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National Vital Statistics System

14. Risk factors in this pregnancy

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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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