EPICure 2 PN:E2

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Affix EPICure 2barcode label here
PNE2
This form should be completed for all births of
gestational age range 220 to 266 weeks and all
live births lt22 weeks. If the baby is admitted to
the neonatal unit, keep the form in the babys
notes and complete at 28 days, or at death if
sooner. Please send completed forms to the
EPICure office. For babies 270 weeks who died,
please complete PDN for CEMACH.
4. Outcome (live births only)
3. Legal abortion?
1. Case definition
2. Timing of death (LFLs SBs only)
Notifiable under the1967-1992 Abortion Act
MOTHERS DETAILS (or hospital label)
DETAILS OF FETUS OR BABY
5. Surname
16. Surname
6. First name
17. First name
7. Address (usual residential address at time of
delivery)
18. NHS number (if applicable)
19. Date of birth (dd/mm/yyyy)
Time of birth (hhmm 24HR)
20. Birth weight (kg)
8. Postcode
21. Gestation at delivery (weeks days)
9. Hospital number
22. Sex
10. NHS number
11. Date of birth (dd/mm/yyyy)
Age (if DOB not known)
23. Number of babies this pregnancy (including
papyraceous)
12. Ethnic group
24. Birth order
PAST OBSTETRIC HISTORY
25. Number of previous
Spontaneous abortions
TOPs
13. Mothers height (cm)
Stillbirths
Mothers height (feet inches)
OR
Live births
14. Mothers weight (kg)
Mothers weight (stones pounds)
OR
Caesarean sections
15. Body mass index (BMI) (if mothers height and
weight not known)
Preterm births 24-36 weeks
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ANTENATAL CARE
38. Antenatal steroids (tick all that apply)
26. Date of last menstrual period (LMP)
(dd/mm/yyyy)
None
Betamethasone
Dexamethasone
27. Date of first booking appointment (dd/mm/yyyy)
Not known
39. Dose (if applicable)
28. Date of first scan (dd/mm/yyyy)
Full course (last dose gt24h before birth)
Incomplete (last dose lt24h before birth)
Not known
29. Gestational age at first scan (weeks days)
40. Tocolysis (tick all tocolytic agents used in
week prior to delivery)
30. Estimated date of delivery (EDD) (dd/mm/yyyy)
31. Intended place of delivery at booking
Office use only
41. Evidence of fetal compromise documented gt24h
before birth(tick all that apply)
32. Actual place of delivery
Office use only
42. Antepartum cardiotography (CTGs) gt24h before
birth
33. Delivery on labour ward? (if hospital
delivery)
43. Antepartum dopplers gt24h before birth
34. Main reason for change between planned and
actual hospital of delivery
44. Was there clinical suspicion of
chorioamnionitis at any time more than one week
before birth?
35. Maternal smoking in pregnancy at time of
first booking?
45. Was maternal pyrexia gt37.5C noted during 24h
prior to birth?
36. Maternal medical complications in pregnancy
(tick all that apply)
46. Was chorioamnionitis noted at time of birth?
37. Obstetric complications (tick all that apply)
47. Antibiotics during 24h prior to birth
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LABOUR AND DELIVERY
48. Labour
57. Fetus alive at admission to hospital?
58. Alive at onset of labour?
49. Fetal monitoring during labour
LIVE BIRTHS ONLY
59. Trunk delivered into plastic bag to avoid
hypothermia?
50. CTG interpretation
60. Was there a heart rate at birth?
51. Epidural?
61. Signs of life within the first hour (tick all
that apply)
52. Presentation immediately prior to delivery
62. Resuscitation (tick all that apply)
53. Mode of delivery (include all modes attempted)
54. Caesarean section indication (if applicable)
63. Heart rate gt100 at 5 minutes?
55. Health professionals present immediately
before birth(tick all that apply)
64. Surfactant given on labour ward
ALL BIRTHS
65. Was a congenital anomaly suspected before
birth?
56. Maternal supporters present at any time
during labour or delivery (tick all that apply)
66. Was a congenital anomaly noted at delivery?
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ALL BIRTHS
LATE FETAL LOSSES, STILLBIRTHS AND NEONATAL DEATHS
75. Place of death
Office use only
67. Was the plan for preterm delivery discussed
with a senior obstetrician?
76. Principal category of death (neonatal deaths
only)
68. Was a decision made not to perform CS for
fetal distress?
69. Paediatric counselling (if applicable tick
all that apply)
77. Post-mortem
70. Did the parents express a choice about
resuscitation and the provision of neonatal
intensive care?
78. Cause of death (clinical details)
a. Main fetal or infant disease or condition
71. Was the possibility of withholding intensive
care discussed?
b. Other fetal or infant diseases or conditions
c. Main maternal disease or condition affecting
fetus or neonate
LATE FETAL LOSSES, STILLBIRTHS AND NEONATAL DEATHS
d. Other maternal diseases or conditions
affecting fetus or neonate
72. Date of death (dd/mm/yyyy)
Time of death (hhmm)
e. Other relevant causes or conditions
73. Gestation at which death confirmed (LFLs
stillbirths only)
79. Extended Wigglesworth Classification (see
guidelines)
74. Cause of IUD after admission
80. Fetal and Infant Classification (see
guidelines)
81. Obstetric (Aberdeen) Classification (see
guidelines)
DETAILS OF PERSON WHO COMPLETED THIS FORM
Please send completed forms to Professor Kate
Costeloe Department of Child Health Neonatal
Unit Homerton University Hospital NHS Foundation
Trust Homerton Row London E9 6SR
Name
Job title or position
Contact telephone number or email address
Date form completed
THANK YOU
All patient identifiable information is collected
on behalf of CEMACH. EPICure will treat these
items in the strictest confidence. CEMACH has
approval under Section 60 of the Health and
Social Care Act 2001 to process patient
identifiable information.
EPICure 2 PNE2 data collection form
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