Birth History Proforma: Essential Components
A comprehensive birth history proforma should systematically document maternal demographics, complete obstetric history including all pregnancy outcomes, current pregnancy details with gestational age and prenatal care, labor and delivery events, and neonatal outcomes including birthweight and any complications. 1
Maternal Demographics and Background Information
- Age, ethnicity, and socioeconomic factors should be documented as these influence pregnancy outcomes and risk stratification 1
- Pre-existing medical conditions require comprehensive documentation, including diabetes, hypertension, thyroid dysfunction, cardiovascular disease, renal disease, and hematologic disorders 2
- Medication history with clear documentation of all medications used during pregnancy and any necessary changes for pregnancy safety 2
Complete Obstetric History
- Gravidity and parity must be clearly documented, specifying the number of previous pregnancies and their outcomes 1
- Previous pregnancy outcomes should include detailed information about each prior pregnancy 2:
- Live births (singleton, twin, or higher multiples documented separately)
- Miscarriages (spontaneous loss before 20 weeks gestation, confirmed by ultrasound)
- Stillbirths (fetal death after 20 completed weeks of gestation)
- Ectopic pregnancies
- Terminations of pregnancy (including selective reductions)
- Previous pregnancy complications including history of cesarean section, congenital malformations, fetal loss, hypertensive disorders, postpartum hemorrhage, preterm delivery, macrosomia, placental abruption, and thrombotic events 2
- Gestational age at previous deliveries should be documented as median and interquartile range 2
- Birthweights of previous infants documented separately for singletons and multiples 2
Current Pregnancy Documentation
- Estimated date of conception and last menstrual period, with gestational age calculated by best obstetric estimate using early ultrasound and/or perinatal details 2
- Prenatal care timeline including number and frequency of visits, with risk-based stratification determining visit frequency 1
- Pregnancy type (singleton, twin, or higher multiple) confirmed by ultrasound 2
- Complications during current pregnancy including gestational diabetes, hypertension, pre-eclampsia, placental complications, and any maternal or fetal concerns 2
Labor and Delivery Events
- Mode of delivery (spontaneous vaginal, operative vaginal, or cesarean section) with clear documentation 2
- Gestational age at delivery in completed weeks, calculated by best obstetric estimate 2
- Labor characteristics including spontaneous versus induced labor, duration of labor stages, and maternal position during delivery 3
- Complications during labor such as postpartum hemorrhage, third or fourth degree lacerations, and any emergency interventions 4
- Anesthesia type used during delivery, particularly documentation of neuraxial anesthesia 2
Neonatal Outcomes
- Birthweight collected within 24 hours using calibrated electronic scale with 10-g resolution, documented separately for each infant in multiple births 2
- Infant sex and Apgar scores at standard intervals 5
- Neonatal complications including early neonatal mortality (first 7 days), late neonatal mortality (8-28 days), and any intensive care requirements 2
- Major congenital anomalies classified using standardized taxonomy, with explicit documentation if identified in multiples 2
- Infant head circumference and other anthropometric measurements 3
Risk Stratification and Care Level
- Maternal risk classification according to four-level system: basic care (Level I), specialty care (Level II), subspecialty care (Level III), or regional perinatal center (Level IV) 1
- Provider type and qualifications clearly documented, particularly for high-risk cases requiring maternal-fetal medicine specialists 1
- Interdisciplinary care plans with clear roles for each provider involved in complex cases 1
Special Considerations for High-Risk Patients
- Consultation notes from relevant specialists for women with pre-existing medical conditions 1
- Specific monitoring parameters based on underlying conditions (e.g., glucose monitoring for diabetes, hematocrit monitoring for polycythemia vera) 2
- Thrombosis history and anticoagulation management, particularly for patients requiring therapeutic anticoagulation during pregnancy 2
- Delivery planning including recommended mode and timing, with multidisciplinary involvement for complex cases 1
Documentation Quality Considerations
Common pitfalls include incomplete documentation of gestational age (missing in up to 15% of maternal recall), maternal position during labor (missing in 65% of records), and infant head circumference (missing in 24% of cases). 6, 3 Electronic medical record systems improve completeness and accuracy compared to paper records, particularly for critical outcome measures 4. Birth certificate data alone has variable reliability, with excellent agreement for infant characteristics and delivery mode but poor sensitivity for labor induction (46%) and pregnancy complications 7, 5.