WARD 50 - Mothercraft. Barcode Mother/Baby Record Sheet Baby. Antenatal and perinatal history (please tick appropriate boxes) Neonatal period

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1 WARD 50 - Mothercraft G1888HWF Barcode Mother/Baby Record Sheet Baby Referral by: Reason for admission: Mother Antenatal and perinatal history (please tick appropriate boxes) This pregnancy was it: Planned Unplanned Did you require medical help to become pregnant? Yes Baby born: Hospital Home If hospital or birthing centre which one How long did you spend in hospital Name of midwife Was the pregnancy normal? Yes Did you have any flu-like illness or rubella? Name of GP Did you feel ready to go home? Did you develop the "third day blues"? Yes Your health after birth - if complications please describe Baby's gestation Birthweight Labour and delivery: (Tick the box) Spontaneous Induced rmal delivery Forceps Caesarean section: Elective Emergency Ventouse If your baby was induced, please describe why Did your baby receive Vitamin K at birth? Yes Oral Injection Neonatal period (the first few days after birth) - were there any problems: Yes If so, please describe To be filed in Clinical Record in Baby Record section. 1 of 6 04/15JB

2 When did your baby pass meconium (the first bowel motion) Was your baby jaundiced at all? Yes If yes, was any treatment required - please give detail Feeding Breast Yes If no, age weaned? How often during the day? How often overnight? Length of feed? (e.g.10 mins each side) Do you feed from both breasts each feed? Yes Do you alternate the side you start on? Yes or bottle Yes Type of formula in current use? Type of formula previously tried, if any? Amount per feed? How often during the day? How often during the night? or breast and bottle Yes How often breast fed during the day? How often bottle fed during the day? Type of formula? Amount of formula given? How often breast fed during the night? How often bottle fed during the night? Solids Yes Age introduced? How often given? Amount given? approx (e.g. 1 /4 cup) What foods given? Baby cereals if given? Do you mix these with formula, breast milk or water? Snack food Do you offer snacks between meals? If yes, what do you offer? How often do you offer snacks? Cup Does your baby drink from a cup? Yes If yes, what do you offer in this? How often is the cup offered? 2 of 6

3 Spilling and vomiting Does your baby spill or vomit? Yes Small amounts Is it forceful? Yes Sleeping patterns or Large amounts Where does your baby sleep? Bassinet Cot Bed Does he/she have a separate room: Yes If no, who does baby share with? please give detail Do you feed your baby to sleep? Yes Do you cuddle your baby to sleep? Yes Can you describe day time sleep patterns and night time patterns Please tick any of the following that you use or have tried to settle baby - Dummy Wrapping Patting Rocking/music Do you have any special bed time routines, e.g. singing or feeding baby to sleep? Do you at any time take your baby into your bed? Yes If you do, please describe when: Crying Do you feel your baby cries too much? Yes Do you recognise different types of crying in your baby? Yes How do you pacify your baby? Do you know about the Power to Protect messages? Yes Bowel motions How often does your baby have a bowel motion? What colour and consistency is his/her s bowel motion? Do you have any concerns about your baby s bowels Yes If so, please describe - Urine How many wet nappies does your baby have in 24 hours? Less than four Eight or more 3 of 6

4 Medications (Include homeopathic, prescribed, and over the counter products that you give your baby. For prescribed medications, please state who prescribed it and when, and are you still using it. If not why?). Allergies or food intolerance - does your baby or any family member have any? (e.g. dairy products, eczema, asthma) Illnesses List previous illnesses and when they occurred (please include ear and throat infections) - Has your baby had any previous hospital admissions? Has your baby seen a specialist or is due to see one or do you have a clinic appointment for follow-up? Have you or your baby been in contact recently with anybody with illness? (e.g. chickenpox, influenza, infectious diseases) Immunisations Please describe which ones: 6 week 3 month 5 month 15 month B.C.G. 4 of 6

5 Family history Your age: Ethnic group: Partner's name: Age: Ethnic group: Are you a migrant to New Zealand? Yes Where were you living previously? How long have you been in New Zealand? Personal and family medical history (please indicate by stating which side of family the condition occurs on). Your past medical history Rheumatic fever Cardiac disease High blood pressure Asthma Epilepsy Diabetes (including gestational diabetes) Urinary tract infections and Kidney disease Sexually transmitted diseases Psychiatric illness Depression Thyroid disease Blood disorders Auto immune diseases Tb Allergies Any accidents or operations including breast surgery, e.g. reduction or implants (if so please describe below) Other (describe below): Family history Depression High blood pressure Diabetes Deafness Tb Congenital abnormalities Allergies Other Adopted Current means of contraception (please state) Recreational drugs In pregnancy: Yes w: Yes Alcohol Yourself: In pregnancy: Nil Social Regular intake w: Nil Social Regular intake Drug allergies Yes - describe t known Current medications Yes - describe Past medications For example - Domperidone Partner: Nil Social Regular Smoking status Current smoker Ex - over one month Never History of exposure to tobacco smoke Interventions Brief advice to quit Yes Nicotine replacement therapy offered Yes Declined Referral offered Yes Declined Patient smoke exposure record faxed Date: Your past medical history (please describe if you have ticked any of the above boxes) Other children Do they live with you Yes Their ages, and gender? 5 of 6

6 Were there any difficulties feeding them? Yes If yes, please describe: Social history Your previous and present occupation: Your partner's occupation: Type of accommodation: How many living in your home? Who cares for baby? Day Night Do you see a Plunket Nurse on a regular basis? Yes Do you have any other support agencies helping you at present? (eg. Family Start, Catholic Family Services) Who are the main support people in your life at present? Have you used any alternative health providers? (e.g. homeopath, osteopath, chiropractor) Have you attended the Waikato Family Centre? Yes If yes. when Have you been referred to or been seen by the Maternal Mental Health Service? Yes If yes, who did you see? Have you been referred to or seen a lactation consultant or a Breastfeeding Support Clinic? Yes Date seen: If yes, what advice were you given? What help would you like with your baby while you are in Mothercraft? We have the support of a social worker, mental health nurse, hospital chaplain and kaiawhena to assist us with our work in Mothercraft. The postnatal period can be a very stressful time for parents, would you like to talk to staff about setting up an appointment? Yes If yes, please state which one: The information I/we have provided on this record is to assist us plan your care. Please sign below that we have discussed your goals and how we will work with you to achieve them. Signed: Signed: Consumers rights Date: Name: Posters and pamphlets which explain the Code of Health and Disability Services Consumers' Rights are available in the hallway pamphlet display bench - please feel free to take pamphlets to read. Students (parent/parents signature ) (nursing staff signature) Waikato Hospital is a training hospital for nurses and doctors. We may ask if you are willing to talk with a student about your experience here. 6 of 6 dd/mm/yy (nursing staff printed name)

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