
Obstetric Procedures (check all that apply)
□ Cervical cerclage
□ Tocolysis
External cephalic version
□
Successful □ Failed
□ None of the above
Onset of Labor (check all that apply)
□ Premature Rupture of the Membranes [prolonged > =12 hours]
□ Precipitous Labor [< 3 hours]
□ Prolonged Labor [> = 20 hours]
□ None of the above
Method of Delivery
Was delivery with forceps attempted but unsuccessful?
□ Yes □ No □ Unknown
Was delivery with vacuum extraction attempted but unsuccessful?
□ Yes □ No □ Unknown
Fetal presentation at birth
□ Cephalic □ Breech □ Other, _________________________
Final route and method of delivery
□ Vagina/Spontaneous □ Vagina/Forceps □ Vagina/Vacuum
If cesarean, was a trial of labor attempted? □ Cesarean
□ Yes □ No □ Unknown
Characteristics of Labor & Delivery
(check all that apply)
□ Induction of labor
□ Augmentation of labor
□ Non-vertex presentation
□ Steroids (glucocorticoids) for fetal lung maturation
received by mother prior to delivery
□ Antibiotics received by mother during labor
□ Chorioamnionitis or maternal temperature > = 38 degrees C or
100.4 degrees F
□ Moderate/heavy meconium staining of the amniotic fluid
□ Fetal intolerance of labor was such that one or more of the
following actions was taken: in-utero resuscitative measures,
further assessments, or operative delivery
□ Epidural or spinal anesthesia during labor
□ None of the above
Child’s Health Information
Birth Weight ________ Grams, or ________LB. ________OZ.
Obstetric Estimate of Gestation (completed weeks): _________
Child’s Sex: □ Male □ Female □ Not yet determined
Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______
Maternal Morbidity – Complications associated
with Labor & Delivery (check all that apply)
□ Maternal transfusion
□ Third or forth degree perineal laceration
□ Ruptured uterus
□ Unplanned hysterectomy
□ Admission to intensive care unit
□ Unplanned operating room procedure following delivery
□ None of the above
Abnormal Conditions of the Newborn (check all that apply)
□ Assisted ventilation required immediately following delivery
□ Assisted ventilation required for more than six hours
□ NICU admission
□ Newborn given surfactant replacement therapy
□ Antibiotics received by the newborn for suspected neonatal sepsis
□ Seizure or serious neurologic dysfunction
□ Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or
soft tissue/solid organ hemorrhage which requires intervention)
□ None of the above
Congenital Anomalies of the Newborn (check all that apply)
□ Anencephaly □ Cleft palate alone
□ Meningomyelocele/Spina bifida □ Down syndrome
□ Cyanotic congenital heart disease
□ Congenital diaphragmatic hernia
□ Omphalocele □ Suspected chromosomal disorder
□ Gastroschisis
□ Limb reduction defect
□ Hypospadias
□ Cleft lip with or without Cleft palate □ None of the above
Was Infant Transferred within 24 hours of Delivery?
□ No □ Yes, Specify Facility _________________
Is Infant Living at Time of Report?
□ Yes □ No
Is Infant Being Breastfed at Discharge?
□ Yes □ No
Hepatitis B Immunization given?
□ Yes □ No
(excluding congenital amputation
and dwarfing syndromes)
□ Karyotype confirmed
□ Karyotype pending
□ Karyotype confirmed
□ Karyotype pending