Substance Misuse in Pregnancy - NHS Lothian
Substance Misuse in Pregnancy - NHS Lothian
Substance Misuse in Pregnancy - NHS Lothian
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<strong>Pregnancy</strong> Outcome Form (<strong>Substance</strong> <strong>Misuse</strong>) SM203<br />
Mother’s name: ........................................................................…… Mother’s d.o.b.: ……………………………………………<br />
Baby’s name: .................................................................................<br />
Address: ........................................................................................................................................................................<br />
�------------------------------------------------------------------------�<br />
Postcode: EH _ _ / _ (only 1 st number of 2 nd part) Mother’s Unit No ..........................................<br />
Baby’s SM number:……………………………………………………… Mother’s Chi No.:………………………………………..<br />
Delivery date: ..........................................................…… Baby’s Chi No.:……………………………………………<br />
Gestation: ...............................................................………. APGARs: ...........................................................………..<br />
Birth weight: .............................................................….. Cord pH: ………………………………………………………………….<br />
Birth length: ................................................................... Head Circumference: ……………………………………………<br />
Labour ward (please give details… if none state ‘none’)<br />
Complications <strong>in</strong> labour? ............................................................................................................................................<br />
Pa<strong>in</strong> relief dur<strong>in</strong>g labour? .........................................................................................................................................<br />
Mode of delivery? …………………………………………………………………………………………………………………………………………………..<br />
Complications of delivery? ........................................................................................................................................<br />
Problems at birth? ......................................................................................................................................................<br />
Postnatal ward<br />
Baby stayed for 72 hours observation?… Yes/No<br />
Neonatal withdrawal symptoms developed with<strong>in</strong> 72 hours?… Yes/No<br />
If yes, severity… Mild /Moderate/ Severe<br />
Drug treatment adm<strong>in</strong>istered? .......................................................................................................................………<br />
Medication on discharge? ……………………………………………………………………………………………………………………………………..<br />
Breast or bottle feed<strong>in</strong>g on discharge? ……………………………………………………………………………………………………………<br />
Other comments? …………………………………………………………………………………………………………………………………………………..<br />
Postnatal ward discharge date: .....................................................................................................................………..<br />
If mother HIV/Hepatitis C positive, baby referred for follow-up?...Yes/No Bloods taken? Yes/No<br />
Neonatal Unit (RIE) / SCBU (West <strong>Lothian</strong>)<br />
Admission date: ........................................................................................................................................…………………<br />
Reason for admission: ........................................................................................................................................………<br />
Neonatal withdrawal symptoms? None / Mild / Moderate /Severe<br />
Drug treatment adm<strong>in</strong>istered? ..........................................................................................................................……<br />
Medication on discharge?………………………………………………………………………………………………………………………………………<br />
Breast or bottle feed<strong>in</strong>g on discharge?……………………………………………………………………………………………………………<br />
Other comments? …………………………………………………………………………………………………………………………………………………..<br />
Neonatal Unit / SCBU discharge date: ...........................................................................................................……<br />
Toxicology Result: ………………………………………………………………………………………………………………………………………………….<br />
<strong>Substance</strong> <strong>Misuse</strong> <strong>in</strong> <strong>Pregnancy</strong>: Appendix 9 / November 2003 / PILOT