Antenatal Record - Family Medicine Reference Page 3
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2
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4Antenatal Record 2
Ontario
In conjunction
Medical
Ministry of Health
with the
Association
and Long-Term Care
Patient’s Last Name
Patient’s First Name
Birth attendant
Newborn care
Family Physician
Final EDB
Allergies or Sensitivities
Medications / Herbals
G
T
P
A
L
Identified Risk Factors
Plan of Management
Recommended Immunoprophylaxis
Rh neg.
Rh IG Given:
YYYY/MM/DD
Rubella booster postpartum
Newborn needs: Hep B IG
Hep B vaccine
Subsequent Visits
GA
Weight.
Urine
Pres.
FHR/
SFH
Date
B.P.
Comments
(weeks)
Prot.
Posn.
FM
IPS, FTS, NT best done between 11w0d and 13w6d
MSS best done between 15w0d and 17w6d
Ultrasound for fetal anatomy best done between 18 and 20 weeks
Antenatal 1 to L&D when final EDB known and Initial Laboratory Investigations complete
Arrange for Prenatal Education Classes
24-28 week blood work with 1 hr. GCT
Rh Immunoprophylaxis at 28 weeks
Group B Strep. screening best done between 35 and 37 weeks
Antenatal 2 to be sent to Labour and Delivery
Review Labour and Delivery plans:
-pain management in labour
-admission and discharge timing
-postpartum contraception
Ultrasound
Additional Lab Investigations
Symphysis-Fundus Height (cm)
Date
GA
Result
Test
Result
90
40
75
Dating scan (if done)
Hb
LARGE FOR
50
DATES AND TWINS
18-20 weeks for morphology
ABO/Rh
35
25
Repeat ABS
10
1 hr. GCT
30
Discussion Topics
2 hr. GTT
GBS
25
Exercise
Preterm labour
Breastfeeding
Work plan
PROM
Circumcision
SMALL FOR DATES
Intercourse
APH
Discharge planning
20
Travel
Fetal movement
Car seat safety
Prenatal classes
Admission timing
Depression
GESTATIONAL AGE (WEEKS)
Birth plans
Pain management
Contraception
15
On call providers
Labour support
Postpartum care
20
22
24
26
28
30
32
34
36
38
40
42
Signature
Date
Signature
Date
4294-64 (05/03)
Canary – Mother’s chart – forward to hospital
Pink – Attendant’s copy
White – infant’s chart
7530-5625
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