"Facility Worksheet for the Live Birth Certificate"

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FACILITY WORKSHEET FOR THE LIVE BIRTH CERTIFICATE
For pregnancies resulting in the births of two or more live-born infants, this worksheet should be completed for the 1st live born
infant in the delivery. For each subsequent live-born infant, complete the “Attachment for Multiple Births.” For any fetal loss in
the pregnancy reportable under State reporting requirements, complete the “Facility Worksheet for the Fetal Death Report."
Mother’s name: ______________________________________________________________________________
Mother’s medical record # ________________________
Facility name: _______________________________________________________________________________
(If not institution, give street and number)
County of birth: _____________________________________________________________________________
City, Town or Location of birth: __________________________________________Zip Code: ____________
Place of birth:
___Hospital
___Freestanding birthing center (Freestanding birthing center is defined as one which has no direct physical
connection with an operative delivery center.)
___Home birth, Planned to deliver at home (Circle one)
Yes
No
___Clinic/Doctor’s Office
___Other (specify, e.g., taxi cab, train, plane, etc.)_____________________________________________
Information for the following items should come from the mother’s prenatal care records and from other medical reports in the
mother’s chart, as well as the infant’s medical record. If the mother’s prenatal care record is not in her hospital chart, please
contact her prenatal care provider to obtain the record, or a copy of the prenatal care information. Preferred and acceptable
sources are given before each section. Please do not provide information from sources other than those listed.
Prenatal
(Sources: Prenatal care records, mother’s medical records, labor and delivery records)
Date of first prenatal care visit (Prenatal care begins when a physician or other health professional first examines
and/or counsels the pregnant woman as part of an ongoing program of care for the pregnancy):
Month __ __ Day__ __Year__ __ __ __
___No prenatal care (The mother did not receive prenatal care at any time during the pregnancy. If no
prenatal care, skip the next question)
Date of last prenatal care visit (Enter the date of the last visit recorded in the mother’s prenatal records):
Month__ __ Day__ __ Year__ __ __ __
Total number of prenatal care visits for this pregnancy (Count only those visits recorded in the record.
If none enter “0”): ____________
Date last normal menses began: Month __ __ Day__ __Year__ __ __ __
Number of previous live births now living (Do not include this child. For multiple deliveries, do not include the
1st born in the set if completing this worksheet for that child. If none enter “0”): ________
Number of previous live births now dead (Do not include this child. For multiple deliveries, do not include the
1st born in the set if completing this worksheet for that child. If none enter “0”): ________
Date of last live birth: Month __ __ Year__ __ __ __
Total number of other pregnancy outcomes (Include fetal losses of any gestational age- spontaneous losses,
induced losses, and/or ectopic pregnancies. If this was a multiple delivery, include all fetal losses delivered before
this infant in the pregnancy. If none enter “0”): ________
Page 1 of 6
FACILITY WORKSHEET FOR THE LIVE BIRTH CERTIFICATE
For pregnancies resulting in the births of two or more live-born infants, this worksheet should be completed for the 1st live born
infant in the delivery. For each subsequent live-born infant, complete the “Attachment for Multiple Births.” For any fetal loss in
the pregnancy reportable under State reporting requirements, complete the “Facility Worksheet for the Fetal Death Report."
Mother’s name: ______________________________________________________________________________
Mother’s medical record # ________________________
Facility name: _______________________________________________________________________________
(If not institution, give street and number)
County of birth: _____________________________________________________________________________
City, Town or Location of birth: __________________________________________Zip Code: ____________
Place of birth:
___Hospital
___Freestanding birthing center (Freestanding birthing center is defined as one which has no direct physical
connection with an operative delivery center.)
___Home birth, Planned to deliver at home (Circle one)
Yes
No
___Clinic/Doctor’s Office
___Other (specify, e.g., taxi cab, train, plane, etc.)_____________________________________________
Information for the following items should come from the mother’s prenatal care records and from other medical reports in the
mother’s chart, as well as the infant’s medical record. If the mother’s prenatal care record is not in her hospital chart, please
contact her prenatal care provider to obtain the record, or a copy of the prenatal care information. Preferred and acceptable
sources are given before each section. Please do not provide information from sources other than those listed.
Prenatal
(Sources: Prenatal care records, mother’s medical records, labor and delivery records)
Date of first prenatal care visit (Prenatal care begins when a physician or other health professional first examines
and/or counsels the pregnant woman as part of an ongoing program of care for the pregnancy):
Month __ __ Day__ __Year__ __ __ __
___No prenatal care (The mother did not receive prenatal care at any time during the pregnancy. If no
prenatal care, skip the next question)
Date of last prenatal care visit (Enter the date of the last visit recorded in the mother’s prenatal records):
Month__ __ Day__ __ Year__ __ __ __
Total number of prenatal care visits for this pregnancy (Count only those visits recorded in the record.
If none enter “0”): ____________
Date last normal menses began: Month __ __ Day__ __Year__ __ __ __
Number of previous live births now living (Do not include this child. For multiple deliveries, do not include the
1st born in the set if completing this worksheet for that child. If none enter “0”): ________
Number of previous live births now dead (Do not include this child. For multiple deliveries, do not include the
1st born in the set if completing this worksheet for that child. If none enter “0”): ________
Date of last live birth: Month __ __ Year__ __ __ __
Total number of other pregnancy outcomes (Include fetal losses of any gestational age- spontaneous losses,
induced losses, and/or ectopic pregnancies. If this was a multiple delivery, include all fetal losses delivered before
this infant in the pregnancy. If none enter “0”): ________
Page 1 of 6
Date of last other pregnancy outcome (Date when last pregnancy which did not result in a live birth ended):
Month __ __ Year__ __ __ __
Risk factors in this pregnancy (Check all that apply):
Diabetes - (Glucose intolerance requiring treatment)
___Prepregnancy - (Diagnosis prior to this pregnancy)
___Gestational - (Diagnosis in this pregnancy)
Hypertension -
___Prepregnancy - (Chronic) Elevation of blood pressure above normal for age, gender, and physiological
condition diagnosed prior to the onset of this pregnancy.
___Gestational - (PIH, preeclampsia) Elevation of blood pressure above normal for age, gender, and physiological
condition diagnosed during this pregnancy. May include proteinuria (protein in the urine) without seizures or
coma and pathologic edema (generalized swelling, including swelling of the hands, legs and face).
___Eclampsia - Pregnancy induced hypertension with proteinuria with generalized seizures or coma. May include
pathologic edema.
___Previous preterm births - (History of pregnancy(ies) terminating in a live birth of less than 37 completed weeks
of gestation)
___Other previous poor pregnancy outcome - (Includes perinatal death, small for gestational age/intrauterine
growth restricted birth) - (History of pregnancies continuing into the 20th week of gestation and resulting in
any of the listed outcomes. Perinatal death includes fetal and neonatal deaths.)
___Vaginal bleeding during this pregnancy prior to the onset of labor.
Infertility Treatment-
___Pregnancy resulted from infertility treatment. - Any assisted reproduction technique used to initiate the pregnancy.
Includes fertility-enhancing drugs (e.g., Clomid, Pergonal), artificial insemination, or intrauterine insemination
and assisted reproduction technology (ART) procedures (e.g., IVF, GIFT and ZIFT).
___Fertility-enhancing drugs - Any fertility-enhancing drugs (e.g., Clomid, Pergonal), artificial insemination, or
intrauterine insemination used to initiate the pregnancy.
___Assisted reproductive technology - Any assisted reproductive technology (ART)/ technical procedures (e.g., IVF,
GIFT, ZIFT) used to initiate the pregnancy.
___Mother had a previous cesarean deliver? (Circle one)
Yes
No
If Yes, how many? ____
___None of the above
Infections present and/or treated during this pregnancy -(Present at start of pregnancy or confirmed diagnosis during
pregnancy with or without documentation of treatment.) (Check all that apply):
____Gonorrhea - (a diagnosis of or positive test for Neisseria gonorrhoeae)
____Syphilis - (also called lues - a diagnosis of or positive test for Treponema pallidum)
____Chlamydia - (a diagnosis of or positive test for Chlamydia trachomatis)
____Herpes Simplex Virus (HSV)
____Hepatitis B - (HBV, serum hepatitis - a diagnosis of or positive test for the hepatitis B virus)
____Hepatitis C - (non A, non B hepatitis, HCV - a diagnosis of or positive test for the hepatitis C virus)
____None of the above
Obstetric procedures -(Medical treatment or invasive/manipulative procedure performed during this pregnancy
specifically in the treatment of the pregnancy, management of labor and/or delivery.) (Check all that apply):
____Cervical cerclage - (Circumferential banding or suture of the cervix to prevent or treat passive dilatation. Includes
MacDonald’s suture, Shirodkar procedure, abdominal cerclage via laparotomy.)
____Tocolysis - (Administration of any agent with the intent to inhibit preterm uterine contractions to extend length of the
pregnancy.)
External cephalic version -(Attempted conversion of a fetus from a non-vertex to a vertex presentation by external
manipulation.) ____Successful ____ Failed
____None of the above
Mother’s Medical Record Number: ____________________________________________________
Page 2 of 6
Labor and Delivery
(Sources: Labor and delivery records, mother’s medical records)
Onset of Labor (Check all that apply):
____Premature Rupture of the Membranes (prolonged >=12 hours) (Spontaneous tearing of the amniotic sac, (natural
breaking of the bag of waters), 12 hours or more before labor begins. )
____Precipitous labor (<3 hours) (Labor that progresses rapidly and lasts for less than 3 hours.)
____Prolonged labor (>=20 hours) (Labor that progresses slowly and lasts for 20 hours or more.)
____None of the above
Date of birth: Month __ __ Day__ __Year__ __ __ __
Time of birth (12-hour clock): ___________Time
(Circle one) a.m.
p.m.
noon
midnight
Attendant/Certifier name and title: __________________________________________________
(Either the individual physically present at the delivery who is responsible for the delivery or the individual who certifies to
the fact that the birth occurred.)
____M.D.
____CNM/CM (Certified Nurse Midwife /
____D.O.
Certified Midwife)
____Hospital administrator or designee
____Other (Specify)___________________________
Attendant/Certifier mailing address: Street and Number_____________________________________________
City_______________________________________ State___________________ Zip Code_________
Principal source of payment for this delivery (At time of delivery):
____Private Insurance
____Other (Specify, e.g., Indian Health Service,
____Medicaid
CHAMPUS/TRICARE, Other Government
____Self-pay (No third party identified)
(federal, state, local))
___________________________________
Infant’s medical record number: ___________________________________
Was the mother transferred to this facility for maternal medical or fetal indications for delivery?
(Transfers include hospital to hospital, birth facility to hospital, etc.): (Circle One)
Yes
No
If Yes, enter the name and location of the facility mother transferred from:
______________________________________________________________________________________
Mother’s weight at delivery (pounds): ________
Characteristics of labor and delivery (Check all that apply):
____Induction of labor - (Initiation of uterine contractions by medical and/or surgical means for the purpose of
delivery before the spontaneous onset of labor.)
____Augmentation of labor - (Stimulation of uterine contractions by drug or manipulative technique with the intent
to reduce the time to delivery.)
____Non-vertex presentation - (Includes any non-vertex fetal presentation, e.g., breech, shoulder, brow, face
presentations, and transverse lie in the active phase of labor or at delivery other than vertex.)
____Steroids (glucocorticoids) for fetal lung maturation received by the mother prior to delivery - (Includes
betamethasone, dexamethasone, or hydrocortisone specifically given to accelerate fetal lung maturation in
anticipation of preterm delivery. Excludes steroid medication given to the mother as an anti-inflammatory
treatment.)
____Antibiotics received by the mother during labor - (Includes antibacterial medications given systemically
(intravenous or intramuscular) to the mother in the interval between the onset of labor and the actual delivery:
Ampicillin, Penicillin, Clindamycin, Erythromycin, Gentamicin,
Cefataxime, Ceftriaxone, etc.)
Mother’s Medical Record Number: ____________________________________________________
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____Clinical chorioamnionitis diagnosed during labor or maternal temperature >=38° C (100.4° F) - (Clinical
diagnosis of chorioamnionitis during labor made by the delivery attendant. Usually includes more than one of
the following: fever, uterine tenderness and/or irritability, leukocytosis and fetal tachycardia. Any maternal
temperature at or above 38°C (100.4°F).
____Moderate/heavy meconium staining of the amniotic fluid - (Staining of the amniotic fluid caused by passage of
fetal bowel contents during labor and/or at delivery which is more than enough to cause a greenish color
change of an otherwise clear fluid.)
____Fetal intolerance of labor was such that one or more of the following actions was taken: in utero resuscitative
measures, further fetal assessment, or operative delivery - (In Utero Resuscitative measures such as any of the
following - maternal position change, oxygen administration to the mother, intravenous fluids administered to
the mother, amnioinfusion, support of maternal blood pressure, and administration of uterine relaxing agents.
Further fetal assessment includes any of the following - scalp pH, scalp stimulation, acoustic stimulation.
Operative delivery – operative intervention to shorten time to delivery of the fetus such as forceps, vacuum, or
cesarean delivery.)
____Epidural or spinal anesthesia during labor - (Administration to the mother of a regional anesthetic for control
of the pain of labor, i.e., delivery of the agent into a limited space with the distribution of the analgesic effect
limited to the lower body.)
____None of the above
Method of Delivery (The physical process by which the complete delivery of the infant was effected)
(Complete A, B, C, and D):
A. Was delivery with forceps attempted? - (Obstetric forceps was applied to the fetal head in an attempt at vaginal
delivery.) (Circle One)
Yes
No
If Yes, Was it successful? (Circle One)
Yes
No
B. Was delivery with vacuum extraction attempted? - (Ventouse or vacuum cup was applied to the fetal head in an
attempt at vaginal delivery.) (Circle One) Yes
No
If Yes, Was it successful? (Circle One)
Yes
No
C. Fetal presentation at birth (Check one):
____Cephalic - (Presenting part of the fetus listed as vertex, occiput anterior (OA), occiput posterior (OP))
____Breech - (Presenting part of the fetus listed as breech, complete breech, frank breech, footling breech)
____Other - (Any other presentation not listed above)
D. Final route and method of delivery (Check one):
____Vaginal/Spontaneous - (Delivery of the entire fetus through the vagina by the natural force of labor with or
without manual assistance from the delivery attendant.)
____Vaginal/Forceps - (Delivery of the fetal head through the vagina by application of obstetrical forceps to the
fetal head.)
____Vaginal/Vacuum - (Delivery of the fetal head through the vagina by application of a vacuum cup or ventouse
to the fetal head.)
____Cesarean - (Extraction of the fetus, placenta and membranes through an incision in the maternal abdominal
and uterine walls.) If cesarean, was a trial of labor attempted? - (Labor was allowed, augmented or induced
with plans for a vaginal delivery.)
(Circle One) Yes
No
Maternal morbidity (Serious complications experienced by the mother associated with labor and delivery)
(Check all that apply):
____Maternal transfusion - (Includes infusion of whole blood or packed red blood cells associated with
labor and delivery.)
____Third or fourth degree perineal laceration - (3° laceration extends completely through the perineal skin,
vaginal mucosa, perineal body and anal sphincter. 4° laceration is all of the above with extension through the
rectal mucosa.)
____Ruptured uterus - (Tearing of the uterine wall.)
____Unplanned hysterectomy - (Surgical removal of the uterus that was not planned prior to the admission.
Includes anticipated but not definitively planned hysterectomy.)
____Admission to intensive care unit - (Any admission of the mother to a facility/unit designated as providing
intensive care.)
____Unplanned operating room procedure following delivery - (Any transfer of the mother back to a surgical area
for an operative procedure that was not planned prior to the admission for delivery. Excludes postpartum tubal
ligations.)
____None of the above
Mother’s Medical Record Number: ____________________________________________________
Page 4 of 6
Newborn
(Sources: Labor and delivery records, Newborn’s medical records, mother’s medical records)
Birthweight (grams preferred): ________________grams or
_________pounds and ________ounces
Obstetric estimate of gestation at delivery (completed weeks):________
(The birth attendant’s final estimate of gestation based on all perinatal factors and assessments, but not the
neonatal exam. Do not compute based on date of the last menstrual period and the date of birth.)
Sex (Circle One)
Male
Female
Not yet determined
Apgar score (A systematic measure for evaluating the physical condition of the infant at specific intervals at
birth ):
Score at 5 minutes ______
Score at 10 minutes (If 5 minute score is less than 6)______
Plurality (Specify 1 (single), 2 (twin), 3 (triplet), 4 (quadruplet), 5 (quintuplet), 6 (sextuplet), 7 (septuplet), etc.)
(Include all live births and fetal losses resulting from this pregnancy.):________
If not single birth (Order delivered in the pregnancy, specify 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.) (Include all live
births and fetal losses resulting from this pregnancy):________
Abnormal conditions of the newborn (Disorders or significant morbidity experienced by the newborn)
(Check all that apply):
_____Assisted ventilation required immediately following delivery - (Infant given manual breaths for any duration
with bag and mask or bag and endotracheal tube within the first several minutes from birth. Excludes oxygen
only and laryngoscopy for aspiration of meconium.)
_____Assisted ventilation required for more than six hours - (Infant given mechanical ventilation (breathing
assistance) by any method for > 6 hours. Includes conventional, high frequency and/or continuous positive
pressure (CPAP).)
_____NICU admission - (Admission into a facility or unit staffed and equipped to provide continuous mechanical
ventilatory support for a newborn.)
_____Newborn given surfactant replacement therapy - (Endotracheal instillation of a surface active suspension for
the treatment of surfactant deficiency due to preterm birth or pulmonary injury resulting in respiratory
distress. Includes both artificial and extracted natural surfactant.)
_____Antibiotics received by the newborn for suspected neonatal sepsis - (Any antibacterial drug (e.g., penicillin,
ampicillin, gentamicin, cefotoxine, etc.) given systemically (intravenous or intramuscular).)
____ Seizure or serious neurologic dysfunction - (Seizure is any involuntary repetitive, convulsive movement or
behavior. Serious neurologic dysfunction is severe alteration of alertness such as obtundation, stupor, or
coma, i.e., hypoxic-ischemic encephalopathy. Excludes lethargy or hypotonia in the absence of other
neurologic findings. Exclude symptoms associated with CNS congenital anomalies.)
_____ Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ
hemorrhage which requires intervention) - (Defined as present immediately following delivery or
manifesting soon after delivery. Includes any bony fracture or weakness or loss of sensation, but excludes
fractured clavicles and transient facial nerve palsy. Soft tissue hemorrhage requiring evaluation and/or
treatment includes sub-galeal (progressive extravasation within the scalp) hemorrhage, giant
cephalohematoma, extensive truncal, facial and/or extremity ecchymosis accompanied by evidence of
anemia and/or hypovolemia and/or hypotension. Solid organ hemorrhage includes subcapsular hematoma of
the liver, fractures of the spleen, or adrenal hematoma.)
_____None of the above
Congenital anomalies of the newborn (Malformations of the newborn diagnosed prenatally or after delivery.)
(Check all that apply):
_____Anencephaly - (Partial or complete absence of the brain and skull. Also called anencephalus, acrania, or
absent brain. Also includes infants with craniorachischisis (anencephaly with a contiguous spine defect).
_____Meningomyelocele/Spina bifida - (Spina bifida is herniation of the meninges and/or spinal cord tissue through
a bony defect of spine closure. Meningomyelocele is herniation of meninges and spinal cord tissue.
Meningocele (herniation of meninges without spinal cord tissue) should also be included in this category.
Both open and closed (covered with skin) lesions should be included. Do not include Spina bifida occulta (a
midline bony spinal defect without protrusion of the spinal cord or meninges).)
_____ Cyanotic congenital heart disease - (Congenital heart defects which cause cyanosis. Includes but is not
limited to: transposition of the great arteries (vessels), tetratology of Fallot, pulmonary or pulmonic valvular
Mother’s Medical Record Number: ____________________________________________________
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