High-Risk Checklist

A pregnancy diagnosed as “high-risk” can have different definitions. Variables depend on each mother, the extent of her complications, and even on the physician himself. This checklist has been developed by Sidelines in an attempt to help mothers and their healthcare team to mutually define needs in specific situations. Since variables change during each individually pregnancy, you may wish to make several copies of this checklist, to be completed at various stages of your pregnancy.

Activity Level

  • Maintain normal activity level
  • Decrease activity level
  • Cease any unnecessary activity

Working Outside the Home

  • Maintain full-time job
  • Work part-time ___hours
  • Work in home ___hours
  • Stop work completely (physician letter to employer ___ yes/no)

Working Inside the Home

  • Decrease housework including: ______________
  • May sit at desk with computer
  • Recline in bed with laptop/iPad

Childcare

  • May care for other children
  • No lifting children
  • Caregiver recommended

Outside Stress Influences

  • Visitors in home/time limit? ________________
  • Restriction of types of movies/books___________

Mobility

  • Continue normal mobility
  • Limit mobility (sit frequently)
  • Lie down each day ___hours
  • Recline all day (propped up)
  • Lie flat all day (on side primarily)
  • May climb stairs ___times per day
  • May take shower/wash hair ___minutes
  • May take bath/water temp___
  • May eat at table
  • May eat propped up in bed

Driving

  • May drive a car
  • May drive only to appointments
  • Cease driving
  • May be passenger in car

Bathroom Privileges

  • May use bathroom normally
  • Should actively avoid constipation/how________________
  • Use bedside commode

Sexual Relations

  • May continue normal sexual relations
  • Avoid sexual intercourse
  • Avoid all activities that may stimulate female orgasm

Monitoring Pregnancy

  • Monitor fetal movement ___ times daily
  • Monitor contractions ___ times daily
  • Call if __________________________
  • Call perinatal nurse ____daily ___ weekly

Treatments

  • Take medication/injection at home/type__________
  • Times daily/weekly/dosage_________________________
  • Come to office to receive injection of ____________
  • How often_______________________________________
  • Decrease___ increase___ caloric intake
  • Special dietary rules ______________________________

What I Might Expect in the Future

  • More frequent OB or maternal healthcare provider (HCP) visits
  • Assessment by or transfer to Perinatologist or other specialist
  • Makena (hydroxyprogesterone caproate injection) to lower the risk of preterm birth in women pregnant with a single baby with a history of unexpectedly delivering a baby
  • Vaginal progesterone cream for women who have a short cervix who do not have a history of preterm birth.
  • Cervical stitch ___week
  • Labor inhibiting medication__________________
  • Hospitalization
  • Amniocentesis ___week
  • Ultrasound
  • ROM test
  • Blood sugar screening ____week
  • Non-stress test (NST) ___week
  • Contraction stress test (CST)___week

If Problems Arise

  • What symptoms should alert me to call my OB/HCP___________
  • Consult with Neonatologist/Pediatrician prior to delivery
    Name/Phone ________________________________
    Name/Phone ________________________________
  • Which hospital should I go to in case of emergency_____________

Additional Instructions

___________________________________________________
OB/HCP Office phone #_____________________
After hours phone # ________________________
Other OB/HCP ____________________________

Hospitalization Checklist

Visitors Allowed

  • No
  • Yes, restricted to _________________________
  • Yes, unrestricted

Mobility/Activity

  • Unrestricted
  • Walk within hospital room
  • Sit in chair
  • Use hospital wheelchair
  • Bed rest with bathroom privileges
  • Bed rest with shower privileges
  • Bed rest with bed pan/beside commode only

Treatments, Tests, Technologies

  • Tocolysis for preterm labor___________________________
  • Fetal fibronectin (fFN)________________________________
  • Makena (hydroxyprogesterone caproate injection) to lower the risk of preterm birth in women pregnant with a single baby with a history of unexpectedly delivering a baby
  • Vaginal progesterone cream for women who have a short cervix who do not have a history of preterm birth.
  • Monitor fetal movement_________________________________
  • Monitor contractions ___________________________________
  • Screening for gestational diabetes ________________________

Consults

  • Physical therapist
  • Neonatologist
  • Social Worker
  • Dietician
  • Hospital support group

Available for Patients in Hospital

  • iPad
  • Childbirth educator/education
  • Laptop
  • Book cart/magazines
  • Crafts

Other Directions

________________________________________________________________________

Doctor’s office # ______________________________________
Other doctors who may be on call ___________________________

©2015 Sidelines National Support Network

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