National Center for Health Statistics

Guide to Completing the Facility Worksheets for the Certificate of Live and Report of Fetal Death

(2003 revision)

Updated May 2016

National Vital Statistics System 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: http://www.cdc.gov/nchs/training/BirthCertificateElearning. Table of Contents

Instructions resulted from infertility treatment ...... 18. . How to Use This Guide ...... 5 Fertility-enhancing drugs, , or intrauterine insemination ...... 18. . . Mother ...... 7 . . . Assisted reproductive technology ...... 19. . . Facility Information Mother had a previous cesarean delivery ...... 19. . . Facility name ...... 7 . . . Infections present and/or treated during this pregnancy ...... 20 . . Facility ID ...... 8 . . . Gonorrhea ...... 20 . . . Syphilis ...... 21. . . . City, town, or location of birth ...... 8 Chlamydia ...... 21 County of birth ...... 8. . . . Hepatitis B ...... 21 . . . Place where birth occurred (Birthplace) ...... 9 Hepatitis C ...... 21 . . . and Pregnancy History Obstetric procedures ...... 22. . . External cephalic version ...... 22 . . . Date of first prenatal care visit ...... 10 . . Total number of prenatal care visits for this pregnancy ...... 10. . Labor and Delivery Date last normal menses began ...... 11 . . Date of birth ...... 23 . . . Number of previous live now living ...... 12 Time of birth ...... 23 . . . Number of previous live births now dead ...... 13 . . Certifier’s name and title ...... 23. . . Date of last live birth ...... 13 Date certified ...... 23 Number of other pregnancy outcomes ...... 14 Principal source of payment ...... 24 . . . Date of last other pregnancy outcome ...... 14. . . Infant’s medical record number ...... 24 . . Risk factors in this pregnancy ...... 14 Was the mother transferred to this facility for maternal medical or Diabetes ...... 15. . . . fetal indications for delivery? ...... 25 . . Prepregnancy ...... 15 Attendant’s name, title, and ID ...... 26 . . Gestational ...... 15. . . . Mother’s weight at delivery ...... 26 . . . Hypertension ...... 16. . . . Characteristics of labor and delivery ...... 27 Prepregnancy ...... 16 Induction of labor ...... 27. . . Gestational ...... 16. . . . Augmentation of labor ...... 28. . . Eclampsia ...... 16 . . . Steroids (glucocorticoids) for fetal lung maturation received by Previous preterm births ...... 17. . . the mother before delivery ...... 28 . . Table of Contents—Continued

Labor and Delivery—Continued Cyanotic congenital heart disease ...... 42 . . Antibiotics received by the mother during delivery ...... 29. . Congenital diaphragmatic hernia ...... 43 Clinical chorioamnionitis diagnosed during labor or maternal Omphalocele ...... 43 temperature ≥ 38°C (100 .4°F) ...... 29 Gastroschisis ...... 43. . . . Epidural or spinal anesthesia during labor ...... 30. . . Limb reduction defect ...... 44 Method of delivery ...... 30 . . . Cleft lip with or without cleft palate ...... 44. . . Fetal presentation at birth ...... 30 Cleft palate alone ...... 44. . . Final route and method of delivery ...... 31 Down syndrome ...... 44 If cesarean, was a trial of labor attempted? ...... 32 Suspected chromosomal disorder ...... 45 Maternal morbidity ...... 32 Hypospadias ...... 45 Maternal transfusion ...... 32 . . . Was the infant transferred within 24 hours of delivery? ...... 46 Third- or fourth-degree perineal laceration ...... 32 . . Is the infant living at the time of the report? ...... 46 Ruptured uterus ...... 33 . . . Is the infant being breastfed at discharge? ...... 47 Unplanned ...... 33 . . . Method of disposition ...... 47 . . . Admission to an intensive care unit ...... 33 Index of Items ...... 48 Newborn Information Birthweight or weight of fetus ...... 34 Obstetric estimate of gestation at delivery ...... 34 . . Sex of child ...... 36 ...... 37 Plurality ...... 37 If not a single birth, order born in the delivery ...... 37 If not a single birth, number of infants in the delivery born alive . . . . 37. . Abnormal conditions of the newborn ...... 38 . . Assisted ventilation required immediately following delivery ...... 38 Assisted ventilation required for more than six hours ...... 39 . . NICU admission ...... 40 Newborn given surfactant replacement therapy ...... 40 . . Antibiotics received by the newborn for suspected neonatal sepsis . . . .40 . Seizure or serious neurologic dysfunction ...... 41. . . Congenital anomalies of the newborn ...... 41 . . Anencephaly ...... 41 Meningomyelocele/Spina bifida ...... 42. . . 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 Provides specific instructions for Identifies the sources in the medical ► Identifies alternative, usually appear on the facility worksheet . completing each item . records where information for each synonymous terms and common item can be found . The specific abbreviations and acronyms records available will differ somewhat for items . The keywords and from facility to facility . The source abbreviations given in this guide listed first is considered the best are not intended as inclusive . or preferred source . Please use Facilities and practitioners will this source whenever possible . All likely add to the lists . subsequent sources are listed in order Example: of preference . The precise location Keywords and abbreviations for within the records where an item can prepregnancy diabetes are: 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 Type 2 diabetes in this pregnancy” (item #14) in the Noninsulin dependent diabetes records: mellitus The first or best source is the prenatal Class B DM care record . Class C DM Class D DM Within the prenatal care record, Class F DM information on diabetes may be found Class R DM under: Class H DM • Medical history ► Medications commonly used for • Previous obstetric (OB) history items . • Problem list or initial risk assessment Example: “Clomid” for “Assisted reproduction treatment .” • Historical risk summary • Complications of previous • Factors this pregnancy 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 All birth certificate information delivered the infant . reported 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 Enter the name of the facility where delivery took place . the birth occurred . If this birth did not occur in a or freestanding , 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, village, or other location where the township, village, or other location birth occurred . where the birth 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 Enter the name of the county where birth occurred . 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 . 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 Check the box that best describes 1st Admission history and occurred . the type of place where the birth physical (H&P) under–General occurred . Admission under– Hospital • Admitted from home, doctor’s Freestanding birthing center office, other or– FBC–Freestanding birthing center No direct physical connection with an • Problem list or findings operative delivery center . 2nd Delivery record under– Home birth If home birth is checked, check The birth occurred at a private whether the home birth was planned . • Delivery information residence . If unknown whether a planned home • Labor and delivery summary birth, write “unknown .” (L&D) • Maternal obstetric (OB) or labor Clinic/doctor’s office Specify taxi, train, plane, etc . summary under–delivery Other 3rd Basic admission data 4th Progress notes or Note Page 10 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 Enter the month, day, and year of the 1st Prenatal care record under– PNC–Prenatal care care professional first examined or first prenatal care visit . • Intake information counseled the pregnant woman for the If date information is incomplete, • Initial physical examination pregnancy . enter all parts of the date that are • Prenatal visit flow sheet known . Report "unknown" for any • Current pregnancy parts of the date that are missing . 2nd Initial physical examination 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 Access the most recent prenatal 1st Prenatal care record under– PNC–Prenatal care the record . records available . If up-to-date Prenatal visit flow sheet records are not available, contact the (count visits) A prenatal visit is one in which prenatal care provider for the most the physician or other health care current information . professional examines or counsels the pregnant woman for her pregnancy . Count the prenatal visits recorded in the record . Exclude visits for Do not include visits for laboratory laboratory and other tests or classes and other testing in which a physician in which the mother was not seen or health care professional did not by a physician or other health care examine or counsel the pregnant professional for pregnancy-related woman . 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 11 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 Count only visits recorded in the See above See above classes, where the physician most current record available . Do not or health care professional did estimate additional prenatal visits not provide individual care to the when the prenatal record is not up to pregnant woman . date . Enter the total number of prenatal visits . If no visits are recorded, enter “0 .” If the number of prenatal visits is equal to 0, 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 began . Report "unknown" for any This item is used to compute the • Labor and delivery nursing parts of the date that are missing . of the infant . admission triage form Do not estimate the date . 2nd Admission history and physical (H&P) under–Medical history Page 12 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- Do not include this infant . 1st Prenatal care record under– L–Now living born infants now living . Include all previous live-born infants • Intake information Look for: who are still living . • Gravida section–L (living)–last G–Gravida–Total number of number in series pregnancies For multiple deliveries: • Para section–L–last number in P–Para–Previous live births and fetal Include all live-born infants before series deaths > 28 weeks of gestation this infant in the pregnancy . • Pregnancy history information T–Term–Delivered at 37 to 40 weeks If the first born, do not include this • Previous OB history gestation infant . • Past pregnancy history If the second born, include the first 2nd Labor and delivery nursing born, etc . admission triage form under– If no previous live-born infants, Patient data check “none .” 3rd Admission history and physical See “Attachment to the Facility (H&P) Worksheet for the Live Birth Certificate for Multiple Births .” 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

10 . Number of previous live births now dead (BC #35b, FDFWS #10, FDR #29b)

The total number of previous live- Do not include this infant . 1st Prenatal care record under– See above born infants now dead . Include all previous live-born infants • Pregnancy history information– Expired who are no longer living . comments, complications • Previous OB history– For multiple deliveries: comments, complications Include all live-born infants before • Past pregnancy history– this infant in the pregnancy who are comments, complications now dead . 2nd Admission history and physical If the first born, do not include this (H&P) infant . If the second born, include the first born, etc . 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 1st Prenatal care record under– DOB–Date of birth infant . year . • Pregnancy history information– Include live-born infants now living date and now dead . • Previous OB history–date • Past pregnancy history–date If date information is incomplete, enter all parts of the date that are 2nd Admission history and physical known . Report “unknown” for any (H&P) parts of the date that are missing . Do not estimate or guess a date . 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

12 . Number of other pregnancy outcomes (BC #36a)

Total number of other pregnancy Include all previous pregnancy losses 1st Prenatal care record under– Miscarriages outcomes that did not result in a live that did not result in a live birth . • Gravida section–“A” ( Fetal demise birth . If no previous pregnancy losses, or miscarriage) AB–Abortion induced Includes pregnancy losses of any check “none .” • PARA section–“A” SAB–Spontaneous abortion gestational age . • Pregnancy history information– For multiple deliveries: TAB–Therapeutic abortion comments, complications Examples: spontaneous or induced Abortion spontaneous Include any losses regardless of losses or ectopic pregnancy • Previous OB history– Septic abortion gestational age that occurred before comments, complications Ectopic pregnancy the delivery of this infant . This could • Past pregnancy history– Tubal pregnancy include losses occurring in this comments, complications pregnancy or in a previous pregnancy . FDIU–Fetal death in utero 2nd Labor and delivery nursing IUFD–Intrauterine fetal death admission triage form 3rd Admission history and physical (H&P)

13 . Date of last other pregnancy outcome (BC #36b)

The date the last pregnancy that did If applicable, enter the month and 1st Prenatal care record under– not result in a live birth ended . year . • Pregnancy history information Includes pregnancy losses at any If date information is incomplete, • Previous OB history gestational age . enter all parts of the date that are • Past pregnancy history known . Report “unknown” for any Examples: spontaneous or induced parts of the date that are missing . Do 2nd Admission history and physical losses or ectopic pregnancy not estimate or guess a date . (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 See below See below pregnancy . mother may have more than one risk factor . If the mother has none of the risk factors, check “none of the above .” 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

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 prepregnancy or gestational diabetes . • Medical history treatment . 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 admission triage form under– mellitus • Medical complications Class B DM • Comments Class C DM 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 4th Delivery record under– gestational diabetes mellitus • Maternal OB or labor summary Class A1 or A2 diabetes mellitus • Labor and delivery admission history • Labor summary record 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

14 . Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued

Hypertension If hypertension is present, check See Diabetes Elevation of blood pressure above either prepregnancy or gestational normal for age, sex, and physiological hypertension . Do not check both . condition .

Prepregnancy (chronic) Prepregnancy: Diagnosis prior to the onset of CHT–Chronic hypertension this pregnancy–does not include Benign essential hypertension gestational (pregnancy-induced Essential hypertension hypertension [PIH]) . Preexisting hypertension

Gestational Gestational: Diagnosis in this pregnancy PIH–Pregnancy-induced hypertension (Pregnancy-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 prepregnancy) may be checked . include pathologic edema . 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

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 • Medical history P–Premature in a live birth of less than 37 • Previous OB history under– completed weeks 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 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

Pregnancy resulted from infertility Check if any infertility treatment was 1st Prenatal care record under– See below treatment used to initiate the pregnancy . This • Medical history Any assisted reproductive treatment information is included on both the • Current pregnancy history mother’s and the facility worksheets . used to initiate the pregnancy . • Problem list or–initial risk Check “yes” if treatment is reported assessment Includes: on either worksheet . - 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 See Pregnancy resulted from Fertility-enhancing drugs, or artificial insemination, or intrauterine or insemination) was used . This infertility treatment or intrauterine insemination: insemination information is included on both the Medications Any fertility-enhancing drugs (e .g ., mother’s and the facility worksheets . Clomid, Serophene Check “yes” if treatment is reported Clomid or Pergonal), artificial Pergonal insemination, or intrauterine on either worksheet . Metrodin insemination used to initiate the pregnancy . Profasi Progesterol Crinone (progesterone gel) Follistim FSH–Follicle stimulating hormone Gonadotropins Hcg–Human chorionic gonadotropin IUI– Intrauterine insemination 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

Assisted reproductive technology Check if assisted reproductive See Pregnancy resulted from Assisted reproductive technology: (e .g ., in-vitro fertilization [IVF] therapy was used . This information infertility treatment ART gamete intrafallopian transfer is included on both the mother’s and Artificial insemination [GIFT]) the facility worksheets . Check “yes” AIH–Artificial insemination by if treatment is reported on either Any assisted reproductive technology husband ([ART]/technical procedures [e .g ., worksheet . AID/DI–Artificial insemination by IVF, GIFT, or ZIFT]) used to initiate donor the 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 1st Prenatal care record under– C/S–Cesarean section delivery cesarean delivery, indicate the number • Past pregnancy history Repeat C/S Previous delivery by extracting the of previous cesarean deliveries she • Past OB history VBAC– after has had . fetus, , and membranes • Problem list or–initial risk cesarean through an incision in the mother’s assessment LSTCS (or LTCS) low segment abdominal and uterine walls . transverse cesarean section 2nd Labor and delivery nursing If yes, how many? Classical cesarean section admission triage form under– Comments Low vertical C/S 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 20 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 See below “+” indicates that the test for the pregnancy diagnosis or a confirmed mother may have more than one infection was positive and the diagnosis during the pregnancy infection . woman has the infection . with or without documentation of If the mother has none of the “–” indicates that the test was treatment . infections, check “none of the above .” negative, and the woman does not Documentation of treatment during have the infection . this pregnancy is adequate if a Look for: treatment or Rx for specific definitive diagnosis is not present in infection . the available record .

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 21 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 A positive test for Treponema agglutination 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 HBV virus . Treatment or Rx for hepatitis B

Hepatitis C (non A or non B See Gonorrhea Hep C hepatitis [HCV]) HCV A positive test for the hepatitis C Treatment or Rx for hepatitis C virus . 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

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 procedures, check “none of the during this pregnancy to treat the above .” 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 If more than one attempt, report • Historical risk summary by external manipulation . results of most recent attempt . • Complications this pregnancy • Factors this pregnancy Successful Successful version: 2nd Labor and delivery nursing Fetus was converted to a vertex Breech version admission triage form under– presentation . External version • Complications • Comments Failed Failed version: 3rd Admission history and physical Fetus was not converted to a vertex Unsuccessful external version (H&P) under– presentation . Attempted version • Current pregnancy history Failed version • Medical history Look for: malpresentation • Problem list/findings 4th Delivery record under– • Maternal OB/labor summary • Labor and delivery admission history • Labor summary record 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

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 1st Labor and delivery under– DOB–Date of birth year of birth . Delivery record If the date of birth of the infant is 2nd Newborn admission H&P unknown 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 1st Labor and delivery under– based on a 24-hour clock (military Delivery record time) . If time 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 Enter the name and title of the fact that the birth occurred: individual who certified to the fact that the birth occurred . M .D . (doctor of ) The individual may be, but need not D .O . (doctor of osteopathy) be, the same as the attendant at birth . Hospital administrator or designee CNM/CM (certified nurse or certified midwife) Other midwife (midwife other than CNM/CM) Other (specify)

20 . Date certified (BC #12)

The date the birth was certified . Enter the date the birth was certified . 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

21 . Principal source of payment (BC #38)

The primary source of payment for Check the box that best describes the 1st Hospital face sheet the delivery at the time of delivery: primary source of payment for this delivery . If more than one source of 2nd Admitting office face sheet Private insurance payment for the delivery is recorded, (Blue Cross/Blue Shield, Aetna, etc .) choose the source that appears to pay Medicaid for most of the delivery . (or a comparable state program) Check the source of payment for Self-pay the delivery, not the payer for the (no third party identified) newborn care or prenatal care, if different . Other If “other” is checked, specify the (Indian Health Service; CHAMPUS payer . or TRICARE; other government If the principal source of payment is [federal, state, or local]; or charity) not known, enter “unknown” in the The principal source of payment is space . important information If unsure what source of payment a and is needed to monitor access to given insurance falls under, check care during delivery . with the billing office .

22 . Infant’s medical record number (BC #48)

The medical record number assigned Enter the medical record number . 1st Infant’s medical record to the newborn . addressograph plate 2nd Admitting office face sheet under–History number 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

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 1st Labor and delivery nursing birth facility to hospital, etc . Does not another facility to this facility admission triage form under– include home to hospital . for medical reasons related to the • Reason for admission pregnancy, check “yes .” • Comments If yes, enter the name of the facility 2nd Admission history and physical the mother was transferred from . If (H&P) the name of the facility 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 Page 26 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 1st Delivery record under– Identifier (NPI) number of the person number of the person responsible for Signature of delivery attendant responsible for delivering the child . delivering the child . (medical) M .D . (doctor of medicine) Check one box to specify the attendant’s title . If “other” is checked, D .O . (doctor of osteopathy) enter the specific title of the attendant . CNM/CM (certified or Examples include nurse, father, police certified midwife) officer, and EMS technician . Other midwife (midwife other than This item should be completed by the CNM/CM) facility . If the birth did not occur in a facility, the attendant or certifier Other (specify) should complete it . The attendant at birth is the individual 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 1st Labor and delivery nursing Wgt–Weight delivery . of delivery . Use pounds in whole admission triage form under– numbers only . For example, enter Physical assessment–Weight 140½ pounds as 140 pounds . 2nd Admission history and physical If the mother’s delivery weight is (H&P) under–Physical unknown, enter “unknown .” examination–Weight Page 27 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 Check all characteristics that apply . See below See below and 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 1st Delivery record under– IOL–Induction of labor Initiation of uterine contractions given or procedures to induce labor Maternal OB/labor summary Pit Ind–Pitocin induction by medical or surgical means for were performed before labor began . • Labor and delivery admission ROM/NIL–Amniotomy induction or the purpose of delivery before the If it is not clear whether medication history induction for , spontaneous onset of labor (i .e ., before or procedures were performed before • Labor summary record not in labor or after labor had begun, review labor has begun) . AROM–Artificial rupture of records to determine when labor 2nd Physician progress note membranes done before labor Examples of methods include, but began and when medications were are not limited to: artificial rupture given or procedures performed . If this 3rd Labor and delivery nursing Balloons of membranes, balloons, oxytocin, information is unclear or unavailable, admission triage form Oxytocin prostaglandin, laminaria, or other check with the . Prostaglandin cervical ripening agents . Induction of labor should be checked Laminaria even if the attempt to initiate labor Cervidil is not successful or the induction follows a spontaneous rupture of the membrane without contractions . NOTE: Does not include augmentation of labor, which applies only after labor or contractions have begun . Page 28 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 Same as 1st and 2nd sources for Pit stim–Pitocin stimulation Stimulation of uterine contractions given or procedures to augment of labor Pit aug–Pit augmentation by drug or manipulative technique were performed after labor began . If AROM–Artificial rupture of with the intent to reduce the time of it is not clear whether medication or membranes done during labor procedures were performed before delivery (i .e ., after labor has begun) . Cervidil or after labor had begun, review records to determine when 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 mother before delivery medication was given to the mother comments Betamethasone phosphate 2) prior to delivery 3) for fetal lung Steroids received by the mother prior • Labor summary record– Beta-PO4 to delivery to accelerate fetal lung maturation . comments Betamethasone acetate maturation . Typically administered Steroids may be administered to 2nd Maternal medication record Beta-Ac in anticipation of preterm (less than the mother prior to admittance to 37 completed weeks of gestation) Dexamethasone the hospital for delivery . Review 3rd Newborn admission H&P delivery . the mother’s prenatal care and other Steroids include: betamethasone, hospital records for mention of steroid 4th Maternal physician order sheet administration for this purpose . dexamethasone, or hydrocortisone 5th Prenatal care records specifically given to accelerate fetal lung maturation . Does not include steroid medication given to the mother for anti- inflammatory treatment before or after delivery . 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

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 Penicillin given systemically (intravenous or administration of the antibacterial Clindamycin intramuscular) to the mother in the medications . Check this item Erythromycin interval between the onset of labor only if medications were received Gentamicin and the actual delivery . systemically by the mother during Cefotaxime Includes: labor . If information on onset of labor cannot be determined from Ceftriaxone Ampicillin the records, check with the birth Vancomycin Penicillin attendant . Look for: SBE (sub-acute bacterial endocarditis) Clindamycin prophylaxis Erythromycin GBS positive or GBS + (Group B Gentamicin streptococcus) Maternal fever Cefotaxime Mother febrile Ceftriaxone

Clinical chorioamnionitis Check that recorded maternal 1st Delivery record under– Chorioamnionitis diagnosed during labor or maternal temperature is at or above 38°C • Maternal OB/labor summary– Chorio temperature ≥ 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 Maternal fever attendant . 2nd Newborn admission H&P Mother febrile Usually includes more than one of the following: fever, uterine tenderness 3rd Physician progress note or irritability, leukocytosis, fetal tachycardia, maternal tachycardia, or 4th Maternal vital signs record malodorous vaginal discharge . under–Temperature recordings Any recorded maternal temperature at or above 38°C (100.4°F). 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

26 . Characteristics of labor and delivery (BC #45)—Continued

Epidural or spinal anesthesia Mother should have undergone labor, 1st Delivery record under– Epidural analgesia during labor regardless of method of delivery . • Maternal OB labor summary Epid . given Administration to the mother of a under–analgesia or anesthesia Spinal given regional anesthetic to control the pain • Labor summary record under– of labor . analgesia or anesthesia Delivery of the agent into a limited space 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 Cephalic: listed as vertex, occiput anterior (OA), birth . Vertex–OA, OP, LOA, ROA, LOP, or occiput posterior (OP) . ROP, LOT, ROT Face–LMA, LMT, LMP , RMA, RMP, RMT Brow Sinciput Mentum–chin

Breech–presenting part of the fetus Breech: (Buttocks, sacrum) listed as breech, complete breech, Frank breech–LSA, LST, LSP, RSP, frank breech, or footling breech . RST Single footling breech Double footling breech Complete breech

continued on next page continued on next page 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

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 Transverse lie listed above . Funis Compound

D . Final route and method of Check one of the boxes . 1st Delivery record under–Method delivery of delivery Vaginal/spontaneous 2nd Newborn admission H&P Vaginal/spontaneous: Delivery of the entire fetus through VAG Del–Vaginal delivery 3rd Recovery room record under– the vagina by the natural force SVD–Spontaneous vaginal delivery of labor with or without manual Maternal data–Delivered assistance from the delivery attendant .

Vaginal/forceps Vaginal/forceps: Delivery of the fetal head through LFD–Low forceps delivery the vagina by the application of to the fetal head .

Vaginal/vacuum Vaginal/vacuum: Delivery of the fetal head through the Vac Ext vagina by the application of a vacuum vacuum cup or ventouse to the fetal head .

Cesarean Cesarean: C/S–Cesarean section Extraction of the fetus, placenta, and LSTCS–Low segment transverse membranes through an incision in the maternal abdominal and uterine walls . Look for: TOL–Trial of labor 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

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 Check all boxes that apply . See below See below the mother associated with labor and If the mother has none of the delivery . 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 . PRBC–Packed red blood cells 2nd Physician delivery notes or Operative notes Whole blood 3rd Intake & output form

Third- or fourth-degree perineal 1st Delivery record under– 4th degree lac . laceration • section 4° LAC degree 3° laceration extends through the • Lacerations section 3rd degree lac . perineal skin, vaginal mucosa, 3° LAC degree perineal body, and partially or 2nd Recovery room record under– 3a completely through the anal sphincter . Maternal data–Delivered 3b 4° laceration is all of the above with 3c extension through the rectal mucosa . 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

28 . Maternal morbidity (BC #47, FDFWS #24, FDR #39)—Continued

Ruptured uterus 1st Delivery record under– Tearing of the uterine wall . Uterine • Delivery summary note– rupture is a full-thickness disruption • Comments or Complications of the uterine wall that also involves the overlying visceral peritoneum 2nd Operative note (uterine serosa) . 3rd Physician progress note Does not include uterine dehiscence, in 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 Look for: was 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 MICU–Medical intensive care unit 2nd Transfer note unplanned, of the mother to a facility SICU–Surgical intensive care unit or unit designated as providing L&D ECU–Labor and delivery intensive care . emergency care unit 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

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 1st Delivery record under– Infant BW–Birthweight infant at birth . data Gms–Grams Do not convert pounds (lbs .) and kg–Kilograms ounces (oz .) to grams . Lbs–Pounds If the weight in grams is unavailable, oz–Ounces enter the in lbs . and oz .

30 . Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)

The best obstetric estimate of the For the nonclinician: 1st OB admission H&P under– Gestation weeks (wks) infant’s gestational age (OE) in Enter the final best obstetric estimate • Weeks weeks gestational age completed weeks is based on the of the infant’s gestational age in • Gestational age GA–Gestational age clinician’s final estimate of gestation . completed weeks . EGA–Estimated gestational age For the clinician: The OE should be based on the The best estimated delivery date clinician’s estimate of gestational (EDD) is determined by the date age at delivery . Look for the most of the last menstrual period (LMP) recent gestational age estimate in the if confirmed by early ultrasound . records (this can often be found in If ultrasound is not performed the labor and delivery records under or is unknown, the best EDD is “gestational age”) . determined by the LMP . If the LMP If the most recent gestational age is is unknown or inconsistent with the dated on or after the infant’s date of early ultrasound, the best EDD is delivery, enter this estimate . determined by early ultrasound . For deliveries resulting from the use of If the most recent gestational age assisted reproductive technology, the is dated before the date of delivery, best EDD is based on the known date add the number of days between the of fertilization .* most recent gestational age and the date of delivery to the gestational age Accurate pregnancy dating is estimate . For example, if the most important to improve outcomes recent gestational age in the records and is a research and public health is 32 weeks, 5 days and is dated 3/24, imperative . The best estimated due and the date of delivery is 3/31, add date should be documented clearly in 7 days to the gestational age for the the medical records .* final total of 33 weeks, 5 days . continued on next page continued on next page 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

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 See above See above “Obstetric Data Definitions” reported in completed weeks . If the (available from: https://www .acog . OE includes a fraction of a week (e .g ., org/-/media/Departments/Patient- 33 weeks, 5 days) always round down Safety-and-Quality-Improvement/ to the nearest whole week (e .g ., 33 2014reVITALizeObstetricDataDe weeks) . finitionsV10 .pdf) and “Method for If a final best obstetric estimate of Estimating Due Date” (available from: gestation cannot be found, search for http://www .acog .org/Resources-And- the best obstetrical estimated due date Publications/Committee-Opinions/ (EDD) and calculate the OE as shown Committee-on-Obstetric-Practice/ below . Method-for-Estimating-Due-Date) . If both the EDD and the OE are not known, enter “unknown .” 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 36 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, 1st Delivery record under– Infant M–Male female, or if the sex of the infant is data F–Female ambiguous, enter “unknown .” A–Ambiguous or Not yet determined (same as unknown) U–Unknown 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

32 . Apgar score (BC #51)

A systematic measure for evaluating Enter the infant’s Apgar score at 5 1st Delivery record under–Infant the physical condition of the infant at minutes . data specific 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 1st Delivery record Single or dead at any time in the pregnancy in this pregnancy . Twin, triplet, quadruplet, etc . Multiple regardless of gestational age, or if the 2nd Admission history and physical If two or more live births in this (a, b, c …) or (1, 2, 3 …) fetuses were delivered at different (H&P) delivery, see “Attachment to the dates in the pregnancy . Facility Worksheet for the Live “Reabsorbed” fetuses (those that are Birth Certificate for Multiple not delivered: expulsed or extracted Births .” 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 If this is a single birth, leave this item 1st Delivery record under–Birth Baby A, B, or Baby 1, 2, etc . born or fetal death (1st, 2nd, 3rd, 4th, blank . order Twin A, B, or Twin 1, 2 5th, 6th, 7th, etc .) . Include all live births and fetal deaths 2nd Infant data 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 If this is a single birth, leave this item 1st Delivery record Look for: delivery born alive at any point in the blank . Condition pregnancy . 2nd Admission history and physical If this is not a single birth, specify (H&P) the number of infants in this delivery born alive at any point in the pregnancy . Include this birth . 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

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 ventilation and endotracheal tube within the first PPV bag/mask or ET–Positive several minutes from birth . pressure ventilation via bag, mask, Excludes free-flow (blow-by) oxygen or endotracheal intubation only, laryngoscopy for aspiration of IPPV bag–Intermittent positive meconium, nasal cannula, and bulb pressure ventilation via bag suction . IPPV ET–Intermittent positive pressure ventilation via endotracheal intubation O2 via ET–Oxygen via endotracheal intubation Oxygen 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

36 . Abnormal conditions of the newborn (BC #54)—Continued

Assisted ventilation required for Count the number of hours of 1st Newborn respiratory care flow If in use for more than 6 hours: more than six hours mechanical ventilation given . sheet CPAP–Continuous positive airway Infant given mechanical ventilation pressure (breathing assistance) by any method IPPV–Intermittent positive pressure for more than six hours . ventilation Includes conventional, high HFV–High frequency ventilation frequency, or continuous positive IMV–Intermittent mandatory volume pressure (CPAP) . ventilation Excludes free-flow oxygen only, HFOV–High frequency oscillatory laryngoscopy for aspiration of ventilation meconium, and nasal cannula . 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 40 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 ICN–Intensive care nursery Admission into a facility or unit during the infant’s hospital stay record under–Disposition SCN–Special care nursery staffed and equipped to provide following delivery . under– NICU–Neonatal intensive care unit continuous mechanical ventilatory Do not include units that do not • Intensive care nursery (ICN) PICU–Pediatric intensive care unit support for a newborn . provide continuous mechanical • Special care nursery (SCN) Level II nursery 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 Check both 1st and 2nd sources before 1st Labor and delivery summary If given to newborn after birth: replacement therapy completion . under–Neonatal medication Medications (given to newborn): Endotracheal instillation of a Surfactant 2nd Newborn medication surface-active suspension for treating Survanta administration record surfactant deficiency due to preterm Exosurf birth or pulmonary injury resulting in Curosurf respiratory distress . Infasurf Includes both artificial and extracted natural surfactant .

Antibiotics received by the newborn 1st Newborn medication Medications (given to newborn for for suspected neonatal sepsis administration record sepsis): Any antibacterial drug (penicillin, Nafcillin, Chloramphenicol ampicillin, gentamicin, cefotaxime, Penicillin, Penicillin G etc .) given systemically (intravenous Ampicillin, Gentamicin, or intramuscular) . Does not include Kanamycin, Cefotaxime, Cefoxitin, antibiotics given to infants who are Vancomycin, Acyclovir, Amikacin, not suspected of having neonatal Ceftazidime, Ceftriaxone, Cefazolin sepsis . Page 41 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 Tonic/Clonic/Clonus 2nd Physician progress notes under– Seizure is any involuntary repetitive, Neuro examination Twitching convulsive movement or behavior . Eye rolling Serious neurologic dysfunction is Rhythmic jerking severe alteration of alertness . Hypotonia Excludes: Obtundation Stupor - Lethargy or hypotonia in the absence of other neurologic findings Coma HIE-Hypoxic-ischemic - Symptoms associated with CNS encephalopathy congenital anomalies

37 . Congenital anomalies of the newborn (BC #55)

Malformations of the newborn Check all boxes that apply . diagnosed prenatally or after delivery .

Anencephaly 1st Labor and delivery summary Anencephalus Partial or complete absence of the record under–Infant data Acrania brain 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 42 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 Rachischisis meninges 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 Congenital heart defects that cause • Circulation arteries cyanosis . • Cardiovascular TOF–Tetralogy of Fallot 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 43 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 2nd Labor and delivery summary diaphragm allowing herniation of record under–Infant data abdominal organs into the thoracic cavity .

Omphalocele 1st Labor and delivery summary Exomphalos A defect in the anterior abdominal record under–Infant data wall in which the umbilical ring 2nd Admission history and physical is widened, allowing herniation of (H&P) under–G .I . abdominal organs 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 44 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 Look for: congenital amputation and dwarfing record 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 Incomplete closure of the lip . May be median) 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 1st Infant progress notes Trisomy 21 Trisomy 21–A chromosomal syndrome, Trisomy 21 is confirmed or Positive (confirmed) 2nd Genetic consult abnormality caused by the presence pending . Possible Down (pending) of all or part of a third copy of Rule out (R/O) Down (pending) chromosome 21 . Trisomy 21 mosaicism Karyotype confirmed Karyotype pending 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

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 chromosomal disorder is confirmed or 13–Patau’s syndrome congenital malformations resulting pending . (May include Trisomy 21 .) 17 or 18–Edward syndrome from or compatible with known Positive (confirmed) syndromes caused by detectable Possible trisomy (pending) defects in chromosome structure . Rule out (R/O) (pending) Karyotype confirmed Karyotype pending

Hypospadias 1st Labor and delivery summary Incomplete closure of the male under–Infant data urethra resulting in the urethral 2nd Newborn H&P under– meatus opening on the ventral surface Genitourinary (GU) 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) 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

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 1st Infant progress notes Look for: facility to another within 24 hours transferred from this facility to Disposition after delivery . another within 24 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 47 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 1st Labor and delivery summary Pumping receiving breastmilk or colostrum breastfed at any time before being record under–Infant data Lactation consultation during the period between birth and discharged from the hospital . LATCH score (Latch on, Audible discharge from the hospital . 2nd Maternal progress note Check “no” if the infant was not swallow, Type of nipple, Comfort, Breastfeeding refers to the breastfed before being discharged 3rd Newborn flow record under– and Help—used to measure establishment of breastmilk through from the hospital . Feeding and attachment of the baby on the the action of breastfeeding or breast) 4th Lactation consult pumping (expressing) . Breast pump Include any attempt to establish Breast pump protocol breastmilk production during the Breast milk period between birth and discharge MM–Mother’s milk from the hospital . FBM–Fresh breast milk Include if the infant received formula Attempt to breastfeed in addition to being breastfed . Does not include the intent to breastfeed .

41 . Method of disposition* (FDFWS #32, FDR #13)

Burial Check only one method . 1st Labor and delivery summary record under–Infant data Cremation Hospital disposition 2nd Nursing note Donation 3rd Attending death note Removal from state 4th Social work note Other (specify) * 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 48 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death

Index of Items

A County of birth 8 Abnormal conditions of the newborn 38 Cyanotic congenital heart disease (Congenital anomalies of the newborn) 42 Admission to an intensive care unit (Maternal morbidity) 33 D Anencephaly (Congenital anomalies of the newborn) 41 Date certified 23 Antibiotics received by the mother during delivery (Characteristics of labor and delivery) 29 Date last normal menses began 11 Antibiotics received by the newborn for suspected neonatal sepsis Date of birth 23 (Abnormal conditions of the newborn) 40 Date of first prenatal care visit 10 Assisted reproductive technology (Risk factors in this pregnancy) 19 Date of last live birth 13 Assisted ventilation required for more than six hours Date of last other pregnancy outcome 14 (Abnormal conditions of the newborn) 39 Diabetes (Risk factors in this pregnancy) 15 Assisted ventilation required immediately following delivery Prepregnancy (Risk factors in this pregnancy) 15 (Abnormal conditions of the newborn) 38 Gestational (Risk factors in this pregnancy) 15 Attendant’s name, title, and ID 26 Down syndrome (Congenital anomalies of the newborn) 44 Augmentation of labor (Characteristics of labor and delivery) 28 Apgar score 37 E Eclampsia (Risk factors in this pregnancy) 16 B Epidural or spinal anesthesia during labor (Characteristics of Birthweight or weight of fetus 34 labor and delivery) 30 External cephalic version (Obstetric procedures) 22 C Certifier’s name and title 23 F Characteristics of labor and delivery 27 Facility ID 8 Chlamydia (Infections present and/or treated during this pregnancy) 21 Facility name 7 City, town, or location of birth 8 Fertility-enhancing drugs, artificial insemination, or Cleft lip with or without cleft palate (Congenital anomalies of the newborn) 44 intrauterine insemination (Risk factors in this pregnancy) 18 Cleft palate alone (Congenital anomalies of the newborn) 44 Fetal presentation at birth (Method of delivery) 30 Clinical chorioamnionitis diagnosed during labor or maternal Final route and method of delivery (Method of delivery) 31 temperature ≥ 38°C (100.4°F) (Characteristics of labor and delivery) 29 G Congenital anomalies of the newborn 41 Congenital diaphragmatic hernia (Congenital anomalies of the newborn) 43 Gastroschisis (Congenital anomalies of the newborn) 43 Page 49 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death

Gonorrhea (Infections present or treated during this pregnancy) 20 N Newborn given surfactant replacement therapy (Abnormal conditions H of the newborn) 40 Hepatitis B (Infections present and/or treated during this pregnancy) 21 NICU admission (Abnormal conditions of the newborn) 40 Hepatitis C (Infections present and/or treated during this pregnancy) 21 Number of other pregnancy outcomes 14 Hypertension (Risk factors in this pregnancy) 16 Number of previous live births now dead 13 Prepregnancy (Risk factors in this pregnancy) 16 Number of previous live births now living 12 Gestational (Risk factors in this pregnancy) 16 Hypospadias (Congenital anomalies of the newborn) 45 O Obstetric estimate of gestation at delivery 34 I Obstetric procedures 22 If cesarean, was a trial of labor attempted? (Method of delivery) 32 Omphalocele (Congenital anomalies of the newborn) 43 If not a single birth, number of infants in the delivery born alive 37 If not a single birth, order born in the delivery 37 P Induction of labor (Characteristics of labor and delivery) 27 Place where birth occurred (Birthplace) 9 Infant’s medical record number 24 Plurality 37 Infections present and/or treated during this pregnancy 20 Pregnancy resulted from infertility treatment Is the infant being breastfed at discharge? 47 (Risk factors in this pregnancy) 18 Is the infant living at the time of the report? 46 Previous preterm births (Risk factors in this pregnancy) 17 Principal source of payment 24 L Limb reduction defect (Congenital anomalies of the newborn) 44 R Risk factors in this pregnancy 14 M Ruptured uterus (Maternal morbidity) 33 Maternal morbidity 32 Maternal transfusion (Maternal morbidity) 32 S Meningomyelocele/Spina bifida (Congenital anomalies of the newborn) 42 Seizure or serious neurologic dysfunction (Abnormal conditions of Method of delivery 30 th e ne wbor n) 41 Method of disposition 47 Sex of child 36 Mother 7 St e r oids ( g lu co corticoids) for fetal lung maturation received by the mother before delivery (Characteristics of labor and delivery) 28 Mother had a previous cesarean delivery (Risk factors in this pregnancy) 19 Suspected chromosomal disorder (Congenital anomalies of the newborn) 45 Mother’s weight at delivery 26 Syphilis (Infections present and/or treated during this pregnancy) 21 Page 50 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death

T Third- or fourth-degree perineal laceration (Maternal morbidity) 32 Time of birth 23 Total number of prenatal care visits for this pregnancy 10

U Unplanned hysterectomy (Maternal morbidity) 33

W Was the infant transferred within 24 hours of delivery? 46 Was the mother transferred to this facility for maternal medical or fetal indications for delivery? 25