolism (includes PE) / / Sepsis / /

Amniotic fluid embolism Septic Pelvic Thrombophlebitis / /

Aortic aneurysm / / Seroma (required intervention) / / Cardiac arrest / Ventricular fibrillation / / Severe anesthesia related complications / /

Disseminated intravascular coagulation / / Shock (e.g. septic, cardiogenic, hypovolemic,etc.) / /

DVT / / Sickle Cell Disease with crisis / /

Eclampsia / / Small bowel obstruction / /

Endometritis / / Stroke (hemorrhagic or thrombotic) / / Heart failure / / Surgical site infection (Superficial or Deep SSI) / /

Hematoma (required intervention) / / Wound Dehiscence of skin, Fascia intact / /

Hypertension (new diagnosis of Wound Dehiscence of Fascia / / gestational hypertension or pre-eclampsia / / made after delivery None of the above Was there a maternal death within 30 days of delivery? Yes; Date: No

Were you able to access postpartum clinic notes to inform this chart review? Yes No

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OPIOIDS

If the patient was discharged with an opioid prescription, what of opioid(s) were prescribed:

Buprenorphine patch Fentanyl buccal or SL tabs Hydromorphone PO Oxycodone PO

Buprenorphine tab/film Fentanyl film/oral spray Levorphanol tartrate Oxymorphone

Butorphanol Fentanyl nasal spray Meperidine Pentazocine

Codeine Fentanyl patch Methadone Tapentadol

Dihydrocodeine Hydrocodone Morphine Tramadol

Nalbuphine Other, specify:

Opioid dose prescribed: Opioid dose unit: Quantity prescribed:

mg mcg/hr mg/mL Not documented mcg/mL

POST DISCHARGE EVENTS

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):

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