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 Midwife Family Practice Gravidity on admission: Parity on admission: Maternal Fetal Medicine Obstetrics Physician Height at admission: Weight at admission: Pre-pregnancy weight: IN LBS LBS CM KG KG Did patient receive prenatal care? Date prenatal care started: Transfer of care from an intended home birth? 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 placenta – 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 rupture of membranes 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 Page 2 of 8 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 Cervical dilation 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 Page 3 of 8 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 doula 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 position? 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 Gestational age 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: Page 4 of 8 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