Indiana Certificate Of Live Birth Worksheet Template (Page 10 of 12) in pdf

77. Abnormal conditions of the newborn (Disorders or significant morbidity experienced by the newborn)

(Check all that apply):

None

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. pencillin, ampicillin, gentamicin,

cefotoxine etc) given systemically ( intravenous or intramuscular)

Seizure or serious neurological dysfunction ( Seizure in any involuntary repetitive, convulsive movement of behavior. Serious

neurologic dysfunction is severe alteration or alertness such as obtundation, stipor or coma , i.e. hypoxic-ischemic encephalopathy.

Excludes lethargy or hypotonia in the bascence of other neurologic findings. Exclude systems associated with CNS congential

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 neve palsy. Soft tissue hemorrhage requiring

evaluation andor treatment includes sub-galeal (progressive extravasation within the scalp) hemorrhage, giant cephalohematoma,

extensive truncal, facial andor extremity echymosis accompanied by evidence of anemia andor hypovolemia andor hypotension.

Solid organ hemorrhage includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma)

78. Congenital anomalies of the newborn (Malformations of the newborn diagnosed prenatal or after

delivery.)

(Check all that apply):

None of the anomalies listed

Anencephaly - (Partial or complete absence of the brain and skull. Also called anencephalus, acrania, or abscent brain. Also

includes infants with craniorachischisis ( anencephaly with a contiguous spine defect)

Meningomyelocele/Spina bifida ( Spina Bifida is herniation of the meninges andor 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 limited to: transposition of the

great arteries (vessels) tetratology of Fallott , pulmonary or pulmonic valvular atresia, tricuspid atresia, truncus arteriosus, totalpartial

anomalous pulmonary venous return with or without obstruction)

Congenital diaphragmatic hernia ( Defect in the formation of the diaphragm allowing hernation of abdominal organs into the

thoracic cavity)

Omphalocele ( A defect in the anterior abdominal wall, accompanied by hernation of some abdominal organs through a

widened umbilibal stalk. The defect is covered by a membrane ( different from gastroschisis, see below) although this sac may

rupture. Also called exomphalos. Do Not include umbilical hernia (completely covered by skin) in this category)

Gastroschisis ( An abnormalitiy of the anterior abdominal wall, lateral to the umbilicus, resulting in hernation of the abdominal

contents directly into the amniotic cavity. Differentiated from omphalocele by the location of the defect and absence of a protective

membrane)

Limb reduction defect (excluding congenital amputation and dwarfing syndromes) ( Complete or partial absence of a portion of an

extremity associated with failure to develop)

Cleft Lip with or without Cleft Palate ( Incomplete closure of the lip. May be unilateral, bilateral or median)

Cleft Palate alone ( Incomplete fusion of the palatal shelves. May be limited to the soft palate or may extend into the hard palate.

Cleft palate in the presence of the cleft lip should be included in the “cleft lip with or without Cleft Palate” category above)

Down Syndrome - (Trisomy 21)

Karyotype Confirmed

Karyotype Pending

U n k n o w n

Suspected chromosomal disorder ( Includes any constellation of congenital malformations resulting from or compatible with

known syndromes caused by detectable defects in chromosome structure)

Karyotype Confirmed

5/25/2012

PAGE 10

VERSION 27 INDIANA'S BIRTH WORKSHEET

Indiana Certificate Of Live Birth Worksheet Template Page 10

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