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FIRST VISIT ASSESSMENT

Partner details
Obstetric history (add delivery entries)
Date Mode Hospital GA Tear Repair Maternal complications Fetal/neonatal complications PPH Transfusion Anti-D Remove
Medical history (add disorders)
System/organ Disorder Status Disease details Medications Remove
Surgical history
Gynaecological surgeries
Procedure Remove
Non-gynaecological surgeries
Procedure Remove
Baseline vitals
System examination
Additional information

Anatomy map (abnormal = red)

BOOKING / BASELINE LABS

Routine labs
Blood group
Hb (g/dL)
Ferritin
Rubella status
Varicella status
Syphilis
HSV2 antibodies
Hepatitis B
HIV
Viral load
CD4 count
Hb electrophoresis
Hb electrophoresis abnormalities
Asymptomatic bacteriuria screening
Organism
Treated
Proteinuria
Results
Other results
Cervical screening
Cervical screening status
Previous result
Type of abnormality
Plan of follow-up
Plan of follow-up
Specific labs
Risk of pregestational diabetes
HbA1c
Fructosamine
High risk of infection
Gonorrhea
Chlamydia
Bacterial vaginosis
Tuberculosis
Hepatitis C
Baseline labs completed

Reference range

Indications of testing

Comments

FIRST TRIMESTER ULTRASOUND

Biometry / findings (per fetus)
Overall impression
Plan / recommendations
Genetic screening

Mother

Previous children

First degree relatives


Second degree relatives

Aunts
Uncles
Nephews
Nieces

Mother

Previous children

First degree relatives


Second degree relatives

Aunts
Uncles
Nephews
Nieces

Genetic history counselling note

First trimester screening

First trimester risks

1 :
1 :
1 :

Second trimester screening

Second trimester risks

1 :
1 :
1 :

Cell free fetal DNA (cffDNA) results

Final diagnosis

Carrier screen

Chorionic villus sampling (CVS)

Amniocentesis

Final genetic counselling note

Indication of testing

Aneuploidy screening should be offered to all pregnant women. However, possible outcomes should be discussed including the possibility of high risk results that would warrant invasive testing.

Forms

Open consent forms:
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Second trimester ultrasound
General information
Placenta & cord
Amniotic fluid (current fetus)
Biometry (current fetus)
BPD HC AC FL
Fetal sex (current fetus)
Adnexa
Right ovary
Left ovary
Uterus
Cranial (current fetus)
Ventricles
Choroid plexus
Cerebellum
Posterior fossa
CSP
Fetal head and neck (current fetus)
Orbits
Nasal bone
Lips and palate
Neck
Fetal heart (current fetus)
Heart position
Four chambers
LVOT
RVOT
Ductal arch
Aortic arch
Fetal chest (current fetus)
Lungs
Diaphragm
Fetal abdomen (current fetus)
Stomach
Umbilical vessels
Left kidney
Right kidney
Bladder
Spine (current fetus)
Spine
Extremities (current fetus)
Upper extremities
Hands
Lower extremities
Feet
Additional information
FINAL DIAGNOSIS
The printed report will include all fetuses, biometry, amniotic fluid, anatomy, and this final diagnosis summary.
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28-week labs
Routine 28-week labs
g/dL
/µL
Diabetes screening testing
mg/dL
Fasting glucose mg/dL
2-hour glucose mg/dL
Not done.
Fasting glucose mg/dL
1-hour glucose mg/dL
2-hour glucose mg/dL
3-hour glucose mg/dL
Not done.
Additional labs
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Maternal counselling
Trial of vaginal delivery after Caesarean (TOLAC)
VBAC score % Benefit of TOLAC
Screening for group B streptococci (GBS)
GBS result:
Counselling details / additional information
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36-week labs
GBS screening
Date of GBS swab
Penicillin allergy status
GBS result
GBS negative status
Antibiotic susceptibility
Additional tests
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Labor counselling
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Third trimester ultrasound
Fetus 1
Fetus 2
Fetus 3
Fetus 4
Amniotic fluid cm cm
PDF ECV consent form
PDF ECV consent form
IMM
Immunological / Rheumatology Disorders
Diagnosis and Management
Date GA Setting Disease control Acute flare Current symptoms Fetal echo FBC C3 level C4 level Anti-dsDNA Other tests Current management Change in medications Next follow-up
Date GA Setting Disease control Acute flare Current symptoms Fetal echo FBC LFT Other tests Management Change in medications Next follow-up
Follow-up visits
Date GA Setting Disease control Symptoms Investigations Current treatment Change in treatment Recommendations Next follow-up
TORCH
TORCH Infections
Viral infections
Plan of care
Details of diagnosis
Date GA Ultrasound findings
Plan of care
Management
Ultrasound assessment
MRI assessment
Plan of care
Details of diagnosis
Treatment
Plan of care
Details of diagnosis
Date GA Ultrasound findings MCA PSV
Plan of care
Details of diagnosis
Date GA Ultrasound findings
Plan of care
Serial US results
Date GA Ultrasound findings Fetal growth Amniotic fluid Dopplers Presentation
Summary of fetal medicine consultation