Updated March 2012 March 2003 Yellow Highlights indicate updated text. Guide to Completing The Facility Worksheets for the Certificate of Live and Report of Fetal Death (2003 revision)

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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. (Facility worksheet (FWS), Birth Certificate (BC), Facility worksheet for the Report of Fetal Death (FDFWS), Report of Fetal Death (FDR))

NOTE: All information on the mother should be for the woman who gave birth to, or delivered the infant.

Definitions Instructions Sources Key Words/Abbreviations Defines the items in the order they Provides specific instructions for Identifies the sources in the  Identifies alternative, usually appear on the facility worksheet completing each item medical records where information synonymous terms and common for each item can be found. The abbreviations and acronyms for specific records available will items. The keywords and differ somewhat from facility to abbreviations given in this guide are facility. The source listed first not intended as inclusive. Facilities (1st) is considered the best or and practitioners will likely add to preferred source. Please use this the lists. source whenever possible. All Example― subsequent sources are listed in Keywords/Abbreviations for order of preference. The precise prepregnancy diabetes are: location within the records where DM - diabetes mellitus an item can be found is further Type 1 diabetes identified by “under” and “or.” IDDM - Insulin dependent Example— diabetes mellitus Type 2 diabetes To determine whether gestational Non-insulin dependent diabetes diabetes is recorded as a “Risk mellitus factor in this ” (item 14) Class B DM in the records: st Class C DM The 1 or best source is : Class D DM The prenatal care record. Class F DM Class R DM Within the prenatal care record, Class H DM information on diabetes may be  Medications commonly found under: used for items. • Medical history Example: “Clomid” for • Previous obstetric (OB) “Assisted reproduction history treatment.” • Problem list, or initial risk assessment

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How To Use This Guide – Con.

Definitions Instructions Sources Key Words/Abbreviations

• Historical risk summary,  “Look for” is used to indicate Complications of previous terms that may be associated with, but are not synonymous with an • Factors this pregnancy. 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”)

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

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

Definitions Instructions Sources Keywords/Abbreviations

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 hospital or freestanding birthing center, enter the street and number of the place where the birth occurred. If this birth occurred en route, 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 air space or waters, enter “plane” or “boat.”

2. Facility I.D. (BC #17, FDFWS #2, FDR #9) National Provider Identifier. Enter the facility’s National NPI Provider Identification Number (NPI). 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, Enter the name of the city, town, township, village, or other location township, village, or other location where the 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.

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

Definitions Instructions Sources Keywords/Abbreviations 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.

5. Place where birth/delivery 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— occurred. General Admission under— Hospital . Admitted from home, doctor’s office, other or— Freestanding birthing center . Problem list/findings FBC – Freestanding birthing center No direct physical connection with nd 2 Delivery Record under— an operative delivery center. . Delivery information

. Labor and delivery summary Home birth If home birth is checked, check . Maternal obstetric (OB)/labor The birth occurred at a private whether the home birth was summary under—delivery residence. planned. If unknown whether a . Summary of labor and planned home birth write delivery (L & D) “unknown.” Clinic/Doctor’s office 3rd Basic Admission Data th 4 Progress Notes or Note Other Specify taxi, cab, train, plane etc.

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

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.

Definitions Instructions Sources Keywords/Abbreviations 6(a). 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 1st Prenatal Care Record under— PNC - Prenatal care care professional first examined the first prenatal care visit. . Intake information and/or counseled the pregnant Complete all parts of the date that . Initial physical exam woman for the pregnancy. are available. Leave the rest blank. . Prenatal visits flow sheet . Current pregnancy If “no prenatal care,” check the box and skip to 6(c). 2nd Initial Physical Examination

6(b). Date of last prenatal care visit (BC #29b, FDFWS #6b, FDR #23b) The month, day, and year of the last Enter the month, day, and year of 1st Prenatal Care Record under— PNC - Prenatal care prenatal care visit recorded in the the last prenatal care visit recorded Current Pregnancy records. in the records. 2nd Prenatal Visits Flow Sheets (last date shown) NOTE: Enter the date of the last

visit given in the most current record available. Do not estimate the date of the last visit. Complete all parts of the date that are available. Leave the rest blank.

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

Definitions Instructions Sources Keywords/Abbreviations 7. Total number of prenatal care visits for this pregnancy (BC #30, FDFWS #7, FDR #24) The total number of visits recorded Count only those visits recorded in 1st Prenatal Care Record under— PNC - Prenatal care in the record. the record. Prenatal Visit Flow Sheet (count visits) NOTE: Enter the total number of visits listed in the most current record available. Do not estimate additional visits when the prenatal record is not current. If none, enter “0.” The “no prenatal care” box should also be checked in item 6(a).

8. Date last normal menses began (BC #30, FDFWS #8, FDR #24) The date the mother’s last normal Enter all known parts of the date of 1st Prenatal Care Record under— LMP – last menstrual period menstrual period began. the mother’s last normal menstrual . Menstrual history period began. If no parts of the date . Nursing admission triage This item is used to compute the are known, write in “unknown.” form gestational age of the infant. nd 2 Admission H&P under—

Medical History

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

Definitions Instructions Sources Keywords/Abbreviations 9. Number of previous live 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 . Intake information infants who are still living. . Gravida section – L (living) – Look for: last number in series G -- Gravida - Total number of For multiple deliveries: . Para section – L – last pregnancies Include all live born infants before number in series P – Para – Previous live births and this infant in the pregnancy. . Pregnancy history fetal deaths >28 weeks of gestation If the first born, do not include this information T – Term – delivered at 37 to 40 infant. . Previous OB history weeks gestation If the second born, include the first . Past pregnancy history born, etc. 2nd Labor and Delivery Nursing If no previous live born infants, Admission Triage Form check “none.” under—Patient Data See “Attachment for 3rd Admission H&P Multiple Births.” 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 . Pregnancy history Expired infants who are no longer living. information - comments, complications For multiple deliveries: Include all live born infants before . Previous OB history - this infant in the pregnancy who are comments, complications now dead. . Past pregnancy history - If the first born, do not include this comments, complications infant. nd 2 Admission H&P If the second born, include the first born, etc. If no previous live born infants now dead, check “none.” See “Attachment for Multiple Births.”

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

Definitions Instructions Sources Keywords/Abbreviations 11. Date of last live birth (BC #35c, FDFWS #11, FDR #29c) The date of birth of the last live- If applicable, enter the month and 1st Prenatal Care Record under— DOB – Date of birth born infant. year of birth of the last live-born . Pregnancy history infant. information - date . Previous OB history - date Include live-born infants now living . Past pregnancy history - date and now dead. 2nd Admission H&P

12. Number of other pregnancy outcomes (BC #36a, FDFWS #12, FDR #30a) Total number of other pregnancy Include all previous pregnancy 1st Prenatal Care Record under— Miscarriages outcomes that did not result in a losses that did not result in a live . Gravida section – “A” Fetal demise live birth. birth. (abortion/miscarriage) AB - Abortion induced . PARA section - “A” SAB - Spontaneous abortion Includes pregnancy losses of any If no previous pregnancy losses, . Pregnancy history TAB - Therapeutic abortion gestation age. check “none.” information - comments, Abortion spontaneous Examples: spontaneous or induced For multiple deliveries: complications Septic abortion losses or ectopic pregnancy. Include all previous pregnancy . Previous OB history - Ectopic pregnancy losses before this infant in this comments, complications Tubal pregnancy pregnancy and in previous . Past pregnancy history - FDIU – fetal death in-utero pregnancies. comments, complications IUFD – intrauterine fetal death nd 2 Labor and Delivery Nursing Admission Triage Form 3rd Admission H&P

13. Date of last other pregnancy outcome (BC #36b, FDFWS #13, FDR #30b) The date that the last pregnancy that If applicable, enter the month and 1st Prenatal Care Record under— did not result in a live birth ended. year. . Pregnancy history information Includes pregnancy losses at any . Previous OB history gestational age. . Past pregnancy history Examples: spontaneous or induced nd 2 Admission H&P losses or ectopic pregnancy.

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

Definitions Instructions Sources Keywords/Abbreviations 14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36) Risk factors of the mother during Check all boxes that apply. The See below See below this pregnancy. mother may have more than one risk factor. If the mother has none of the risk factors, check “none of the above.”

Diabetes If diabetes is present, check either 1st Prenatal Care Record under— Glucose intolerance requiring prepregnancy or gestation diabetes. . Medical history treatment. Do not check both. . Previous OB history under— summary of previous Prepregnancy pregnancies Prepregnancy: Diagnosis before this pregnancy. . Problem list or— initial DM - diabetes mellitus risk assessment Type 1 diabetes . Historical risk summary IDDM - Insulin dependent . Complications of previous diabetes mellitus pregnancies Type 2 diabetes . Factors this pregnancy Non-insulin dependent diabetes nd 2 Labor and Delivery Nursing mellitus

Admission Triage Form Class B DM

under— Class C DM

. Medical complications Class D DM

. Comments Class F DM

rd Class R DM 3 Admission H&P under— Class H DM . Current pregnancy history

. Medical history Gestational: Gestational . Previous OB history under— GDM -- gestational diabetes Diagnosis during this pregnancy. pregnancy related mellitus . Problem list/findings IDGDM -- insulin dependent 4th Delivery Record under— gestational diabetes mellitus . Maternal OB/labor summary Class A1 or A2 diabetes mellitus . Labor and delivery admission history . Labor summary record

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

Definitions Instructions Sources Keywords/Abbreviations 14. Risk factors in this pregnancy – Con. Hypertension If hypertension is present, check See above Elevation of blood pressure above either prepregnancy or gestational normal for age, gender, and hypertension. Do not check both. physiological condition.

Prepregnancy (chronic) Prepregnancy: Diagnosis prior to the onset of this CHT – chronic hypertension pregnancy-does not include gestational (pregnancy induced hypertension (PIH).

Gestational Gestational: Diagnosis in this pregnancy PIH – pregnancy-induced (Pregnancy induced hypertension, hypertension preeclampsia). Preeclampsia Eclampsia Transient hypertension HELLP Syndrome

Eclampsia If eclampsia is present, one type of See above See above Hypertension with proteinuria with hypertension (either gestational or generalized seizures or coma. May chronic) may be checked). include pathologic edema.

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

Definitions Instructions Sources Keywords/Abbreviations 14. Risk factors in this pregnancy – Con. st Previous preterm births 1 Prenatal Care Record under— PTL – preterm labor History of pregnancy(ies) . Medical history P – premature terminating in a live birth of less . Previous OB history under— than 37 completed weeks of summary of previous gestation. 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 H&P under— . Medical history . Previous OB history under— pregnancy related . Problem list/findings

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

Definitions Instructions Sources Keywords/Abbreviations 14. Risk factors in this pregnancy – Con. Other previous poor pregnancy 1st Prenatal Care Record under— IUGR – intrauterine growth outcome . Medical history retardation . Previous OB history under— FDIU – fetal death in-utero History of pregnancies continuing th summary of previous SGA – small for gestational age into the 20 week of gestation and pregnancies SFD – small for dates resulting in any of the listed . Problem list or—initial risk Stillborn outcomes: assessment - Perinatal death (including fetal . Historical risk summary Look for: and neonatal deaths) . Complications of previous PROM – premature rupture of - Small for gestational age pregnancies membranes - Intrauterine-growth-restricted nd PPROM – preterm premature 2 Labor and Delivery Nursing birth rupture of membranes Admission Triage Form

under— Comments 3rd Admission H&P under— . Previous OB history under— pregnancy related . Complications Previous Pregnancies . Problem list/findings

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

Definitions Instructions Sources Keywords/Abbreviations 14. Risk factors in this pregnancy – Con. Pregnancy resulted from Check if any fertility therapy was 1st Prenatal Care Record under— See lists below infertility treatment. used. . Medical history Any assisted reproductive treatment . Current pregnancy history used to initiate the pregnancy. . Problem list or—initial risk assessment Includes: . Medications this pregnancy - Drugs (such as Clomid, Pergonal) - Artificial insemination 2nd Labor and Delivery Nursing - Technical procedures (such as Admission Triage Form in-vitro fertilization) under— . Comments . Medications 3rd Admission H&P under— . Current pregnancy history . Problem list/findings

Fertility-enhancing drugs, Check if specific therapy (drugs or Fertility-enhancing drugs, artificial artificial insemination or insemination) was used. or intrauterine insemination: intrauterine insemination Medications Any fertility enhancing drugs (e.g., Clomid, Serophene Clomid, Pergonal), artificial Pergonal insemination or intrauterine Metrodin insemination used to initiate the Profasi pregnancy. Progesterol Crinone (progesterone gel) Follistim FSH (follicule stimulating hormone) Gonadotropins, HcG (human chorionic gonadotropin) Pergonal

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

Definitions Instructions Sources Keywords/Abbreviations 14. Risk factors in this pregnancy – Con. Assisted reproductive Check if assisted reproductive See above Assisted reproductive technology: technology (e.g. in vitro therapy was used. ART fertilization (IVF), gamete Artificial insemination intrafallopian transfer (GIFT)) AIH – artificial insemination by Any assisted reproductive husband technology (ART/technical AID/DI – artificial insemination procedures (e.g., IVF, GIFT, by donor ZIFT)) used to initiate the In-vitro fertilization pregnancy. 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 . Past pregnancy history Repeat C/S Previous delivery by extracting the number of previous cesarean . Past OB history VBAC – after fetus, placenta, and membranes deliveries she has had. . Problem list or—initial risk cesarean through an incision in the mother’s assessment LSTCS (or LTCS) low segment abdominal and uterine walls. nd transverse cesarean section 2 Labor and Delivery Nursing Classical cesarean section Admission Triage Form If yes, how many?______Low vertical C/S under—Comments Low transverse C/S 3rd Admission H&P under— . Past OB history Look for: . Past pregnancy history TOL – trial of labor under—problem list/findings

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

Definitions Instructions Sources Keywords/Abbreviations 15. Infections present and/or treated during this pregnancy (BC #42, FDFWS #15, FDR #37) 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. women has the infection. with or without documentation of “--“ indicates that the test was treatment. If the mother has none of the risk negative, and the women does not factors, check “none of the above.” 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/culture for Neisseria . Infection history Gonorrheal gonorrhoeae. . Sexually transmitted diseases Gonoccocal . Problem list Treatment or Rx for Gonocchea . Complications this pregnancy NAAT – Nucleic amplification tests . Factors this pregnancy . Medical history 2nd Labor and Delivery Nursing Admission Triage Form under—Comments 3rd Admission H&P under— . Current pregnancy history . Medical history . Problem list/findings 4th Delivery Record under— . Maternal OB/labor summary . Labor and delivery admission history

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

Definitions Instructions Sources Keywords/Abbreviations 15. Infections present and/or treated during this pregnancy – Con. 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 See gonorrhea Hep B hepatitis) HBV A positive test for the hepatitis B virus.

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

*Listeria (LM) See gonorrhea LM A diagnosis of or positive test for Treatment or Rx for LM Listeria monocytogenes.

* Applicable to fetal deaths only.

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

Definitions Instructions Sources Keywords/Abbreviations 15. Infections present and/or treated during this pregnancy – Con. *Group B Streptococcus (GBS) See gonorrhea GBS A diagnosis of or positive test for Treatment or Rx for GBS Streptococcus agalactiae or group B streptococcus.

*Cytomegalovirus (CMV) See gonorrhea CMV A diagnosis of or positive test for Treatment or Rx for CMV Cytomegalovirus.

*Parvovirus (B19) See gonorrhea B19 A diagnosis of or positive test for Treatment or Rx for B19 Parvovirus B19.

*Toxoplasmosis (Toxo) See gonorrhea Toxo A diagnosis of or positive test for Treatment or Rx for Toxo Toxoplasma gondii.

* Applicable to fetal deaths only.

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

Definitions Instructions Sources Keywords/Abbreviations 16. Obstetric procedures (BC #43) Medical treatment or Check all boxes that apply. The See below See below invasive/manipulative procedure mother may have more than one performed during this pregnancy to procedure. treat the pregnancy or to manage If the mother has none of the labor and/or delivery. procedures, check “none of the

above.”

Cervical cerclage 1st Prenatal Record under— MacDonald’s suture Circumferential banding or suture . Medical history Shirodkar procedure of the to prevent or treat . Problem list or— initial Abdominal cerclage via laparotomy passive dilation. risk assessment Look for: . Historical risk summary Includes: Incompetent cervix . Complications this pregnancy MacDonald’s suture, Shirodkar Incompetent os . Factors this pregnancy procedure, abdominal cerclage via laparotomy 2nd Labor and Delivery Nursing Admission Triage Form under— . Complications . Comments 3rd Admission H&P under— . Current pregnancy history . Medical history . Problem list/findings 4th Delivery Record under— . Maternal OB . Labor and delivery admission history

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

Definitions Instructions Sources Keywords/Abbreviations 16. Obstetric procedures – Con. Tocolysis Check all boxes that apply. The 1st Prenatal Care Record under— Medications Administration of any agent with mother may have more than one . Medical history Magnesium sulfate - Mag SO4 the intent to inhibit preterm uterine procedure. . Problem list or— initial Terbutaline - Terb contractions to extend the length of risk assessment Indocin If the mother has none of the the pregnancy. . Historical risk summary procedures, check “none of the Look for: . Complications of previous Medications: above.” Preterm labor (this pregnancy) pregnancies - Magnesium sulfate (for preterm . Factors this pregnancy labor) - Terbutaline 2nd Labor and Delivery Nursing - Indocin (for preterm labor) Admission Triage Form under— . Complications this pregnancy . Medications . Comments 3rd Admission H&P under— . Current pregnancy history . Medication . Medical history . Problem list/findings 4th Delivery Record under— . Maternal OB/labor summary . Labor and delivery admission history . Labor summary record

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

Definitions Instructions Sources Keywords/Abbreviations 16. Obstetric procedures – Con. External cephalic version If checked, also indicate whether 1st Prenatal Care Record under— Attempted conversion of a fetus the procedure was a success or a . Problem list from a nonvertex to a vertex failure. . Historical risk summary presentation by external . Complications this pregnancy manipulation. . Factors this pregnancy nd 2 Labor and Delivery Nursing Successful Successful version: Admission Triage Form Fetus was converted to a vertex Breech version under— presentation. External version . Complications

. Comments Failed version: Failed rd Unsuccessful external version Fetus was not converted to a vertex 3 Admission H&P under— Attempted version presentation. . Current pregnancy history Failed version . Medical history . Problem list/findings Look for: th malpresentation 4 Delivery Record under— . Maternal OB/labor summary . Labor and delivery admission history . Labor summary record

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

Definitions Instructions Sources Keywords/Abbreviations 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 not known, 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 nd 2 Newborn Admission H&P (foundlings) enter unknown.

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 M.D. (doctor of medicine) that the birth occurred. D.O. (doctor of osteopathy) The individual may be, but need not Hospital administrator or be, the same as the attendant at designee birth. CNM/CM (certified nurse midwife/certified midwife) Other midwife (midwife other than a CNM/CM) Other (specify)

20. Date certified (BC #12) The date that the birth was certified. Enter the date that the birth was certified.

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

Definitions Instructions Sources Keywords/Abbreviations 21. Principal source of payment (BC #38) The principal source of payment at Check the box that best describes 1st Hospital Face Sheet the time of delivery: the principal source of payment for nd 2 Admitting Office Face Sheet this delivery. Private insurance (Blue Cross/Blue Shield, Aetna, If “other” is checked, specify the etc.) payer. Medicaid If the principal source of payment is (or a comparable State program) not known, enter “unknown” in the Self-pay space. (no third party identified) This item should be completed by Other the facility. If the birth did not (Indian Health Service, occur in a facility, it should be CHAMPUS/TRICARE, completed by the attendant or other government [Federal, State, certifier. local])

22. Infant’s medical record number (BC #48) The medical record number Enter the medical record number. 1st Infant’s Medical Record assigned to the newborn. Addressograph Plate nd 2 Admitting Office Face Sheet under—History Number

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

Definitions Instructions Sources Keywords/Abbreviations 23. Was the mother transferred to this facility for maternal medical or fetal indications for delivery? (BC #28, FDFWS #20, FDR #35) Transfers include hospital to If the mother was transferred from 1st Labor & Delivery Nursing hospital, birth facility to hospital, another facility check “yes.” Admission Triage Form etc. Does not include home to under— If “yes,” enter the name of the hospital. . Reason for admission facility the mother transferred from. . Comments If the name of the facility is not known, enter “unknown.” 2nd Admission H&P Check “no” if the mother was 3rd Labor & Delivery – Delivery transferred from home. Record . Maternal OB/labor summary . Labor and delivery admission history . Labor summary record

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

Definitions Instructions Sources Keywords/Abbreviations 24. Attendant’s name, title, and I.D. (BC #27, FDFWS #21, FDR #14) The name, title, and National Enter the name, title, and NPI 1st Delivery Record under— Provider Identification Number number of the person responsible Signature of Delivery (NPI) of the person responsible for for delivering the child. Attendant (Medical) delivering the child. Check one box to specify the M.D. (doctor of medicine) attendant’s title. If “other” is D.O. (doctor of osteopathy) checked, enter the specific title of CNM/CM (certified nurse the attendant. Examples include midwife/certified midwife) nurse, father, police officer, and EMS technician. Other midwife (midwife other than a CNM/CM) This item should be completed by Other (specify) the facility. If the birth did not occur in a facility, the attendant or The attendant at birth is defined as certifier should complete it. 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.

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

Definitions Instructions Sources Keywords/Abbreviations 25. Mother’s weight at delivery (BC #33, FDFWS #22, FDR #27) The mother’s weight at the time of Enter the mother’s weight at the 1st Labor and Delivery Nursing Wgt - Weight delivery. time of delivery. Use pounds only. Admission Triage Form For example, enter 140½ pounds as under—Physical Assessment 140 pounds. - Weight If the mother’s delivery weight is 2nd Admission H&P under— unknown, enter “unknown.” Physical Exam – Weight

26. Onset of labor (BC #44) Premature rupture of the Check all that apply (prolonged 1st Labor & Delivery Record PROM – premature rupture of membranes labor and precipitous labor should under— membranes Prolonged, greater than or equal to not both be checked). . Maternal OB/labor summary PPROM – preterm premature rupture 12 hours before the onset of labor. . Labor and delivery admission If none apply, check “none of the of membranes history above.” . Labor summary record – time Look for: ROM (rupture of membranes) ROM – rupture of membranes . Delivery record - ROM

st Precipitous labor If precipitous labor is indicated 1 Labor & Delivery Record Less than 3 hours. check that labor lasted less than 3 under— hours. . Labor summary – total length of labor . Labor chronology – total length of labor 2nd Delivery Comments

Prolonged labor If prolonged labor is indicated Same as precipitous labor above Greater than or equal to 20 hours. check that labor lasted 20 or more hours.

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

Definitions Instructions Sources Keywords/Abbreviations 27. Characteristics of labor and delivery (BC #45) Information about the course of Check all characteristics that apply. See below See below labor 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 by given or procedures to induce labor . Maternal OB/labor summary Pit Ind - Pitocin induction medical and/or surgical means for were performed BEFORE labor . Labor and delivery admission ROM/NIL - Amniotomy induction the purpose of delivery before the began. history or induction for rupture of spontaneous onset of labor (i.e., . Labor summary record membranes, not in labor before labor has begun). nd 2 Physician Progress Note

3rd Labor and Delivery Nursing Admission Triage Form

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 induction of labor above. Pit aug - pit augmentation by drug or manipulative technique labor were performed AFTER AROM – artificial rupture of with the intent to reduce the time of labor began. membranes done during labor delivery (i.e., after labor has begun).

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

Definitions Instructions Sources Keywords/Abbreviations 27. Characteristics of labor and delivery – Con. Nonvertex presentation 1st Delivery Record under— Breech (buttocks) (sacrum): Includes any nonvertex fetal Presentation Frank breech presentation. nd 2 Physician Progress Note LSA - left sacrum anterior For example: rd LST - left sacrum transverse 3 Newborn Admission H&P - Breech RSP - right sacrum posterior

- Shoulder RST - right sacrum transverse - Brow Complete breech - Face presentations Single footling breech - Transverse lie in the active phase Double footling breech of labor and delivery other than Shoulder presentation vertex - Compound Transverse lie NOTES: Nonvertex is Face presentation (mentum) presentation of other than the upper LMA - left mentum anterior and back part of the infant’s head. LMT - left mentum transverse Vertex is presentation of the upper NOTE: Item dropped from national dataset. LMP - left mentum posterior or back part of the infant’s head.

Steroids (glucocorticoids) for fetal Medications given before the 1st Delivery Record under— Medications – (before delivery) lung maturation received by the delivery. . Maternal OB/labor summary - - Betamethasone mother before delivery. comments - Dexamethasone . Labor summary record - - Hydrocortisone Includes: betamethasone, comments dexamethasone, or hydrocortisone specifically given to accelerate fetal 2nd Maternal Medication Record lung maturation in anticipation of rd 3 Newborn Admission H&P preterm delivery. Does not include steroid medication 4th Maternal Physician Order Sheet given to the mother as an anti- inflammatory treatment before or after delivery.

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Definitions Instructions Sources Keywords/Abbreviations 27. Characteristics of labor and delivery – Con. Antibiotics received by the Medications received during Same as steroids (glucocorticoids) Medications (during delivery): mother during delivery delivery. above Ampicillin Includes antibacterial medications Penicillin given systemically (intravenous or Clindamycin intramuscular) to the mother in the Erythromycin interval between the onset of labor Gentamicin and the actual delivery. Cefataxine Ceftriaxone Includes: Vancomycin Ampicillin Penicillin Look for: Clindamycin SBE (sub-acute bacterial Erythromycin endocarditis) prophylaxis Gentamicin GBS positive or GBS + (Group B Cefataxine Streptococcus) Ceftriaxone Maternal fever Mother febrile

Clinical chorioamnionitis Check that recorded maternal 1st Delivery Record under— Chorioamnionitis diagnosed during labor or temperature is at or above 38°C . Maternal OB/labor summary Chorio maternal temperature greater (100.4°F). – comments/complications Temp > 38 or 100.4 than or equal to 38°C (100.4°F) . Labor summary record – Clinical diagnosis of comments/complications Look for: nd Maternal fever chorioamnionitis during labor made 2 Newborn Admission H&P by the delivery attendant. Mother febrile 3rd Physician Progress Note Usually includes more than one of th the following: fever, uterine 4 Maternal Vital Signs Record tenderness and/or irritability, under—Temperature leukocytosis, or fetal tachycardia. Recordings

Any recorded maternal temperature at or above 38°C (100.4°F).

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Definitions Instructions Sources Keywords/Abbreviations 27. Characteristics of labor and delivery – Con. Moderate or heavy meconium 1st Delivery Record under— Mec – Meconium staining of the amniotic fluid . Maternal OB/labor summary Staining of the amniotic fluid – comments/complications caused by passage of fetal bowel . Labor summary record – contents during labor and/or at comments/complications delivery that is more than enough to . Amniotic fluid summary cause a greenish color change of an section – comments, color otherwise clear fluid. . Time membranes ruptured section 2nd Newborn Admission H&P 3rd Physician Progress Note

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Definitions Instructions Sources Keywords/Abbreviations 27. Characteristics of labor and delivery – Con. Fetal intolerance of labor was Check that recorded maternal 1st Delivery Record under— LLP – left lateral position such that one or more of the temperature is at or above 38°C . Maternal OB/labor summary O2 – oxygen following actions was taken: (100.4°F). . Labor summary record IV fluids In-utero resuscitative measures, nd 2 Newborn Admission H&P further fetal assessment, or Nitroglycerine operative delivery. 3rd Physician Progress Note Acoustic stimulation th Vibroacoustic stimulation Includes any of the following: 4 Physician Order Sheet or— Scalp pH sampling - Maternal position change Nursing Notes Fetal oxygen saturation - Oxygen administration to the monitoring mother Terbutaline - Intravenous fluids administered to Low forcep delivery the mother - Amnioinfusion C/S --Cesarean delivery - Support of maternal blood pressure - Administration of uterine relaxing agents Further fetal assessment including any of the following: scalp pH, scalp stimulation, acoustic stimulation. Operative delivery to shorten time to delivery of the fetus such as forceps, vacuum, or cesarean delivery.

Epidural or spinal anesthesia 1st Delivery Record under— Epidural analgesia during labor . Maternal OB labor summary Epid. given Administration to the mother of a under— analgesia/anesthesia Spinal given regional anesthetic to control the . Labor summary record pain of labor. under—analgesia/anesthesia Delivery of the agent into a limited space with the distribution of the analgesic effect limited to the lower body. Page 31 of 51

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Definitions Instructions Sources Keywords/Abbreviations 28. Method of delivery (BC #46, FDFWS #23, FDR #38) The physical process by which the Complete every section: See below See below complete delivery of the fetus was A, B, C, and D. affected.

A. Was delivery with forceps Check “yes” or “no.” 1st Delivery Record under— LFD --Low forcep delivery attempted but unsuccessful? Delivery Summary (attempted) Obstetric forceps were applied to 2nd Physician Delivery Summary LFD (attempted) the fetal head in an unsuccessful or—Progress Note rd attempt at vaginal delivery. NOTE: Item dropped 3 Recovery Room Record from national dataset. under—Maternal Data ― Complications

B. Was delivery with vacuum Check “yes” or “no.” Same as above Vac ext -- Vacuum extraction extraction attempted but (attempted) unsuccessful? Vac ext (attempted) Ventouse or vacuum cup was VAD --Vacuum assisted delivery applied to the fetal head in an NOTE: Item dropped unsuccessful attempt at vaginal from national dataset. delivery.

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Definitions Instructions Sources Keywords/Abbreviations 28. Method of delivery – Con. C. Fetal presentation at birth Check one of the three boxes.. 1st Delivery Record under— Fetal Birth Presentation Cephalic – presenting part of the Cephalic fetus listed as vertex, occiput Vertex – OA, OP, LOA, ROA, anterior (OA), occiput posterior LOP, ROP, LOT, ROT (OP). Face – LMA, LMT, LMP , RMA, RMP, RMT Brow Sinciput Mentum – chin

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

Single footling breech

Double footling breech

Complete breech

Other Other – any other presentation not Shoulder listed above. Transverse lie

Funis Compound

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Definitions Instructions Sources Keywords/Abbreviations 28. Method of delivery – Con. D. Final route and method of Check one of the boxes. 1st Delivery Record under— delivery Method of Delivery nd Vaginal/spontaneous: Vaginal/spontaneous 2 Newborn Admission H&P VAG Del - vaginal delivery Delivery of the entire fetus through rd 3 Recovery Room Record SVD - spontaneous vaginal delivery the vagina by the natural force of under—Maternal Data – labor with or without manual 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 Vac Ext the vagina by the application of a vacuum vacuum cup or ventouse to the fetal head.

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

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.

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Definitions Instructions Sources Keywords/Abbreviations 28. Method of delivery – Con. *Hysterotomy/ Colpohysterotomy

Uterotomy Hysterotomy Porro’s Operation The incision into the uterus extending into the uterine cavity. May be performed vaginally or transabdominally. Hysterectomy The surgical removal of the uterus. May be performed abdominally or vaginally.

* Applicable to fetal deaths only.

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Definitions Instructions Sources Keywords/Abbreviations 29. Maternal morbidity (BC #47, FDFWS #24, FDR #39) Serious complications experienced Check all boxes that apply. See below See below by the mother associated with labor If the mother has none of the and 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 . Delivery summary with labor and delivery. nd Look for: 2 Physician Delivery PRBC – packed red blood cells Notes/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 completely . Lacerations section 3rd degree lac. nd 3° LAC degree through the perineal skin, vaginal 2 Recovery Room Record mucosa, perineal body, and anal under—Maternal Data – sphincter. Delivered 4° laceration is all of the above with extension through the rectal mucosa.

Ruptured uterus 1st Delivery Record under— Tearing of the uterine wall. Delivery Summary Note – Comments/Complications

2nd Operative Note 3rd Physician Progress Note

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Definitions Instructions Sources Keywords/Abbreviations 29. Maternal morbidity – Con. Unplanned hysterectomy Same as ruptured uterus above Hysterectomy

Surgical removal of the uterus

that was not planned before the Look for: admission. laparotomy Includes an anticipated, but not definitively planned, hysterectomy.

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

Unplanned operating room 1st Physician Operative Note Repair of laceration procedure following delivery nd Repair of laparotomy 2 Physician Progress Note Any transfer of the mother back to Drainage of prurulent/septic a surgical area for an operative 3rd Physician Order material procedure that was not planned Exploratory laparotomy before the admission for delivery. Excludes postpartum tubal ligations.

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Definitions Instructions Sources Keywords/Abbreviations 30. 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— BW - Birthweight infant at birth. Infant Data Gms - grams nd kg - kilograms Do not convert pounds and ounces 2 Admission Assessment Lbs - pounds (lbs. and oz.) to grams. under— Weight oz - ounces If the weight in grams is not available, enter the birth weight in lbs. and oz.

31. Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d) The best obstetric estimate of the Enter the best obstetric estimate of 1st OB Admission H&P under— Gestation _____ weeks (wks) infant’s gestation in completed the infant’s gestation in completed . Weeks _____ weeks gestational age weeks based on the birth weeks. . Gestational age GA – gestational age attendant’s final estimate of EGA – estimated gestational age If a fraction of a week is given gestation. (e.g., 32.2 weeks) round down to This estimate of gestation should be the next whole week (.e.g., 32 determined by all perinatal factors weeks). and assessments such as ultrasound, If the obstetric estimate of gestation but not the neonatal exam. is not known, enter “unknown” in Ultrasound taken early in the space. pregnancy is preferred. Do not complete this item based solely on the infant’s date of birth and the mother’s date of last menstrual period.

32. Sex of child (BC #3, FDFWS #27, FDR #3) The sex of the infant. Enter whether the infant is male, 1st Delivery Record under— M – male female, or unknown. Infant Data F – female A – ambiguous (same as unknown) U - unknown

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Definitions Instructions Sources Keywords/Abbreviations 33. Apgar score (BC #51) A systematic measure for evaluating Enter the infant’s Apgar score at 5 Same as sex of infant above the physical condition of the infant minutes. at specific intervals following birth. If the score at 5 minutes is less than 6, enter the infant’s Apgar score at 10 minutes.

34. Plurality (BC #52, FDFWS #28, FDR #33) The number of fetuses delivered Enter the number of fetuses 1st Delivery record Single live or dead at any time in the delivered in this pregnancy. nd Twin, triplet, quadruplet, etc… 2 Admission H&P pregnancy regardless of gestational Multiple (a,b,c…) or (1,2,3…) If two or more live births in this age, or if the fetuses were delivered delivery, see “Facility Worksheet at different dates in the pregnancy. attachment for multiple births.” “Reabsorbed” fetuses (those that are not delivered: expulsed or extracted from the mother) should not be counted.

35. 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 1st Delivery Record under— Baby A, B, or Baby 1, 2 etc. born or fetal death (1st, 2nd, 3rd, 4th, item blank. Birth Order Twin A, B, or Twin 1, 2 th th th 5 , 6 , 7 , etc.). nd Triplet A, B, C, or Triplet 1, 2, 3 etc. Include all live births and fetal 2 Infant data

deaths from this pregnancy. Look for:

Birth order/Set order

36. 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 1st Delivery record Look for: delivery born alive at any point in item blank. nd Condition 2 Admission H&P the pregnancy. If this is not a single birth, specify

the number of infants in this delivery born alive at any point in the pregnancy. Include this birth.

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Definitions Instructions Sources Keywords/Abbreviations 37. 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/Breathing Intubation Infant given manual breaths for any Intubation and PPV - positive duration with bag and mask or bag pressure ventilation and endotracheal tube within the PPV bag/mask or ET - positive first several minutes from birth. pressure ventilation via bag, mask or endotracheal intubation Excludes free flow oxygen only, IPPV Bag - intermittent positive laryngoscopy for aspiration of pressure ventilation via bag meconium and nasal cannula. IPPV ET - intermittent positive pressure ventilation via endotracheal intubation O2 via ET - oxygen via endotracheal intubation Oxygen

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Definitions Instructions Sources Keywords/Abbreviations 37. Abnormal conditions of the newborn – Con. Assisted ventilation required for st If in use for more than 6 hours: Count the number of hours of 1 Newborn Respiratory Care more than six hours. CPAP -Continuous positive airway mechanical ventilation given. Flow Sheet Infant given mechanical ventilation pressure (breathing assistance) by any IPPV - Intermittent positive method for more than six hours. pressure ventilation HFV - High frequency ventilation Includes conventional, high IMV - intermittent mandatory frequency and/or continuous volume ventilation positive pressure (CPAP). HFOV - High frequency oscillatory Excludes free flow oxygen only, ventilation laryngoscopy for aspiration of IPPV - Intermittent positive meconium and nasal cannula. 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

NICU Admission NICU admission at any time during 1st Labor and Delivery Summary ICN - Intensive Care Nursery Admission into a facility or unit the infant’s hospital stay following Record under—Disposition SCN - Special Care Nursery staffed and equipped to provide delivery. under— NICU - Neonatal intensive care continuous mechanical ventilatory . Intensive Care Nursery (ICN) unit support for a newborn. . Special Care Nursery PICU - Pediatric intensive care unit (SCN)

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Definitions Instructions Sources Keywords/Abbreviations 37. Abnormal conditions of the newborn – Con. st Newborn given surfactant st 1 Labor and Delivery Summary If given to newborn after birth: Check both primary (1 ) and replacement therapy nd under—Neonatal Medication Medications (given to newborn): secondary (2 ) sources before Endotracheal instillation of a nd Surfactant completion. 2 Newborn Medication surface-active suspension for Survanta Administration Record treating surfactant deficiency due to Exosurf preterm birth or pulmonary injury Curosurf resulting in respiratory distress. Infasurf Includes both artificial and extracted natural surfactant.

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

Seizure or serious neurologic 1st Newborn H&P Seizures dysfunction nd Tonic/Clonic/Clonus 2 Physician Progress Notes Seizure – any involuntary Twitching under—Neuro Exam repetitive, convulsive movement or Eye rolling behavior. Rhythmic jerking Serious neurologic dysfunction – Hypotonia severe alteration of alertness. Obtundation Stupor Excludes: Coma - Lethargy or hypotonia in the (HIE) - Hypoxic-ischemic absence of other neurologic encephalopathy findings

- Symptoms associated with CNS congenital anomalies

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Definitions Instructions Sources Keywords/Abbreviations 37. Abnormal conditions of the newborn – Con. Significant birth injury 1st Labor and Delivery Summary Look for: (as applies to infant) Skeletal fracture(s), peripheral Record under—Newborn Trauma nerve injury, and/or soft tissue or Delivery Information Facial asymmetry solid organ hemorrhage that nd Subgaleal (progressive 2 Newborn Admission H&P requires intervention. Present extravasation within the scalp) immediately following or soon after 3rd Physician Progress Notes Hemorrhage delivery. Giant cephalohematoma

Extensive truncal, facial and/or Includes any bony fracture or extremity ecchymosis weakness or loss of sensation, but accompanied by evidence of excludes fractured clavicles and anemia and/or hypovolemia transient facial nerve palsy. and/or hypotension Soft tissue hemorrhage requiring Subcapsular hematoma of the liver evaluation and/or treatment, Fractures of the spleen includes subgaleal (progressive Adrenal hematoma extravasation within the scalp) hemorrhage, giant cephalohematoma, extensive truncal, facial and/or extremity ecchymosis accompanied by evidence of anemia and/or hypovolemia and/or hypotension. Solid organ hemorrhage includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma.

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Definitions Instructions Sources Keywords/Abbreviations 38. Congenital anomalies of the newborn (BC #55, FDFWS #31, FDR #40) 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. nd Absent brain 2 Newborn Admission H&P Craniorachischisis Also called anencephalus, acrania, or absent brain. Also includes infants with craniorachischisis (anencephaly with a contiguous spine defect).

Meningomyelocele/Spina bifida Same as anencephaly Meningocele Spina bifida is herniation of the meninges and/or spinal cord tissue through a bony defect of spine closure. Meningomyelocele is herniation of meninges and spinal cord tissue. Meningocele (herniation of meninges without spinal cord tissue) should also be included in this category. Both open and closed (covered with skin) lesions should be included. Do not include Spina bifida occulta (a midline bony spinal defect without protrusion of the spinal cord or meninges).

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Definitions Instructions Sources Keywords/Abbreviations 38. Congenital anomalies of the newborn – Con. Cyanotic congenital heart disease 1st Physician Progress Notes TGA - Transposition of the great Congenital heart defects that cause under— arteries cyanosis. . Circulation TOF - Tetratology of Fallot . 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 - hyposplastic left heart syndrome

Congenital diaphragmatic hernia 1st Infant H&P Defect in the formation of the nd 2 Labor and Delivery Summary diaphragm allowing herniation of Record under—Infant Data abdominal organs into the thoracic cavity.

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Definitions Instructions Sources Keywords/Abbreviations 38. Congenital anomalies of the newborn – Con. Omphalocele 1st Labor and Delivery Summary Exomphelos

Record under—Infant Data A defect in the anterior abdominal wall, accompanied by herniation of 2nd Admission H&P under—G.I. some abdominal organs through a widened umbilical ring into the umbilical stalk. The defect is covered by a membrane (different from gastroschisis [see below]), although this sac may rupture. Also called exomphalos. Do not include umbilical hernia (completely covered by skin) in this category. Do not include Spina bifida occulta (a midline bony spinal defect without protrusion of the spinal cord or meninges).

Gastroschisis Same as Omphalocele An abnormality of the anterior abdominal wall, lateral to the umbilicus, resulting in herniation of the abdominal contents directly into the amniotic cavity. Differentiated from omphalocele by the location of the defect and the absence of a protective membrane.

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Definitions Instructions Sources Keywords/Abbreviations 38. Congenital anomalies of the newborn – Con. Limb reduction defect—excluding 1st Labor and Delivery Summary Look for: congenital amputation and dwarfing Record under—Infant Data Amniotic bands syndromes nd ABS – amniotic band syndrome 2 Newborn H&P Complete or partial absence of a portion of an extremity, secondary to failure to develop.

Cleft lip with or without cleft Same as limb reduction defect Cleft lip (unilateral, bilateral, or palate median) Incomplete closure of the lip. May be unilateral, bilateral, or median.

Cleft palate alone Same as limb reduction defect Incomplete fusion of the palatal shelves. May be limited to the soft palate or may extend into the hard palate. Cleft palate in the presence of cleft lip should be included in the category above.

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

Suspected chromosomal disorder Check if a diagnosis of a suspected Same as Down syndrome Trisomy and then a number such as: Includes any constellation of chromosomal disorder is confirmed 13 - Patau’s syndrom congenital malformations resulting or pending. (May include Trisomy 17 or 18 - Edward syndrome from or compatible with known 21.) Positive (confirmed) syndromes caused by detectable Possible Trisomy __(pending) defects in chromosome structure. Rule out (R/O) (pending) Karyotype confirmed Karyotype pending

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Definitions Instructions Sources Keywords/Abbreviations 38. Congenital anomalies of the newborn – Con. Hypospadias 1st Labor & Delivery Summary Incomplete closure of the male under—Infant Data urethra resulting in the urethral nd 2 Newborn H&P meatus opening on the ventral under—Genitourinary (GU) surface of the penis.

Includes: - First degree (on the glans ventral to the tip) - Second degree (in the coronal sulcus) - Third degree (on the penile shaft)

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Definitions Instructions Sources Keywords/Abbreviations 39. Was the infant transferred within 24 hours of delivery? (BC #56) Transfer status of the infant within Check “yes” if the infant was 1st Infant Progress Notes Look for: 24 hours after delivery. transferred from this facility to nd Disposition 2 Transfer Form another within 24 hours of delivery.

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.

40. Is the 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 was transferred and the status is known, indicate the known status.

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Definitions Instructions Sources Keywords/Abbreviations 41. Is the infant being breast-fed at discharge? (BC #58) Information on whether the infant Check “yes” if the infant is being 1st Labor and Delivery Summary Pumping was being breast-fed during the breast-fed. Record under—Infant Data Lactation consultation period between birth and discharge nd LATCH score (Latch on, Audible Check “no” if the infant is not 2 Maternal Progress Note from the hospital. swallow, Type of nipple, Comfort being breast-fed. rd 3 Newborn Flow Record and Help – used to measure Refers to the action of breast- under—Feeding position and attachment of the baby feeding or pumping (expressing) th on the breast) milk. It is not the intent to breast- 4 Lactation Consult Breast pump feed or bottle-feed. Breast pump protocol Breast milk MM - Mother’s milk FBM - fresh breast milk

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

Definitions Instructions Sources Keywords/Abbreviations Method of Disposition* (FDFWS #32, FDR #13) Burial Check only one method. 1st Labor and Delivery Summary Cremation Record under—Infant Data Hospital Disposition nd 2 Nursing note Donation Removal from State 3rd Attending death note 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.

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