Indiana Certificate Of Live Birth Worksheet Template Page 8
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1267. 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):
None
Cervical cerclage (Circumferential banding or structure 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 pregnancy)
External cephalic version – (Attempted conversion of a fetus from a non-vertex presentation by external manipulation)
Successful
Failed
68. Were precautions taken against ophthalmia neonatorum?
□ Yes □ No
If Yes, then specify the Medication Used: _____________________________________________
69. Was a Serological test for Syphilis performed for the Mother?
YES If Yes give the date the specimen was taken:________________(MMDDYYYY)
If Yes when was the test performed?
□ During pregnancy
□ Time of Delivery
NO
If No give reason (check one below)
Mother's Refusal
□ Syphilis Status Known
Other (specify): _______________________________________________________
Unknown (Reason why there was no test is unknown)
Unknown (Unknown whether or not the test was performed)
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70. Onset of Labor
. Onset of Labor
. Onset of Labor (Check all that apply):
. Onset of Labor
None
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 last less than 3 hours)
Prolonged labor (>=20 hours) (Labor that progresses slowly and last for 20 hours or more
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71. Characteristics of labor and delivery
. Characteristics of labor and delivery
. Characteristics of labor and delivery (Check all that apply):
. Characteristics of labor and delivery
None
Induction of labor (Initiation of uterine contractions by medical andor 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 accerlate 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,
Clinical chorioamnionitis diagnosed during labor or maternal temperature > 38o C (100.4o F) (Clinical diagnosis of
chroniamninitis 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)
5/25/2012
PAGE 8
VERSION 27 INDIANA'S BIRTH WORKSHEET
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