Patient code number*
* May be medical record # or project-specific code #
depending on the evaluation circumstances.
CenteringPregnancy® Chart Abstraction Form
Complete this form only if your CenteringPregnancy® (CP) program is conducting chart
abstraction for the purposes of outcome evaluation.
1. Name and title of abstracter:
2. Today's date (MM-DD-YY)
____- ____- ____
3. Mother's birth date (MM-DD-YY)
____- ____- ____
4. Was this pregnancy
singleton
multiple
If this was a multiple pregnancy, do not answer any additional questions.
Prenatal Care
5. Gestational age at first prenatal visit (enter in a form like 12 weeks and 5 days)
_____ weeks and _____ days
If gestational age in weeks and days at first prenatal visit is not known, indicate:
month (enter a number, 1-9) _____ OR trimester (enter a number, 1-3) _____
6. Gestational age at first CP session attended
_____ weeks and _____ days or
Not applicable (mother did not attend CP)
7. Total number of prenatal visits (including CP)
______
8. Total number of CP visits
______
Maternal Birth History
9. Four-item OB Index from the Mother’s chart. (If the five-item OB Index is in the chart, note
the last four numbers only.)
X __ __ __ __
a. The first number is the total number of births (prior to this pregnancy)
b. The second number is the total number of preterm births (prior to this pregnancy)
c. The third number is the total number of miscarriages, stillbirths, and intentional
abortions (prior to this pregnancy)
d. The fourth number is the total number of currently living children (excluding this
pregnancy)
10. Prior to this pregnancy, did the mother ever have a cesarean delivery?
OB Issues for This Pregnancy
11. Pre-existing hypertension
No
Yes
12. Gestational hypertension
No
Yes
13. Preeclampsia
No
Yes
No
Yes
14. Placenta previa
No
Yes
15. Pre-existing diabetes
No
Yes
16. Gestational diabetes
No
Yes
17. Smoking in mo. before pregnancy
No
Yes
18. # of cigs. per day, mo. before pregnancy _______ (0 if none) or
19. Smoking during pregnancy
No
20. # of cigs. per day, during pregnancy
Unknown
Yes
_______ (0 if none) or
Unknown
21. Mother’s weight at the beginning of the pregnancy?
Underweight (BMI below 18.5)
Normal weight (BMI 18.5 – 24.9)
Overweight (BMI 25.0 – 29.9)
Obese (BMI 30.0 and above)
Not in chart
22. Maternal weight gain in pounds (rounded to the nearest pound)? ______
Outcomes for This Pregnancy
23. Due date of this pregnancy (MM-DD-YY)
____- ____- ____
24. Outcome of this pregnancy
Please fill in the event date in the one row that describes the outcome of this pregnancy.
Pregnancy
Outcome
Date of Event
(enter in the form
MM-DD-YY)
Next Step
Live Birth
Please go to question 25
Stillbirth
Please go to question 30
Miscarriage
Please do not answer any additional questions
25. Type of delivery
Vaginal birth
Cesarean
26. Was the delivery induced?
No
Yes
27. Was the infant admitted to a NICU?
No
Yes
Unknown
28. Was there a neonatal death prior to postpartum visit?
No
Yes
29. Baby’s gender
Unknown (not seen postpartum)
Female
Male
30. Infant's birth weight in grams (rounded to the nearest 0.1 grams) _______
31. Gestational age at birth (enter in a form like 39 weeks and 3 days)
_____ weeks and _____ days
Thank you for your time, expertise, and all that you do to help mothers and babies!
CenteringPregnancy® Program Outcomes Chart Abstraction Form, p. 2