Indiana Certificate Of Live Birth Worksheet Template (Page 9 of 12) in pdf

Moderate/heavy meconium staining of the amniotic fluid ( staining of the amniotic fluid caused by passage of fetal bowel

contents during labor andor 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 Resucative 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 delivery 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 anesthic 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)

Abruptio Placenta

7 7 7 7 2 2 2 2 . Method of delivery

. Method of delivery (The physical process by which the complete delivery of the infant was affected)

. Method of delivery

(Complete A, B, C, and D):

A. Was delivery with forceps attempted but unsuccessful? (Obstetric forceps was applied to the fetal head in an unsuccessful attempt at

vaginal delivery)

Yes

B. Was delivery with vacuum extraction attempted but unsuccessful? ( Ventouse or vacuum cup was applied to the fetal head in an

unsuccessful attempt at vaginal delivery)

Yes

C. Fetal presentation at birth (Check one):

Cephalic - (Presenting part of the fetus listed as vertex, occipital anterior (OA), occipital 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)

Yes

73. Maternal morbidity (Serious complications experienced by the mother associated with labor and delivery)

(Check all that apply):

None

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 perinatal 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.)

74. Birthweight:

GRAMS: _______________

POUNDS/OUNCES: __________________

75. 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)

76. Apgar score (A systematic measure for evaluating the infant's physical condition at specific intervals at birth)

Score at 5 minutes _______ 0 through 10

N o t T a k e n

U n k n o w n

If 5 minute score is less than 6:

Score at 10 minutes _______ 0 through 10

N o t T a k e n

U n k n o w n

5/25/2012

PAGE 9

VERSION 27 INDIANA'S BIRTH WORKSHEET

Indiana Certificate Of Live Birth Worksheet Template Page 9

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