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Monarch.Antenatal.and.Delivery.MCR.01

South Africa, 2015 - 2016
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MO-01.Monarch.Antenatal.and.Delivery.MCR
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Jun 06, 2017
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Jun 06, 2017
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Data file: MO-01 Monarch Antenatal & Delivery MCR

Cases: 2551
Variables: 575

Variables

BarcodeStickerId
Barcoded sticker ID number (M10.........)
RedCapEventName
Red cap Event Name
RedCapDataAccessGroup
Access Group
BarcodeIdAd
Barcoded sticker ID number (M10 ___)
BrcodePhotoAd
Bar code for photo (if different)
DateCollectedAd
Data Collection Date
CollectedByAd
Data Collector who did first enrolment:
PlaceDelAd
Place of delivery
OtherPlaceDelAd
If Other, please specify
DobMotherAd
Mother DoB
DobEstimatedAd
Is DOB estimated?
MotherIdAd
Mother ID number
ConfirmGunjaneni
Gunjaneni
ConfirmMachibini
Machibini
ConfirmEsiyembeni
Esiyembeni
ConfirmSomkhele
Somkhele
ConfirmMpukonyoni
Mpukunyoni
ConfirmMtubatuba
Mtubatuba
ConfirmKwaMsane
KwaMsane
ConfirmOther
Other
ConfirmUnknown
Uknown
OtherClinSpecAd
If Other, please specify
BlankMcrAd
Is the MCR blank?
HospAdmissionsAd
Was the mother admitted to hospital during the current pregnancy?
AdmitCodeDateAd
If Yes, please enter hospital code by admission date
HospAdmDxandTxAd
Diagnosis and treatment during hospital admission(s)
PrevPregAd
Number of PREVIOUS pregnancies
MiscarrNumAd
If any of the pregnancies ended in Intra-uterine Death (miscarriage), how many?
NndInfantDeathAd
If any children died at birth or within a week after birth, how many?
ChildLiveNumAd
How many OTHER live born children does mother have?
DescrObstNeonatcxAd
Description of complications (obstetric & neonatal history)
MedHisHealthy
Healthy
MedHisHypertension
Hypertension
MedHisEpilepsy
Epilepsy
MedHisDiabetes
Diabetes
MedHisCardiac
Cardiac
MedHisTB
TB
MedHisOther
Other
MedHisUnknown
Unknown
OtherMedhxAd
If Other, please specify
DescrMedGenhxAd
Description of medical & general history
MedicationAd
Does/did the mother take any medication for any of the above illnesses/medical co
MedicationNameAd
If yes, please specify
OperationsMedGenhxAd
Did the mother have any operations for any of the above medical conditions?
DetailOperationshxAd
Specify details of operations (if Yes to above)
SocialStatAd
What is mother's social status?
OtherSocStatAd
If Other, please specify
NoFamHis
No family history
FamHisTwins
Twins/Multiple Births
FamHisDiabetes
Diabetes
FamHisTB
TB
FamHisCongenital
Congenital
FamHisOther
Other
FamHisUnknown
Unknown/data not recorded
FamHistoryOtherAd
If Other, specify
FirstClinicBookingAd
At which clinic was the First Examination/Booking done?
lnmpAd
When was the mothers Last Known Menstrual Period (LNMP)
lnmpCertainAd
Was mother certain about LNMP?
DeliveryBookedAd
Was the mother booked to deliver at a specific date?
DateDelBookAd
If Yes, what was the date for delivery?
DeliverFacilityAd
If Yes, at which facility?
ContraceptionPlanAd
Which method for future contraception was chosen/indicated?
ContracepSpecAd
If other, specify
SmokingAd
What was the mothers status regarding the use of tobacco (smoking)?
AlcoholAd
What was the mothers status regarding the use of alcohol?
DrugSubsAd
What was the mother's status regarding the use of any other drugs/substances?
FeedChoice1BookAd
Which feeding option did mother choose at First Booking?
FeedCommentsAd
If Other or Comments, please specify
DateFirstAncExamAd
Date of first ANC visit. (Date 1)
GestageAd
For Date 1, what was the gestational age that was recorded? Review MCR for entrie
FirstBPAncExamAd
Blood pressure at first ANC (Date 1) examination
Bp2Date1Ad
For date 1, what was the recorded BP2 ? (If more than one BP available for one da
Bp3Date1Ad
For date 1, what was the recorded BP3 ? (If more than one BP available for one da
PulseRate1Ad
For Date 1, what was the Pulse (P) rate?
WtFirstAncExamAd
Weight at first ANC (Date 1) examination (kg)
Weight2Date1Ad
For date 1, what was the weight2? (If more than one weight available for one day,
HeightFirstAncExamAd
t at first ANC (Date 1) examination (cm)
BmiFirstAncExamAd
BMI (kg/m2)
ThyroidFirstAncExamAd
Thyroid exam
HeartFirstAncExamAd
Heart exam
LungFirstAncExamAd
Lungs exam
AbdofirstAncExamAd
Abdomen exam
FirstMuacAd
At First Booking (Date 1), what was the mother's MUAC?
SfFirstAd
At First Booking (Date 1), what was the SF Measurement?
UrineFirstAncExamAd
Was an urine exam done?
UrineDip1Protein
P (protein): nil
UrineDip1P1Plus
P 1+
UrineDip1P2Plus
P 2+
UrineDip1P3Plus
P 3+
UrineDip1Sugar
S (sugar): nil
UrineDip1Strace
S trace
UrineDip1S1Plus
S 1+
UrineDip1S2Plus
S 2+
UrineDip1S3Plus
S 3+
UrineDip1Unknown
Unknown
UrineDip1Other
Other (specify)
Date1PhAd
For Date 1 was the pH of the urine recorded?
UrinPheDate1Ad
If yes, what was the pH?
Date1OtherUrineAd
For date 1 were there any other urine results noted?
ResultOtherUrine1Ad
If other urine results (eg Bilirubin) were recorded, what was the result?
PapsmearAd
Pap smear done?
ResultPapsmearAd
Result of pap smear
OtherPapsmearAd
If "Other" please specify
AbnormalPapmng1Ad
If abnormal pap smear result (CIN I, II,III,Cervical Cancer, indeterminate or oth
Rvd1Ad
Did the mother have a HIV Antibody test (RVD)?
DateRvd1Ad
If Yes, what was the date of her first HIV Antibody (RVD) test?
RvdResult1Ad
If Yes, what was the result?
Cd4FirstAd
Was the CD4 count determined?
ValueFirstCd4Ad
If Yes, what was the CD4 count?
WhoStagingAd
If WHO staging was done, specify
Date1ViralAd
For date 1 was there any viral load requested or done?
Date1ViralLoadActionAd
If Yes to Date1 viral load, what was noted/done? If viral load count available,
TherapyInitiatedAd
Was she initiated on ART (antiretroviral therapy) at THIS antenatal visit?
DateTherapyInitiateAd
If Yes, what was the date?
ArtStarCombFixed
Fixed dose combination (TDF/FTC/EFV)
ArtStarCombTDF
TDF (tenofovir)
ArtStarCombFTC
FTC (emtricitabine)
ArtStarCombAZT
AZT (zidovudine)
ArtStarComb3TC
3TC (lamivudine)
ArtStarCombABC
ABC (abacavir)
ArtStarCombd4T
d4T (stavudine)
ArtStarCombEFV
EFV (efavirenz)
ArtStarCombNVP
NVP (nevirapine)
ArtStarCombLPV
LPV/r (lopinavir/ritonavir, aluvia)
ArtStarCombATV
ATV/r (atazanavir/ritonavir)
ArtStarCombRAL
RAL (raltegravir)
ArtStarCombUnknown
Unknown
SyphScrAd
Did the mother receive a rapid syphilis test?
SyphScr1Ad
If yes what was the result?
RprSyphAd
If the syphilis screen was positive what was the RPR (titre)?
TphaSyphAd
If syphilis screen was positive what was the TPHA?
SyphTreatNeg
Negative syphilis test
SyphTreatNo
No treatment received
SyphTreatRec1st
Received 1st injection (penicillin)
SyphTreatRec2nd
Received 2nd injection (penicillin)
SyphTreatRec3rd
Received 3rd injection (penicillin)
TbScreenDate1Ad
For First Booking (Date 1), was the mother screened for TB ?
Date1TbScrResultAd
For Date 1, if yes to above, what was the result?
Date1TbpxAd
For Date 1 was the mother commenced on isoniazid (INH) prophylaxis (with pyridoxi
Date1TbTreatAd
For Date 1, was the mother started on Tb treatment?
Date1TbNot
Not screened for Tb
Date1TbNeg
Negative Tb screen
Date1TbIsoniazid
Isoniazid (INH or H)
Date1TbRifampicin
Rifampicin (RIF, or R)
Date1TbRifabutin
Rifabutin
Date1TbEthambutol
Ethambutol (E)
Date1TbPyrazinamide
Pyrazinamide (Z)
Date1TbPyridoxine
Pyridoxine (vitamin for INH side effects)
Date1TbStreptomycin
Streptomycin
Date1TbAmikacin
Amikacin
Date1TbClarithromycin
Clarithromycin
Date1TbAzithromycin
Azithromycin
Date1TbCiprofloxacin
Ciprofloxacin
Date1TbMoxifloxacin
Moxifloxacin
Date1TbPAS
Para Amino Salicylic acid (PAS)
Date1TbCapreomycin
Capreomycin
Date1TbEthionamide
Ethionamide
Date1TbCycloserine
Cycloserine
Date1TbBedaquiline
Bedaquiline
Date1TbUnknown
Unknown
Date1Suppl1Multi
Multi-vitamins (mvt)
Date1Suppl1Ferrous
Ferrous Sulphate/FeSO4/Iron
Date1Suppl1Folic
Folic Acid
Date1Suppl1Calcium
Calcium Suppl
Date1Suppl1Pregamal
Pregamal
Date1Suppl1VitaminB
Vitamin B-Complex
Date1Suppl1Other
Other
Date1OtherSupplAd
On Date 1 which other supplements were prescribed?
Date1AdviceContracepAd
For Date 1, was any advice/information/counselling on contraception/safe sex give
Date1AdviceIfAd
For Date 1, was there any advice/counselling/information given with regards to in
Date1AddAdviceAd
For Date 1, was there anything else in clinical notes not covered by the above? (
AntenatalUssAd
Did the mother have an ultrasound during pregnancy?
UssResultAd
If yes, what was the result of the USS? Enter BPD, FL, Abd.Circ., Placenta, Other
Date1PalpitationsAd
For Date 1 were there any palpitations reported?
Date1IxPalpnsAd
What investigations were performed for palpitations? e.g. ECG, ECHO, scans
Date1TxPalpnsAd
Was any treatment prescribed for palpitations?
Date1HypertensionAd
For Date 1 was there any Hypertension (HPT)/Pregnancy Induced Hypertension (PIH)
Date1OtherHypertensionAd
If Other, please specify
IxhtDate1Ad
What investigations were performed for hypertension?
Date1hyperAldomet
Aldomet (methyldopa)
Date1hyperAdalat
Adalat (nifedipine)
Date1hyperNil
Nil Treatment prescribed
Date1hyperOther
Other (specify)
Date1hyperBeta
Beta Blocker (eg labelatol)
Date1HypertxAd
If Other treatment for hypertension related conditions, please specify.
Headache1Ad
Date 1: Was there any headache recorded?
HeadacheInvest1Ad
What investigations were performed for headache (Date 1)?
RxHeadache1Ad
Date 1: Was there any treatment prescribed for the headache?
GestDiabScrDate1Ad
Was the mother screened for diabetes in pregnancy?
GestDiabUrine
Urine dipstick (glucose)
GestDiabRandom
Random blood glucose (blood test)
GestDiabFasting
Fasting blood glucose (blood test)
GestDiabGlucose
Glucose tolerance test, OGTT (blood tests over 3 hours)
GestDiabUnknown
Unknown
GestDiabResult1Ad
If yes, what was the result of the diabetes screening test?
TxGestDiabDate1Ad
What treatment and/or advice was the mother given for diabetes (or glucose intole
Date1OtherCondAd
For Date 1, please list other conditions not listed above.
IxDate1OtherCondAd
Were any additional investigations performed for Other Conditions listed above?
Date1OtherMedPrescAd
For Date 1, were there any other medications prescribed? eg. Amoxil, Panado
InvestigProtocolAd
Which other investigations/protocols were followed according to the Maternity Cas
OtherLabAd
Were there other lab results available?
OtherLabResSodium
Sodium
OtherLabResPotassium
Potassium
OtherLabResChloride
Chloride
OtherLabResBicarbonate
Bicarbonate
OtherLabResUrea
Urea
OtherLabResCreatinine
Creatinine
OtherLabResAlbumin
Albumin
OtherLabResALT
ALT (alanine aminotransferase)
OtherLabResALP
ALP (alkaline phosphatase)
OtherLabResGGT
GGT (gamma glutamyl transferase)
OtherLabResAST
AST (aspartate aminotransferase)
OtherLabResBilirubin
Bilirubin
OtherLabResHepatitisB
Hepatitis B tests
OtherLabResHepatitisC
Hepatitis C tests
OtherLabResCMV
CMV
OtherLabResVirology
Other virology
OtherLabResHb
Haemoglobin (Hb)
OtherLabResWBC
White blood cells
OtherLabResPlatelets
Platelets
HbDate1Ad
What was the Hb value on this result?
MrnHema1Ad
If yes to any of the above lab tests, what was the MRN for Haematology?
LabnoHaem1Ad
If yes to any of the above lab tests, what is the lab number for Haematology?
Mrnchempath1Ad
If yes to any of the above lab tests, what was the MRN for Chemical Pathology?
Labnochempath1Ad
If yes to any of the above lab tests, what is the lab number for Chemical Patholo
MrnVirol1Ad
If yes to any of the above lab tests, what was the MRN for Virology?
LabnoVirol1Ad
If yes to any of the above lab tests, what is the lab number for Virology?
MrnImmunol1Ad
Is there an MRN for Immunology?
LabnoImmunol1Ad
Is there a lab number for Immunology?
BarcodeDate1Ad
For Date 1, is there any barcoded sticker for lab tests on the clinical notes?
AnnrBarcodeAd
Date 1: What are the AA codes underneath the barcode?
ProblemsListAd
Were there any other problems listed in the top section of the Clinical Notes on
ListProblem1Ad
If Yes, write down any information/problem that was written in the "Problems Bloc
ConsentRvdResulAd
Did the mother give consent to RVD Results?
ConfirmDate2AncAd
Did the mother attend ANC a second time during pregnancy?
AncVisitDates2Ad
Second ANC Visit (Date 2)
GestageAge2Ad
For Date 2, what was the gestational age? Review MCR for entries.
Bp1Anc2Ad
Blood pressure at Second ANC (Date 2) examination
Bp2Date2Ad
For Date 2, what was the recorded BP2 ? (If more than one BP available for one da
Bp3Date2Ad
For Date 2, what was the recorded BP3 ? (If more than one BP available for one da
PulseRate2Ad
Pulse rate Date 2
Weight1Dt2Ad
Weight (kg) at Date 2
Weight2Dt2Ad
For Date 2, what was the weight2? (If more than one weight available for one day,
Sf2Ad
At Second Booking (Date 2), what was the SF Measurement?
UrineTest2Ad
Date 2: Was a urine test done?
UrineDip2Protein
P (protein): nil
UrineDip2P2Plus
P 1+
UrineDip2P3Plus
P 2+
UrineDip2P4Plus
P 3+
UrineDip2Sugar
S (sugar): nil
UrineDip2Strace
S trace
UrineDip2S1Plus
S 1+
UrineDip2S2Plus
S 2+
UrineDip2S3Plus
S 3+
UrineDip2Unknown
Unknown
UrineDip2Other
Other (specify)
PhDoneDate2Ad
Date 2: was the pH of the urine recorded?
PhDate2Ad
If yes, what was the pH for date 2?
OtherUrineDate2Ad
For date 1 were there any other urine results noted?
ResultOtherUrine2Ad
If other urine results (eg Bilirubin) were recorded, what was the results?
Papsmear2Ad
For Date 2: Pap smear done?
ResultPapsmear2Ad
Date 2: Result of pap smear
PapsmearOtherRes2Ad
If Other, please specify
AbnormalPapmng2Ad
Date 2: If abnormal pap smear result (CIN I, II,III,Cervical Cancer, indeterminat
Date2RvdTestAd
Date 2: Did the mother have a HIV Antibody (RVD) test?
RvdResult2Ad
If Yes, what was the result?
Cd4Date2Ad
Date 2: Was the CD4 count determined?
ResultCd4Date2Ad
If Yes, what was the CD4 count?
ViralDate2RequestAd
Date 2: Was there any viral load requested or done?
ViraLaod2Ad
If Yes, what was the viral load?
Artrx2Ad
On Date 2, was she initiated on ART? (antiretroviral therapy) at THIS antenatal v
ArtStarComb2Fixed
Fixed dose combination (TDF/FTC/EFV)
ArtStarComb2TDF
TDF (tenofovir)
ArtStarComb2FTC
FTC (emtricitabine)
ArtStarComb2AZT
AZT (zidovudine)
ArtStarComb23TC
3TC (lamivudine)
ArtStarComb2ABC
ABC (abacavir)
ArtStarComb2d4T
d4T (stavudine)
ArtStarComb2EFV
EFV (efavirenz)
ArtStarComb2NVP
NVP (nevirapine)
ArtStarComb2LPV
LPV/r (lopinavir/ritonavir, aluvia)
ArtStarComb2ATV
ATV/r (atazanavir/ritonavir)
ArtStarComb2RAL
RAL (raltegravir)
ArtStarComb2Unknown
Unknown
SyphScrt2Ad
Did the mother receive a rapid syphilis test?
SyphScr2Ad
If yes what was the result?
SyphTreatment2Ad
If syphilis positive did the mother receive treatment?
ResrprSyph2Ad
If the syphilis screen was positive what was the RPR (titre)?
TphaSyph2Ad
If syphilis screen was positive what was the TPHA?
Date2TbScrAd
For date 2, was the mother screened for Tb during pregnancy?
Date2TbScrResultAd
For date 2, if yes to above, what was the result?
Date2TbPxAd
For date 2, was the mother prescribed isoniazid (INH) prophylaxis (with pyridoxi
Date2TbTreatAd
For date 2, was the mother started on Tb treatment?
Date2TbTreatNot
Not screened for Tb
Date2TbTreatNeg
Tb screen negative
Date2TbTreatIsoniazid
Isoniazid (INH or H)
Date2TbTreatRifampicin
Rifampicin (RIF, or R)
Date2TbTreatRifabutin
Rifabutin
Date2TbTreatEthambutol
Ethambutol (E)
Date2TbTreatPyrazinamide
Pyrazinamide (Z)
Total: 575
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