National Center for Health Statistics
Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death
(2003 revision)
Updated September 2019
National Vital Statistics System
CS264012 Training for completing medical and health information for the birth certificate and report of fetal death is available online! To access “Applying Best Practices for Reporting Medical and Health Information on Birth Certificates” go to: https://www.cdc.gov/nchs/training/BirthCertificateElearning. Table of Contents Instructions Pregnancy resulted from infertility treatment ...... 21 . How to Use This Guide ...... 5 Fertility-enhancing drugs, artificial insemination, or intrauterine insemination . 21. Mother ...... 7 Assisted reproductive technology ...... 22 Mother had a previous cesarean delivery ...... 22. Facility Information Infections present and/or treated during this pregnancy ...... 23 . Facility name ...... 7 . Gonorrhea ...... 23. Facility ID ...... 8 . Syphilis ...... 24 . City, town, or location of birth ...... 8 . Chlamydia ...... 24 Hepatitis B ...... 24. County of birth ...... 8 . Hepatitis C ...... 24. Place where birth occurred (Birthplace) ...... 9 . Obstetric procedures ...... 25 . Prenatal Care and Pregnancy History External cephalic version ...... 25 Date of first prenatal care visit ...... 13 Labor and Delivery Total number of prenatal care visits for this pregnancy ...... 13 Date of birth ...... 29 . Date last normal menses began ...... 14 Time of birth ...... 29 . Number of previous live births now living ...... 15 Certifier’s name and title ...... 29. Number of previous live births now dead ...... 16 Date certified ...... 29 Date of last live birth ...... 16 . Principal source of payment ...... 30 . Number of other pregnancy outcomes ...... 17 Infant’s medical record number ...... 30 . Date of last other pregnancy outcome ...... 17 Was the mother transferred to this facility for maternal medical or Risk factors in this pregnancy ...... 17 fetal indications for delivery? ...... 31 . Diabetes ...... 18 . Attendant’s name, title, and ID ...... 32 . Prepregnancy ...... 18 Mother’s weight at delivery ...... 32 Gestational ...... 18 . Characteristics of labor and delivery ...... 33 . Hypertension ...... 19 . Induction of labor ...... 33 . Prepregnancy (chronic) ...... 19. Augmentation of labor ...... 34 . Gestational ...... 19 . Steroids (glucocorticoids) for fetal lung maturation received by Eclampsia ...... 19 the mother before delivery ...... 34 . Previous preterm births ...... 20 Table of Contents—Continued
Labor and Delivery—Continued Congenital anomalies of the newborn ...... 50 . Antibiotics received by the mother during delivery ...... 35 . Anencephaly ...... 50 . Clinical chorioamnionitis diagnosed during labor or maternal Meningomyelocele/Spina bifida ...... 51 . temperature ≥ 38°C (100.4°F) ...... 35 . Cyanotic congenital heart disease ...... 51 . Epidural or spinal anesthesia during labor ...... 36 Congenital diaphragmatic hernia ...... 52 . Method of delivery ...... 36 Omphalocele ...... 52 . Fetal presentation at birth ...... 36. Gastroschisis ...... 52 Final route and method of delivery ...... 37 . Limb reduction defect ...... 53 If cesarean, was a trial of labor attempted? ...... 38 . Cleft lip with or without cleft palate ...... 53 Maternal morbidity ...... 38. Cleft palate alone ...... 53 . Maternal transfusion ...... 38. Down syndrome ...... 53. Third- or fourth-degree perineal laceration ...... 38 . Suspected chromosomal disorder ...... 54 . Ruptured uterus ...... 39. Hypospadias ...... 54 . Unplanned hysterectomy ...... 39 . Was the infant transferred within 24 hours of delivery? ...... 55. Admission to an intensive care unit ...... 39 . Is the infant living at the time of the report? ...... 55 Is the infant being breastfed at discharge? ...... 56 . Newborn Information Method of disposition ...... 56 Birthweight or weight of fetus ...... 43. Obstetric estimate of gestation at delivery ...... 43 . Index of Items ...... 57 Sex of child ...... 45 . Apgar score ...... 46 Plurality ...... 46 . If not a single birth, order born in the delivery ...... 46 . If not a single birth, number of infants in the delivery born alive ...... 46 . Abnormal conditions of the newborn ...... 47 . Assisted ventilation required immediately following delivery ...... 47 . Assisted ventilation required for more than six hours ...... 48 . NICU admission ...... 49. Newborn given surfactant replacement therapy ...... 49 Antibiotics received by the newborn for suspected neonatal sepsis ...... 49. Seizure or serious neurologic dysfunction ...... 50. Page 5 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death How to Use This Guide
This guide was developed to assist in completing the facility worksheets for the revised Certificate of Live Birth and Report of Fetal Death (birth certificate [BC], facility worksheet for the report of fetal death [FDFWS], report of fetal death [FDR]).
Definitions Instructions Sources Keywords and abbreviations
Defines the items in the order they appear Provides specific instructions for Identifies the sources in the medical ► Identifies alternative, usually on the facility worksheet. completing each item. records where information for each synonymous terms and common item can be found. The specific records abbreviations and acronyms for items. available will differ somewhat from The keywords and abbreviations facility to facility. The source listed first given in this guide are not intended as is considered the best or preferred inclusive. Facilities and practitioners source. Please use this source whenever will likely add to the lists. possible. All subsequent sources are Example: listed in order of preference. The precise Keywords and abbreviations for location within the records where an item prepregnancy diabetes are: can be found is further identified by under and or. DM–Diabetes mellitus Type 1 diabetes Example: IDDM–Insulin dependent diabetes To determine whether gestational mellitus diabetes is recorded as a “Risk factor in Type 2 diabetes this pregnancy” (item #14) in the records: Noninsulin dependent diabetes The first or best source is the prenatal mellitus care record. Class B DM Within the prenatal care record, Class C DM information on diabetes may be found Class D DM under: Class F DM • Medical history Class R DM • Previous obstetric (OB) history Class H DM • Problem list or initial risk assessment ► Medications commonly used for items. • Historical risk summary Example: “Clomid” for “Assisted • Complications of previous pregnancies reproduction treatment.” • Factors this pregnancy Page 6 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death How to Use This Guide—Continued
This guide was developed to assist in completing the facility worksheets for the revised Certificate of Live Birth and Report of Fetal Death. (birth certificate [BC], facility worksheet for the report of fetal death [FDFWS], report of fetal death [FDR])
Definitions Instructions Sources Keywords and abbreviations
► Look for is used to indicate terms that may be associated with, but are not synonymous with, an item. 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. Example: “Trial of labor” for “cesarean delivery”
MISSING INFORMATION Where information for an item cannot be located, please check “unknown” or write “unknown” (if using the paper copy of the worksheet). Page 7 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
Mother
The woman who gave birth to, or delivered All birth certificate information reported the infant. for the mother should be for the woman who delivered the infant. In cases of surrogacy or gestational carrier, the information reported should be for the surrogate or the gestational carrier, that is, the woman who delivered the infant.
FACILITY INFORMATION
1 Facility name (BC #5, FDFWS #1, FDR #8)
The name of the facility where the delivery Enter the name of the facility where the took place. birth occurred. If this birth did not occur in a hospital or freestanding birthing center, enter the street and number of the place where the birth occurred. If this birth occurred en route to a hospital or freestanding birthing center, that is, in a moving conveyance, enter the city, town, village, or location where the child was first removed from the conveyance. If the birth occurred in international waters or air space, enter “boat” or “plane.” Page 8 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
2 Facility ID (BC #17, FDFWS #2, FDR #9)
National Provider Identifier. Enter the facility’s National Provider NPI Identifier (NPI) number. If no NPI, enter the state hospital code.
3 City, town, or location of birth (BC #6, FDFWS #3, FDR #5)
The name of the city, town, township, Enter the name of the city, town, township, village, or other location where the birth village, or 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.
4 County of birth (BC #7, FDFWS #4, FDR #6)
The name of the county where the birth Enter the name of the county where the occurred. 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. Page 9 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
5 Place where birth occurred (Birthplace) (BC #26, FDFWS #5, FDR #7)
The type of place where the birth occurred. Check the box that best describes the type 1st Admission history and physical Hospital of place where the birth occurred. (H&P) under–General Admission under– Freestanding birthing center • Admitted from home, doctor’s FBC–Freestanding birthing center No direct physical connection with an office, other or– operative delivery center. • Problem list or findings Home birth If home birth is checked, check whether The birth occurred at a private residence. the home birth was planned. If unknown 2nd Delivery record under– whether a planned home birth, write • Delivery information “unknown.” • Labor and delivery summary (L&D) Clinic/doctor’s office Specify taxi, train, plane, etc. • Maternal obstetric (OB) or labor summary under–delivery Other 3rd Basic admission data 4th Progress notes or Note Page 13 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
PRENATAL CARE AND PREGNANCY HISTORY The prenatal care record is the preferred source for items 6 through 16. If the prenatal care record is not in the mother’s file, please contact the prenatal care provider and obtain a copy of the record.
6 Date of first prenatal care visit (BC #29a, FDFWS #6a, FDR #23a)
The date a physician or other health care Enter the month, day, and year of the first 1st Prenatal care record under– PNC–Prenatal care professional first examined or counseled prenatal care visit. • Intake information the pregnant woman for the pregnancy. If date information is incomplete, enter all • Initial physical examination Information obtained on prenatal care parts of the date that are known. Report • Prenatal visit flow sheet received in countries other than the "unknown" for any parts of the date that • Current pregnancy United States and in languages other than are missing. English is permitted and should be used. If mother’s earliest prenatal care records are not available (i.e., the date of the first prenatal care visit is unavailable), report “unknown.” If “no prenatal care,” check the box and enter “0” for item “total number of prenatal care visits.”
7 Total number of prenatal care visits for this pregnancy (BC #30)
The total number of visits recorded in the Access the most recent prenatal records 1st Prenatal care record under– PNC–Prenatal care record. available. If up-to-date records are not Prenatal visit flow sheet A prenatal visit is one in which available, contact the prenatal care (count visits) the physician or other health care provider for the most current information. professional examines or counsels the Count the prenatal visits recorded in the pregnant woman for her pregnancy. record. Exclude visits for laboratory and Do not include visits for laboratory and other tests or classes in which the mother other testing in which a physician or was not seen by a physician or other health care professional did not examine health care professional for pregnancy- or counsel the pregnant woman. related care. If it is not clear whether the mother was seen by a physician or other health care professional, include the visit(s) in the total number.
continued on next page continued on next page Page 14 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
7 Total number of prenatal care visits for this pregnancy (BC #30)—Continued
Do not include classes, such as childbirth Count only visits recorded in the most See above See above classes, where the physician or health current record available. Do not estimate care professional did not provide additional prenatal visits when the individual care to the pregnant woman. prenatal record is not up to date. Information obtained on prenatal care Enter the total number of prenatal visits. received in countries other than the If no visits are recorded, enter “0.” If the United States and in languages other than number of prenatal visits is equal to 0, English is permitted and should be used. the “no prenatal care” box should also be checked for item “Date of first prenatal care visit.”
8 Date last normal menses began (BC #30, FDFWS #8, FDR #32)
The date the mother’s last normal Enter all known parts of the date the 1st Prenatal care record under– LMP–Last menstrual period menstrual period began. mother’s last normal menstrual period • Menstrual history This item is used to compute the began. Report "unknown" for any parts of • Labor and delivery nursing gestational age of the infant. the date that are missing. admission triage form Do not estimate the date. 2nd Admission history and physical (H&P) under–Medical history Page 15 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
9 Number of previous live births now living (BC #35a, FDFWS #9, FDR #29a)
The total number of previous live-born Do not include this infant. 1st Prenatal care record under– L–Now living infants now living. Include all previous live-born infants who • Intake information Look for: are still living. • Gravida section–L (living)–last G–Gravida–Total number of pregnancies number in series For multiple deliveries: P–Para–Previous live births and fetal Include all live-born infants before this • Para section–L–last number in deaths > 28 weeks of gestation series infant in the pregnancy. T–Term–Delivered at 37 to 40 weeks If the first born, do not include this infant. • Pregnancy history information gestation If the second born, include the first born, • Previous OB history etc. • Past pregnancy history If no previous live-born infants, check 2nd Labor and delivery nursing “none.” admission triage form under– See “Attachment to the Facility Patient data Worksheet for the Live Birth Certificate for Multiple Births.” 3rd Admission history and physical (H&P) Page 16 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
10 Number of previous live births now dead (BC #35b, FDFWS #10, FDR #29b)
The total number of previous live-born Do not include this infant. 1st Prenatal care record under– See above infants now dead. Include all previous live-born infants who • Pregnancy history information– Expired are no longer living. comments, complications For multiple deliveries: • Previous OB history–comments, Include all live-born infants before this complications infant in the pregnancy who are now dead. • Past pregnancy history–comments, complications If the first born, do not include this infant. If the second born, include the first born, 2nd Admission history and physical etc. (H&P) If no previous live-born infants now dead, check “none.” See “Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births.”
11 Date of last live birth (BC #35c, FDFWS #11, FDR #29c)
The date of birth of the last live-born If applicable, enter the month and year. 1st Prenatal care record under– DOB–Date of birth infant. Include live-born infants now living and • Pregnancy history information– now dead. date If date information is incomplete, enter all • Previous OB history–date parts of the date that are known. Report • Past pregnancy history–date “unknown” for any parts of the date that are missing. Do not estimate or guess a 2nd Admission history and physical date. (H&P) Page 17 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
12 Number of other pregnancy outcomes (BC #36a)
Total number of other pregnancy Include all previous pregnancy losses that 1st Prenatal care record under– Miscarriages outcomes that did not result in a live birth. did not result in a live birth. • Gravida section–“A” (abortion or Fetal demise Includes pregnancy losses of any If no previous pregnancy losses, miscarriage) AB–Abortion induced gestational age. check “none.” • PARA section–“A” SAB–Spontaneous abortion Examples: spontaneous or induced losses For multiple deliveries: • Pregnancy history information– TAB–Therapeutic abortion or ectopic pregnancy Include any losses regardless of comments, complications Abortion spontaneous gestational age that occurred before the • Previous OB history–comments, delivery of this infant. This could include complications Septic abortion losses occurring in this pregnancy or in a • Past pregnancy history–comments, Ectopic pregnancy previous pregnancy. complications Tubal pregnancy 2nd Labor and delivery nursing FDIU–Fetal death in utero admission triage form IUFD–Intrauterine fetal death 3rd Admission history and physical (H&P)
13 Date of last other pregnancy outcome (BC #36b)
The date the last pregnancy that did not If applicable, enter the month and year. 1st Prenatal care record under– result in a live birth ended. If date information is incomplete, enter all • Pregnancy history information Includes pregnancy losses at any parts of the date that are known. Report • Previous OB history gestational age. “unknown” for any parts of the date that • Past pregnancy history Examples: spontaneous or induced losses are missing. Do not estimate or guess a or ectopic pregnancy date. 2nd Admission history and physical (H&P)
14 Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)
Risk factors of the mother during this Check all boxes that apply. The mother See below See below pregnancy. may have more than one risk factor. If the mother has none of the risk factors, check “none of the above.” Page 18 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
14 Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Diabetes If diabetes is present, check either 1st Prenatal care record under– Glucose intolerance requiring treatment. prepregnancy or gestational diabetes. • Medical history Do not check both. • Previous OB history under– summary of previous pregnancies
Prepregnancy • Problem list or–initial risk Prepregnancy: Diagnosis before this pregnancy. assessment DM–Diabetes mellitus • Historical risk summary Type 1 diabetes • Complications of previous IDDM–Insulin dependent diabetes pregnancies mellitus • Factors this pregnancy Type 2 diabetes 2nd Labor and delivery nursing Non-insulin dependent diabetes mellitus admission triage form under– Class B DM • Medical complications Class C DM • Comments Class D DM 3rd Admission history and physical Class F DM (H&P) under– Class R DM • Current pregnancy history Class H DM • Medical history • Previous OB history under– Gestational pregnancy related Gestational: Diagnosis during this pregnancy. • Problem list or findings GDM–Gestational diabetes mellitus IDGDM–Insulin dependent gestational 4th Delivery record under– • Maternal OB or labor summary diabetes mellitus Class A1 or A2 diabetes mellitus • Labor and delivery admission history • Labor summary record Page 19 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
14 Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Hypertension If hypertension is present, check either See Diabetes Elevation of blood pressure above normal prepregnancy or gestational hypertension. for age, sex, and physiological condition. Do not check both.
Prepregnancy (chronic) Prepregnancy: Diagnosis prior to the onset of this CHT–Chronic hypertension pregnancy–does not include gestational Benign essential hypertension (pregnancy-induced hypertension [PIH]). Essential hypertension Preexisting hypertension
Gestational Gestational: Diagnosis in this pregnancy (Pregnancy- PIH–Pregnancy-induced hypertension induced hypertension or preeclampsia). Preeclampsia Eclampsia Transient hypertension HELLP Syndrome
Eclampsia If eclampsia is present, one type of See Diabetes See Hypertension Hypertension with proteinuria with hypertension (either gestational or generalized seizures or coma. May include prepregnancy) may be checked. pathologic edema. Page 20 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
14 Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Previous preterm births 1st Prenatal care record under– PTL–Preterm labor History of pregnancy(ies) terminating in a • Medical history P–Premature live birth of less than 37 completed weeks • Previous OB history under– of gestation. summary of previous pregnancies • Problem list or–initial risk assessment • Historical risk summary • Complications of previous pregnancies 2nd Labor and delivery nursing admission triage form under– • Medical complications • Comments 3rd Admission history and physical (H&P) under– • Medical history • Previous OB history under– pregnancy related • Problem list/findings Page 21 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
14 Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Pregnancy resulted from infertility Check if any infertility treatment was used 1st Prenatal care record under– See below treatment to initiate the pregnancy. This information • Medical history Any assisted reproductive treatment used is included on both the mother’s and • Current pregnancy history the facility worksheets. Check “yes” if to initiate the pregnancy. • Problem list or–initial risk treatment is reported on either worksheet. Includes: assessment - Drugs (e.g., Clomid or Pergonal) • Medications this pregnancy - Artificial insemination 2nd Labor and delivery nursing - Technical procedures (e.g., in vitro admission triage form under– fertilization) • Comments • Medications 3rd Admission history and physical (H&P) under– • Current pregnancy history • Problem list/findings
Fertility-enhancing drugs, artificial Check if specific therapy (drugs or See Pregnancy resulted from infertility Fertility-enhancing drugs, or artificial or insemination, or intrauterine insemination) was used. This information treatment intrauterine insemination: insemination is included on both the mother’s and Medications the facility worksheets. Check “yes” if Any fertility-enhancing drugs (e.g., Clomid Clomid, Serophene or Pergonal), artificial insemination, or treatment is reported on either worksheet. Pergonal intrauterine insemination used to initiate the pregnancy. Metrodin Profasi Progesterol Crinone (progesterone gel) Follistim FSH–Follicle stimulating hormone Gonadotropins Hcg–Human chorionic gonadotropin IUI– Intrauterine insemination Page 22 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
14 Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Assisted reproductive technology Check if assisted reproductive therapy See Pregnancy resulted from infertility Assisted reproductive technology: (e.g., in-vitro fertilization [IVF] gamete was used. This information is included treatment ART intrafallopian transfer [GIFT]) on both the mother’s and the facility Artificial insemination Any assisted reproductive technology worksheets. Check “yes” if treatment is AIH–Artificial insemination by husband ([ART]/technical procedures [e.g., reported on either worksheet. IVF, GIFT, or ZIFT]) used to initiate the AID/DI–Artificial insemination by donor pregnancy. In vitro fertilization IVF-ET–In vitro fertilization embryo transfer GIFT–Gamete intrafallopian transfer ZIFT–Zygote intrafallopian transfer Ovum donation Donor embryo Embryo adoption
Mother had a previous cesarean If the mother has had a previous cesarean 1st Prenatal care record under– C/S–Cesarean section delivery delivery, indicate the number of previous • Past pregnancy history Repeat C/S cesarean deliveries she has had. Previous delivery by extracting the fetus, • Past OB history VBAC–Vaginal delivery after cesarean placenta, and membranes through an • Problem list or–initial risk LSTCS (or LTCS) low segment transverse incision in the mother’s abdominal and assessment uterine walls. cesarean section Classical cesarean section If yes, how many? 2nd Labor and delivery nursing admission triage form under– Low vertical C/S Comments Low transverse C/S 3rd Admission history and physical Look for: (H&P) under– TOL–Trial of labor • Past OB history • Past pregnancy history under– problem list/findings Page 23 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
15 Infections present and/or treated during this pregnancy (BC #42)
Infections present at the time of the Check all boxes that apply. The mother See below “+” indicates that the test for the infection pregnancy diagnosis or a confirmed may have more than one infection. was positive and the woman has the diagnosis during the pregnancy with or If the mother has none of the infections, infection. without documentation of treatment. check “none of the above.” “–” indicates that the test was negative, Documentation of treatment during this and the woman does not have the pregnancy is adequate if a definitive infection. diagnosis is not present in the available Look for: treatment or Rx for specific record. infection.
Gonorrhea 1st Prenatal record under– GC A positive test or culture for Neisseria • Infection history Gonorrheal gonorrhoeae. • Sexually transmitted diseases Gonococcal • Problem list Treatment or Rx for Gonorrhea • Complications this pregnancy NAAT–Nucleic amplification tests • Factors this pregnancy • Medical history 2nd Labor and delivery nursing admission triage form under– Comments 3rd Admission history and physical (H&P) under– • Current pregnancy history • Medical history • Problem list/findings 4th Delivery record under– • Maternal OB/labor summary • Labor and delivery admission history Page 24 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
15 Infections present and/or treated during this pregnancy (BC #42)—Continued
Syphilis (also called lues) See Gonorrhea TP-PA–T. pallidum particle agglutination A positive test for Treponema pallidum. STS–Serologic test for syphilis RPR–Rapid plasma regain 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 hepatitis) See Gonorrhea Hep B A positive test for the hepatitis B virus. HBV Treatment or Rx for hepatitis B
Hepatitis C (non A or non B hepatitis See Gonorrhea Hep C [HCV]) HCV A positive test for the hepatitis C virus. Treatment or Rx for hepatitis C Page 25 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
16 Obstetric procedures (BC #43)
Medical treatment or invasive or If the mother has had none of the See below See below manipulative procedure performed during procedures, check “none of the above.” this pregnancy to treat the pregnancy or to manage labor or delivery.
External cephalic version If checked, also indicate whether the 1st Prenatal care record under– Attempted conversion of a fetus from procedure was a success or a failure. • Problem list a nonvertex to a vertex presentation by If more than one attempt, report results of • Historical risk summary external manipulation. most recent attempt. • Complications this pregnancy • Factors this pregnancy Successful Successful version: 2nd Labor and delivery nursing Fetus was converted to a vertex admission triage form under– Breech version presentation. • Complications External version • Comments Failed Failed version: 3rd Admission history and physical Fetus was not converted to a vertex (H&P) under– Unsuccessful external version presentation. • Current pregnancy history Attempted version • Medical history Failed version • Problem list/findings Look for: malpresentation 4th Delivery record under– • Maternal OB/labor summary • Labor and delivery admission history • Labor summary record Page 29 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
LABOR AND DELIVERY
17 Date of birth (BC #4, FDFWS #16, FDR #4)
The infant’s date of birth. Enter the month, day, and four-digit year 1st Labor and delivery under– DOB–Date of birth of birth. Delivery record If the date of birth of the infant is unknown 2nd Newborn admission H&P because the infant is a foundling, enter the date the infant was found.
18 Time of birth (BC #2, FDFWS #17, FDR #2)
The infant’s time of birth. Enter the time the infant was born based 1st Labor and delivery under– on a 24-hour clock (military time). If time Delivery record of birth is unknown (foundling), enter “unknown.” 2nd Newborn admission H&P
19 Certifier’s name and title (BC #11)
The individual who certified to the fact Enter the name and title of the individual that the birth occurred: who certified to the fact that the birth M.D. (doctor of medicine) occurred. D.O. (doctor of osteopathy) The individual may be, but need not be, the same as the attendant at birth. Hospital administrator or designee CNM/CM (certified nurse midwife or certified midwife, includes APRN) Other midwife (midwife other than CNM/ CM, includes CPM) Other (specify)
20 Date certified (BC #12)
The date the birth was certified. Enter the date the birth was certified. Page 30 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
21 Principal source of payment (BC #38)
The primary source of payment for the Check the box that best describes the 1st Hospital face sheet delivery at the time of delivery: primary source of payment for this 2nd Admitting office face sheet Private insurance delivery. If more than one source of (Blue Cross/Blue Shield, Aetna, etc.) payment for the delivery is recorded, choose the source that appears to pay for Medicaid most of the delivery. (or a comparable state program) Check the source of payment for the Self-pay delivery, not the payer for the newborn (no third party identified) care or prenatal care, if different.
Other If “other” is checked, specify the payer. (Indian Health Service; CHAMPUS or If the principal source of payment is not TRICARE; other government [federal, known, enter “unknown” in the space. state, or local]; or charity) If unsure what source of payment a given The principal source of payment is insurance falls under, check with the important public health information and billing office. is needed to monitor access to care during delivery.
22 Infant’s medical record number (BC #48)
The medical record number assigned to Enter the medical record number. 1st Infant’s medical record the newborn. 2nd Admitting office face sheet under–History number Page 31 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
23 Was the mother transferred to this facility for maternal medical or fetal indications for delivery? (BC #28)
Transfers include hospital to hospital, If the mother was transferred from another 1st Labor and delivery nursing birth facility to hospital, etc. Does not facility to this facility for medical reasons admission triage form under– include home to hospital. related to the pregnancy, check “yes.” • Reason for admission If yes, enter the name of the facility • Comments the mother was transferred from. If the name of the facility is not known, enter 2nd Admission history and physical “unknown.” (H&P) Check “no” if the mother was transferred 3rd Labor & delivery – Delivery record from home. • Maternal OB/labor summary • Labor and delivery admission history • Labor summary record Page 32 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
24 Attendant’s name, title, and ID (BC #27, FDFWS #21, FDR #14)
The name, title, and National Provider Enter the name, title, and NPI number of 1st Delivery record under– Identifier (NPI) number of the person the person responsible for delivering the Signature of delivery attendant responsible for delivering the child. child. (medical) M.D. (doctor of medicine) Check one box to specify the attendant’s D.O. (doctor of osteopathy) title. If “other” is checked, enter the specific title of the attendant. Examples CNM/CM (certified nurse midwife or include nurse, father, police officer, and certified midwife, includes APRN) EMS technician. Other midwife (midwife other than CNM/ This item should be completed by the CM, includes CPM) facility. If the birth did not occur in a Other (specify) facility, the attendant or certifier should The attendant at birth is the individual complete it. physically present at the delivery who is responsible for the delivery. 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 must be reported as the attendant.
25 Mother’s weight at delivery (BC #33)
The mother’s weight at the time of Enter the mother’s weight at the time of 1st Labor and delivery nursing Wgt–Weight delivery. delivery. Use pounds in whole numbers admission triage form under– only. For example, enter 140½ pounds as Physical assessment–Weight 140 pounds. 2nd Admission history and If the mother’s delivery weight is unknown, physical (H&P) under–Physical enter “unknown.” examination–Weight Page 33 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
26 Characteristics of labor and delivery (BC #45)
Information about the course of labor and Check all characteristics that apply. See below See below delivery. If none of the characteristics of labor and delivery apply, check “none of the above.”
Induction of labor Check this item if medication was given 1st Delivery record under– IOL–Induction of labor Initiation of uterine contractions by or procedures to induce labor were Maternal OB/labor summary Pit Ind–Pitocin induction performed before labor began. If it is not medical or surgical means for the purpose • Labor and delivery admission ROM/NIL–Amniotomy induction or of delivery before the spontaneous onset clear whether medication or procedures history induction for rupture of membranes, of labor (i.e., before labor has begun). were performed before or after labor had • Labor summary record begun, review records to determine when not in labor Examples of methods include, but labor began and when medications were 2nd Physician progress note AROM–Artificial rupture of membranes are not limited to: artificial rupture given or procedures performed. If this done before labor of membranes, balloons, oxytocin, information is unclear or unavailable, 3rd Labor and delivery nursing Balloons prostaglandin, laminaria, or other cervical check with the birth attendant. admission triage form ripening agents. Oxytocin Induction of labor should be checked Prostaglandin even if the attempt to initiate labor is Laminaria not successful or the induction follows a spontaneous rupture of the membrane Cervidil without contractions. NOTE: Does not include augmentation of labor, which applies only after labor or contractions have begun. Page 34 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
26 Characteristics of labor and delivery (BC #45)—Continued
Augmentation of labor Check this item if medication was given Same as 1st and 2nd sources for Pit stim–Pitocin stimulation Stimulation of uterine contractions by or procedures to augment labor were Induction of labor Pit aug–Pit augmentation performed after labor began. If it is not drug or manipulative technique with the AROM–Artificial rupture of membranes intent to reduce the time of delivery clear whether medication or procedures done during labor (i.e., after labor has begun). were performed before or after labor had begun, review records to determine when Cervidil labor began and when medications were given or procedures performed. If this information is unclear or unavailable, check with the birth attendant. NOTE: Do not include if induction of labor was performed.
Steroids (glucocorticoids) for fetal Three conditions must be met for this 1st Delivery record under– Medications (before delivery): lung maturation received by the item. Check this item when 1) steroid • Maternal OB/labor summary– Betamethasone (Celestone) mother before delivery medication was given to the mother comments Betamethasone phosphate Steroids received by the mother prior 2) prior to delivery 3) for fetal lung • Labor summary record–comments Beta-PO4 to delivery to accelerate fetal lung maturation. maturation. Typically administered in Steroids may be administered to the 2nd Maternal medication record Betamethasone acetate anticipation of preterm (less than 37 mother prior to admittance to the hospital 3rd Newborn admission H&P Beta-Ac completed weeks of gestation) delivery. for delivery. Review the mother’s prenatal Dexamethasone Steroids include: betamethasone, care and other hospital records for 4th Maternal physician order sheet dexamethasone, or hydrocortisone mention of steroid administration for this 5th Prenatal care records specifically given to accelerate fetal lung purpose. maturation. Does not include steroid medication given to the mother for anti-inflammatory treatment before or after delivery. Page 35 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
26 Characteristics of labor and delivery (BC #45)—Continued
Antibiotics received by the mother Mother should have undergone labor, See steroids (glucocorticoids) Medications (during delivery): during delivery regardless of method of delivery. Ampicillin Includes antibacterial medications Check the timing of the administration of Penicillin given systemically (intravenous or the antibacterial medications. Check this Clindamycin intramuscular) to the mother in the item only if medications were received interval between the onset of labor and systemically by the mother during labor. Erythromycin the actual delivery. If information on onset of labor cannot be Gentamicin Includes: determined from the records, check with Cefotaxime the birth attendant. Ampicillin Ceftriaxone Penicillin Vancomycin Clindamycin Look for: Erythromycin SBE (sub-acute bacterial endocarditis) Gentamicin prophylaxis Cefotaxime GBS positive or GBS + (Group B Ceftriaxone streptococcus) Maternal fever Mother febrile
Clinical chorioamnionitis diagnosed Check that recorded maternal 1st Delivery record under– Chorioamnionitis during labor or maternal temperature temperature is at or above 38°C • Maternal OB/labor summary– Chorio ≥ 38°C (100.4°F) (100.4°F). comments/complications Temp > 38°C or 100.4°F Clinical diagnosis of chorioamnionitis • Labor summary record– Look for: during labor made by the delivery comments/complications attendant. Maternal fever 2nd Newborn admission H&P Usually includes more than one of the Mother febrile following: fever, uterine tenderness or 3rd Physician progress note irritability, leukocytosis, fetal tachycardia, maternal tachycardia, or malodorous 4th Maternal vital signs record vaginal discharge. under–Temperature recordings Any recorded maternal temperature at or above 38°C (100.4°F). Page 36 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
26 Characteristics of labor and delivery (BC #45)—Continued
Epidural or spinal anesthesia during Mother should have undergone labor, 1st Delivery record under– Epidural analgesia labor regardless of method of delivery. • Maternal OB labor summary Epid. given Administration to the mother of a regional under–analgesia or anesthesia Spinal given anesthetic to control the pain of labor. • Labor summary record Delivery of the agent into a limited space under–analgesia or anesthesia with the distribution of the analgesic effect limited to the lower body.
27 Method of delivery (BC #46, FDFWS #23, FDR #38)
The physical process by which the Complete sections C and D. See below See below complete delivery of the fetus was affected.
C. Fetal presentation at birth Check one of the three boxes. 1st Delivery record under–Fetal birth presentation Cephalic–presenting part of the fetus Check only the final presentation at birth. Cephalic: listed as vertex, occiput anterior (OA), or Vertex–OA, OP, LOA, ROA, LOP, ROP, LOT, occiput posterior (OP). ROT Face–LMA, LMT, LMP , RMA, RMP, RMT Brow Sinciput Mentum–chin
Breech–presenting part of the fetus listed Breech: (Buttocks, sacrum) as breech, complete breech, frank breech, Frank breech–LSA, LST, LSP, RSP, RST or footling breech. Single footling breech Double footling breech Complete breech
continued on next page continued on next page Page 37 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
27 Method of delivery (BC #46, FDFWS #23, FDR #38)—Continued
C. Fetal presentation at birth— See above See above Other: Continued Shoulder Other–any other presentation not listed Transverse lie above. Funis Compound
D. Final route and method of delivery Check one of the boxes. 1st Delivery record under–Method of Vaginal/spontaneous delivery Delivery of the entire fetus through the 2nd Newborn admission H&P Vaginal/spontaneous: vagina by the natural force of labor with VAG Del–Vaginal delivery or without manual assistance from the 3rd Recovery room record under– delivery attendant. Maternal data–Delivered SVD–Spontaneous vaginal delivery
Vaginal/forceps Vaginal/forceps: Delivery of the fetal head through the LFD–Low forceps delivery vagina by the application of obstetrical forceps to the fetal head.
Vaginal/vacuum Vaginal/vacuum: Delivery of the fetal head through the Vac Ext vagina by the application of a vacuum cup vacuum or ventouse to the fetal head.
Cesarean Cesarean: Extraction of the fetus, placenta, and C/S–Cesarean section membranes through an incision in the LSTCS–Low segment transverse maternal abdominal and uterine walls. Look for: TOL–Trial of labor Page 38 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
27 Method of delivery (BC #46, FDFWS #23, FDR #38)—Continued
If cesarean, was a trial of labor Check “yes” or “no.” TOL–Trial of labor attempted? Labor was allowed, augmented, or induced with plans for a vaginal delivery.
28 Maternal morbidity (BC #47, FDFWS #24, FDR #39)
Serious complications experienced by the Check all boxes that apply. See below See below mother associated with labor and delivery. If the mother has none of the complications, check “none of the above.”
Maternal transfusion 1st Delivery record under– Transfused Includes infusion of whole blood or • Labor summary Blood transfusion packed red blood cells associated with • Delivery summary Look for: labor and delivery. 2nd Physician delivery notes or PRBC–Packed red blood cells Operative notes Whole blood 3rd Intake & output form
Third- or fourth-degree perineal 1st Delivery record under– 4th degree lac. laceration • Episiotomy section 4° LAC degree 3° laceration extends through the • Lacerations section 3rd degree lac. perineal skin, vaginal mucosa, perineal 3° LAC degree body, and partially or completely through 2nd Recovery room record under– the anal sphincter. Maternal data–Delivered 3a 4° laceration is all of the above with 3b extension through the rectal mucosa. 3c Page 39 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
28 Maternal morbidity (BC #47, FDFWS #24, FDR #39)—Continued
Ruptured uterus 1st Delivery record under– Tearing of the uterine wall. Uterine rupture • Delivery summary note– is a full-thickness disruption of the uterine • Comments or Complications wall that also involves the overlying visceral peritoneum (uterine serosa). 2nd Operative note Does not include uterine dehiscence, in 3rd Physician progress note which the fetus, placenta, and umbilical cord remain contained with the uterine cavity. Does not include a silent or incomplete rupture or an asymptomatic separation.
Unplanned hysterectomy See Ruptured uterus Hysterectomy Surgical removal of the uterus that was Look for: not planned before the admission. laparotomy Includes an anticipated, but not definitively planned, hysterectomy.
Admission to an intensive care unit 1st Physician progress note ICU–Intensive care unit Any admission, planned or unplanned, of 2nd Transfer note MICU–Medical intensive care unit the mother to a facility or unit designated SICU–Surgical intensive care unit as providing intensive care. L&D ECU–Labor and delivery emergency care unit Page 43 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
NEWBORN INFORMATION
29 Birthweight or weight of fetus (BC #49, FDFWS #25, FDR #18c)
The weight of the infant at birth. Enter the weight (in grams) of the infant 1st Delivery record under– Infant data BW–Birthweight at birth. Gms–Grams Do not convert pounds (lbs.) and ounces kg–Kilograms (oz.) to grams. Lbs–Pounds If the weight in grams is unavailable, enter oz–Ounces the birth weight in lbs. and oz.
30 Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)
The best obstetric estimate of the infant’s For the nonclinician: 1st OB admission H&P under– Gestation weeks (wks) gestational age (OE) in completed weeks Enter the final best obstetric estimate of • Weeks weeks gestational age is based on the clinician’s final estimate the infant’s gestational age in completed • Gestational age GA–Gestational age of gestation. weeks. EGA–Estimated gestational age For the clinician: The OE should be based on the clinician’s The best estimated delivery date (EDD) estimate of gestational age at delivery. is determined by the date of the last Look for the most recent gestational age menstrual period (LMP) if confirmed by estimate in the records (this can often be early ultrasound. If ultrasound is not found in the labor and delivery records performed or is unknown, the best EDD under “gestational age”). is determined by the LMP. If the LMP is If the most recent gestational age is dated unknown or inconsistent with the early on or after the infant’s date of delivery, ultrasound, the best EDD is determined by enter this estimate. early ultrasound. For deliveries resulting If the most recent gestational age is from the use of assisted reproductive dated before the date of delivery, add the technology, the best EDD is based on the number of days between the most recent known date of fertilization.* gestational age and the date of delivery Accurate pregnancy dating is important to the gestational age estimate. For to improve outcomes and is a research example, if the most recent gestational and public health imperative. The age in the records is 32 weeks, 5 days and best estimated due date should be is dated 3/24, and the date of delivery is documented clearly in the medical 3/31, add 7 days to the gestational age records.* for the final total of 33 weeks, 5 days. continued on next page continued on next page Page 44 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
30 Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)—Continued
* Adopted from: ACOG reVITALize The gestational age for the OE is reported See above See above “Obstetric Data Definitions” (available in completed weeks. If the OE includes a from: https://www.acog.org/-/media/ fraction of a week (e.g., 33 weeks, 5 days) Departments/Patient-Safety-and- always round down to the nearest whole Quality-Improvement/2014reVITALi week (e.g., 33 weeks). zeObstetricDataDefinitionsV10.pdf) If a final best obstetric estimate of and “Method for Estimating Due Date” gestation cannot be found, search for the (available from: https://www.acog.org/ best obstetrical estimated due date (EDD) Clinical-Guidance-and-Publications/ and calculate the OE as shown below. Committee-Opinions/Committee- If both the EDD and the OE are not known, on-Obstetric-Practice/Methods-for- enter “unknown.” Estimating-the-Due-Date). If the date of delivery occurs before the EDD, then use the following calculation: 1) Find the most recent best EDD (this may only be found in the prenatal care records) and the date of delivery. 2) Calculate the difference between the EDD and the date of delivery in days (e.g., EDD of 1/7/2015 – date of delivery of 12/30/2014 = 8 days). 3) Subtract difference between the EDD and the date of delivery from 280 days (e.g., 280 days – 8 days = 272 days). 4) Divide the total number of days from step 3 by 7 days (e.g., 272 days ÷ 7 days = 38.9 weeks) to determine the OE in weeks. 5) Enter the OE in completed weeks (e.g., 38 weeks). continued on next page Page 45 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
30 Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)—Continued
See above If the date of delivery occurs after See above See above the EDD, then use the following calculation: 1) Find the most recent best EDD (this may only be found in the prenatal care records) and the date of delivery. 2) Calculate the difference between the date of delivery and EDD in days (e.g., date of delivery of 1/5/2015 – EDD of 12/28/2014 = 8 days). 3) Add the difference between the date of delivery and the EDD to 280 days (e.g., 280 + 8 = 288 days). 4) Divide the total number of days from step 3 by 7 days (e.g., 288 days ÷ 7 days = 41.1 weeks) to determine the OE in weeks. 5) Enter the OE in completed weeks (e.g., 41 weeks).
31 Sex of child (BC #3, FDFWS #27, FDR #3)
The sex of the infant. Enter whether the infant is male, female, 1st Delivery record under– Infant data M–Male or if the sex of the infant is ambiguous, F–Female enter “unknown.” A–Ambiguous or Not yet determined (same as unknown) U–Unknown Page 46 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
32 Apgar score (BC #51)
A systematic measure for evaluating the Enter the infant’s Apgar score at 5 1st Delivery record under–Infant data physical condition of the infant at specific minutes. intervals following birth. If the score at 5 minutes is less than 6, enter the infant’s Apgar score at 10 minutes.
33 Plurality (BC #52, FDFWS #28, FDR #33)
The number of fetuses delivered live Enter the number of fetuses delivered in 1st Delivery record Single or dead at any time in the pregnancy this pregnancy. 2nd Admission history and physical Twin, triplet, quadruplet, etc. Multiple regardless of gestational age, or if the If two or more live births in this (H&P) (a, b, c …) or (1, 2, 3 …) fetuses were delivered at different dates delivery, see “Attachment to the in the pregnancy. Facility Worksheet for the Live Birth “Reabsorbed” fetuses/“vanishing twin” Certificate for Multiple Births.” (those that are not delivered: expulsed or extracted from the mother) should not be counted.
34 If not a single birth, order born in the delivery (BC #53, FDFWS #29, FDR #34)
The order born in the delivery, live born or If this is a single birth, leave this item 1st Delivery record under–Birth order Baby A, B, or Baby 1, 2, etc. fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, blank. Twin A, B, or Twin 1, 2 7th, etc.). 2nd Infant data Include all live births and fetal deaths Triplet A, B, C, or Triplet 1, 2, 3, etc. from this pregnancy. Look for: Birth order or Set order
35 If not a single birth, number of infants in the delivery born alive (FDFWS #30)
The number of infants in this delivery born If this is a single birth, leave this item 1st Delivery record Look for: alive at any point in the pregnancy. blank. 2nd Admission history and physical Condition If this is not a single birth, specify the (H&P) number of infants in this delivery born alive at any point in the pregnancy. Include this birth. Page 47 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
36 Abnormal conditions of the newborn (BC #54)
Disorders or significant morbidity Check all boxes that apply. See below See below experienced by the newborn. If none of the conditions apply, check “none of the above.”
Assisted ventilation required 1st Labor delivery summary Bag and mask ventilation immediately following delivery under– Infant Data or Breathing Intubation Infant given manual breaths for any Intubation and PPV–Positive pressure duration with bag and mask or bag and ventilation endotracheal tube within the first several PPV bag/mask or ET–Positive pressure minutes from birth. ventilation via bag, mask, or Excludes free-flow (blow-by) oxygen only, endotracheal intubation laryngoscopy for aspiration of meconium, IPPV bag–Intermittent positive pressure nasal cannula, and bulb suction. ventilation via bag IPPV ET–Intermittent positive pressure ventilation via endotracheal intubation O2 via ET–Oxygen via endotracheal intubation Oxygen Page 48 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
36 Abnormal conditions of the newborn (BC #54)—Continued
Assisted ventilation required for more Count the number of hours of mechanical 1st Newborn respiratory care flow If in use for more than 6 hours: than six hours ventilation given. sheet CPAP–Continuous positive airway Infant given mechanical ventilation pressure (breathing assistance) by any method for IPPV–Intermittent positive pressure more than six hours. ventilation Includes conventional, high frequency, or HFV–High frequency ventilation continuous positive pressure (CPAP). IMV–Intermittent mandatory volume Excludes free-flow oxygen only, ventilation laryngoscopy for aspiration of meconium, HFOV–High frequency oscillatory and nasal cannula. ventilation IPPV–Intermittent positive pressure ventilation PIP–Peak inspiratory pressure PEEP–Positive end expiratory pressure CMV–Continuous mandatory ventilation HFPPV–High frequency positive pressure ventilation HFFI–High frequency flow interruption ventilation HFJV–High frequency jet ventilation Inhaled nitric oxide Page 49 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
36 Abnormal conditions of the newborn (BC #54)—Continued
NICU admission Include NICU admission at any time 1st Labor and delivery summary record ICN–Intensive care nursery Admission into a facility or unit staffed during the infant’s hospital stay following under–Disposition under– NICU–Neonatal intensive care unit delivery. and equipped to provide continuous • Intensive care nursery (ICN) PICU–Pediatric intensive care unit mechanical ventilatory support for a Do not include units that do not provide newborn. continuous mechanical ventilation. Do not include well-baby nurseries or special care nurseries (i.e., Level II nursery). Do not include if the newborn was taken to the NICU for observation but is not admitted to the NICU.
Newborn given surfactant replacement Check both 1st and 2nd sources before 1st Labor and delivery summary If given to newborn after birth: therapy completion. under–Neonatal medication Medications (given to newborn): Endotracheal instillation of a surface- 2nd Newborn medication Surfactant active suspension for treating surfactant administration record Survanta deficiency due to preterm birth or Exosurf pulmonary injury resulting in respiratory Curosurf distress. Infasurf Includes both artificial and extracted natural surfactant.
Antibiotics received by the newborn 1st Newborn medication Medications (given to newborn for sepsis): for suspected neonatal sepsis administration record Nafcillin, Chloramphenicol Any antibacterial drug (penicillin, Penicillin, Penicillin G ampicillin, gentamicin, cefotaxime, Ampicillin, Gentamicin, Kanamycin, etc.) given systemically (intravenous Cefotaxime, Cefoxitin, Vancomycin, or intramuscular). Does not include Acyclovir, Amikacin, Ceftazidime, antibiotics given to infants who are not Ceftriaxone, Cefazolin suspected of having neonatal sepsis. Page 50 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
36 Abnormal conditions of the newborn (BC #54)—Continued
Seizure or serious neurologic 1st Newborn H&P Seizures dysfunction 2nd Physician progress notes under– Tonic/Clonic/Clonus Seizure is any involuntary repetitive, Neuro examination Twitching convulsive movement or behavior. Eye rolling Serious neurologic dysfunction is severe Rhythmic jerking alteration of alertness. Hypotonia Excludes: Obtundation - Lethargy or hypotonia in the absence of other neurologic findings Stupor - Symptoms associated with CNS Coma congenital anomalies HIE-Hypoxic-ischemic encephalopathy
37 Congenital anomalies of the newborn (BC #55)
Malformations of the newborn diagnosed Check all boxes that apply. See below See below prenatally or after delivery.
Anencephaly 1st Labor and delivery summary record Anencephalus Partial or complete absence of the brain under–Infant data Acrania and skull. 2nd Newborn admission H&P Absent brain Also called anencephalus, acrania, or Craniorachischisis absent brain. Exencephaly Also includes infants with Hydraencephaly craniorachischisis (anencephaly with a contiguous spine defect). Page 51 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
37 Congenital anomalies of the newborn (BC #55)—Continued
Meningomyelocele/Spina bifida See Anencephaly Meningocele Spina bifida is herniation of the meninges Rachischisis 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 1st Physician progress notes under– TGA–Transposition of the great arteries Congenital heart defects that cause • Circulation TOF–Tetralogy of Fallot cyanosis. • Cardiovascular Pulmonary or pulmonic valvular 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 IAA–Interrupted aortic arch Page 52 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
37 Congenital anomalies of the newborn (BC #55)—Continued
Congenital diaphragmatic hernia 1st Infant H&P Defect in the formation of the diaphragm 2nd Labor and delivery summary record allowing herniation of abdominal organs under–Infant data into the thoracic cavity.
Omphalocele 1st Labor and delivery summary record Exomphalos A defect in the anterior abdominal wall under–Infant data in which the umbilical ring is widened, 2nd Admission history and physical allowing herniation of abdominal organs (H&P) under–G.I. into the umbilical cord. The herniating organs are covered by a nearly transparent membranous sac (different from gastroschisis [see below]), although this sac may rupture. Also called exomphalos. Do not include umbilical hernia (completely covered by skin) in this category.
Gastroschisis See 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. Page 53 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
37 Congenital anomalies of the newborn (BC #55)—Continued
Limb reduction defect excluding 1st Labor and delivery summary record Look for: congenital amputation and dwarfing under–Infant data Amniotic bands syndromes. 2nd Newborn H&P ABS–Amniotic band syndrome Complete or partial absence of a portion of an extremity, secondary to failure to develop.
Cleft lip with or without cleft palate See Limb reduction defect Cleft lip (unilateral, bilateral, or median) Incomplete closure of the lip. May be unilateral, bilateral, or median.
Cleft palate alone See 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 Check if a diagnosis of Down syndrome, 1st Infant progress notes Trisomy 21 Trisomy 21–A chromosomal abnormality Trisomy 21 is confirmed or pending. 2nd Genetic consult Positive (confirmed) caused by the presence of all or part of a Possible Down (pending) third copy of chromosome 21. Rule out (R/O) Down (pending) Karyotype confirmed Trisomy 21 mosaicism Karyotype pending Page 54 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
37 Congenital anomalies of the newborn (BC #55)—Continued
Suspected chromosomal disorder Check if a diagnosis of a suspected See Down syndrome Trisomy and then a number such as: Includes any constellation of congenital chromosomal disorder is confirmed or 13–Patau syndrome pending. (May include Trisomy 21.) malformations resulting from or 17 or 18–Edward syndrome compatible with known syndromes caused Positive (confirmed) by detectable defects in chromosome structure. Possible trisomy (pending) Karyotype confirmed Rule out (R/O) (pending) Karyotype pending
Hypospadias 1st Labor and delivery summary Incomplete closure of the male urethra under–Infant data resulting in the urethral meatus opening 2nd Newborn H&P under–Genitourinary on the ventral surface of the penis. (GU) Includes: - First degree (on the glans ventral to the tip) - Second degree (in the coronal sulcus) - Third degree (on the penile shaft) Page 55 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
38 Was the infant transferred within 24 hours of delivery? (BC #56)
Transfer status of the infant from this Check “yes” if the infant was transferred 1st Infant progress notes Look for: facility to another within 24 hours after from this facility to another within 24 Disposition delivery. hours of delivery. 2nd Transfer form 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.
39 Is infant living at time of the report? (BC #57)
Information on the infant’s survival. Check “yes” if the infant is living. 1st Infant progress notes 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 has died, make sure that a death certificate is filed. If the infant was transferred and the status is known, indicate the known status. Page 56 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Definitions Instructions Sources Keywords and abbreviations
40 Is the infant being breastfed at discharge? (BC #58)
Information on whether the infant was Check “yes” if the infant was breastfed at 1st Labor and delivery summary Pumping receiving breastmilk or colostrum during any time before being discharged from the record under–Infant data Lactation consultation the period between birth and discharge hospital. 2nd Maternal progress note LATCH score (Latch on, Audible swallow, from the hospital. Check “no” if the infant was not breastfed Type of nipple, Comfort, and Help— Breastfeeding refers to the establishment before being discharged from the under 3rd Newborn flow record – used to measure position and of breastmilk through the action of hospital. Feeding attachment of the baby on the breastfeeding or pumping (expressing). 4th Lactation consult breast) Include any attempt to establish Breast pump breastmilk production during the period Breast pump protocol between birth and discharge from the hospital. Breast milk Include if the infant received formula in MM–Mother’s milk addition to being breastfed. FBM–Fresh breast milk Does not include the intent to breastfeed. Attempt to breastfeed
41 Method of disposition* (FDFWS #32, FDR #13)
Burial Check only one method. 1st Labor and delivery summary record Cremation under–Infant data Hospital disposition 2nd Nursing note Donation 3rd Attending death note Removal from state Other (specify) 4th Social work note * Applicable to fetal deaths only.
The use of trade names is for identification only and does not imply endorsement by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Page 57 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Index of Items
A Congenital diaphragmatic hernia (Congenital anomalies of the newborn) 52 Abnormal conditions of the newborn 47 County of birth 8 Admission to an intensive care unit (Maternal morbidity) 39 Cyanotic congenital heart disease (Congenital anomalies of the newborn) 51 Anencephaly (Congenital anomalies of the newborn) 50 D Antibiotics received by the mother during delivery (Characteristics of labor and delivery) 35 Date certified 29 Antibiotics received by the newborn for suspected neonatal sepsis Date last normal menses began 14 (Abnormal conditions of the newborn) 49 Date of birth 29 Assisted reproductive technology (Risk factors in this pregnancy) 22 Date of first prenatal care visit 13 Assisted ventilation required for more than six hours Date of last live birth 16 (Abnormal conditions of the newborn) 48 Date of last other pregnancy outcome 17 Assisted ventilation required immediately following delivery Diabetes (Risk factors in this pregnancy) 18 (Abnormal conditions of the newborn) 47 Prepregnancy (Risk factors in this pregnancy) 18 Attendant’s name, title, and ID 32 Gestational (Risk factors in this pregnancy) 18 Augmentation of labor (Characteristics of labor and delivery) 34 Down syndrome (Congenital anomalies of the newborn) 53 Apgar score 46 E B Eclampsia (Risk factors in this pregnancy) 19 Birthweight or weight of fetus 43 Epidural or spinal anesthesia during labor (Characteristics of labor and delivery) 36 C External cephalic version (Obstetric procedures) 25 Certifier’s name and title 29 Characteristics of labor and delivery 33 F Chlamydia (Infections present and/or treated during this pregnancy) 24 Facility ID 8 City, town, or location of birth 8 Facility name 7 Cleft lip with or without cleft palate (Congenital anomalies of the newborn) 53 Fertility-enhancing drugs, artificial insemination, or intrauterine insemination (Risk factors in this pregnancy) 21 Cleft palate alone (Congenital anomalies of the newborn) 53 Fetal presentation at birth (Method of delivery) 36 Clinical chorioamnionitis diagnosed during labor or maternal temperature ≥ 38°C (100.4°F) (Characteristics of labor and delivery) 35 Final route and method of delivery (Method of delivery) 37 Congenital anomalies of the newborn 50 Page 58 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
G Mother had a previous cesarean delivery (Risk factors in this pregnancy) 22 Gastroschisis (Congenital anomalies of the newborn) 52 Mother’s weight at delivery 32 Gonorrhea (Infections present or treated during this pregnancy) 23 N H Newborn given surfactant replacement therapy (Abnormal conditions of the newborn) 49 Hepatitis B (Infections present and/or treated during this pregnancy) 24 NICU admission (Abnormal conditions of the newborn) 49 Hepatitis C (Infections present and/or treated during this pregnancy) 24 Number of other pregnancy outcomes 17 Hypertension (Risk factors in this pregnancy) 19 Number of previous live births now dead 16 Prepregnancy (chronic) (Risk factors in this pregnancy) 19 Gestational (Risk factors in this pregnancy) 19 Number of previous live births now living 15 Hypospadias (Congenital anomalies of the newborn) 54 O I Obstetric estimate of gestation at delivery 43 If cesarean, was a trial of labor attempted? (Method of delivery) 38 Obstetric procedures 25 If not a single birth, number of infants in the delivery born alive 46 Omphalocele (Congenital anomalies of the newborn) 52 If not a single birth, order born in the delivery 46 P Induction of labor (Characteristics of labor and delivery) 33 Place where birth occurred (Birthplace) 9 Infant’s medical record number 30 Plurality 46 Infections present and/or treated during this pregnancy 23 Pregnancy resulted from infertility treatment Is the infant being breastfed at discharge? 56 (Risk factors in this pregnancy) 21 Is the infant living at the time of the report? 55 Previous preterm births (Risk factors in this pregnancy) 20 L Principal source of payment 30 Limb reduction defect (Congenital anomalies of the newborn) 53 R M Risk factors in this pregnancy 17 Ruptured uterus (Maternal morbidity) 39 Maternal morbidity 38 Maternal transfusion (Maternal morbidity) 38 Meningomyelocele/Spina bifida (Congenital anomalies of the newborn) 51 Method of delivery 36 Method of disposition 56 Mother 7 Page 59 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
S Seizure or serious neurologic dysfunction (Abnormal conditions of the newborn) 50 Sex of child 45 Steroids (glucocorticoids) for fetal lung maturation received by the mother before delivery (Characteristics of labor and delivery) 34 Suspected chromosomal disorder (Congenital anomalies of the newborn) 54 Syphilis (Infections present and/or treated during this pregnancy) 24
T Third- or fourth-degree perineal laceration (Maternal morbidity) 38 Time of birth 29 Total number of prenatal care visits for this pregnancy 13
U Unplanned hysterectomy (Maternal morbidity) 39
W Was the infant transferred within 24 hours of delivery? 55 Was the mother transferred to this facility for maternal medical or fetal indications for delivery? 31