Prenatal Care Worklist

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Smoking Status:

yo G0 P0000 @ wks by LMP or U/S.

Any history of C/S, Vacuum, or Forceps:

Referral to Genetics: Reason:

Referral to MFM: Reason:


Initial Testing:

Blood type w/ Rh: Antibody screen:

RPR:

HepBsAg:

Rubella:

Varicella:

HIV:

Hgb:

Carrier Screens

Hgb Electrophoresis:
Cystic Fibrosis:
Spinal Muscle Atrophy:

Vaginal Exam:

PAP:
Chlamydia:
Gonorrhea:

Urine

C&S
Tox screen:
Herpes History:

Genetics referral 1st trimester screening (11.0-13.6 weeks): referral given


Reviewed Genetics History______ Family History ________ OB History __________ Past Pregs _______ Gyne History ___________ Infection History ___________
Surgical History _______

2nd Trimester:

Labs:

Quad Screen(15w-21w6d if 1st trimester screen not done):
AFP (15-25w6d weeks only if 1st trimester screen done):
Cell Free DNA Alternative:

Flu shot:

Imaging(18-20 weeks):

Cervical length(Hx of PTB/Cervical Proc?):

3rd Trimester:

Antenatal Monitoring Recommended starting @ 28-32 weeks: Yes / No

(q4wk growth U/S or biweekly NST)

Tdap (27 - 36)

Labs:

Glucola(24-28):
CBC(28):
RPR(28):
Rhogam if Rh-(28) & Recheck Antibody Screen Prior to Dosing:
Group B Strep(35-37):

Delivery timing:

Placental location:

Presentation: (breech/cephalic)

Cervical Exam:

Planned method of delivery:

Consent for C/S: (yes/no, date)

BTL Desired (yes/no)

BTL consent: (yes/no, date)

Child's name:

Child's PCP:

Planned feeding method:

Planned b/c method:

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