Microsoft word - antenatal form c d.doc

Greater Manchester, East Cheshire & High Peak Form C
Neonatal Network Transport Service
Antenatal Transfers

Transfer Ref No:
Indication for transfer (please circle):
Threatened or actual prem labour / PET / Maternal medical condition / other (specify)
Foetal: specify

EDD: Gestation


Condition at Referral
Was patient contracting/ in labour?
(please enter either a tick for yes or a cross for no)
-If yes, what is cervical dilation (in cms) at decision to transfer? _______ Date and Time of exam:_____________
- And, how frequent are contractions at decision to transfer?
- If yes, specify which treatments?

- If no, has patient completed a course of steroids
at least 24 hrs prior to transfer?
Patients with PET
Is the Patient receiving anti-hypertensive medication?
-If yes, please specify which medication and if
2. Hydrallazine oral / iv
3. Labetalol oral / iv
Any intravenous medication required pre-transfer? -If yes, please specify which medication
Blood pressure recordings at point of decision to transfer: Systolic: Date & Time
Diastolic: of measurement:___________
-If no, please indicate why?
5. Other (specify)__________________________ Were there any problems during transfer? -If yes, ( please circle) Delivery
Seizures Other____________________________________ Did Consultant to Consultant discussion take place * For a guide on how to complete this form please see reverse*
Completing Form C

The referring (base) unit that requests a transfer will be responsible for completing the appropriate forms for each individual journey. Form C is to be completed at the time that a transfer is being requested by the medical, nursing or midwifery staff in charge of the arrangements. If you are the referring unit you will need to complete Form C.
The Transfer Ref No will be allocated by the Cot Bureau Administrator who takes the call. Please
ensure this number is put in the space allocated on the form.

For any sections of the form where there is a please either place a tick (√) if answering Yes or a
cross (X) if answering No.
For any section of the form where there is a list of answers to choose from, please circle the appropriate answer, and specify further if necessary. Once Form C has been completed it should then be brought to the attention of the ward clerk who will fax it together with Form A to the Cot Bureau, at St Mary’s Hospital on 0161 276 6451.
The unit log sheet provided should also be completed at this time, regardless of whether or not a transfer was successful. It is anticipated that Form A will be completed by the ward clerk (or another designated member of
staff) to provide some further details about both the mother and infant. Both Forms A and C should
then be retained in the file provided
, as these will be needed in the future for review by the audit



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