**ATTACHMENT TO THE FACILITY WORKSHEET FOR**

**THE LIVE BIRTH CERTIFICATE FOR**

**[MULTIPLE BIRTHS]{.underline}**

**FINAL 2/6/04**

***This attachment is to be completed when at least two infants in a
multiple pregnancy are born alive.\* Complete a full worksheet for the
first-born infant and an attachment for each additional live-born
infant. A "Facility Worksheet for the Report of Fetal Death" should be
completed for any fetal loss in this pregnancy reportable under State
reporting requirements. Item numbers refer to item numbers on the full
worksheet***

***\*For "Delayed Interval Births," that is, births in a multiple
pregnancy delivered at least 24 hours apart, a full worksheet, not an
attachment should be completed.***

**Mother's medical record #\_\_\_\_\_\_\_\_\_\_\_\_**

**Mother's name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Child's name/medical record \# \_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Attachment \_\_\_\_\_\_\_ of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**[Mother's Pregnancy History]{.underline}**

**[Sources: Prenatal care records, mother's medical
records]{.underline}**

**9. Number of previous live births now living** (For this multiple
delivery include live born infants born before this

infant in the delivery who are still living, in addition to infants from
prior pregnancies):

Number\_\_\_\_  None

**10. Number of previous live births now dead** (For this multiple
delivery, include live born infants born before this

infant in the delivery who are now dead in addition to infants from
prior pregnancies):

Number\_\_\_\_  None

**12. Total number of other pregnancy outcomes** (For this multiple
delivery, include all fetal losses of any gestational

age delivered before this infant in the pregnancy in addition to losses
from prior pregnancies):

Number \_\_\_\_  None

**[Labor and Delivery]{.underline}**

**[Source: Labor and delivery records, mother's medical
records]{.underline}**

**18**. **Date of birth:** \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_

M M D D Y Y Y Y

**19. Time of birth: \_\_\_\_\_\_\_\_\_\_\_**24 hour clock

**35.** **Order delivered in the pregnancy** (Specify born 2^nd^, 3^rd^,
4^th^, 5^th^, 6^th^, 7^th^, etc.) (Include all live births and fetal
losses

resulting from this pregnancy):\_\_\_\_\_\_\_\_\_

**27. Characteristics of labor and delivery** (Check all that apply to
[this]{.underline} infant):

 Induction of labor - (Initiation of uterine contractions by medical
and/or surgical means for the purpose of delivery

before the spontaneous onset of labor.)

⁭Augmentation of labor - (Stimulation of uterine contractions by drug or
manipulative technique with the intent to

reduce the time to delivery.)

⁭Non-vertex presentation - (Includes any non-vertex fetal presentation,
e.g., breech, shoulder, brow, face presentations,

and transverse lie in the active phase of labor or at delivery other
than vertex.)

 Steroids (glucocorticoids) for fetal lung maturation received by the
mother prior to delivery -

(Includes betamethasone, dexamethasone, or hydrocortisone specifically
given to accelerate fetal lung maturation in

anticipation of preterm delivery. Excludes steroid medication given to
the mother as an anti-inflammatory treatment.)

 Antibiotics received by the mother during labor - (Includes
antibacterial medications given systemically

(intravenous or intramuscular) to the mother in the interval between the
onset of labor and the actual delivery: Ampicillin,

Penicillin, Clindamycin, Erythromycin, Gentamicin, Cefataxime,
Ceftriaxone, etc.)

 Clinical chorioamnionitis diagnosed during labor or maternal
temperature [\>]{.underline} 38^o^ C (100.4^o^ F) --

(Clinical diagnosis of chorioamnionitis during labor made by the
delivery attendant. Usually includes more than one of the

following: fever, uterine tenderness and/or irritability, leukocytosis
and fetal tachycardia. Any maternal temperature at or

above 38C (100.4F)).

 Moderate/heavy meconium staining of the amniotic fluid - (Staining of
the amniotic fluid caused by

passage of fetal bowel contents during labor and/or at delivery which is
more than enough to cause a greenish color change

of an otherwise clear fluid.)

 Fetal intolerance of labor was such that one or more of the following
actions was taken: in-

utero resuscitative measures, further fetal assessment, or operative
delivery - (I*n Utero Resuscitative*

*measures* such as any of the following - maternal position change,
oxygen administration to the mother, intravenous fluids

administered to the mother, amnioinfusion, support of maternal blood
pressure, and administration of uterine relaxing agents.

*further fetal assessment* includes any of the following - scalp pH,
scalp stimulation, acoustic stimulation. *Operative delivery* --

operative intervention to shorten time to delivery of the fetus such as
forceps, vacuum, or cesarean delivery.)

 Epidural or spinal anesthesia during labor - (Administration to the
mother of a regional anesthetic for control of

the pain of labor, i.e., delivery of the agent into a limited space with
the distribution of the analgesic effect limited to the lower

body.)

 None of the above

**28. Method of delivery** (The physical process by which the complete
delivery of the infant was effected):

(Complete A, B, C, and D):

A. Was delivery with forceps attempted but unsuccessful? - (Obstetric
forceps was applied to the fetal head in an

unsuccessful attempt at vaginal delivery.)

 Yes  No

B. Was delivery with vacuum extraction attempted but unsuccessful? -
(Ventouse or vacuum cup was applied to

the fetal head in an unsuccessful attempt at vaginal delivery.)

 Yes  No

C. Fetal presentation at birth (Check one):

 Cephalic - (Presenting part of the fetus listed as vertex, occiput
anterior (OA), occiput posterior (OP))

 Breech - (Presenting part of the fetus listed as breech, complete
breech, frank breech, footling breech)

 Other - (Any other presentation not listed above)

D. Final route and method of delivery (Check one):

 Vaginal/Spontaneous - (Delivery of the entire fetus through the vagina
by the natural force of labor with

or without manual assistance from the delivery attendant.)

 Vaginal/Forceps - (Delivery of the fetal head through the vagina by
application of obstetrical forceps to the fetal head.)

 Vaginal/Vacuum - (Delivery of the fetal head through the vagina by
application of a vacuum cup or ventouse to the fetal

head.)

 Cesarean - (Extraction of the fetus, placenta and membranes through an
incision in the maternal abdominal and uterine

walls)

If cesarean, was a trial of labor attempted? - (Labor was allowed,
augmented or induced with plans for a vaginal delivery.)

 Yes  No

**29. Maternal morbidity** (Serious complications experienced by the
mother associated with labor and delivery)

(Check all that apply to [this]{.underline} infant):

 Maternal transfusion - (Includes infusion of whole blood or packed red
blood cells associated with labor and delivery.)

 Third or fourth degree perineal laceration - (3° laceration extends
completely through the perineal skin, vaginal

mucosa, perineal body and anal sphincter. 4° laceration is all of the
above with extension through the rectal mucosa.)

 Ruptured uterus - (Tearing of the uterine wall.)

 Unplanned hysterectomy - (Surgical removal of the uterus that was not
planned prior to the admission. Includes

anticipated but not definitively planned hysterectomy.)

 Admission to intensive care unit - (Any admission of the mother to a
facility/unit designated as providing intensive care.)

 Unplanned operating room procedure following delivery - (Any transfer
of the mother back to a surgical area for

an operative procedure that was not planned prior to the admission for
delivery. Excludes postpartum tubal ligations.)

 None of the above

**[Newborn]{.underline}**

**[Sources: Labor and delivery records, newborn's medical records,
mother's medical records]{.underline}**

**30. Birthweight: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(**grams) ([Do
not]{.underline} convert lb/oz to grams)

If weight in grams is not available, birthweight:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(lb/oz)

**31. Obstetric estimate of gestation at delivery (completed
weeks):\_\_\_\_\_\_\_\_**

(The birth attendant's final estimate of gestation based on all
perinatal factors and assessments, but not the neonatal exam.

[Do not]{.underline} compute based on date of the last menstrual period
and the date of birth.)

**32. Sex** (Male, Female, or Not yet determined): \_\_\_\_\_\_\_\_

**33. Apgar score** (A systematic measure for evaluating the physical
condition of the infant at specific intervals at birth):

Score at **5** minutes \_\_\_\_\_\_\_

If **5** minute score is less than 6:

Score at **10** minutes \_\_\_\_\_\_\_

**37. Abnormal conditions of the newborn** (Disorders or significant
morbidity experienced by the newborn.)

(Check all that apply):

-   Assisted ventilation required immediately following delivery -
    (Infant given manual breaths for any duration with bag and mask or
    bag and endotracheal tube within the first several minutes from
    birth. Excludes oxygen only and laryngoscopy for aspiration of
    meconium.)

-   Assisted ventilation required for more than six hours - (Infant
    given mechanical ventilation (breathing assistance) by any method
    for \> 6 hours. Includes conventional, high frequency and/or
    continuous positive pressure (CPAP).)

-   NICU admission - (Admission into a facility or unit staffed and
    equipped to provide continuous mechanical ventilatory support for a
    newborn.)

-   Newborn given surfactant replacement therapy - (Endotracheal
    instillation of a surface active suspension for the treatment of
    surfactant deficiency due to preterm birth or pulmonary injury
    resulting in respiratory distress. Includes both artificial and
    extracted natural surfactant.)

-   Antibiotics received by the newborn for suspected neonatal sepsis -
    (Any antibacterial drug (e.g., penicillin, ampicillin, gentamicin,
    cefotoxine etc.) given systemically (intravenous or intramuscular).)

-   Seizure or serious neurologic dysfunction - (Seizure is any
    involuntary repetitive, convulsive movement or behavior. Serious
    neurologic dysfunction is severe alteration of alertness such as
    obtundation, stupor, or coma, i.e., hypoxic-ischemic encephalopathy.
    Excludes lethargy or hypotonia in the absence of other neurologic
    findings. Exclude symptoms associated with CNS congenital
    anomalies.)

-   Significant birth injury (skeletal fracture(s), peripheral nerve
    injury, and/or soft tissue/solid organ hemorrhage which requires
    intervention) - (Defined as present immediately following delivery
    or manifesting soon after delivery. Includes any bony fracture or
    weakness or loss of sensation, but excludes fractured clavicles and
    transient facial nerve palsy. Soft tissue hemorrhage requiring
    evaluation and/or treatment includes sub-galeal (progressive
    extravasation within the scalp) hemorrhage, giant cephalohematoma,
    extensive truncal, facial and/or extremity ecchymosis accompanied by
    evidence of anemia and/or hypovolemia and/or hypotension. Solid
    organ hemorrhage includes subcapsular hematoma of the liver,
    fractures of the spleen, or adrenal hematoma.)

-   None of the above

**38.** **Congenital anomalies of the newborn** (Malformations of the
newborn diagnosed prenatally or after delivery.)

(Check all that apply):

-   Anencephaly - (Partial or complete absence of the brain and skull.
    Also called anencephalus, acrania, or absent brain. Also includes
    infants with craniorachischisis (anencephaly with a contiguous spine
    defect).)

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

-   Cyanotic congenital heart disease - (Congenital heart defects which
    cause cyanosis. Includes but is not limited to: transposition of the
    great arteries (vessels), tetratology of Fallot, pulmonary or
    pulmonic valvular atresia, tricuspid atresia, truncus arteriosus,
    total/partial anomalous pulmonary venous return with or without
    obstruction.)

-   Congenital diaphragmatic hernia - (Defect in the formation of the
    diaphragm allowing herniation of abdominal organs into the thoracic
    cavity.)

-   Omphalocele - (A defect in the anterior abdominal wall, accompanied
    by herniation of 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]{.underline} include
    umbilical hernia (completely covered by skin) in this category.)

-   Gastroschisis - (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 absence of a
    protective membrane.)

-   Limb reduction defect (excluding congenital amputation and dwarfing
    syndromes) - (Complete or partial absence of a portion of an
    extremity associated with failure to develop)

-   Cleft Lip with or without Cleft Palate - (Incomplete closure of the
    lip. May be unilateral, bilateral or median.)

-   Cleft Palate alone - (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
    "Cleft Lip with or without Cleft Palate" category above.)

-   Down Syndrome - (Trisomy 21)

 Karyotype confirmed

-   Karyotype pending

>  Suspected chromosomal disorder - (Includes any constellation of
> congenital malformations resulting from or compatible with known
> syndromes caused by detectable defects in chromosome structure.)
>
>  Karyotype confirmed

-   Karyotype pending

-   Hypospadias - (Incomplete closure of the male urethra resulting in
    the urethral meatus opening on the ventral surface of the penis.
    Includes first degree - on the glans ventral to the tip, second
    degree - in the coronal sulcus, and third degree - on the penile
    shaft..)

-   None of the anomalies listed above

**39.** **Was infant transferred within 24 hours of delivery?** (Check
"yes" if the infant was transferred from this facility to another within
24 hours delivery. If transferred more than once, enter name of first
facility to which the infant was transferred.)

 Yes  No

If yes, name of facility infant transferred
to:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**40. Is infant living at time of report?** (Infant is living at the
time this birth certificate is being completed. Answer "Yes" if the
infant has already been discharged to home care.)

 Yes  No  Infant transferred, status unknown

**41.** **Is infant being breastfed at discharge?**

Yes  No