Completing the Facility Worksheet for the Certificate of Live Birth

State of Illinois Revised May 2015

Completing The Facility Worksheet For the Certificate of Live Birth

How to Use this Guide Page Guide to Completing the Facility Worksheet for the Certificate of Live Birth NOTE: The birth certificate must be filed by the local registrar within 7 days from the date of birth. If the record is not filed, it will not be included on your monthly hospital statistics report. 1. Child’s name 5 2. Time of birth 6

3. Sex 6 4. Date of birth 7 5. Facility name 7 CHILD 6a. City or town 7 b. Zip code 8 7. County of birth 8 8a. Mother/co-parent’s current legal name 8 b. Date of birth 9 c. Mother/co-parent’s name prior to first marriage/civil union 9

d. Birthplace 10

/ / 9a. Residence of Mother/co-parent – state 10 b. County 11 c. City or town 11

d. Street and number 11

OTHER

M e. Apartment number 11 f. Zip code 12

g. Inside city limits 12 PARENT

- 10a. Father/co-parent’s current legal name 12

CO FATHER / FATHER b. Date of birth 12 c. Father/co-parent’s name prior to first marriage/civil union 13 d. Birthplace 13 11. Certifier’s name 14

12. Date certified 14 13. Local registrar’s 14 14. Date filled by registrar 14 15. Mother/co-parent’s mailing address 14 16. Mother/co-parent married 15 CERTIFIER 17. Social security number requested 15 18. Facility ID (NPI) 15 1

How to Use this Guide Page Guide to Completing the Facility Worksheet for the Certificate of Live Birth

19. Mother/co-parent’s social security number 15 20. Father/co-parent’s social security number 16 21. Mother/co-parent’s education 16

PARENT 22. Mother/co-parent of Hispanic origin 16

- 23. Mother/co-parent’s race 16

MOTHER MOTHER CO FATHER / FATHER 24. Father/co-parent’s education 17 25. Father/co-parent of Hispanic origin 17 26. Father/co-parent’s race 17 27. Place where birth occurred 18 28. Attendant’s name, title, and NPI 19 29. Mother transferred for maternal medical or fetal indication for delivery 20 30a. Date of first prenatal care visit 20 b. Date of last prenatal care visit 21 31. Total number of prenatal care visits for this pregnancy 21 32. Mother’s height 22

33. Mother’s pre-pregnancy weight 22

34. Mother’s weight at delivery 22 35. Did mother get WIC food for herself during this pregnancy 23 36a. Number of previous live births now living 23

MOTHER b. Number of previous live births now dead 24 c. Date of last live birth 25 37a. Number of other pregnancy outcomes 25 b. Date of last other pregnancy outcome 26 38. Cigarette smoking before and during pregnancy 26 39. Principal source of payment for this delivery 27 40. Date last normal menses began 27 41. Mother’s medical record number 28

How to Use this Guide Page

Guide to Completing the Facility Worksheet for the Certificate of Live Birth 42. Risk factors in this pregnancy 28-34

43. Infections present and/or treated during this pregnancy 35-37

44. Obstetric procedures 38-40

45. Onset of labor 41-42 46. Characteristics of labor and delivery 42-49 47a. Method of delivery - was delivery with forceps attempted but unsuccessful 49

HEALTH HEALTH b. Method of delivery - was delivery with vacuum attempted but unsuccessful 50 MEDICAL AND AND MEDICAL

INFORMATION c. Fetal presentation at birth 50 d. Final route and method of delivery 51-52 48. Maternal morbidity 52-54 49. Newborn medical record number 55 50. Birth weight of newborn 55 51. Obstetric estimate of gestation at delivery 56 52. APGAR score 56 53. Plurality 57 54. If not single birth 57

NEWBORN 55. Abnormal conditions of the newborn 58-62 56. Congenital anomalies of the newborn 63-67 57. Was infant transferred within 24 hours of delivery? 68 58. How is the infant being fed? 69 59. Is the infant living at the time of this report? 70

How to Use This Guide

This guide was developed to assist in completing the facility worksheet for the revised Certificate of Live Birth.

Note: All information on the mother should be based on the woman who gave birth to or delivered the infant.

Definitions Instructions Sources Key word/Abbreviations Define the items in the order Provide specific instructions Identify the sources in the Identify alternative, usually they appear on the facility for completing each item. medical records where synonymous terms and common worksheet. information for each item can abbreviations and acronyms for be found. The specific records items. The key words and available will differ somewhat abbreviations given in this guide from facility to facility. are not intended as inclusive. Facilities and practitioners will likely The source listed first (1st) is have others to add to the list. considered the best or preferred source. Medications commonly used for items. Please use this source whenever possible. All For example: “Clomid” for “assisted subsequent sources are listed reproduction treatment” in order of preference. The precise location within the “Look for” is used to indicate terms records where an item can be that may be associated with, but are found is further identified by not synonymous with an item. “under” and “or”. Terms listed under “look for” may indicate that an item should be reported for the pregnancy, but additional information will be needed before it can be determined whether the item should be reported.

“Trial of labor” for “cesarean delivery”

Missing Information: Where information for an item cannot be located please write “unknown” on the paper copy of the worksheet.

Guide to Completing the Facility Worksheet for the Certificate of Live Birth

1. Child’s name Definitions Instructions Sources Key word/Abbreviations The name given to the child Enter the first name, middle 1st Parents/co-parent’s report name, last name, and any suffix (Jr, II, III, etc.)

If a child has no first or middle name do not put Baby Girl or Baby Boy. Leave these fields blank. Enter only a last name in this case; last name cannot be blank.

When child has two last names or middle names, put just one space between names.

The electronic request, via Apostrophes will work unless they IVRS, for a Social Security either follow or are preceded by a Number will not be processed space or another character. Below by the Social Security are some examples of what will work Administration in cases where and what won’t. The key is that any certain special characters in combination (back to back) of a the child’s name were entered. space, hyphen, or apostrophe will The parents will need to cause a reject. request the issuance of the child’s Social Security number directly from the Social Security Administration office in the area where they live.

2. Time of birth Definitions Instructions Sources Key word/Abbreviations The infant’s time of birth Enter the time the infant was 1st Labor & Delivery under: born based on a 24-hour clock Delivery record (military time). If time of birth is unknown (foundlings) enter 2nd Newborn Admission H&P “unknown”. Enter a birth that occurs at exactly noon as 12:00 NOON. One minute after noon should be recorded as 12:01 pm.

Enter a birth that occurs at exactly midnight as 12:00 MIDNIGHT. One minute after midnight should be recorded as 12:01 am.

Do not record AM or PM for births occurring at exactly midnight or noon.

3. Sex Definitions Instructions Sources Key word/Abbreviations The sex of the infant Enter whether the infant is 1st Delivery Record under: M ~ Male male, female, or unknown Infant data F ~ Female A ~ Ambiguous (same as unknown) U ~ Unknown

4. Date of birth Definitions Instructions Sources Key word/Abbreviations The infant’s date of birth Enter the month, day, and four- 1st Labor & Delivery under: digit year of birth. Delivery record

If the date of birth of the infant 2nd Newborn Admission H&P is not known, because the infant is a foundling, enter the date the infant was found.

5. Facility name Definitions Instructions Sources Key word/Abbreviations The name of the facility Enter the name of the where the birth occurred. hospital/institution. If not a hospital/institution, enter complete street and number.

6a. City or town Definitions Instructions Sources Key word/Abbreviations The name of the city, town, Enter the name of the city, township, village, or other town, township, village, or location where the birth other location where the birth occurred. occurred. If the birth occurred in international waters or air space, enter the location where

the infant was first removed from the boat or plane.

6b. Zip code Definitions Instructions Sources Key word/Abbreviations The zip code of the hospital Enter the zip code of the or other location where the hospital or other location where birth occurred. the birth occurred.

7. County of birth Definitions Instructions Sources Key word/Abbreviations The name of the county Enter the name of the county where the birth occurred. where the birth occurred. If the birth occurred in international waters or air space, enter the name of the county where the infant was removed from the

boat or plane.

8a. Mother/co-parent’s current legal name Definitions Instructions Sources Key word/Abbreviations The mother’s legal name at Enter the first name, middle Hospital Face/admission If the mother/co-parent is married or in a the time the birth occurred. name & last name. Sheet. Verbal confirmation with civil union, and they took their spouse’s Mother. or partner’s name, this is where their Do NOT use periods after “new” name will be entered. initials. If they did not take their spouse’s or For someone with more than partner’s name, the name entered should one first, middle, or last name be consistent with what is on their birth only put one space between record. names.

If they have more than one last name, they can put a hyphen between the names. Make sure you don’t put a space between the hyphen and name.

8b. Date of birth Definitions Instructions Sources Key word/Abbreviations The birth mother’s date of Enter the month, day, and four- Hospital Face/Admission birth. digit year of birth. Sheet. Verbal confirmation with Mother.

8c. Mother/co-parent’s name prior to first marriage/civil union Definitions Instructions Sources Key word/Abbreviations The mother’s legal name Enter the first name, middle Mother’s report prior to her first marriage/ name & last name civil union. If the name is the same as what Example: maiden name. was entered above, put a Y in this box and the information entered above will auto-populate to these fields. If it is not the same, put an N and the fields will open for you to enter the correct name.

8d. Birthplace Definitions Instructions Sources Key word/Abbreviations State where mother was Enter the state of birth, territory Mother’s report If the mother was born in Canada, we born. or Foreign Country where the will need the province. mother was born.

This field defaults to the United States. If the mother/co-parent was born in another country, click the drop down and choose the correct country of birth.

State of Birth: If the mother/co-parent was born in the United States, pick the correct state or territory from the State of Birth drop down. Please remember that American Samoa, District of Columbia, Guam, Northern Marianas, Puerto Rico and the Virgin Islands are in the State drop down field as they are all territories of the United States.

9a. Residence of Mother/co-parent – state Definitions Instructions Sources Key word/Abbreviations The mother’s state where Enter the state where the Hospital Face/admission she currently resides/lives. mother currently resides/lives. Sheet. Verbal confirmation with An address is required. If in a Mother. shelter, use the shelter address.

9b. County Definitions Instructions Sources Key word/Abbreviations The mother’s county where Enter the county where the Hospital Face/admission she currently resides/lives. mother currently resides/lives. Sheet. Verbal confirmation with Mother.

9c. City or town Definitions Instructions Sources Key word/Abbreviations The mother’s city or town Enter the city or town where Hospital Face/admission where she currently the mother currently Sheet. Verbal confirmation with resides/lives. resides/lives. Mother.

9d. Street and number Definitions Instructions Sources Key word/Abbreviations The mother’s street and Enter the street and number Hospital Face/admission number (address) where she where the mother currently Sheet. Verbal confirmation with currently resides/lives. resides/lives. Mother.

Don’t enter extra spaces, P.O. Boxes or special characters (ex

#, &, *) in this field.

9e. Apt. no. Definitions Instructions Sources Key word/Abbreviations The mother’s apartment Enter the apartment number Hospital Face/admission number where she currently where the mother currently Sheet. Verbal confirmation with resides/lives. resides/lives. Mother.

9f. Zip code Definitions Instructions Sources Key word/Abbreviations The mother’s Zip code of Enter the Zip code where the Hospital Face/admission where she currently mother currently resides/lives. Sheet. Verbal confirmation with resides/lives. Mother.

9g. Inside city limits? Definitions Instructions Sources Key word/Abbreviations Is the mother’s residence Check the yes/no box. Hospital Face/Admission inside the city limits? Sheet. Verbal confirmation with This field is based on the Mother. mother’s response.

10a. Father/co-parent’s current legal name Definitions Instructions Sources Key word/Abbreviations The father’s legal name at Enter the first name, middle Father’s report the time the birth occurred. name, last name & suffix.

If father has multiple last names, don’t put any extra spaces or punctuation.

When entering father’s suffix, you can only put one suffix (ex Jr, III).

10b. Date of birth Definitions Instructions Sources Key word/Abbreviations The father’s date of birth. Enter the month, day, and four- Father’s report digit year of birth.

10c. Father/co-parent’s name prior to first marriage/civil union Definitions Instructions Sources Key word/Abbreviations The father’s legal name prior Enter the first name, middle Father’s report to his first marriage/civil name & last name union. If father has multiple last names, don’t put any extra spaces or punctuation.

10d. Birthplace Definitions Instructions Sources Key word/Abbreviations State where father was born. Enter the state, territory or Father’s report Foreign Country of the father. If father was born in Canada, we will This field defaults to the United need the province he was born. States. If the father/co-parent was born in another country, click the drop down and choose the correct country of birth.

State of Birth: If the father/co- parent was born in the United States, pick the correct state or territory from the State of Birth drop down. Please remember that American Samoa, District of Columbia, Guam, Northern Marianas, Puerto Rico and the

Virgin Islands are in the State

drop down field as they are all territories of the United States.

11. Certifier’s name Definitions Instructions Sources Key word/Abbreviations The name of the certifier of Enter by typing or printing the the birth certificate certifier’s name. Check the box for the appropriate title or complete the other box and specify.

12. Date certified Definitions Instructions Sources Key word/Abbreviations The date the birth was Enter the date the birth was certified. certified. This date cannot precede the date of birth.

13. Local registrar Definitions Instructions Sources Key word/Abbreviations The signature of the local Sign this box where indicated registrar. by the arrow.

14. Date filed by registrar Definitions Instructions Sources Key word/Abbreviations The date the birth certificate Enter the month, day, and four- is filed by the registrar. digit year of birth.

15. Mother/co-parent’s mailing address Definitions Instructions Sources Key word/Abbreviations Mother/co-parent’s mailing Add mother’s/co-parent’s Mother’s report address mailing address if different from her residence

16. Mother/co-parent married or in a civil union? Definitions Instructions Sources Key word/Abbreviations Is mother married or not? Enter “Yes” for married or in a civil union and “No” if she is not married or in a civil union.

17. Social Security number requested Definitions Instructions Sources Key word/Abbreviations Apply for a Social Security Mark “Yes” if you want to apply number for your child. for a social security card through the electronic birth system or answer “No” and you will get the social security card on your own. If the mother’s residence is a foreign country, if the infant passed away after birth or if the child’s first and middle name is left blank, you will have to mark “No” for social security card.

18. Facility ID (NPI) Definitions Instructions Sources Key word/Abbreviations Enter your facility’s ID (NPI) Enter the facility’s identification number

19. Mother/co-parent Social Security number Definitions Instructions Sources Key word/Abbreviations Enter Mother’s Social Enter the mother’s complete 9 Security number. digit social security number. Do not enter only the last 4 digits of the complete number. If mom does not have a social security number, enter 999-999-9999

20. Father/co-parent Social Security number Definitions Instructions Sources Key word/Abbreviations Enter Father’s Social Enter the father’s complete 9 Security number. digit social security number. Do not enter only the last 4 digits of the complete number. If father does not have a social security number, enter 999-999-9999

21. Mother/co-parent’s education Definitions Instructions Sources Key word/Abbreviations The mother/co-parent’s Check the box that best Mother’s report education. describes the highest degree or level of education completed at the time of delivery.

22. Mother/co-parent of Hispanic origin? Definitions Instructions Sources Key word/Abbreviations Is the mother/co-parent of Check the box best describing Mother’s report Hispanic origin? whether the mother/co-parent is Spanish/Hispanic/Latino. Check the “No” box if mother/co-parent is not Spanish/Hispanic/Latino

23. Mother/co-parent’s race Definitions Instructions Sources Key word/Abbreviations The mother/co-parent’s race. Check one or more races as Mother’s report identified by the mother/co- parent.

24. Father/co-parent’s education Definitions Instructions Sources Key word/Abbreviations The father/co-parent’s Check the box that best Father’s report education. describes the highest degree or level of education completed at the time of delivery.

25. Father/co-parent of Hispanic origin? Definitions Instructions Sources Key word/Abbreviations Is the father/co-parent of Check the box best describing Father’s report Hispanic origin? whether the father/co-parent is Spanish/Hispanic/Latino. Check the “No” box if father/ co-parent is not Spanish/Hispanic/Latino.

26. Father/co-parent’s race Definitions Instructions Sources Key word/Abbreviations The father/co-parent’s race. Check one or more races as Father’s report identified by the father/ co-parent.

27. Place where birth occurred Definitions Instructions Sources Key word/Abbreviations The place where the birth Check the box that best 1st Admission History and What if the vehicle stopped on the occurred: describes the type of place Physical (H&P) under side of the road? where the birth occurred. general Admission under Hospital Admitted from home, If the birth occurred in a moving If the birth occurred in a vehicle doctor’s office, other conveyance (car, ambulance, etc.), Freestanding birthing while en-route to the hospital Problem list/findings whether or not en route to a hospital, center ~ No direct physical AND the vehicle did not stop enter the place where the baby is first nd connection with an AND the baby was not 2 Delivery Record Under: removed from the conveyance. The operative delivery center transferred to another vehicle, Delivery information geographic location information of where complete the delivery record by Labor and Delivery the baby is removed from the En-Route marking “En-Route”. Summary conveyance must be entered into the Maternal obstetric place of birth fields. For example, child Home birth – the birth (OB)/labor summary was born in the parent’s car while driving occurred at a private If home birth is checked, check under delivery to the hospital. An ambulance meets the residence whether the home birth was Summary of labor and parents at the intersection of Route 4 planned. If unknown whether a delivery (L&D) Clinic/Doctor’s office planned home birth write and Plummer Road in the city of Chatham. The child and mother are “unknown”. 3rd Basic Admission removed from the parent’s car and put in Other Data the ambulance at Route 4 and Plummer OTHER -- “en route” Road. The mother and child are 4th Progress Notes or Note transported to a Springfield hospital. The place of birth entered on the birth record will be Sangamon County, Chatham, Corner of Route 4 and Plummer Road.

28. Attendant’s name, title, and NPI Definitions Instructions Sources Key word/Abbreviations The name, title, and National Enter the name, title, and NPI 1st Delivery Record under: Provider Identification number of the person Signature of Delivery Number (NPI) of the person responsible for delivering the Attendant (Medical) responsible for delivering child. the child. Check one box to specify the M.D. (doctor of medicine) attendant’s title. If “other” is D.O. (doctor of osteopathy) checked, enter the specific title CNM/CM (certified nurse or the attendant. midwife/certified midwife) Examples include: Other midwife (midwife other Nurse than a CNM/CM) Father Other (specify) Police Officer EMS Technician. The attendant at birth is defined as: This item should be completed The individual physically by the facility. If the birth did present at the delivery not occur in a facility, it should who is responsible for be completed by the attendant the delivery. or certifier.

For example: if an intern or nurse midwife delivers an infant under the supervision of an obstetrician who is present in the delivery room, the obstetrician should be reported as the attendant.

If the obstetrician is not physically present, the intern or nurse midwife should be reported as the attendant.

29. Mother transferred for maternal medical or fetal indications for delivery? Definitions Instructions Sources Key word/Abbreviations Transfers include: If the mother was transferred 1st Labor & Delivery Nursing Hospital to hospital from another facility check Admission Triage Form Birth facility to hospital “yes”. under: Reason for admission Does not include home to If “yes,” enter the name of the Comments hospital. facility the mother transferred from. If the name of the facility 2nd Admission H&P is not known, enter “unknown”. 3rd Labor & Delivery ~ Delivery Check “no” if the mother was record transferred from home. Maternal OB/labor summary Labor and delivery admission history Labor summary record

30a. Date of first prenatal care visit Definitions Instructions Sources Key word/Abbreviations The date the pregnant Enter the month, day, and year 1st Prenatal Care Record PNC ~ Prenatal care woman was first examined of the first prenatal care visit under: and/or counseled by a recorded in the records. Intake information Initial physical exam provider or healthcare Enter the date listed in the Prenatal visits flow sheet professional for the current most current record available. Current pregnancy pregnancy. Do not estimate the date of the

first visit. 2nd Initial Physical Examination

Complete all parts of the date, rd using 99 for unknown. For 3 Mother’s report

example, if the exact day is

unknown, enter the known

month and year but enter “99”

for the day.

If “no prenatal care” check the box and skip to 32.

30b. Date of last prenatal care visit Definitions Instructions Sources Key word/Abbreviations The month, day, and year of Enter the month, day, and year 1st Prenatal Care Record PNC ~ Prenatal Care the last prenatal care visit of the last prenatal care visit under Current Pregnancy recorded in the records. recorded in the records. 2nd Prenatal Visits Flow NOTE: Please enter the date Sheets (last date shown) of the last visit given in the most current record available. Do not estimate the date of the last visit.

Complete all parts of the date that are available.

Unknown portions of the date should be entered as "99”.

31. Total number of prenatal care visits for this pregnancy Definitions Instructions Sources Key word/Abbreviations The total number of visits Count only those visits NOTE: Please enter the total number recorded in the record. recorded in the prenatal of visits listed in the most current record. record available. Do not estimate If none, enter “0”. The “no additional visits when the prenatal prenatal care” box should also record is not current. be checked in item 30a. If prenatal record is not available mark “Unknown”.

32. Mother’s height Definitions Instructions Sources Key word/Abbreviations Mother’s height Enter the mother’s height in 1st Labor & Delivery Nursing feet and inches (ex: 5’ 6”) Admission Triage Form under: Physical Assessment ~ height

2nd Admission H&P under: Physical Exam ~ height

33. Mother’s pre-pregnancy weight Definitions Instructions Sources Key word/Abbreviations Mother’s weight prior to Enter mother’s weight before Prenatal record. Weight by Wt. ~ weight pregnancy pregnancy diagnosed. (Ex: provider on prenatal record. Wgt ~ weight 142½ as 142).

If the mother’s pre-pregnant weight is unknown, enter “unknown”.

34. Mother’s weight at delivery Definitions Instructions Sources Key word/Abbreviations The mother’s weight at the Enter the mother’s weight at 1st Labor & Delivery Nursing Wt. ~ weight time of delivery. the time of delivery. Use Triage Form under: Wgt ~ weight pounds only. Physical Assessment ~ (ex: 180½ as 180). weight. If the mother’s delivery weight is unknown, enter “unknown”. 2nd Admission H&P under: Physical Exam ~ weight

35. Did Mother get WIC food for herself during this pregnancy? Definitions Instructions Sources Key word/Abbreviations Is mother receiving WIC? Enter “Yes” if the mother is Hospital worksheet receiving WIC and “No” if she is not. If mom doesn’t know, enter “unknown”.

36a. Number of previous live births now living Definitions Instructions Sources Key word/Abbreviations The total number of previous Do not include this infant. 1st Prenatal Care Record under: L ~ now living live born infants now living. Include all previous live born Intake information infants who are still living. Gravida section ~ L Look for: (living) last number in G ~ Gravida ~ total number of Do not include abortions series. pregnancies (spontaneous miscarriages or Para section ~ L last P ~ Para ~ Previous live births as therapeutic or elective number in series well as fetal deaths > 20 weeks abortions), fetal Pregnancy history of gestation deaths/stillbirths. information T ~ Term ~ delivered at 37 to 40 weeks gestation For multiple deliveries: Previous OB history

Include all live born nd Note: NCHS reference to fetal death infants before this infant in 2 Labor and Delivery Nursing > 28 weeks is clinically incorrect. It is the pregnancy. If the first Admission Triage form correct in other poor pregnancy born, do not include this under Patient Data outcomes. infant. rd If the second born, 3 Admission H&P

include the first born, etc.

If no previous live born infants, check “none”.

See “Attachment for Multiple Births”

3 36b. Number of previous live births now dead Definitions Instructions Sources Key word/Abbreviations The total number of previous Do not include this infant. 1st Prenatal Care Record Expired live born infants now dead. Include all previous live born under: infants who are no longer Pregnancy history living. information ~ comments, complications For multiple deliveries: Previous OB history ~ Include all live born infants comments, complications before this infant in the Past pregnancy history ~ pregnancy that is now dead. comments, complications If this is a first born, do

not include this infant. nd 2 Admission H&P If the second born, include the first born, etc.

If no previous live born infants

now dead, enter 0.

If no information about previous births is available enter “unknown”.

See “Attachment for Multiple Births”.

36c. Date of last live birth Definitions Instructions Sources Key word/Abbreviations The birth date of the last live If applicable, enter the month 1st Prenatal Care Record DOB ~ Date of Birth born infant. and year of the last live born under: infant. Pregnancy history information ~ date Include live born infants now Previous OB history ~ living and now dead. date

Unknown portions of the date Past pregnancy history ~ should be entered as “99”. If date

the entire date is unknown nd mark the Unknown box. 2 Admission H&P

37a. Number of other pregnancy outcomes Definitions Instructions Sources Key word/Abbreviations Total number of other Include all previous 1st Prenatal care record under: Miscarriages pregnancy outcomes that did pregnancy losses that did Gravida section ~ “A” Fetal demise not result in a live birth. not result in a live birth. (abortion/miscarriage) AB ~ Abortion induced PARA section ~ “A” EAB ~ Elective abortion Includes pregnancy losses of If no previous pregnancy Pregnancy history SAB ~ spontaneous abortion any gestational age. losses mark “0”. information, comments, TAB ~ Therapeutic abortion complications Septic abortion Examples: spontaneous or For Multiple deliveries: Past pregnancy history ~ Ectopic pregnancy induced losses or ectopic Include all previous comments, complications Tubal pregnancy pregnancy. pregnancy losses before FDIU ~ fetal death in utero this infant in this 2nd Labor and Delivery Nursing IUFD ~ intrauterine fetal death/demise pregnancy and in Admission Triage Form previous pregnancies. 3rd Admission H&P

37b. Date of last other pregnancy outcome Definitions Instructions Sources Key word/Abbreviations The date the last pregnancy If applicable, enter the month 1st Prenatal Care Record under: Examples: that did not result in a live and year. Pregnancy history Stillbirths birth ended. information Spontaneous or induced Unknown portions of the date Previous OB history abortions or losses Includes pregnancy losses at should be entered as “99”. Past pregnancy history Ectopic pregnancy any gestational age. miscarriages If the entire date is unknown 2nd Admission H&P mark the Unknown box.

38. Cigarette smoking before and during pregnancy Definitions Instructions Sources Key word/Abbreviations Did the mother smoke For each time period, enter 1st Prenatal record cigarettes before and during either the number of cigarettes pregnancy. or the number of packs of 2nd Mother’s report cigarettes smoked per day. If none enter “0”.

Three months before pregnancy

First three months of pregnancy

Second three months of pregnancy

Third Trimester of pregnancy

39. Principal source of payment Definitions Instructions Sources Key word/Abbreviations The principal source of Check the box that best 1st Hospital Face Sheet payment at the time of describes the principal source nd delivery: of payment for this delivery. 2 Admitting Office Face Sheet

Private Insurance If “other” is checked, enter the 3rd Admitting Office Managed Medicaid payer as listed. Care reference Self-Pay Patients with insurance Other through the Affordable Care (specify: ______) Act (ACA) are to be entered If the principal source of as private insurance (it does payment is not known, choose not matter which insurance “unknown” from the drop down carrier is listed or if the patient list. receives a government

subsidy).

40. Date last normal menses began Definitions Instructions Sources Key word/Abbreviations The date the mother’s last Enter the date that the 1st Prenatal Care Record under: LMP ~ last menstrual period normal menstrual period mother’s last normal Menstrual history began. menstrual period began. Nursing admission triage Also may be entered as “LNMP” = form Last NORMAL Menstrual Period. Unknown portions of the date should be entered as “99”. 2nd Admission H&P under:

Medical History

41. Mother’s medical record number Definitions Instructions Sources Key word/Abbreviations The hospital medical record Write the medical record Hospital Face sheet number of the mother. number for the delivery admission of the mother.

42. Risk factors in this pregnancy Definitions Instructions Sources Key word/Abbreviations Risk factors of the mother Check all boxes that apply. during this pregnancy. The mother may have more than one risk factor.

If the mother has none of the risk factors, check “None”.

If you don’t have information

regarding the mother’s history mark “Unknown”.

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Diabetes: Glucose intolerance If diabetes is present, check 1st Prenatal Care Record under: Pre-pregnancy: requiring treatment. either pre-pregnancy or Previous OB history under: DM ~ Diabetes mellitus gestational diabetes. Do not summary of previous Type 1 Diabetes Pre-pregnancy: Glucose check both. pregnancies IDDM ~ Insulin dependent intolerance diagnosed Problem list or initial risk diabetes mellitus BEFORE this pregnancy. assessment Type 2 diabetes Historical risk summary Non-insulin dependent diabetes Complications of previous mellitus Gestational Diabetes: pregnancies Glucose intolerance that was Factors in this pregnancy Gestational: diagnosed DURING this GDM ~ gestational diabetes pregnancy. 2nd Labor and Delivery Nursing mellitus, either diet controlled or Admission Triage form medication controlled. under Medical IDGDM ~ Insulin dependent complications gestational diabetes mellitus. Comment

3rd Admission H&P under: Current pregnancy history Medical history Previous OB history under ~ pregnancy related Problem list/findings

4th Delivery Record under: Maternal OB/labor summary Labor and delivery admission history Labor summary record

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Hypertension: Check “pre-pregnancy or See above Pre-pregnancy: Elevation of blood pressure chronic hypertension” only if CHT ~ Chronic Hypertension above normal for age, gender, the mom had hypertension Essential hypertension and physiological condition; before the pregnancy or high blood pressure. between 0-20 weeks gestation. Gestational: Pre-pregnancy or chronic PIH ~ Pregnancy Induced hypertension: Elevation of Do not check both types of Hypertension blood pressure above normal hypertension—you must select Preeclampsia one or the other. for age of mother and Eclampsia physiological condition Eclamptic Seizure Check “gestational diagnosed PRIOR to the onset of this pregnancy or hypertension” if hypertension before 20 weeks gestation. was present only after 20

Gestational hypertension: weeks gestation. Elevation of blood pressure above 140 systolic or 90 Do not check both types of diastolic diagnosed AFTER 20 hypertension—you must select weeks gestation during this one or the other. pregnancy.

May also be called pre- Eclampsia: eclampsia and/or pregnancy- Eclampsia is hypertension and induced hypertension (PIH). generalized seizure or coma

If eclampsia is present, one type of hypertension (either gestational or chronic) may be checked.

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Previous preterm births: If the mom has older children, 1st Prenatal care record under: Look for: A history of a previous were any of them born early? Medical history Preterm Labor pregnancy resulting in a live Include only LIVE BIRTHS that Previous OB history under Preterm PROM born infant prior to 37 happened prior to 37 ~ summary of previous Advanced cervical completed weeks (include live completed weeks. pregnancies. dilation/effacement births born up to and including Problem list or ~ initial risk 36 weeks 6 days). Do not include miscarriages, assessment stillbirths, or fetal deaths. This Historical risk summary PTL ~ preterm labor is a different variable. Complications of previous P ~ Premature pregnancies

2nd Labor and Delivery Nursing Admission Triage Form under: Medical history Previous OB history under pregnancy related Problem list/findings

3rd Admission H&P under: Medical History Previous OB history under pregnancy related

Problem list/findings

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Other previous poor 1st Prenatal care record under: IUGR ~ intrauterine growth pregnancy outcome or risk Medical history restriction (retardation) factor Previous OB history under FDIU ~ fetal death in-utero summary of previous IUFD ~ intrauterine fetal death History of pregnancies pregnancies. SGA ~ small for gestational age th continuing into the 20 week of Problem list or initial risk SFD ~ small for dates gestation and resulting in any assessment Stillborn ~ infant/fetus born of any of the following outcomes: Historical risk summary gestational age without signs of life Perinatal Death: Complications of previous including fetal and pregnancies PROM ~ premature rupture of neonatal deaths membranes Small for gestational age 2nd Labor and Delivery Nursing PPROM ~ preterm premature Intrauterine growth Admission Triage Form rupture of membranes restricted birth under: Comments

3rd Admission H&P under: Medical History

Previous OB history under

pregnancy related

Problem list/findings

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Pregnancy resulted from any Check if any fertility therapy 1st Prenatal care record under: See lists below infertility enhancing drugs, was used. Medical history artificial insemination or Current pregnancy history intrauterine insemination. Problem list or initial risk assessment Any assisted reproductive Medications this treatment used to initiate the pregnancy pregnancy. 2nd Labor and Delivery Nursing Includes: Admission Triage Form Drugs (such as Clomid, under: Pergonal) Comments Artificial insemination Medications Technical procedures (such as in-vitro fertilization) 3rd Admission H&P under: Current pregnancy history Problem list/findings

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations

Fertility – enhancing drugs, Check if specific therapy (drugs Fertility-enhancing drugs, artificial or artificial insemination or or insemination) was used. intrauterine insemination: intrauterine insemination Medications Clomid Any fertility enhancing drugs Serophene (e.g. Clomid, Pergonal), Pergonal Metrodin artificial insemination or Profasi intrauterine insemination used Progesterol (NOT progesterone) to initiate the pregnancy Crinone (progesterone gel) Follistim FSH (follicle stimulating hormone) Gonadotropins HCG (human chorionic gonadotropin) 33

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Pregnancy resulted from any Check if assisted reproductive See above ART: assisted reproductive assisted reproductive therapy was used. technology technology. Artificial insemination AIH: artificial insemination by Any assisted reproductive husband technology (ART/technical In-vitro fertilization embryo transfer procedures [e.g. IVF, GIFT, GIFT: gamete intrafallopian transfer ZIFT]) used to initiate the ZIFT: zygote intrafallopian transfer pregnancy Ovum donation Sperm donation Donor embryo Embryo adoption

42. Risk factors in this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Mother had previous If the mother has had a 1st Prenatal care record under: C/S ~ cesarean section cesarean delivery previous cesarean delivery, Past pregnancy history Repeat C/S indicate the number of previous Past OB history VBAC ~ vaginal delivery after a Previous delivery by extracting cesarean deliveries she has Problem list or initial risk cesarean the fetus, placenta, and had. assessment LSTCS (or LTCS) ~ low segment membranes through an incision Do not count this delivery. transverse cesarean section in the mother’s abdominal and 2nd Labor and Delivery Nursing Classical cesarean section uterine walls. Admission Triage Form Low vertical C/S under comments Low transverse C/S If yes, how many? _____ 3rd Admission H&P under: Look for: Past OB history TOL ~ trial of labor Past pregnancy history TOLAC~ Trial of labor after under problem list/findings cesarean

43. Infections present and/or treated during this pregnancy Definitions Instructions Sources Key word/Abbreviations Infections present at the time Check all boxes that apply. See below “+” indicates that the test for the of the pregnancy diagnosis The mother may have more infection was positive and the woman or a confirmed diagnosis than one infection. has the infection. during the pregnancy with or without documentation of If the mother has none of the “-“indicates that the test was treatment. risk factors check “none of the negative, and the woman does not infections listed above”. have the infection. Documentation of treatment during this pregnancy is Look for treatment or prescription adequate if a definitive (Rx) for specific infection. diagnosis is not present in the available record.

43. Infections present and/or treated during this pregnancy (continued) Definitions Instructions Sources Key word/Abbreviations Gonorrhea See above 1st Prenatal care record under: GC

A positive test/culture for Infection history Gonorrheal Neisseria gonorrhea. Sexually transmitted Gonoccocal diseases Problem list Treatment or Rx for Gonorrhea Complications this pregnancy NAAT ~ Nucleic amplification tests Factor this pregnancy Medical history

2nd Labor and Delivery Nursing Admission Triage Form under comments

3rd Admission H&P under: Current pregnancy history

Medical history

Problem list/findings

4th Delivery Record under:

Maternal OB/labor summary Labor and delivery admission history

43. Infections present and/or treated during this pregnancy Definitions Instructions Sources Key word/Abbreviations Syphilis (also called lues) See above See Gonorrhea TP-TA ~ T. pallidum particle agglutination A positive test for Treponema STS ~ Serologic test for syphilis pallidum RPR ~ rapid plasma reagent VDRL ~ venereal disease research laboratories FTA-AS ~ Fluorescent antibody test Lues - Treatment or Rx for syphilis or lues

Chlamydia See Gonorrhea Treatment or Rx for chlamydia

A positive test for Chlamydia trachomatis. Hepatitis B (HBV, serum See Gonorrhea Hep B hepatitis) HBV A positive test for the hepatitis B virus Hepatitis C (non A non B See Gonorrhea Hep C hepatitis HCV) HCV A positive test for the hepatitis Treatment or Rx for any of the above C virus

44. Obstetric procedures Definitions Instructions Sources Key word/Abbreviations Medical treatment or Check all boxes that apply. The See below See below invasive/manipulative mother may have more than procedure performed during one procedure. this pregnancy to treat the pregnancy or to manage If the mother has none of the labor and/or delivery. risk factors, check “none”.

If you don’t have the information regarding the mother’s history mark “Unknown”. Cervical Cerclage: 1st Prenatal record under: MacDonald’s suture Circumferential banding or Medical history Shirodkar procedure suture of the cervix to prevent Problem list or initial risk Abdominal cerclage via or treat passive dilation. assessment laparotomy Historical risk summary . Complications this Look for: pregnancy Incompetent cervix Factors this pregnancy Incompetent os

2nd Labor and Delivery Nursing Admission Triage Form under: Complications Comments

3rd Admission H&P under: Current pregnancy history Medical history Problem list/findings

4th Delivery record under: Maternal OB Labor and delivery admission history

44. Obstetric procedures (continued) Definitions Instructions Sources Key word/Abbreviations Tocolysis 1st Prenatal Care Record Medications: under: Magnesium sulfate Administration of any agent Medical history Terbutaline (subcutaneous only) with the intent to inhibit preterm Problem list or initial risk Indocin (indomethacin) uterine contractions to extend assessment Nifedipine the length of the pregnancy. Historical risk summary Sulindac Complications of previous pregnancies Look for: Factors this pregnancy Preterm labor during this pregnancy 2nd Labor and Delivery Nursing Admission Triage form under: Complication this pregnancy Medications Comments

3rd Admission H&P under: Current pregnancy history Medication Medical history Problem list/findings

4th Delivery record under:

Maternal OB/labor

summary

Labor and delivery

admission history Labor summary record

44. Obstetric procedures (continued) Definitions Instructions Sources Key word/Abbreviations External cephalic version: If checked, also indicate 1st Prenatal Care Record Successful version: whether the procedure was a under: Breech version Attempted conversion of a success or a failure Problem list External version fetus from a non-vertex to a Historical risk summary vertex presentation by external Complications of this Failed Version: manipulation. pregnancy Unsuccessful external version Factors this pregnancy Attempted version Successful (fetus was Failed version converted to a vertex 2nd Labor and Delivery presentation) Nursing Admission Triage Look for: form under: Malpresentation Failed (fetus was not Complication this converted to a vertex pregnancy presentation) Comments

3rd Admission H&P under: Current pregnancy history

Medical history

Problem list/findings

4th Delivery record under:

Maternal OB/labor summary Labor and delivery admission history Labor summary record

45. Onset of labor Definitions Instructions Sources Key word/Abbreviations Premature rupture of the Check all that apply (prolonged 1st Labor & Delivery Record PROM ~ premature rupture of membranes: labor and precipitous labor under: membranes should not both be checked). If Maternal OB/labor This variable may be marked if none apply, check “none”. summary PPROM ~ preterm premature rupture any of the 3 conditions below Labor and delivery of membranes are documented: admission history Premature ROM (PROM) Labor summary record Look for: refers to rupture of the ~ time ROM (rupture of ROM ~ rupture of membranes. fetal membranes prior to membranes) the onset of labor at any Delivery record ~ ROM gestational age. Premature Prolonged Rupture of Membranes refers to PROM occurring 12 hours or more before the onset of labor. Preterm PROM (PPROM) is the PROM occurring prior to 37 weeks of gestation.

This does not refer to Spontaneous Rupture of Membranes (SROM) which is a normal finding at the start of or during labor.

45. Onset of labor (continued) Definitions Instructions Sources Key word/Abbreviations Precipitous Labor: If precipitous labor is indicated, 1st Labor & Delivery record check that labor lasted less under: Less than 3 hours than 3 hours Labor summary ~ total length of labor Labor chronology ~ total length of labor

2nd Delivery comments Prolonged Labor: If prolonged labor is indicated See above check that labor lasted 20 or Greater than or equal to 20 more hours hours

46. Characteristics of labor and delivery Definitions Instructions Sources Key word/Abbreviations Information about the Check all characteristics that See below See below course of labor and delivery. apply.

Definition of labor If none of the characteristics of labor and delivery apply, check Presence of regular uterine “none of the above”. contractions resulting in cervical change

46. Characteristics of labor and delivery Definitions Instructions Sources Key word/Abbreviations Induction of labor: Some of the methods and 1st Delivery Record under: IOL ~ induction of labor medicines used to start, or Maternal OB/labor Pit Ind ~ Pitocin induction Initiation of uterine induce, labor are the same as summary Misoprostol contractions by medical and/or Miso those used to advance, or Labor and delivery surgical means. These admission history Cervidil augment, labor. Some medications and/or Labor summary record Foley Pit interventions are given examples include: Prostaglandin BEFORE labor begins. artificial rupture of 2nd Physician Progress note membranes (AROM) balloons 3rd Labor and Delivery Nursing Oxytocin (Pitocin) Admission Triage Form prostaglandin laminaria other cervical ripening agents Also include patients with spontaneous rupture of membranes (SROM) without contractions because they do not meet the definition of labor.

Check to see if labor had begun before deciding which IVRS category is correct.

See definition of labor above. Augmentation of labor: Some of the methods and Same as 1st and 2nd sources Pit stim ~ Pitocin stimulation medicines used to induce labor from induction of labor above. Pit aug ~ Pitocin augmentation Augmentation of labor occurs are the same as those used to AROM ~ artificial rupture of AFTER labor has started. membranes done during labor advance, or augment labor. Stimulation of uterine contractions to increase their Some examples are: Check to see if labor had begun frequency and/or strength Oxytocin (Pitocin) before deciding which IVRS following the onset of labor. artificial rupture of category is correct. Please see definition of labor membranes (AROM) above. This one does not apply if there was an induction. 43

46. Characteristics of labor and delivery (continued) Definitions Instructions Sources Key word/Abbreviations Nonvertex presentation This item has been dropped 1st Delivery Record under Breech (buttocks) (sacrum) Includes any Non-vertex fetal from the national dataset. Presentation Frank Breech presentation LSA ~ left sacrum anterior Examples: 2nd Physician Progress Note LST ~ left sacrum transverse Breech RSP ~ right sacrum posterior Shoulder 3rd Newborn Admission H&P RST ~ right sacrum transverse Brow Complete breech Face Single footling breech Transverse lie Double footling breech Compound Shoulder presentation Nonvertex is fetal Transverse lie presentation other than the Face presentation (mentum) upper and back of the infant’s LMA ~ left mentum anterior fetal head. LMT ~ left mentum transverse LMP ~ left mentum posterior Vertex is fetal presentation of the upper or back part of the infant’s head.

46. Characteristics of labor and delivery (continued) Definitions Instructions Sources Key word/Abbreviations Steroids (glucocorticoids) Medications given before the 1st Delivery Record under: Medications: (Before delivery) for fetal lung maturation delivery. Maternal OB/labor Betamethasone received by the mother prior summary/comments Dexamethasone to delivery Thoroughly check the patient’s Labor summary record Hydrocortisone chart for use of this medication, comments Steroids or glucocorticoids which also could have been Antenatal corticosteroids (ANCS) given to accelerate fetal lung given at a doctor’s office or 2nd Maternal Medication or (ACT) maturity in anticipation of a another hospital before arrival Record preterm delivery. These at your facility. Includes: medications are given 3rd Newborn Admission H&P Betamethasone BEFORE delivery. Check box if any antenatal Dexamethasone th steroids were received before 4 Maternal Physician Order Hydrocortisone specifically given or at any time during labor and Sheet to accelerate fetal lung delivery. maturation in anticipation of preterm delivery.

Does not include steroid medication given to the mother as an anti- inflammatory treatment before or after delivery, not prednisone.

46. Characteristics of labor and delivery (continued) Definitions Instructions Sources Key word/Abbreviations Antibiotics received by the Check the box only if the Same as steroids Medications: may include, but is not mother during labor mother received any antibiotic limited to: medicines after labor began but Ampicillin Antibacterial medications before delivery. Do not check Penicillin received by the mother during box if mother did not labor, Clindamycin labor Erythromycin such as during a scheduled Gentamicin cesarean section. Cefotaxime Ceftriaxone Antibiotics usually are given to Cefazolin women in labor for these and Amoxicillin other medical conditions (which Vancomycin should appear in the patient chart) Key words to look for: chorioamnionitis positive group B strep (GBS+) SBE (sub-acute bacterial endocarditis) prophylaxis maternal fever mother febrile

46. Characteristics of labor and delivery (continued) Definitions Instructions Sources Key word/Abbreviations Clinical chorioamnionitis Check that recorded maternal 1st Delivery Record under: Chorioamnionitis diagnosed during labor or temperature is at or above 380C Maternal OB/labor Chorio maternal temperature (100.40F). summary ~ comments/ Temp > 38 or 100.4 greater than or equal to 380C complications (100.40F). Labor summary record ~ comments/ complications Look for: Clinical diagnosis of Maternal fever chorioamnionitis during labor 2nd Newborn Admission H&P Mother febrile made by the delivery attendant. 3rd Physician Progress Note

Usually includes more than 4th Maternal Vital Signs record one of the following: under: Temperature fever Recordings uterine tenderness and/or irritability leukocytosis fetal tachycardia

Any recorded maternal temperature at or above 380C (100.40F).

46. Characteristics of labor and delivery (continued) Definitions Instructions Sources Key word/Abbreviations Moderate or heavy 1st Delivery Record under: Mec ~ Meconium meconium staining of the Maternal OB/labor summary amniotic fluid. comments/ complications Labor summary record ~ Staining of the amniotic fluid comments/ complications caused by passage of fetal Amniotic fluid summary bowel contents during labor section ~ comments, color and/or at delivery that is more Time membranes ruptured section than enough to cause a 2nd Newborn Admission H&P greenish color change of an 3rd Physician Progress Note otherwise clear fluid. 47

46. Characteristics of labor and delivery (continued) Definitions Instructions Sources Key word/Abbreviations Fetal intolerance of labor: If there was fetal intolerance of 1st Delivery Record under: Prolonged Category II Refers to an abnormal or labor, it will have been recorded Maternal OB/labor Category III tracing concerning fetal heart rate in the delivery note and may be summary Non-reassuring fetal heart rate Lateral position tracing during labor that does called: Labor summary record O2 ~ Oxygen not respond to procedures to non-reassuring fetal heart nd 2 Newborn Admission H&P IV Fluid Bolus rate tracing improve the fetal heart rate Amnioinfusion tracing and therefore requires non-reassuring fetal status 3rd Physician Progress Note Nitroglycerine an operative vaginal delivery fetal intolerance of labor Terbutaline (forceps or vacuum assisted prolonged Category 2 4th Physician Order Sheet or Low forceps delivery Category 3 fetal heart rate vaginal delivery) or cesarean Nursing notes Vacuum extraction tracing C/S ~ Cesarean delivery delivery in order to shorten persistent decelerations time to delivery. fetal bradycardia fetal distress other terms Procedures includes any of the describing an abnormal fetal following: heart rate tracing requiring maternal position change delivery using forceps, Oxygen administration to vacuum, or emergency the mother cesarean section. amnioinfusion support of maternal blood pressure including medications and I.V. fluids administration of uterine relaxing agents

Further fetal assessment including any of the following: scalp pH scalp stimulation acoustic stimulation

46. Characteristics of labor and delivery (cont.) Definitions Instructions Sources Key word/Abbreviations Epidural or spinal 1st Delivery Record under: Epidural analgesia anesthesia during labor Maternal OB labor Epidural given summary ~ analgesia/ Spinal given Administration to the mother of anesthesia LEA a regional anesthetic to control Labor summary record the pain of labor. under analgesia/ anesthesia Delivery of the agent into a limited space with the distribution of the analgesic effect limited to the lower body.

47a. Method of delivery Definitions Instructions Sources Key word/Abbreviations Was delivery with forceps Check “yes” or “no” 1st Delivery Record under: LFD ~ Low forceps delivery attempted but Delivery summary LFD ~ (attempted) unsuccessful? 2nd Physician Delivery Obstetric forceps were applied Summary or Progress to the fetal head in an note unsuccessful attempt at vaginal delivery 3rd Recovery Room Record under Maternal Data Complications

47b. Method of delivery Definitions Instructions Sources Key word/Abbreviations Was delivery with vacuum Check “yes” or “no” Same as above Vac ext ~ vacuum extraction extraction attempted but (attempted) unsuccessful? VAD ~ vacuum assisted delivery Ventouse or vacuum cup was unsuccessful applied to the fetal head in an unsuccessful attempt to vaginal delivery.

47c. Method of Delivery (continued) Definitions Instructions Sources Key word/Abbreviations Fetal presentation at birth Check one of the three boxes. 1st Delivery Record under: Cephalic Fetal Birth Presentation Vertex ~ OA, OP, LOA, ROA, Cephalic ~ presenting part of ROP, LOT, ROT the fetus listed as vertex, Face occiput anterior (OA), occiput Brow posterior (OP). Sinciput Mentum ~ chin

Breech ~ presenting part of Breech the fetus listed as: (Buttocks, sacrum) breech Frank breech complete breech Single footling breech frank breech Double footling breech footling breech. Complete breech

Other ~ any other presentation Other not listed above. Shoulder Transverse lie Funis Compound

47d. Method of delivery (continued) Definitions Instructions Sources Key word/Abbreviations Final route and method of Check one of the boxes. 1st Delivery Record under Vaginal/spontaneous: delivery Method of Delivery VAG DEL ~ vaginal delivery SVD ~ spontaneous vaginal Vaginal/Spontaneous 2nd Newborn Admission H&P delivery Delivery of the entire fetus through the vagina by the 3rd Recovery Room Record natural force of labor with or under Maternal Data Vaginal/forceps: without manual assistance Delivered LFD ~ low forceps delivery from the delivery attendant.

Vaginal/Forceps Vaginal/vacuum: Delivery of the fetal head Vac Ext through the vagina by the Vacuum application of obstetrical forceps to the fetal head. Cesarean: C/S ~ cesarean section Vaginal/vacuum LSTCS ~ low segment transverse Delivery of the fetal head through the vagina by the Look for: application of a vacuum cup or TOL: Trial of labor ventouse to the fetal head.

Cesarean

Extraction of the fetus, placenta, and membranes through an incision in the maternal abdominal and uterine walls.

47d. Method of delivery (continued) Definitions Instructions Sources Key word/Abbreviations If cesarean, was trial of labor Check “yes” or “no” TOL ~ Trial of labor attempted? TOLAC ~ Trial of labor after cesarean Labor was allowed, augmented, or induced with plans for a vaginal delivery.

48. Maternal morbidity Definitions Instructions Sources Key word/Abbreviations Serious complications Check all boxes that apply. If See below See below experienced by the mother the mother has none of the associated with labor and complications, check “none of delivery. the above”.

To find out if a blood st transfusion was given, look for 1 Delivery Record under: Transfused Maternal transfusion the following words in the Labor Summary Blood transfusion

Includes any type of blood patient’s record: Delivery Summary products given to the mother Look for: transfused nd 2 Physician Delivery PRBC ~ packed red blood cells blood transfusion Notes/operative notes Whole blood packed red blood cells (PRBC) 3rd Intake & Output Form whole blood red cells white cells platelets clotting factors (FFP, Cryo)

48. Maternal morbidity (continued) Definitions Instructions Sources Key word/Abbreviations Third or fourth degree 1st Delivery Record under: 4th decree lac. perineal laceration Episiotomy section 40 LAC degree Lacerations section 3rd degree lac 30 laceration extends 30 LAC degree completely through the 2nd Recover Room Record perineal skin, vaginal mucosa, under: perineal body, and anal Maternal Data sphincter. Delivered

0 4 laceration is all of the above with extension through the rectal mucosa.

Ruptured uterus 1st Delivery Record under: Tearing of the uterine wall. Delivery summary note comments /complications

2nd Operative Note

3rd Physician Progress Note

48. Maternal morbidity (continued) Definitions Instructions Sources Key word/Abbreviations Unplanned hysterectomy Same as ruptured uterus Hysterectomy Surgical removal of the uterus above. that was not planned before Look for: the admission. Laparotomy

Includes anticipated, but not definitively planned hysterectomy.

Admission to an intensive 1st Physician Progress Note ICU - Intensive Care Unit care unit. MICU- Medical Intensive care unit Any admission, planned or 2nd Transfer Note SICU - surgical intensive care unit unplanned, of the mother to a L&D ECU- Labor and Delivery facility or unit designated as Emergency Care Unit providing intensive care.

Unplanned operating room Repair of laceration procedure following delivery. Repair of laparotomy Any transfer of the mother back Drainage of purulent/septic material to a surgical area for an 1st Physician Operative Note Exploratory laparotomy operative procedure that was not planned before the 2nd Physician Progress Note admission for the delivery. 3rd Physician Order None of the above

Excludes: postpartum tubal ligations.

49. Newborn medical record number Definitions Instructions Sources Key word/Abbreviations The hospital medical record Write the medical record Newborn chart. Hospital Face number of the baby. number for the delivery sheet admission of the baby.

50. Birth weight of newborn Definitions Instructions Sources Key word/Abbreviations The weight of the infant at Enter the weight (in grams) of 1st Delivery Record under BW ~ birth weight birth the infant at birth. Infant Data Gms ~ grams Kg ~ kilograms Do not convert pounds and 2nd Admission Assessment Lbs.~ pounds ounces (lbs. and oz.) to grams under weight oz ~ ounces

If the weight in grams is not available, enter the birth weight in lbs. and oz.

51. Obstetric estimate of gestation Definitions Instructions Sources Key word/Abbreviations The best estimate of the When entering this number, 1st OB Admission H&P under: Gestation ____weeks (wks) infant’s gestation in NEVER round up or down. Weeks ____weeks gestational age completed weeks based on the Enter number of weeks and Gestational age GA ~ gestational age EGA ~ estimated gestational age prenatal care provider’s days. estimate of gestation. This estimate of gestation should If the number of days is known, be determined by all perinatal enter the correct number factors and assessments but between 0-6. If unknown, enter “99.” NOT the neonatal exam.

(Entering “99” in weeks will Ultrasound completed in 1st auto populate the days field) trimester is preferred. Infant’s gestation in completed weeks based on the prenatal care provider’s estimate of gestation. This estimate of gestation should be determined by all perinatal factors and assessments but NOT the neonatal exam.

52. APGAR score Definitions Instructions Sources Key word/Abbreviations A systemic measure for Enter the infant’s APGAR evaluating the physical score at 5 minutes. conditions of the infant at specific intervals following If the score at 5 minutes is less birth. than 6 enter the infant’s APGAR score at 10 minutes

53. Plurality Definitions Instructions Sources Key word/Abbreviations The number of fetuses Enter the number of fetuses 1st Delivery record Single delivered live or dead at any delivered in this pregnancy. Twin, triplet, quadruplet, etc. time in the pregnancy 2nd Admission H&P Multiple (a, b, c…) or (1, 2, 3...) regardless of gestational If two or more live births in age, or if the fetuses were this delivery, see “Facility delivered at different dates in Worksheet attachment for the pregnancy. multiple births”

“Reabsorbed” fetuses (those that are not delivered, expulsed or extracted from the mother) should not be counted.

54. If not a single birth Definitions Instructions Sources Key word/Abbreviations The order born in the delivery, If this is a single birth, leave 1st Delivery Record under Baby A, B, or Baby 1, 2, etc. live born or fetal death (1st, 2nd, this item blank. Birth order Twin A, B, or Twin 1, 2 3rd, 4th, 5th, 6th, 7th, etc.) Triplet A,B,C, or Triplet 1,2,3 Include all live births and fetal 2nd Infant data deaths from this pregnancy. Look for: Birth order/Set order

55. Abnormal conditions of the newborn Definitions Instructions Sources Key word/Abbreviations Disorders or significant Check all boxes that apply. See below See below morbidity experienced by the newborn. If none of the conditions apply, check “none of the above”.

Assisted ventilation required Check the infant’s medical 1st Labor Delivery Summary Bag and mask ventilation immediately AFTER delivery: record to see if the baby under Infant data/breathing Intubation

needed help breathing within Intubation and PPV (positive Infant is given manual breaths the first few minutes after pressure ventilation) for any duration with bag and delivery. mask, bag and endotracheal PPV bag/mask or ET(positive tube, or with T-piece Help with breathing DOES NOT pressure ventilation via bag, mask, or endotracheal intubation) resuscitator device using a include blow by or free flow mask or endotracheal tube. oxygen or laryngoscopy for IPPV Bag (intermittent positive

aspiration of meconium. pressure ventilation via bag) Assisted ventilation may also IPPV ET (intermittent positive be accomplished using the T- pressure ventilation via endotracheal piece resuscitator device with This DOES NOT include nasal intubation) a mask to deliver CPAP within cannula. the first several minutes Neopuff from birth. O2 via ET (oxygen via endotracheal intubation)

Oxygen

55. Abnormal conditions of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Assisted ventilation required Count the number of hours of 1st Newborn Respiratory Care If in use for more than six hours: for more than six hours. mechanical ventilation given. flow sheet. CPAP (continuous positive airway pressure) Infant given mechanical IPPV (Intermittent positive pressure ventilation) ventilation (breathing HFV (high frequency ventilation) assistance) by any method for IMV (intermittent mandatory volume ventilation) more than six hours. HFOV (high frequency oscillatory ventilation) PIP (peak inspiratory pressure) Includes conventional, high PEEP (positive end expiratory pressure) frequency and/or continuous CMV (continuous mandatory ventilation) positive pressure (CPAP). HFPPV (high frequency positive pressure ventilation) HFFI (high frequency flow interruption ventilation) HVJV (High frequency jet ventilation) Inhaled Nitric Oxide (INO)

55. Abnormal conditions of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations NICU admission: DO NOT chose NICU 1st Labor and Delivery ICN (Intensive Care Nursery) admission if the infant was Summary Record SCN (Special Care Nursery) Admission to a facility or unit transferred to another hospital. Disposition NICU (Neonatal Intensive Care with staffing and equipment to Nursery) This is a different variable. Intensive Care Nursery provide continuous mechanical PICU (Pediatric Intensive Care Unit) Do choose NICU admission, if Special Care Nursery ventilator support for a newborn. the infant was admitted to the: NICU Special Care Nursery Intensive Care Nursery Pediatric Intensive Care This can occur at ANY time during the infant’s stay at your hospital only.

Level II+ or III hospital should be the only facilities with a “yes” answer in this box.

55. Abnormal conditions of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Newborn given surfactant Check both primary (1st) and 1st Labor and Delivery If given to newborn after birth: replacement therapy secondary (2nd) sources before Summary Surfactant completion. Neonatal Medication Survanta Endotracheal instillation of a Exosurf nd surface-active suspension for 2 Newborn Medication Curosurf treating surfactant deficiency Administration Record Infasurf due to preterm birth or pulmonary injury resulting in respiratory distress.

Includes both artificial and extracted natural surfactant.

55. Abnormal conditions of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Antibiotics received by the 1st Newborn Medication Medications (given to newborn for newborn for suspected Administration Record sepsis) neonatal sepsis. Acyclovir Any antibacterial drug Amikacin (penicillin, ampicillin, Ampicillin gentamicin, Cefotaxime, etc.) Cefazolin given systemically (intravenous Cefotaxime or intramuscular). Does not Cefoxitin, include antibiotics given to Ceftazidime infants who are NOT Ceftriaxone suspected of having neonatal Chloramphenicol sepsis. Gentamicin Kanamycin Nafcillin Penicillin Penicillin G Vancomycin

55. Abnormal conditions of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Seizure or serious 1st Newborn H&P Coma neurologic dysfunction Eye rolling 2nd Physician Progress Notes HIE (hypoxic-ischemic Seizure ~ any involuntary under Neuro Exam encephalopathy) repetitive, convulsive Hypotonia movement or behavior. Obtundation Rhythmic jerking Serious neurologic dysfunction Seizures ~ severe alteration of alertness Stupor Tonic/clonic/clonus Excludes: Twitching Lethargy or hypotonia in the absence of other neurologic findings Symptoms associated with CNS congenital anomalies

55. Abnormal conditions of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Significant birth injury 1st Labor and Delivery Looking for: (as applies to infant) Summary Record under Trauma Skeletal fracture(s), peripheral Newborn Delivery Information Facial asymmetry nerve injury, and/or soft tissue Subgaleal (progressive nd or solid organ hemorrhage that 2 Newborn Admission H&P extravasation within the scalp) requires intervention. Present Hemorrhage rd immediately following or soon 3 Physician progress notes Giant cephalohematoma after delivery. Extensive truncal, facial and/or extremity ecchymosis Includes: accompanied by evidence of Any bony fracture or anemia and/or hypovolemia weakness or loss of and/or hypotension. sensation, but excludes Subcapsular hematoma of the fractured clavicles and liver transient facial nerve palsy. Fractures of the spleen Soft tissue hemorrhage Adrenal hematoma requiring evaluation and/or treatment, including, subgaleal (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.

56. Congenital anomalies of the newborn Definitions Instructions Sources Key word/Abbreviations Malformations of the newborn Check all boxes that apply. If diagnosed prenatally or after no malformation identified mark delivery “none”. Anencephaly 1st labor and delivery summary Anencephalus record under infant data Acrania Partial or complete absence of Absent brain the brain and skull. 2nd Newborn Admission H&P Craniorachischisis

Meningomyelocele/Spina Same as anencephaly Meningocele 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 meninges)

56. Congenital anomalies of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Cyanotic congenital heart 1st Physician Progress Notes TGA ~ Transposition of the great disease under: arteries Circulation TOF ~ Tetralogy of Fallot Congenital heart defects that Cardiovascular Pulmonary or pulmonic valvular cause cyanosis atresia Tricuspid atresia Truncus arteriosus TAPVR ~ total/partial anomalous pulmonary venous return with or without obstruction COA ~ Coarctation of the aorta HLHS ~ hypoplastic left heart syndrome Congenital diaphragmatic 1st Infant H&P hernia 2nd Labor and Delivery Summary Record under Infant Defect in the formation of the Data diaphragm allowing herniation of abdominal organs into the thoracic cavity

56. Congenital anomalies of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Omphalocele 1st Labor and Delivery Exomphelos Summary Record under Infant A defect in the anterior Data abdominal wall, accompanied by herniation of some 2nd Admission H&P under GI abdominal organs through a widened umbilical ring into the umbilical stalk.

The defect is covered by a membrane (different from gastroschisis [see below]), although this sac may rupture. .

Do not include umbilical hernia (completely covered by skin) in this category.

Gastroschisis Same as Omphalocele

An abnormality of the anterior abdominal wall, lateral to the umbilicus, resulting in herniation of the abdominal contents directly into the amniotic cavity.

Differentiated from omphalocele by the location of the defect and the absence of a protective membrane.

Do not include umbilical hernia (completely covered by skin) in this category

56. Congenital anomalies of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Limb reduction defect ~ 1st Labor and Delivery Look for: excluding congenital Summary Record under Infant Amniotic bands amputation and dwarfing Data ABS ~ amniotic band syndrome syndromes. 2nd Newborn H&P Complete or partial absence of a portion of an extremity, secondary to failure to develop.

Cleft lip with or without cleft Same as limb reduction defect Cleft lip (unilateral, bilateral, or palate median)

Incomplete closure of the lip. May be unilateral, bilateral, or median.

Cleft palate alone Same as limb reduction defect

Incomplete fusion of the palatal shelves. May be limited to the soft palate or may extend into the hard palate.

Cleft palate in the presence of cleft lip should be included in the category above.

Down syndrome ~ Karyotype Check if a diagnosis of Down 1st Infant progress notes Trisomy 21 pending syndrome, Trisomy 21 is Positive (confirmed) confirmed or pending. 2nd Genetic Consult Possible Down (pending) Trisomy 21 Rule out (R/O) Down (pending)

Down syndrome ~ Karyotype Check if a diagnosis of Down Same as Down syndrome Trisomy 21 confirmed syndrome, Trisomy 21 is Positive (confirmed) confirmed. Trisomy 21

56. Congenital anomalies of the newborn (continued) Definitions Instructions Sources Key word/Abbreviations Suspected chromosomal Check if a diagnosis of a Same as Down syndrome Trisomy and then a number such disorder ~ Karyotype suspected chromosomal as: pending disorder is pending (may 13 ~ Patau’s syndrome include Trisomy 21) 17 or 18 ~ Edward syndrome Includes any constellation of Possible Trisomy (pending) congenital malformations Rule out (R/O) (pending) resulting from or compatible with known syndromes caused by detectable defects in chromosome structure.

Suspected chromosomal Check if a diagnosis of a Same as Down syndrome Trisomy and then a number such disorder ~ karyotype suspected chromosomal as: confirmed disorder is confirmed (may 13 ~ Patau’s syndrome include Trisomy 21) 17 or 18 ~ Edward syndrome Includes any constellation of Positive (confirmed) congenital malformations resulting from or compatible with known syndromes caused by detectable defects in chromosome structure.

Hypospadias 1st Labor and Delivery Summary under Infant Data Incomplete closure of the male urethra resulting in the urethral 2nd Newborn H&P under meatus opening on the ventral Genitourinary (GU) surface of the penis.

Includes: First degree (on the glans

ventral to the tip)

Second degree (in the

coronal sulcus) Third degree (on the penile shaft)

57. Was the infant transferred within 24 hours of delivery? Definitions Instructions Sources Key word/Abbreviations Transfer status of the infant Check “yes” if the infant was 1st Infant progress note Disposition within 24 hours after transferred from this facility to delivery another within 24 hours of 2nd Transfer form delivery. From the birth facility to another facility Enter the name of the facility to which the infant was transferred. If the name of the facility is not known, enter “unknown”.

If the infant was transferred more than once, enter the name of the first facility to which the infant was transferred.

58. How is infant being fed? Definitions Instructions Sources Key word/Abbreviations How is the infant being fed? This field notes the feeding 1st Labor and Delivery Pumping Breast milk only method at the time the record summary record under Infant Lactation consultation Formula only is created. data LATCH score (Latch on, Audible swallow, Type of nipple, Comfort and Both breast milk and formula If the method changes after 2nd Maternal Progress Notes Help used to measure position

Neither breast milk or submission of the birth and attachment of the baby on the formula certificate but before 3rd Newborn Flow Record breast Unknown discharge, this information under Feeding Breast pump Information on whether the does not change. Breast pump protocol infant is being given human 4th Lactation Consult Breast milk If a baby has only received milk at ANY time prior to MM ~ Mother’s milk breast milk from delivery until HM ~ Human milk completion of the birth the birth certificate record is certificate. Breast-fed is the FBM ~ Frozen breast milk created (including babies fed DM ~ Donor Milk action of breastfeeding or at the breast and babies given pumping (expressing) milk. breast milk in a bottle) then answer: Breast milk only. Do not answer the question based on the mother’s intent to breast-feed or bottle-feed. The answer to this question auto- populates the next field. “Is the Infant Being Breastfed at ANY time between Birth and Discharge?”

The information entered in this field would be the human milk feeding status at the time the record is created. If it changes prior to discharge, this information does not change.

59. Is the infant living at the time of the report? Definitions Instructions Sources Key word/Abbreviations Information on the infant’s Check “yes” if the infant is 1st Infant progress notes survival. living.

Check “yes” if the infant has already been discharged to home care.

Check “no” if it is known that the infant has died.

If the infant was transferred

and the status is known, indicate the known status.