Facility Worksheet For The Live Birth Certificate Template (Page 4 of 6) in pdf

____Clinical chorioamnionitis diagnosed during labor or maternal temperature >=38° C (100.4° F) - (Clinical

diagnosis of chorioamnionitis 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).

____Moderate/heavy meconium staining of the amniotic fluid - (Staining of the amniotic fluid caused by passage of

fetal bowel contents during labor and/or 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 Resuscitative 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 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 anesthetic 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.)

____None of the above

Method of Delivery (The physical process by which the complete delivery of the infant was effected)

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

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

delivery.) (Circle One)

Yes

If Yes, Was it successful? (Circle One)

Yes

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

attempt at vaginal delivery.) (Circle One) Yes

If Yes, Was it successful? (Circle One)

Yes

C. Fetal presentation at birth (Check one):

____Cephalic - (Presenting part of the fetus listed as vertex, occiput anterior (OA), occiput 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.)

(Circle One) Yes

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

(Check all that apply):

____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 perineal 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.)

____None of the above

Mother’s Medical Record Number: ____________________________________________________

Page 4 of 6

Facility Worksheet For The Live Birth Certificate Template Page 4

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