Birth Record Form
ADVERTISEMENT
1Reproductive
Care Program
BIRTH RECORD
of Nova Scotia
Grav
Para
MEMBRANE RUPTURE
________
____________
Ab
SB
NND
Date
SRM
______
______
_____
______
EDD
Gest
Time
_________
____________
______
Suspected
Preg/Med complications:
ARM
Duration
______
Medications (to mother within 24 hours before birth)
Meconium
No
Yes
Time
Drug /Dose/Route
Time first noted
_________
Mat. fever > 38 in labour
INITIATION/PROGRESS OF LABOUR
INDUCTION
Cerv. Ripening: Type
Spontaneous onset
_______
ARM
Oxytocin augmentation
Oxytocin
Induction reason
_______________
Mechanical (catheter)
BABY
Girl
Boy
Weight ____________ (g)
APGAR
0
1
2
1min
5 min
10 min
1st STAGE ESTABLISHED Date
Time
______________
___________
Heart Rate
Below
Above
Absent
100
100
2nd STAGE ONSET
Date
Time
______________
___________
Resp.
Absent
Slow
Good
effort
irregular
crying
BIRTH Date
Time
Position at birth
___________
________
_________
Muscle
Limp
Some
Active
tone
flexion
motion
Spontaneous
C/S:reason
____________ _________________
Reflex
None
Grimace
Cough
Irritab.
sneeze
Vacuum (&/or)
Forceps: reason
_______________________
Colour
Blue
Body Pink
All Pink
Pale
Blue extre.
Mid
Mid
Rotation
APGAR SCORE TOTALS
Low
Low
Manual or
Forceps
Erythromycin eye ointment
_____________________________
Outlet
Outlet
Signature
Place of Birth
Max. % or
RESUSCITATION
Attempted only
Attempted Only
<1 min.
1-3 min.
>3 min.
duration
Hosp
Home
Other
____
O2
Other Intervention (e.g. Breech Extraction)
_____________________
____
Bag & Mask
____
T-Piece
PLACENTAL DELIVERY Date
Time
_______________
____
__________
____
ET tube (ventilation)
Spontaneous
Assisted
Manual
____
LMA
Umbilical Vessels
3
2
Cord pH done
No
Yes
____
CPAP
Abnormalities describe
Weight
_________________
_______________
____
Chest compressions
Oxytocic
No
Yes Type
Dose
Route
_______
_______
_______
Tracheal suctioning
No
Yes
Meconium below cords
No
Yes
Infusion postpartum
_______________________________________
Naloxone
No
Yes Epinephrine
No
Yes Other med
No Yes
.
PPH
No
Yes Estimated blood loss
ml
______________________
<10 sec.
10-60 sec.
>1min.
Age at first breath
EPISIOTOMY
LACERATIONS
2nd ° (perineal)
Age at first cry
None
None
3nd ° (anal sphincter)
Age at sustained resp.
Midline
1st °(vaginal)
4th ° (rectal mucosa)
Mediolateral
Suture required
No
Yes
_________________________________________________
Count verified
Sutures
Sponges
Signature of RN/ MD / MW/RT responsible for resuscitation
ANALGESIA / ANAESTHESIA
None
Narcotic
Spinal
Date / Time last FHR
Stillbirth
________________________
Epidural
Nitrous Oxide
General
Other
Date / Time last FM
_____________
_________________________
COMMENTS
Signature of Nurse Attending Birth ______________________________
Signature of MD/MW Attending Birth _____________________
RCP/04 - Rev. 07/2012
BIRTH RECORD
WHITE- Motherʼs Chart / YELLOW – Newbornʼs chart / PINK – Physicianʼs Office
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical