Facility Worksheet For The Live Birth Certificate Template (Page 5 of 6) in pdf

Newborn

(Sources: Labor and delivery records, Newborn’s medical records, mother’s medical records)

Birthweight (grams preferred): ________________grams or

_________pounds and ________ounces

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.)

Sex (Circle One)

Male

Female

Not yet determined

Apgar score (A systematic measure for evaluating the physical condition of the infant at specific intervals at

birth ):

Score at 5 minutes ______

Score at 10 minutes (If 5 minute score is less than 6)______

Plurality (Specify 1 (single), 2 (twin), 3 (triplet), 4 (quadruplet), 5 (quintuplet), 6 (sextuplet), 7 (septuplet), etc.)

(Include all live births and fetal losses resulting from this pregnancy.):________

If not single birth (Order delivered in the pregnancy, specify 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.) (Include all live

births and fetal losses resulting from this pregnancy):________

Abnormal conditions of the newborn (Disorders or significant morbidity experienced by the newborn)

(Check all that apply):

_____Assisted ventilation required immediately following delivery - (Infant given manual breaths for any duration

with bag and mask or bag and endotracheal tube within the first several minutes from birth. Excludes oxygen

only and laryngoscopy for aspiration of meconium.)

_____Assisted ventilation required for more than six hours - (Infant given mechanical ventilation (breathing

assistance) by any method for > 6 hours. Includes conventional, high frequency and/or continuous positive

pressure (CPAP).)

_____NICU admission - (Admission into a facility or unit staffed and equipped to provide continuous mechanical

ventilatory support for a newborn.)

_____Newborn given surfactant replacement therapy - (Endotracheal instillation of a surface active suspension for

the treatment of surfactant deficiency due to preterm birth or pulmonary injury resulting in respiratory

distress. Includes both artificial and extracted natural surfactant.)

_____Antibiotics received by the newborn for suspected neonatal sepsis - (Any antibacterial drug (e.g., penicillin,

ampicillin, gentamicin, cefotoxine, etc.) given systemically (intravenous or intramuscular).)

____ Seizure or serious neurologic dysfunction - (Seizure is any involuntary repetitive, convulsive movement or

behavior. Serious neurologic dysfunction is severe alteration of alertness such as obtundation, stupor, or

coma, i.e., hypoxic-ischemic encephalopathy. Excludes lethargy or hypotonia in the absence of other

neurologic findings. Exclude symptoms associated with CNS congenital anomalies.)

_____ Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ

hemorrhage which requires intervention) - (Defined as present immediately following delivery or

manifesting soon after delivery. Includes any bony fracture or weakness or loss of sensation, but excludes

fractured clavicles and transient facial nerve palsy. Soft tissue hemorrhage requiring evaluation and/or

treatment includes sub-galeal (progressive extravasation within the scalp) hemorrhage, giant

cephalohematoma, extensive truncal, facial and/or extremity ecchymosis accompanied by evidence of

anemia and/or hypovolemia and/or hypotension. Solid organ hemorrhage includes subcapsular hematoma of

the liver, fractures of the spleen, or adrenal hematoma.)

_____None of the above

Congenital anomalies of the newborn (Malformations of the newborn diagnosed prenatally or after delivery.)

(Check all that apply):

_____Anencephaly - (Partial or complete absence of the brain and skull. Also called anencephalus, acrania, or

absent brain. Also includes infants with craniorachischisis (anencephaly with a contiguous spine defect).

_____Meningomyelocele/Spina bifida - (Spina bifida is herniation of the meninges and/or spinal cord tissue through

a bony defect of spine closure. Meningomyelocele is herniation of meninges and spinal cord tissue.

Meningocele (herniation of meninges without spinal cord tissue) should also be included in this category.

Both open and closed (covered with skin) lesions should be included. Do not include Spina bifida occulta (a

midline bony spinal defect without protrusion of the spinal cord or meninges).)

_____ Cyanotic congenital heart disease - (Congenital heart defects which cause cyanosis. Includes but is not

limited to: transposition of the great arteries (vessels), tetratology of Fallot, pulmonary or pulmonic valvular

Mother’s Medical Record Number: ____________________________________________________

Page 5 of 6

Facility Worksheet For The Live Birth Certificate Template Page 5

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