Start
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One of these questionnaires to be filled in for each baby born during the period of the main survey (first minute March 3rd-last minute 9th, 1958, inclusive) and sent in as instructed.
In addition, during the months of March, April, May 1958, a questionnaire is required for all still births and each infant dying before the age of 28 days, and sent in as instructed as soon as possible after death.
GENERAL INSTRUCTIONS
1. Where the questions have been pre-coded, i.e. the possible answers are listed and a code number or letter attached (e.g. Questions 6, 9, 11a)- indicate the answer by ringing the code of the answer that applies.
2. Ignore the small boxes placed alongside some questions, e.g. Questions 10 and 11; these are to be used in analysis at Headquarters.
3. If you are unable to record an answer to any question because the details are not known or available, please DO NOT LEAVE A BLANK but record "doesn't remember," or "don't know," "no records," etc.

Name of person completing this form

Generic text

Name and address of Institution and/or L.A. to which (1) is attached

Generic text

If the birth is institutional, please give the Regional Hospital Board

Generic text
SECTION I GENERAL INFORMATION

Full name of patient

Generic text

Patient's usual place of residence

Generic text

Address at which baby delivered (If same as Question 4, write "same")

Generic text

Place of delivery

Y
Hospital as booked case
X
Hospital as unbooked case (including emergency)
O
Domiciliary - Midwife booked
1
Domiciliary - Midwife unbooked
2
N.H.S. Maternity Home *
3
Private Nursing Home
4
Private ward of N.H.S. Hospital
5
Elsewhere (specify, e.g. taxi, street, ambulance, etc.)
Generic text
Note.-If baby delivered on way to hospital, in ambulance, taxi, street, etc., this should be classified below as "elsewhere."
One code only see note above
* G.P. unit where there is no resident Medical Officer.

Time and date of delivery ... a.m./p.m. on the ... of ... , 1958

Time
Date
SECTION II
(Questions 8--22 inclusive)
The information required for the questions in this section should be got from the mother only. If the mother cannot be questioned, refer to instructions.

Age of patient last birthday ... yrs.

Age

Present marital status

Y
Married
X
Single
O
Widowed, divorced, separated
IF NOT MARRIED, OMIT Qns. 10-12 inclusive
IF MARRIED, questions about husband's employment refer to time of delivery. If not working, or on National Service, give last occupation, and give reason, e.g. unemployed, sick, National Service, etc.
qc_9 == Y

Date of present marriage ... (day) of ... (month) ... (year)

Date

What was the husband's occupation? Actual job

Generic text

What was the husband's occupation? Industry

Generic text

Is the husband paid weekly, monthly, or is he self-employed?

1
Weekly
2
Monthly
3
Self-employed
If self-employed
qc_11_a == 3

Does he employ 10 or more persons?

4
Yes
5
No
If not self-employed
qc_11_a != 3

Does he supervise others (e.g. foreman, manager, charge-hand?)

6
Yes
7
No

Age of husband last birthday? ... yrs.

Age

Did the patient stay at school after minimum school-leaving age?

Y
Yes
X
No
If stayed at school
qc_13 == Y

At what age did she finish her full-time education? ... yrs.

Age

What was her father's occupation when she left school? Actual job

Generic text

What was her father's occupation when she left school? Industry

Generic text

Was he:

Y
Self-employed, not employing others
X
Employer
O
Employee not supervising others
1
Employee supervising others
At the time she left school, how many brothers and sisters did the patient have (living and dead)?
Number still alive then Number dead
Generic numberGeneric number Generic numberGeneric number
Older than patient
Younger than patient

Did the patient have a paid job when she started this baby? Actual job ... Industry ...

Y
No job
Generic text
Generic text
If employed when pregnancy began
qc_16 != Y

How many hours a week was she working at that time? ... hours

hours per week

When did she finally give up work?

Date

How many persons are there now in the patient's household (including her husband and herself and any boarders, and excluding this baby and any lodgers who take their meals separately)? 15 yrs. and over

Generic number

How many persons are there now in the patient's household (including her husband and herself and any boarders, and excluding this baby and any lodgers who take their meals separately)? Under 15 yrs.

Generic number

How many rooms do these people occupy now (excluding bathroom, scullery, kitchen-unless used as living room)? ... rooms

Generic number

For how many people did the patient cook and keep house at the beginning of pregnancy (including her husband and herself)?

Generic number

Was general anaesthesia administered for any purpose during this pregnancy (including dental gases)?

Y
Yes
O
No
If administered,
qc_18 == Y

when and for what purpose? ... at ... week

Generic text
Week of pregnancy

when and for what purpose? ... at ... week

Generic text
Week of pregnancy

What was the patient's approx. weight before this pregnancy? ... stones ... lbs.

stones
lbs

What was the date of the first day of her last menstrual period? ... day ... month ... 1957

Date

In which week of the pregnancy did the patient make her first visit for antenatal care (excluding visit(s) solely to confirm pregnancy)? ... week

Week of pregnancy
Beginning with, and including, the visit mentioned in 21 (a) how many times did the patient attend for antenatal care at the following places? (Exclude visits solely for relaxation or mothercraft instruction, and dental treatment.)
Place Roster cs_q21b_X How many How many
Hospital antenatal clinic 1 Number of visits: During 1st 28 weeks
Hospital antenatal clinic 1 Number of visits: Rest of Pregnancy
Hospital antenatal clinic 2 Number of visits: During 1st 28 weeks
Hospital antenatal clinic 2 Number of visits: Rest of Pregnancy
L.H.A. clinic (run for, or on behalf of L.A.) 1 Number of visits: During 1st 28 weeks
L.H.A. clinic (run for, or on behalf of L.A.) 1 Number of visits: Rest of Pregnancy
L.H.A. clinic (run for, or on behalf of L.A.) 2 Number of visits: During 1st 28 weeks
L.H.A. clinic (run for, or on behalf of L.A.) 2 Number of visits: Rest of Pregnancy
Surgery (G.P.) 1 Number of visits: During 1st 28 weeks
Surgery (G.P.) 1 Number of visits: Rest of Pregnancy
Surgery (G.P.) 2 Number of visits: During 1st 28 weeks
Surgery (G.P.) 2 Number of visits: Rest of Pregnancy
Patient's home (G.P.) 1 Number of visits: During 1st 28 weeks
Patient's home (G.P.) 1 Number of visits: Rest of Pregnancy
Patient's home (G.P.) 2 Number of visits: During 1st 28 weeks
Patient's home (G.P.) 2 Number of visits: Rest of Pregnancy
Patient's home (midwife) 1 Number of visits: During 1st 28 weeks
Patient's home (midwife) 1 Number of visits: Rest of Pregnancy
Patient's home (midwife) 2 Number of visits: During 1st 28 weeks
Patient's home (midwife) 2 Number of visits: Rest of Pregnancy
Other (specify) 1 Number of visits: During 1st 28 weeks
Other (specify) 1 Number of visits: Rest of Pregnancy
Other (specify) 2 Number of visits: During 1st 28 weeks
Other (specify) 2 Number of visits: Rest of Pregnancy

Does the patient think her B.P. was taken on each occasion mentioned in 21(b) above?

Y
Yes
X
No
If NO
qc_22 == X

on how many visits was B.P. not taken?

Generic number

Did the patient smoke as many as one cigarette a day during the 12 months before the start of this pregnancy? If so, how many per day during that period? Number smoked per day in that period ...

Y
Did not smoke as many as 1 per day
Generic number
If smoked one or more per day
qc_23 != Y

Did the patient change her smoking habits this pregnancy? Record any changes in the table below-and month of pregnancy change made.

Y
No change
Did the patient change her smoking habits this pregnancy? Record any changes in the table below-and month of pregnancy change made.
Month of Pregnancy Changed Number per day smoked after change
Generic textHow many Generic textHow many
Gave up
Cut down
Increased
SECTION III
Please note carefully; the information in this section is to be got from records if at all possible. If this is not possible, get details from mother.
Past Obstetric History.- Exclude present pregnancy.

Has the patient had any previous pregnancies (including miscarriages)?

Y
Yes
X
No
If "Yes"
qc_24 == Y
please give details below, taking the pregnancies in order of occurrence (the earliest first). Record twins as two separate births.
Date of Delivery: Month Date of Delivery: Year Sex Birth Weight ... lbs. Birth Weight ... ozs. Place of Delivery Outcome of Delivery Complications of Pregnancy Method of Delivery
0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

1
2
3
4
5
6
7
8
9
10
PRESENT PREGNANCY

Patient's Height (measure if not recorded, upright against the wall, without shoes) ... ft ... inches

feet
inches
Y
Recorded
X
Measured by midwife
O
Not recorded, unable to measure

Was any booking made for this delivery?

Y
Yes
X
No
If a booking made
qc_26 == Y

Week original booking made? ... week

Week of pregnancy

What kind of booking was this original one?

Y
Domiciliary
X
Hospital
0
N.H.S. Maternity Home
1
Private Nursing Home
2
Private ward of N.H.S. Hospital
3
Other place (specify)
Other
If original booking domiciliary
qc_26_b == Y

Why was this booking domicilliary? ... If not for any of above reasons, specify

Y
No hospital indication
X
Hospital recommended but patient refused
O
Hospital indicated no bed available
Generic text

Was this booking changed to an institutional booking during the pregnancy? If so, in which week was the change made? Changed on the ... week

Y
Not changed
Week of pregnancy

What was reason for the change?

Generic text
SECTION IV
The information for this section is to be got from records or notes only. Where records are not available, mark questions "no records."

Information about records used in this section. Has the person completing this questionnaire full information about each of the places of antenatal care used by the patient? (See Question 21(b).)

Y
Yes
X
No
If notes, etc., not all available
qc_27 == X

Which notes or records are not available?

Generic text

Expected date of delivery ... day ... month ... year

Date

Was this calculated from last menstrual period, or estimated by other means?

O
Calculated from L.M.P.
1
Estimated from other means

Excluding readings taken when hospital in-patient, how many times was blood pressure recorded during the antenatal period, i.e. up to onset of labour. Number of times ...

Generic number
3
No records available
4
Some records only available
If B.P. recorded at all in antenatal period
qc_29 != 3

What were the first, last and highest systolic/ diastolic B.P. readings recorded in this pregnancy, and in which weeks were these taken? (Include readings taken when hospital in-patient). First (or only) reading ... / ... at the ... week

Systolic
Diastolic
Week of pregnancy

What were the first, last and highest systolic/ diastolic B.P. readings recorded in this pregnancy, and in which weeks were these taken? (Include readings taken when hospital in-patient). Last reading ... / ... at the ... week

Systolic
Diastolic
Week of pregnancy

What were the first, last and highest systolic/ diastolic B.P. readings recorded in this pregnancy, and in which weeks were these taken? (Include readings taken when hospital in-patient). Reading with highest diastolic ... / ... at the ... week

Systolic
Diastolic
Week of pregnancy

What was the B.P. reading with the highest diastolic recorded during labour? Reading ... / ...

Systolic
Diastolic
Y
B.P. not taken during labour

Was Oedema observed during this pregnancy?

X
Yes
O
No

Did albuminuria occur during this pregnancy?

1
Yes
2
No
If Albuminuria occurred
qc_31 == 1

In which week of pregnancy did it occur? ... week

Week of pregnancy

Was a catheter specimen taken?

Y
Yes
X
No

Was urinary infection present?

O
Yes
1
No

Did eclamptic fits occur?

Y
Yes
X
No
If eclamptic fits occurred
qc_32 == Y

When?

O
Antepartum
1
Intra partum
2
Post partum

How many fits occurred altogether? Number of fits ...

Generic number

Was the patient admitted to hospital for pre-eclamptic toxaemia (P.E.T.) or hypertension?

Y
Yes
X
No
If Admitted
qc_33 == Y

B.P. reading on admission?

Generic text

In which week was she admitted? ... week

Week of pregnancy
If not Admitted
qc_33 == X

Was P.E.T. diagnosed and treated without hospitalisation

1
Yes
2
No

Was there a blood group test made for this pregnancy? or if not, was there a record of any previous test? One code only

Y
Tested for this pregnancy
X
Not tested, but previous record
O
Not tested and no previous record
If any test made for this or previous pregnancy
qc_34 != O

What was the result? (Ring both Rhesus factor and ABO group)

2
Rh Pos.
3
Rh. Neg.
4
A
5
B
6
AB
7
O
8
ABO group not recorded
If Rh. Negative
qc_34_a == 3

Was blood tested for Rh. Antibodies during this pregnancy?

Y
Yes
X
No

How many times was haemoglobin tested in this pregnancy? Number of times tested ...

O
Not tested at all
Generic number
If Haemoglobin tested at all this Pregnancy?
qc_35 != O

Result. First (or only) test ... % ... week

Percentage
Week of pregnancy

Result. Last test ... % ... week

Percentage
Week of pregnancy

X-ray examinations during this pregnancy. Chest: X-ray at the ... th week

1
No X-ray
Week of pregnancy

X-ray examinations during this pregnancy. Abdominal: X-ray at the ... th week

2
No X-ray
Week of pregnancy

X-ray examinations during this pregnancy. Pelvimetry: X-ray at the ... th week

4
No X-ray
Week of pregnancy

Were any of the following abnormalities or illnesses or any other condition (not P.E.T.) encountered during this pregnancy? If so, please give the week diagnosed in each case.

O
If none encountered ring this code
Y
Diabetes
X
Heart disease
O
Tuberculosis (active)
1
Influenza
2
German measles
3
Vaginal bleeding before 28th week
4
APH: Accidental haemorrhage
5
APH: Placenta praevia
6
APH: Cause unknown
7
Suspected disproportion
8
Psychiatric disorder (under treatment)
9
External version
Ring code if condition encountered

Diabetes (Week First Noted)

Week of pregnancy

Heart disease (Week First Noted)

Week of pregnancy

Tuberculosis (active) (Week First Noted)

Week of pregnancy

Influenza (Week First Noted)

Week of pregnancy

German measles (Week First Noted)

Week of pregnancy

Vaginal bleeding before 28th week (Week First Noted)

Week of pregnancy

APH Accidental haemorrhage (Week First Noted)

Week of pregnancy

APH Placenta praevia (Week First Noted)

Week of pregnancy

APH Cause unknown (Week First Noted)

Week of pregnancy

Suspected disproportion (Week First Noted)

Week of pregnancy

Psychiatric disorder (under treatment) (Week First Noted)

Week of pregnancy

External version (Week First Noted)

Week of pregnancy

OTHER ILLNESSES OR ABNORMALITY Specify (Week First Noted)

Other
Week of pregnancy

Was the patient admitted to a hospital or maternity/nursing home or other institution during the antenatal period (for any other reason than P.E.T.) i.e. in pregnancy up to the time of the onset of labour ? Code all that apply

Y
No
X
Yes, to hospital
O
Yes, to maternity home
1
Yes, to nursing home
2
Yes, to other institutions (specify)
Other
If admitted to any institution in antenatal period
qc_38 != Y
Give the principal diagnosis or reason, date and duration for each admission.
Reason Week of Preg. Days in Ward
Generic textWeek of pregnancyDays in ward Generic textWeek of pregnancyDays in ward Generic textWeek of pregnancyDays in ward
1
2
3

Was patient admitted to institution during labour (include both booked and emergency cases)?

Y
Not admitted during labour
X
Admitted during labour as booked case
O
Admitted during labour as emergency (give reasons for emergency)
Generic text
If admitted as booked or emergency case
qc_39 != Y

Approximate time between onset of labour and admission ... hrs. ... mins.

Duration in hours and minutes
SECTION V.-DETAILS OF LABOUR
The information for this section should be got from records, notes or the experience of the person(s) who actually delivered the infant.

Did the person(s) conducting the delivery have full information about the antenatal period at time of labour?

1
Yes
2
No
If No
qc_40 == 2

Specify what information was missing, and state reason.

Generic text

How long was the labour? First stage ... hrs. ... mins.

Duration in hours and minutes
Y
Not known

How long was the labour? Second stage ... hrs. ... mins.

Duration in hours and minutes
X
Not known

How long before delivery did the membranes rupture, either spontaneously or by artificial means: ... hrs. ... mins.

Duration in hours and minutes
O
Not known

Did the patient run a temperature above normal during this interval?

1
Yes
2
No
3
Not known

Was induction carried out?

Y
Yes
X
No
If delivery induced
qc_43 == Y

Why was induction necessary?

O
Postmaturity
1
Hypertension
2
Other cause (specify)
Other

Which method(s) was used? Code all that Apply

6
Medical: O.B.E.
7
Medical: Pitocin
8
Medical: Other
9
Surgical
If surgical induction used
qc_43_b == 9

Specify method used.

Generic text

How soon after surgical induction did delivery occur? ... hrs. ... mins.

Duration in hours and minutes

What was the presenting part when the baby was delivered?

Y
Vertex O.A.
X
Vertex P.O.P
O
Breech
1
Shoulder
2
Face
3
Other presentation (specify)
Other

Was episiotomy carried out?

Y
Yes
X
No

What was the method of actual delivery?

O
Spontaneous
1
Forceps
2
Elective caesarean
3
Emergency caesarean
4
Other method (specify)
Other
If delivery not spontaneous
qc_46 != O

What was the reason for assistance? Code all that Apply

3
Foetal distress: prolapsed cord
4
Foetal distress: passage of meconium
5
Foetal distress: foetal heart: slow, rapid, irreg.
6
Maternal distress
7
Toxaemia
8
Delay in second stage
9
Other reasons (specify)
Other

Were there are any complications of labour which have not been mentioned above; if so, please specify. Complications ...

Y
No other complications
Generic text

Was inhalational analgesia available at delivery and given?

Y
Not available at delivery
X
Available and given
O
Available, not given (specify reason)
Generic text
If given
qc_48 == X

What agent was given?

3
Gas and Air
4
Trilene
5
Others (specify)
Other

For how long previous to last hour before delivery? ... hrs. ... mins.

Duration in hours and minutes

During the last hour before delivery? ... mins.

Duration in minutes

Was analgesia or sedative given by any other route than inhalation?

Y
Yes
X
No
If yes
qc_49 == Y
What drugs were given and how much was given in last 2 hours (and in the previous 10 hours) of labour?
Name of Drug Amount given: In last 2 hours Amount given: In previous 10 hours
Generic textGeneric textGeneric text Generic textGeneric textGeneric text Generic textGeneric textGeneric text
1
2
3
4

Was any local, general or spinal anaesthetic administered during labour? Code all that Apply

Y
None
X
General
O
Spinal
1
Local
2
Pudendal block
If any anaesthetic administered
qc_50 !=Y

Why was it given?

Generic text
If general
qc_50 == X

What general anaesthetic was given?

Generic text

Which of the following persons were present at the delivery? (Qualified, trained or in training only) Person who delivered the baby

0
No trained person (e.g. B.B.A., policeman, etc)
1
Midwife
2
Consultant obstet.
3
Registrar
4
Hospital M.O.
5
G.P.
6
Medical Student
7
Pupil Midwife
8
Other (specify)
Other

Which of the following persons were present at the delivery? (Qualified, trained or in training only) Also present at delivery

0
No trained person (e.g. B.B.A., policeman, etc)
1
Midwife
2
Consultant obstet.
3
Registrar
4
Hospital M.O.
5
G.P.
6
Medical Student
7
Pupil Midwife
8
Other (specify)
Other
SECTION VI.-THE INFANT. RECORDS, NOTES, OR EXPERIENCE OF PERSON ATTENDING INFANT

What was the outcome of the delivery?

Y
Stillbirth
X
Livebirth
1
Single birth
2
Twin
3
Triplet
Note.-For multiple births, a separate schedule is required for each child, but Sections II, III and IV need only be completed for the first birth. Clip questionnaires together when despatching.

Sex of infant.

Y
Male
X
Female

Weight at birth? ... lbs. ... ozs.

Birth Weight (lbs)
Birth Weight (ozs)
O
Not weighed at birth
If not weighed at birth
qc_54 == O

Estimated weight at birth ... Ibs. ... ozs.

Birth Weight (lbs)
Birth Weight (ozs)
IF LIVE BIRTH
qc_52 == X

Did the baby require resuscitation other than aspiration of the air passages? If so, please specify the method used, including details of oxygen. Methods and drugs used ...

3
Resuscitation not required
Generic text

Was the baby given any drugs or antibiotics during the period covered by this questionnaire (apart from drugs given for the purpose of resuscitation)?

Y
Yes
X
No
Was the baby given any drugs or antibiotics during the period covered by this questionnaire (apart from drugs given for the purpose of resuscitation)?
Name of Drug Reason Given No. of days given Dosage per day
Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text

Did this baby have any laboratory tests or X-rays carried out during the period covered by this questionnaire?

Y
Yes
X
No
Did this baby have any laboratory tests or X-rays carried out during the period covered by this questionnaire?
Nature of test/X-ray Reason Day carried out Result
Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text

Did this baby have any congenital abnormality? If so, please specify. Congenital abnormality ...

O
No congenital abnormality
Generic text

What illnesses did this baby have during the first week of life? Illness(es) ...

O
None
Generic text

Fate of infant at end of first weeks of life.

Y
Alive
X
Died before 7 days old
O
Transferred before 7 days old
If transferred before 7 days old
qc_60 == O

At what age? ... days ... hrs.

Duration in Days and Hours

Where to?

Generic text

Reason for Transfer?

Generic text
Section VII.
The remainder of this questionnaire applies ONLY to stillbirth or neonatal deaths. Information should be got from records, notes or experience of person(s) attending the patient or infant

Date of death? Died at ... days ... hrs. ... mins.

Duration in days, hours and minutes
Y
Stillbirth
IF STILLBIRTH
qc_61 == Y

When did foetal death occur?

Y
Before onset of labour
X
During labour
O
Not known whether before or during labour
If known when foetal death occurred
qc_62 != O

How long before delivery did foetal death occur? ... days ... hrs. ... mins.

Duration in days, hours and minutes

Was the foetus macerated?

Y
Yes
X
No
IF STILLBIRTH OR DIED UNDER 28 DAYS
qc_61 == Y || qc_61 < '28 days'

Was a P.M. examination made? If so, where was this done? Place (address) ...

O
No P.M. examination
Place (address)
TO BE FILLED IN BY M.O.H.

Please give registered cause of this stillbirth (if in Scotland) or neo-natal death.

Generic text
SECTION VII. (Contd.) PLEASE FILL IN THIS SECTION IF THE BABY WAS STILLBORN OR DIED UNDER 28 DAYS.
Please use an extra sheet if short of space

Please give a short summary of present pregnancy, with special reference to abnormalities, illnesses; please include also conditions leading up to foetal death, if these occurred before labour.

Long text

Please give short summary of course of labour, with special reference to any complications; please include also conditions leading up to foetal death if these occurred during labour.

Long text

Please give short clinical history of baby between time of delivery and death, with special reference to any abnormalities or illnesses, and any notes which may help to explain why death occurred.

Long text
End

pms

One of these questionnaires to be filled in for each baby born during the period of the main survey (first minute March 3rd-last minute 9th, 1958, inclusive) and sent in as instructed.
In addition, during the months of March, April, May 1958, a questionnaire is required for all still births and each infant dying before the age of 28 days, and sent in as instructed as soon as possible after death.

GENERAL INSTRUCTIONS

1. Where the questions have been pre-coded, i.e. the possible answers are listed and a code number or letter attached (e.g. Questions 6, 9, 11a)- indicate the answer by ringing the code of the answer that applies.
2. Ignore the small boxes placed alongside some questions, e.g. Questions 10 and 11; these are to be used in analysis at Headquarters.
3. If you are unable to record an answer to any question because the details are not known or available, please DO NOT LEAVE A BLANK but record "doesn't remember," or "don't know," "no records," etc.
Name of person completing this form
Generic text
Name and address of Institution and/or L.A. to which (1) is attached
Generic text
If the birth is institutional, please give the Regional Hospital Board
Generic text

SECTION I GENERAL INFORMATION

Full name of patient
Generic text
Patient's usual place of residence
Generic text
Address at which baby delivered (If same as Question 4, write "same")
Generic text
Place of delivery
Y
Hospital as booked case
X
Hospital as unbooked case (including emergency)
O
Domiciliary - Midwife booked
1
Domiciliary - Midwife unbooked
2
N.H.S. Maternity Home *
3
Private Nursing Home
4
Private ward of N.H.S. Hospital
5
Elsewhere (specify, e.g. taxi, street, ambulance, etc.)
Generic text
Note.-If baby delivered on way to hospital, in ambulance, taxi, street, etc., this should be classified below as "elsewhere."
One code only see note above
* G.P. unit where there is no resident Medical Officer.
Time and date of delivery ... a.m./p.m. on the ... of ... , 1958
Time
Date

SECTION II

(Questions 8--22 inclusive)
The information required for the questions in this section should be got from the mother only. If the mother cannot be questioned, refer to instructions.
Age of patient last birthday ... yrs.
Age
Present marital status
Y
Married
X
Single
O
Widowed, divorced, separated
IF NOT MARRIED, OMIT Qns. 10-12 inclusive
Date of present marriage ... (day) of ... (month) ... (year)
Date
What was the husband's occupation? Actual job
Generic text
What was the husband's occupation? Industry
Generic text
Is the husband paid weekly, monthly, or is he self-employed?
1
Weekly
2
Monthly
3
Self-employed
Does he employ 10 or more persons?
4
Yes
5
No
Does he supervise others (e.g. foreman, manager, charge-hand?)
6
Yes
7
No
Age of husband last birthday? ... yrs.
Age
Did the patient stay at school after minimum school-leaving age?
Y
Yes
X
No
At what age did she finish her full-time education? ... yrs.
Age
What was her father's occupation when she left school? Actual job
Generic text
What was her father's occupation when she left school? Industry
Generic text
Was he:
Y
Self-employed, not employing others
X
Employer
O
Employee not supervising others
1
Employee supervising others

At the time she left school, how many brothers and sisters did the patient have (living and dead)?

Number still alive then Number dead
Generic numberGeneric number Generic numberGeneric number
Older than patient
Younger than patient
Did the patient have a paid job when she started this baby? Actual job ... Industry ...
Y
No job
Generic text
Generic text
How many hours a week was she working at that time? ... hours
hours per week
When did she finally give up work?
Date
How many persons are there now in the patient's household (including her husband and herself and any boarders, and excluding this baby and any lodgers who take their meals separately)? 15 yrs. and over
Generic number
How many persons are there now in the patient's household (including her husband and herself and any boarders, and excluding this baby and any lodgers who take their meals separately)? Under 15 yrs.
Generic number
How many rooms do these people occupy now (excluding bathroom, scullery, kitchen-unless used as living room)? ... rooms
Generic number
For how many people did the patient cook and keep house at the beginning of pregnancy (including her husband and herself)?
Generic number
Was general anaesthesia administered for any purpose during this pregnancy (including dental gases)?
Y
Yes
O
No
when and for what purpose? ... at ... week
Generic text
Week of pregnancy
when and for what purpose? ... at ... week
Generic text
Week of pregnancy
What was the patient's approx. weight before this pregnancy? ... stones ... lbs.
stones
lbs
What was the date of the first day of her last menstrual period? ... day ... month ... 1957
Date
In which week of the pregnancy did the patient make her first visit for antenatal care (excluding visit(s) solely to confirm pregnancy)? ... week
Week of pregnancy

Beginning with, and including, the visit mentioned in 21 (a) how many times did the patient attend for antenatal care at the following places? (Exclude visits solely for relaxation or mothercraft instruction, and dental treatment.)

Place Roster cs_q21b_X How many How many
Hospital antenatal clinic 1 Number of visits: During 1st 28 weeks
Hospital antenatal clinic 1 Number of visits: Rest of Pregnancy
Hospital antenatal clinic 2 Number of visits: During 1st 28 weeks
Hospital antenatal clinic 2 Number of visits: Rest of Pregnancy
L.H.A. clinic (run for, or on behalf of L.A.) 1 Number of visits: During 1st 28 weeks
L.H.A. clinic (run for, or on behalf of L.A.) 1 Number of visits: Rest of Pregnancy
L.H.A. clinic (run for, or on behalf of L.A.) 2 Number of visits: During 1st 28 weeks
L.H.A. clinic (run for, or on behalf of L.A.) 2 Number of visits: Rest of Pregnancy
Surgery (G.P.) 1 Number of visits: During 1st 28 weeks
Surgery (G.P.) 1 Number of visits: Rest of Pregnancy
Surgery (G.P.) 2 Number of visits: During 1st 28 weeks
Surgery (G.P.) 2 Number of visits: Rest of Pregnancy
Patient&#39;s home (G.P.) 1 Number of visits: During 1st 28 weeks
Patient&#39;s home (G.P.) 1 Number of visits: Rest of Pregnancy
Patient&#39;s home (G.P.) 2 Number of visits: During 1st 28 weeks
Patient&#39;s home (G.P.) 2 Number of visits: Rest of Pregnancy
Patient&#39;s home (midwife) 1 Number of visits: During 1st 28 weeks
Patient&#39;s home (midwife) 1 Number of visits: Rest of Pregnancy
Patient&#39;s home (midwife) 2 Number of visits: During 1st 28 weeks
Patient&#39;s home (midwife) 2 Number of visits: Rest of Pregnancy
Other (specify) 1 Number of visits: During 1st 28 weeks
Other (specify) 1 Number of visits: Rest of Pregnancy
Other (specify) 2 Number of visits: During 1st 28 weeks
Other (specify) 2 Number of visits: Rest of Pregnancy
Does the patient think her B.P. was taken on each occasion mentioned in 21(b) above?
Y
Yes
X
No
on how many visits was B.P. not taken?
Generic number
Did the patient smoke as many as one cigarette a day during the 12 months before the start of this pregnancy? If so, how many per day during that period? Number smoked per day in that period ...
Y
Did not smoke as many as 1 per day
Generic number
Did the patient change her smoking habits this pregnancy? Record any changes in the table below-and month of pregnancy change made.
Y
No change

Did the patient change her smoking habits this pregnancy? Record any changes in the table below-and month of pregnancy change made.

Month of Pregnancy Changed Number per day smoked after change
Generic textHow many Generic textHow many
Gave up
Cut down
Increased

SECTION III

Please note carefully; the information in this section is to be got from records if at all possible. If this is not possible, get details from mother.
Past Obstetric History.- Exclude present pregnancy.
Has the patient had any previous pregnancies (including miscarriages)?
Y
Yes
X
No

please give details below, taking the pregnancies in order of occurrence (the earliest first). Record twins as two separate births.

Date of Delivery: Month Date of Delivery: Year Sex Birth Weight ... lbs. Birth Weight ... ozs. Place of Delivery Outcome of Delivery Complications of Pregnancy Method of Delivery
0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

0 to 12Year of delivery

Y - Male

X - Female

Birth Weight (lbs)Birth Weight (ozs)

0 - Domiciliary

1 - Institutional (including nursing home)

2 - Livebirth: Alive now

3 - Livebirth: Died 28 days or later

4 - Livebirth: Died 7-27 days inclusive

5 - Livebirth: Died under 7 days

6 - Stillborn

7 - Miscarriage

8 - Ectopic Pregnancy

Y - Toxaemia

X - A.P.H

0 - Other complications

1 - No complications at all

2 - Not known whether any complications or not

3 - Spontaneous

4 - Forceps

5 - Caesarean

6 - Others

7 - Method not known

1
2
3
4
5
6
7
8
9
10
PRESENT PREGNANCY
Patient's Height (measure if not recorded, upright against the wall, without shoes) ... ft ... inches
feet
inches
Y
Recorded
X
Measured by midwife
O
Not recorded, unable to measure
Was any booking made for this delivery?
Y
Yes
X
No
Week original booking made? ... week
Week of pregnancy
What kind of booking was this original one?
Y
Domiciliary
X
Hospital
0
N.H.S. Maternity Home
1
Private Nursing Home
2
Private ward of N.H.S. Hospital
3
Other place (specify)
Other
Why was this booking domicilliary? ... If not for any of above reasons, specify
Y
No hospital indication
X
Hospital recommended but patient refused
O
Hospital indicated no bed available
Generic text
Was this booking changed to an institutional booking during the pregnancy? If so, in which week was the change made? Changed on the ... week
Y
Not changed
Week of pregnancy
What was reason for the change?
Generic text

SECTION IV

The information for this section is to be got from records or notes only. Where records are not available, mark questions "no records."
Information about records used in this section. Has the person completing this questionnaire full information about each of the places of antenatal care used by the patient? (See Question 21(b).)
Y
Yes
X
No
Which notes or records are not available?
Generic text
Expected date of delivery ... day ... month ... year
Date
Was this calculated from last menstrual period, or estimated by other means?
O
Calculated from L.M.P.
1
Estimated from other means
Excluding readings taken when hospital in-patient, how many times was blood pressure recorded during the antenatal period, i.e. up to onset of labour. Number of times ...
Generic number
3
No records available
4
Some records only available
What were the first, last and highest systolic/ diastolic B.P. readings recorded in this pregnancy, and in which weeks were these taken? (Include readings taken when hospital in-patient). First (or only) reading ... / ... at the ... week
Systolic
Diastolic
Week of pregnancy
What were the first, last and highest systolic/ diastolic B.P. readings recorded in this pregnancy, and in which weeks were these taken? (Include readings taken when hospital in-patient). Last reading ... / ... at the ... week
Systolic
Diastolic
Week of pregnancy
What were the first, last and highest systolic/ diastolic B.P. readings recorded in this pregnancy, and in which weeks were these taken? (Include readings taken when hospital in-patient). Reading with highest diastolic ... / ... at the ... week
Systolic
Diastolic
Week of pregnancy
What was the B.P. reading with the highest diastolic recorded during labour? Reading ... / ...
Systolic
Diastolic
Y
B.P. not taken during labour
Was Oedema observed during this pregnancy?
X
Yes
O
No
Did albuminuria occur during this pregnancy?
1
Yes
2
No
In which week of pregnancy did it occur? ... week
Week of pregnancy
Was a catheter specimen taken?
Y
Yes
X
No
Was urinary infection present?
O
Yes
1
No
Did eclamptic fits occur?
Y
Yes
X
No
When?
O
Antepartum
1
Intra partum
2
Post partum
How many fits occurred altogether? Number of fits ...
Generic number
Was the patient admitted to hospital for pre-eclamptic toxaemia (P.E.T.) or hypertension?
Y
Yes
X
No
B.P. reading on admission?
Generic text
In which week was she admitted? ... week
Week of pregnancy
Was P.E.T. diagnosed and treated without hospitalisation
1
Yes
2
No
Was there a blood group test made for this pregnancy? or if not, was there a record of any previous test? One code only
Y
Tested for this pregnancy
X
Not tested, but previous record
O
Not tested and no previous record
What was the result? (Ring both Rhesus factor and ABO group)
2
Rh Pos.
3
Rh. Neg.
4
A
5
B
6
AB
7
O
8
ABO group not recorded
Was blood tested for Rh. Antibodies during this pregnancy?
Y
Yes
X
No
How many times was haemoglobin tested in this pregnancy? Number of times tested ...
O
Not tested at all
Generic number
Result. First (or only) test ... % ... week
Percentage
Week of pregnancy
Result. Last test ... % ... week
Percentage
Week of pregnancy
X-ray examinations during this pregnancy. Chest: X-ray at the ... th week
1
No X-ray
Week of pregnancy
X-ray examinations during this pregnancy. Abdominal: X-ray at the ... th week
2
No X-ray
Week of pregnancy
X-ray examinations during this pregnancy. Pelvimetry: X-ray at the ... th week
4
No X-ray
Week of pregnancy
Were any of the following abnormalities or illnesses or any other condition (not P.E.T.) encountered during this pregnancy? If so, please give the week diagnosed in each case.
O
If none encountered ring this code
Y
Diabetes
X
Heart disease
O
Tuberculosis (active)
1
Influenza
2
German measles
3
Vaginal bleeding before 28th week
4
APH: Accidental haemorrhage
5
APH: Placenta praevia
6
APH: Cause unknown
7
Suspected disproportion
8
Psychiatric disorder (under treatment)
9
External version
Ring code if condition encountered
Diabetes (Week First Noted)
Week of pregnancy
Heart disease (Week First Noted)
Week of pregnancy
Tuberculosis (active) (Week First Noted)
Week of pregnancy
Influenza (Week First Noted)
Week of pregnancy
German measles (Week First Noted)
Week of pregnancy
Vaginal bleeding before 28th week (Week First Noted)
Week of pregnancy
APH Accidental haemorrhage (Week First Noted)
Week of pregnancy
APH Placenta praevia (Week First Noted)
Week of pregnancy
APH Cause unknown (Week First Noted)
Week of pregnancy
Suspected disproportion (Week First Noted)
Week of pregnancy
Psychiatric disorder (under treatment) (Week First Noted)
Week of pregnancy
External version (Week First Noted)
Week of pregnancy
OTHER ILLNESSES OR ABNORMALITY Specify (Week First Noted)
Other
Week of pregnancy
Was the patient admitted to a hospital or maternity/nursing home or other institution during the antenatal period (for any other reason than P.E.T.) i.e. in pregnancy up to the time of the onset of labour ? Code all that apply
Y
No
X
Yes, to hospital
O
Yes, to maternity home
1
Yes, to nursing home
2
Yes, to other institutions (specify)
Other

Give the principal diagnosis or reason, date and duration for each admission.

Reason Week of Preg. Days in Ward
Generic textWeek of pregnancyDays in ward Generic textWeek of pregnancyDays in ward Generic textWeek of pregnancyDays in ward
1
2
3
Was patient admitted to institution during labour (include both booked and emergency cases)?
Y
Not admitted during labour
X
Admitted during labour as booked case
O
Admitted during labour as emergency (give reasons for emergency)
Generic text
Approximate time between onset of labour and admission ... hrs. ... mins.
Duration in hours and minutes

SECTION V.-DETAILS OF LABOUR

The information for this section should be got from records, notes or the experience of the person(s) who actually delivered the infant.
Did the person(s) conducting the delivery have full information about the antenatal period at time of labour?
1
Yes
2
No
Specify what information was missing, and state reason.
Generic text
How long was the labour? First stage ... hrs. ... mins.
Duration in hours and minutes
Y
Not known
How long was the labour? Second stage ... hrs. ... mins.
Duration in hours and minutes
X
Not known
How long before delivery did the membranes rupture, either spontaneously or by artificial means: ... hrs. ... mins.
Duration in hours and minutes
O
Not known
Did the patient run a temperature above normal during this interval?
1
Yes
2
No
3
Not known
Was induction carried out?
Y
Yes
X
No
Why was induction necessary?
O
Postmaturity
1
Hypertension
2
Other cause (specify)
Other
Which method(s) was used? Code all that Apply
6
Medical: O.B.E.
7
Medical: Pitocin
8
Medical: Other
9
Surgical
Specify method used.
Generic text
How soon after surgical induction did delivery occur? ... hrs. ... mins.
Duration in hours and minutes
What was the presenting part when the baby was delivered?
Y
Vertex O.A.
X
Vertex P.O.P
O
Breech
1
Shoulder
2
Face
3
Other presentation (specify)
Other
Was episiotomy carried out?
Y
Yes
X
No
What was the method of actual delivery?
O
Spontaneous
1
Forceps
2
Elective caesarean
3
Emergency caesarean
4
Other method (specify)
Other
What was the reason for assistance? Code all that Apply
3
Foetal distress: prolapsed cord
4
Foetal distress: passage of meconium
5
Foetal distress: foetal heart: slow, rapid, irreg.
6
Maternal distress
7
Toxaemia
8
Delay in second stage
9
Other reasons (specify)
Other
Were there are any complications of labour which have not been mentioned above; if so, please specify. Complications ...
Y
No other complications
Generic text
Was inhalational analgesia available at delivery and given?
Y
Not available at delivery
X
Available and given
O
Available, not given (specify reason)
Generic text
What agent was given?
3
Gas and Air
4
Trilene
5
Others (specify)
Other
For how long previous to last hour before delivery? ... hrs. ... mins.
Duration in hours and minutes
During the last hour before delivery? ... mins.
Duration in minutes
Was analgesia or sedative given by any other route than inhalation?
Y
Yes
X
No

What drugs were given and how much was given in last 2 hours (and in the previous 10 hours) of labour?

Name of Drug Amount given: In last 2 hours Amount given: In previous 10 hours
Generic textGeneric textGeneric text Generic textGeneric textGeneric text Generic textGeneric textGeneric text
1
2
3
4
Was any local, general or spinal anaesthetic administered during labour? Code all that Apply
Y
None
X
General
O
Spinal
1
Local
2
Pudendal block
Why was it given?
Generic text
What general anaesthetic was given?
Generic text
Which of the following persons were present at the delivery? (Qualified, trained or in training only) Person who delivered the baby
0
No trained person (e.g. B.B.A., policeman, etc)
1
Midwife
2
Consultant obstet.
3
Registrar
4
Hospital M.O.
5
G.P.
6
Medical Student
7
Pupil Midwife
8
Other (specify)
Other
Which of the following persons were present at the delivery? (Qualified, trained or in training only) Also present at delivery
0
No trained person (e.g. B.B.A., policeman, etc)
1
Midwife
2
Consultant obstet.
3
Registrar
4
Hospital M.O.
5
G.P.
6
Medical Student
7
Pupil Midwife
8
Other (specify)
Other

SECTION VI.-THE INFANT. RECORDS, NOTES, OR EXPERIENCE OF PERSON ATTENDING INFANT

What was the outcome of the delivery?
Y
Stillbirth
X
Livebirth
1
Single birth
2
Twin
3
Triplet
Note.-For multiple births, a separate schedule is required for each child, but Sections II, III and IV need only be completed for the first birth. Clip questionnaires together when despatching.
Sex of infant.
Y
Male
X
Female
Weight at birth? ... lbs. ... ozs.
Birth Weight (lbs)
Birth Weight (ozs)
O
Not weighed at birth
Estimated weight at birth ... Ibs. ... ozs.
Birth Weight (lbs)
Birth Weight (ozs)
Did the baby require resuscitation other than aspiration of the air passages? If so, please specify the method used, including details of oxygen. Methods and drugs used ...
3
Resuscitation not required
Generic text
Was the baby given any drugs or antibiotics during the period covered by this questionnaire (apart from drugs given for the purpose of resuscitation)?
Y
Yes
X
No

Was the baby given any drugs or antibiotics during the period covered by this questionnaire (apart from drugs given for the purpose of resuscitation)?

Name of Drug Reason Given No. of days given Dosage per day
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Did this baby have any laboratory tests or X-rays carried out during the period covered by this questionnaire?
Y
Yes
X
No

Did this baby have any laboratory tests or X-rays carried out during the period covered by this questionnaire?

Nature of test/X-ray Reason Day carried out Result
Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text Generic textGeneric textGeneric numberGeneric text
Did this baby have any congenital abnormality? If so, please specify. Congenital abnormality ...
O
No congenital abnormality
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What illnesses did this baby have during the first week of life? Illness(es) ...
O
None
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Fate of infant at end of first weeks of life.
Y
Alive
X
Died before 7 days old
O
Transferred before 7 days old
At what age? ... days ... hrs.
Duration in Days and Hours
Where to?
Generic text
Reason for Transfer?
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Section VII.

The remainder of this questionnaire applies ONLY to stillbirth or neonatal deaths. Information should be got from records, notes or experience of person(s) attending the patient or infant
Date of death? Died at ... days ... hrs. ... mins.
Duration in days, hours and minutes
Y
Stillbirth
When did foetal death occur?
Y
Before onset of labour
X
During labour
O
Not known whether before or during labour
How long before delivery did foetal death occur? ... days ... hrs. ... mins.
Duration in days, hours and minutes
Was the foetus macerated?
Y
Yes
X
No
Was a P.M. examination made? If so, where was this done? Place (address) ...
O
No P.M. examination
Place (address)
TO BE FILLED IN BY M.O.H.
Please give registered cause of this stillbirth (if in Scotland) or neo-natal death.
Generic text
SECTION VII. (Contd.) PLEASE FILL IN THIS SECTION IF THE BABY WAS STILLBORN OR DIED UNDER 28 DAYS.
Please use an extra sheet if short of space
Please give a short summary of present pregnancy, with special reference to abnormalities, illnesses; please include also conditions leading up to foetal death, if these occurred before labour.
Long text
Please give short summary of course of labour, with special reference to any complications; please include also conditions leading up to foetal death if these occurred during labour.
Long text
Please give short clinical history of baby between time of delivery and death, with special reference to any abnormalities or illnesses, and any notes which may help to explain why death occurred.
Long text
Name

Birth Questionnaire