Health (Notifications by Midwives) Amendment Regulations 2016 (WA)

1356 GOVERNMENT GAZETTE, WA 3 May 2016

Amendment Regulations 2016.

HEALTH

HE302*

Health Act 1911

Health (Notifications by Midwives) Amendment

Regulations 2016

Made by the Governor in Executive Council.

1.            Citation

These regulations are the Health (Notifications by Midwives)

3 May 2016 GOVERNMENT GAZETTE, WA 1357

2.             Commencement

These regulations come into operation as follows -

(a)	regulations 1 and 2—on the day on which these regulations are published in the Gazette;
(b)	the rest of the regulations - on 1 July 2016.

3.             Regulations amended

These regulations amend the Health (Notifications by Midwives)
Regulations 1994.

4.            Schedule amended

In the Schedule delete Form 2 and insert:

FORM 2

[r.4]

Health (Notifications by Midwives) Regulations 1994 Form 2 NOTIFICATION OF CASE ATTENDED- PREGNANCY DETAILS MR15

I jjJ Eutab

Last name	Unit Record No	LI	I	I
I

First name Birth date (Mother) LI LI I Wand

Address of usual residence	Marital status
Nusnise, and Street	1.oenernsor:ed 2-113.dnuond

state Port coda

4eoaeated N-n,amed linoL an 1oct01

Town or suburb Height Weight Ethnic status of mother [T

Maiden name _

(nnholCCmI (tslsaVtiinorOml t.00stun4n tCuiinnInotTorrs5t,aji

Interpreterservfcerequlredonyeoinna) Li lsIonlonIISll 11nTS050sa000gloui

Telephone

Mother's language requiring interpreter 12nubori0nal and ITt

PREVIOUS PREGNANCIES:	I	fertility treatments (include dengs)
total number (excluding this pregnancy):

Parity (excluding this pregnancy):	LIT	2	cervical Velure
3	Cdt/placental biopsy
Previous pregnancy outcomes:	4

- Ilneborn, now bring	5 ultrasound
• Ilneborn, now dead	6 flCTG antepartum

-	stillborn	[E	7	CIA intrapartunn
Number of previous caesareans

Intended piaceolthat onset oitabour:

Caesarean last delivery 1-yes 2-no H fl

- 1-hosoital 2-beth centre attached tohospital 3-beth

Peenious multiple brrths I -yen 2-no	contra freestanding 42hOrna 0.0:110,
THIS PREGNANCY:	LABOUR DETAILS
Esnimeted gest orb at antenatal uuit	Onset of labour:
Total number of antenatal care visits	1.spontan000u 2-rodased 3no labour

Date of IMP:	1 Li IhIEiIIIi	Principal reason for Induction of labour If anaoeedl:
This date certain	lnyes 2nno	[i}

Expected due date:	JIu1I1I
Sasedon t-rtnwol,qn,Jdoreu	Augmentation (tabour has tequ,n):

7- u4rronesodu20e.*s	Ll	I	none
3'rjrrmorrod,.20 045

Smoking:	2	oeytocin
3	Prostaglandins
Number of tobacco cigarettes usually smoked
each day during (lest 20 weeks of pregnancy	4	artificial rupture of membranes

S other

Number of tobacco cigarettes usually smoked

each day often 70 weeks of pregnancy

Wnone con uto'; occo,ioonlorn,nokedu loon 8%';	Induction (before labour begun):
pndeternrisred use '0021
Complications of pregnancy:	2  onytoc:n

threatened abortion (<20wks(	3	prostagland:ns
threatened preterer alms, (c37wbs)	4	artificial rupture of membranes

3	urinary not infection	S	dilatation deuce c. Foley Catheter
4	pre-.eclarnpsia	8	other
antepastum haemorehage (APHI placenta praevra

Analgesia (during tabour):

6         APIs - placental abcaptloo

I none

7        APIs-other

2        nitrous oxide

8        pro-labour rapture of membranes

9 gestational diabetes 4 iepidural/caudal

5spinal

IT gestational hypertension

6 - systemic oploids

12       pre-eclampsia superimposed on essential hypertension

7         combined spnal/epidurul

99 other (spnn:ly) _____________

8        other

Medical Conditions:  II III]

Duration aftabour hr win

- essential hypertension

3 asthma	1" stags (how & fllhl):	-
4genital herpes	stage (hour & win);	-- -. - - -

S	type I. diabetes
6	type 2 diabetes P00103101 blood loss In mis:

0 nrher(specify)_______________________________ Number of babes bore (admo purposes only) J

II lTThH MIDWIFE

Vaccinations during pregnancy:  during Name

O1"VOCCiV5otrCd 2 In,r,esrer Influenza Pertusset Signature

02-l/occ:oored idunony 2'° tr/mester

03nVoCc:nored damp 33 I I LL Date I 1 1210

Reg. NO. N 1 It W

04-Voce:no red in unknown trimester 'rimester I-

Complete tIcs Pregnancy tarn ooce (or each sueran glásg birth, and

5(%'	VOCCI0OICd
99U06oOwn if eac000led	subrrnn one Baby form Ion each may born

1358 GOVERNMENT GAZETTE, WA :3 May 2016

neaitn arm I

PCt's ow Move?, 'vi ne Urrrmnr.o I I

- nra

BIRTH C(TA8.3 Been before amnvak i-ps's 2am

Anesthesia (dcsemqde*very) Bletlr date: .1.

1         none

Birth timer (249r clock)

2         local anaesthesia to perefeam

Plurality: (rrsirrrberqbab.ei this both)

3         pudendal

4	epidural/caudal Birth order. (specify this baby t4 11' baby born, 2cr)
S	spinal Presentation:
6	general 1-cvrteu 22breech yoface 4nbross 8uotlrer
7	combined sprnal/eprdural Water birth .yes 7.rro
8	other Method of birth:

Complications of labour and birth	1	spoetaneoris
frrolrade Ore mosorm 're.enev.t ae:aery)	2	vacuum successful

I	preoptate deks'ery	3	vacuum unsuccessful
2	fetal distress	4	forceps successful

3 _cord tight around neck prolapsed cord

S - forceps ussuccetoful

6         breech (eogiinof)

S	cepfralopefnk disproportion	7	electmee caesarean
7	retained placenta - manual removal	8	emergency caesarean

8 - persistent occipto posterior

9

slrorildet dystocia

Acc.ch.urtu):

10

failure to progress o' 3cm

I obstetrician

Iltaikire to progress o 3cm

2

other medical officer

12

previous caesarean section

3 midwIfe

13

other (specfy}

4	student
S	self/no attendant

Principal reason for caesarean section (YeA eve bouair5,)t

8

other

I	fetal 001p'omce	Gender:	lersrale	2. female 3.irsdetenmnate
2	suspected fetal macrosoma

Statosof baby atbirth: 1.breborn 7.stlllbcrn(unspecfieoi

3	rrsalpeesentation	3oantepartam stillborn 4'intrapartum stillborn
4	lack of peogresue 3cm
Infant weight. (whole giom)
S	lack of progress in the 151 stage. 4cm to 10cm
Length: (e,ifro(e cm)
6	lack of peogress In the 2nd stage
7	placenta peaera	Head circumference! (where cm)
S	placental abruption	Time to establish unassisted regular breathing: (retrofe ,rn)
9	nasa praenia	Resuscitation: lRruo,0 ore ur'e trnrrrooc .tnruw or Pag?mt rn,rnben)
10	antepartum/intrapartum Iran rnonrfrage	1 none
11	multiple pregrsarmy	2 suction only
12	unsuccessful attempt at assisted delivery	3 oxygen therapy only
13	unsuccessful induction	4 continuous positron airway, pressure (CPAP)
14	cord prolapse	S bag and mask (IPPV)
15	previous caesarean section	6 endolracheul intubation
16	previous siroaldee dystocia	7 - vat, cardiac massage and veotdatiovs
17	previous perineal traum4" degree tear	other
18 previous adverse fetal/neonatal outcome	Apgar score:	1 made

19       other obntetnc. medical, surgical, psychological

lnd.catorrs Smesutes

20

maternal chorce in the absence of any obstetric,	Estimated gestation: (.hole weeks)
medical, surgical, psychological indications	girth defects: (specify)

Per at status:  - Birth trauma: (specify)

intact

BABY SEPARATION DETAILS

2         1' degree tearfsagmnal tear

Separation date:

3        2 degree tear

4 3 degree tear Mode of separation:

S - episiotomy t'aris'erred Scdied Pcdrscharged home

41'degree tear	Transferred to: (specify establishment code)
8 other	Special care number of days: (tocicides Level 1. niPple days only)

BABY 0(188,3 MIOVAFE

ABORIGINAL STATUS OF BABY hick one too oerJr) Name -

1 I Aborgioal but rrot Tismres Strait Islander

1 1)

2 TaInts Strait Islander but not Aboriginal Date

3 - Aboriginal and Torres Strait Islander

4 f'otfree Connde Iris Baby later once fat each baby torn, and tubrrl wills

-

K. H. ANDREWS, Clerk of the Executive Council.