National Vital Statistics System

14. Risk factors in this pregnancy

Category: Prenatal Care and Pregnancy History

BC # 41

FDFWS # 14

FDR # 36

Definitions, instructions, sources, keywords and abbreviations
Definitions Risk factors of the mother during this pregnancy.
Instructions

Check all boxes that apply.  The mother may have more than one risk factor.

If the mother has none of the risk factors, check “none of the above.”

Sources See below
Keywords and Abbreviations See below
Diabetes
Definitions

Glucose intolerance requiring treatment.

  • Prepregnancy
    Diagnosis before this pregnancy
  • Gestational
    Diagnosis during this pregnancy
Instructions

If diabetes is present, check either prepregnancy or gestation diabetes.

Do not check both.

Sources 1st  Prenatal care record under
  • Medical history
  • Previous OB history under – summary of previous pregnancies
  • Problem list or – initial risk assessment
  • Historical risk summary
  • Complications of previous pregnancies
  • Factors this pregnancy

2nd  Labor and delivery nursing admission triage form under

  • Medical complications
  • Comments

3rd  Admission history and physical (H&P) under

  • Current pregnancy history
  • Medical history
  • Previous OB history under –
    pregnancy related

4th  Delivery record under

  • Maternal OB/labor summary
  • Labor and delivery admission history
  • Labor summary record
Keywords and Abbreviations Prepregnancy:
  • DM – Diabetes mellitus
  • Type 1 diabetes
  • IDDM – Insulin dependent diabetes mellitus
  • Type 2 diabetes
  • Non-insulin dependent diabetes mellitus
  • Class B DM
  • Class C DM
  • Class D DM
  • Class F DM
  • Class R DM
  • Class H DM

Gestational:

  • GDM – Gestational diabetes mellitus
  • IDGDM – Insulin dependent gestational diabetes mellitus
  • Class A1 or A2 diabetes mellitus
Hypertension
Definitions

Elevation of blood pressure above normal for age, sex, and physiological condition.

  • Prepregnancy (chronic)
    Diagnosis prior to the onset of this pregnancy–does not include gestational (pregnancy-induced hypertension [PIH]).
  • Gestational
    Diagnosis in this pregnancy (Pregnancy-induced hypertension or preeclampsia).  
Instructions

If hypertension is present, check either prepregnancy or gestational hypertension.

Do not check both.

Sources 1st  Prenatal care record under
  • Medical history
  • Previous OB history under – summary of previous pregnancies
  • Problem list or – initial risk assessment
  • Historical risk summary
  • Complications of previous pregnancies
  • Factors this pregnancy

2nd  Labor and delivery nursing admission triage form under

  • Medical complications
  • Comments

3rd  Admission history and physical (H&P) under

  • Current pregnancy history
  • Medical history
  • Previous OB history under –
    pregnancy related

4th  Delivery record under

  • Maternal OB/labor summary
  • Labor and delivery admission history
  • Labor summary record
Keywords and Abbreviations Prepregnancy:
  • CHT – Chronic hypertension
  • Benign essential hypertension
  • Essential hypertension
  • Preexisting hypertension

Gestational:

  • PIH – Pregnancy-induced hypertension
  • Preeclampsia
  • Eclampsia
  • Transient hypertension
  • HELLP Syndrome
Eclampsia
Definitions Hypertension with proteinuria with generalized seizures or coma.  May include pathologic edema.
Instructions If eclampsia is present, one type of hypertension (either gestational or chronic) may be checked.
Sources 1st  Prenatal care record under
  • Medical history
  • Previous OB history under – summary of previous pregnancies
  • Problem list or – initial risk assessment
  • Historical risk summary
  • Complications of previous pregnancies
  • Factors this pregnancy

2nd  Labor and delivery nursing admission triage form under

  • Medical complications
  • Comments

3rd  Admission history and physical (H&P) under

  • Current pregnancy history
  • Medical history
  • Previous OB history under –
    pregnancy related

4th  Delivery record under

  • Maternal OB/labor summary
  • Labor and delivery admission history
  • Labor summary record
Keywords and Abbreviations See hypertension
Previous preterm births
Definitions History of pregnancy(ies) terminating in a live birth of less than 37 completed weeks of gestation.
Instructions
Sources 1st  Prenatal care record under
  • Medical history
  • Previous OB history under – summary of previous pregnancies
  • Problem list or – initial risk assessment
  • Historical risk summary
  • Complications of previous pregnancies

2nd  Labor and delivery nursing admission triage form under

  • Medical complications
  • Comments

3rd  Admission history and physical (H&P) under

  • Medical history
  • Previous OB history under – pregnancy related
  • Problem list/findings
Keywords and Abbreviations

PTL – Preterm labor

P – Premature

Pregnancy resulted from infertility treatment
Definitions Any assisted reproductive treatment used to initiate the pregnancy.

Includes:

  • Drugs (e.g., Clomid or Pergonal)
  • Artificial insemination
  • Technical procedures (e.g., in-vitro fertilization)
Instructions Check if any infertility treatment was used to initiate the pregnancy. This information is included on both the mother’s and the facility worksheets. Check “yes” if treatment is reported on either worksheet.
Sources 1st  Prenatal care record under
  • Medical history
  • Current pregnancy history
  • Problem list or–initial risk assessment
  • Medications this pregnancy

2nd  Labor and delivery nursing admission triage form under

  • Comments
  • Medications

3rd  Admission history and physical (H&P) under

  • Current pregnancy history
  • Problem list/findings
Keywords and Abbreviations See below
Fertility-enhancing drugs, artificial insemination, or intrauterine insemination
Definitions Any fertility enhancing drugs (e.g., Clomid or Pergonal), artificial insemination, or intrauterine insemination used to initiate the pregnancy.
Instructions Check if specific therapy (drugs or insemination) was used.This information is included on both the mother’s and the facility worksheets. Check “yes” if treatment is reported on either worksheet.
Sources 1st  Prenatal care record under
  • Medical history
  • Current pregnancy history
  • Problem list or–initial risk assessment
  • Medications this pregnancy

2nd  Labor and delivery nursing admission triage form under

  • Comments
  • Medications

3rd  Admission history and physical (H&P) under

  • Current pregnancy history
  • Problem list/findings
Keywords and Abbreviations Fertility-enhancing drugs, or artificial or intrauterine insemination:
  • Artificial insemination
  • AIH – Artificial insemination by husband
  • AID/DI – Artificial insemination
    by donor
  • Medications
  • Clomid, Serophene
  • Pergonal
  • Metrodin
  • Profasi
  • Progesterol
  • Crinone (progesterone gel)
  • Follistim
  • FSH–Follicule stimulating hormone
  • Gonadotropins
  • Hcg–Human chorionic gonadotropin
  • Pergonal
  • IUI
Assisted reproductive technology
Definitions Any assisted reproductive technology ([ART] or technical procedures [e.g., IVF, GIFT, or ZIFT]) used to initiate the pregnancy.
Instructions Check if assisted reproductive therapy was used. This information is included on both the mother’s and the facility worksheets. Check “yes” if treatment is reported on either worksheet.
Sources 1st  Prenatal care record under
  • Medical history
  • Current pregnancy history
  • Problem list or–initial risk assessment
  • Medications this pregnancy

2nd  Labor and delivery nursing admission triage form under

  • Comments
  • Medications

3rd  Admission history and physical (H&P) under

  • Current pregnancy history
  • Problem list/findings
Keywords and Abbreviations Assisted reproductive technology:
  • ART
  • In-vitro fertilization
  • IVF-ET – In-vitro fertilization embryo transfer
  • GIFT – Gamete intrafallopian
    transfer
  • ZIFT – Zygote intrafallopian
    transfer
  • Ovum donation
  • Donor embryo
  • Embryo adoption
Mother had a previous cesarean delivery
Definitions

Previous delivery by extracting the fetus, placenta, and membranes through an incision in the mother’s abdominal and uterine walls.

If yes, how many? ________

Instructions If the mother has had a previous cesarean delivery, indicate the number of previous cesarean deliveries she has had.
Sources 1st  Prenatal care record under
  • Past pregnancy history
  • Past OB history
  • Problem list or – initial risk assessment

2nd  Labor and delivery nursing admission triage form under – Comments

3rd  Admission history and physical (H&P) under

  • Past OB history
  • Past pregnancy history under – problem list /findings
Keywords and Abbreviations

C/S – Cesarean section

Repeat C/S

VBAC – Vaginal delivery after cesarean

LSTCS  (or LTCS) low segment transverse cesarean section

Classical cesarean section

Low vertical C/S

Low transverse C/S

Look for:

TOL – Trial of labor

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