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STUDY FORM A: Pa g e 2.
PREGNANCY/lABOUR RI SK FACTORS (tick whe r e a pp ropriate)
Anaemia
Antepartum haemo rrage
Other(state)
preeclampsia
multiple pregnancy
Date and time' _ Infant(s) sex H
Type of d e liv e r y _
To tal duration o f Lebcu r- (h rs) Stillbirth
Bl ood loss at delivery (ml s )
Birtnweight(s) l.__Ckgs) 2 . _ _ {kgs }
COMPLICATIONS OF lABOUR (tick wh e re appropriate)
Antepa rtum haemo rrhage
Pns t part um hae mo r r hag e
Premature raptu re of membr a ne s
Other
PRE-DELIVERY HAEMOGLOBI N LEVEL
Bl ood samp l e 1
Date and t ime collect ed' _
samp l e numbe r _
Ll v e bi r t h
(stateJ _
Name or s i g na t ure o f collect or _
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