Medical Data Worksheet For Child'S Birth Certificate Form Page 2
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1
2Obstetric Procedures
Onset of Labor
(check all that apply)
(check all that apply)
□
□
Cervical cerclage
Premature Rupture of the Membranes [prolonged > =12 hours]
□
□
Tocolysis
Precipitous Labor [< 3 hours]
□
Prolonged Labor [> = 20 hours]
External cephalic version
□
□
□
Successful
Failed
None of the above
□
None of the above
Method of Delivery
Was delivery with forceps attempted but unsuccessful?
Characteristics of Labor & Delivery
□
□
□
Yes
No
Unknown
(check all that apply)
□
Was delivery with vacuum extraction attempted but unsuccessful?
Induction of labor
□
□
□
Yes
No
Unknown
□
Augmentation of labor
Fetal presentation at birth
□
□
□
□
Non-vertex presentation
Cephalic
Breech
Other, _________________________
□
Steroids (glucocorticoids) for fetal lung maturation
Final route and method of delivery
received by mother prior to delivery
□
□
□
Vagina/Spontaneous
Vagina/Forceps
Vagina/Vacuum
□
Antibiotics received by mother during labor
□
If cesarean, was a trial of labor attempted?
Cesarean
□
□
□
□
Chorioamnionitis or maternal temperature > = 38 degrees C or
Yes
No
Unknown
100.4 degrees F
□
Moderate/heavy meconium staining of the amniotic fluid
Child’s Health Information
□
Fetal intolerance of labor was such that one or more of the
Grams, or
LB.
OZ.
________
________
________
Birth Weight
following actions was taken: in-utero resuscitative measures,
further assessments, or operative delivery
_________
Obstetric Estimate of Gestation (completed weeks):
□
Epidural or spinal anesthesia during labor
□
□
□
Child’s Sex:
Male
Female
Not yet determined
□
None of the above
Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______
Maternal Morbidity – Complications associated
Abnormal Conditions of the Newborn
(check all that apply)
with Labor & Delivery
(check all that apply)
□
Assisted ventilation required immediately following delivery
□
□
Maternal transfusion
Assisted ventilation required for more than six hours
□
□
Third or forth degree perineal laceration
NICU admission
□
□
Ruptured uterus
Newborn given surfactant replacement therapy
□
□
Unplanned hysterectomy
Antibiotics received by the newborn for suspected neonatal sepsis
□
□
Admission to intensive care unit
Seizure or serious neurologic dysfunction
□
□
Unplanned operating room procedure following delivery
Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or
□
soft tissue/solid organ hemorrhage which requires intervention)
None of the above
□
None of the above
Congenital Anomalies of the Newborn
(check all that apply)
□
□
Anencephaly
Cleft palate alone
Was Infant Transferred within 24 hours
of
Delivery?
□
□
□
□
_________________
Meningomyelocele/Spina bifida
Down syndrome
No
Yes, Specify Facility
□
□
Karyotype confirmed
Cyanotic congenital heart disease
Is Infant Living at Time of Report?
□
□
Karyotype pending
Congenital diaphragmatic hernia
□
□
Yes
No
□
□
Omphalocele
Suspected chromosomal disorder
□
□
Karyotype confirmed
Is Infant Being Breastfed at Discharge?
Gastroschisis
□
□
□
□
Karyotype pending
Yes
No
Limb reduction defect
(excluding congenital amputation
□
Hypospadias
and dwarfing syndromes)
Hepatitis B Immunization given?
□
□
□
□
Cleft lip with or without Cleft palate
None of the above
Yes
No
VS-109.2 (09/11)
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