Mississippi Administrative Code › Title 18 - HUMAN SERVICES › Part 6 - Division of Family and Children's Services › Chapter 1 - DFCS Policy Manual › Section 18-6-1-G - Adoption Policy › ADOPTION ASSISTANCE › Section 18-6-1-G-XII - APPENDICES › Appendix 18-6-1-G-XII-B - Form 430- Obstetrical and Newborn Record

Current through June 25, 2024
______________________________________________________________________________
Birth:
[] Male
[] Female child of ________________
						  ______________________ Race: ____________
Family Name Mother's Given Name
Hospital Number _____________ _______________ Attending
						  Physician _______________
Mother Infant Mother
Time ________________________________________ Attending
						  Physician _______________
a.m. p.m. Day Month Year Infant
______________________________________________________________________________
Maternal History:
Mother's age ________________ Blood type ___________ RH
						  ______________
Total # previous pregnancies ____ # Premature ____ #
						  Neonatal deaths ____ # Now living ____ Maternal disease:
Complications of this pregnancy:
Drugs taken during pregnancy:
Prenatal S.T.S.: Date _________ Results _________ If
						  ever positive, give summary of treatment:
Maternal chest X-ray: Date _______ Results ________
						  HIV: Date _______ Results ________
Hep B: Date _______ Results ______ Other Significant
						  lab. Results _____________________
______________________________________________________________________________
Present Delivery:
Duration of gestation _______ Mo. Of pregnancy prenatal
						  care started _________ EDC _______
Labor induced? ____________ How? ______________ Why?
						  ___________________________
Duration of labor: 1st stage
						  _________ 2nd stage _________
						  1st or 2nd stage oxytocic
						  __________
Membrane ruptured: Spontaneously _____ artificially
						  _____ # hours before delivery _________
Presentation _________________ Position ______________
						  Type delivery ________________
Reasons if operative
						  _____________________________________________________________
Analgesia (type and time before delivery)
						  __________________ Total Amount _____________
Anesthesia (type and duration before labor)
						  ________________ Amount ___________________
Placenta: Normal ___________________ Abnormal
						  (describe) _________________________
Complications of delivery:
______________________________________________________________________________
Infant Record:
Breathed Spontaneously (time) _________________
						  Resuscitation required? _______________
Eye prophylaxis ______ Blood type ______ RH _____ P K U
						  Date _______ Results _________
T4 Date _______ Results _______ Sickle(s) Hgb. Date
						  ________ Results __________________
HIV Screen Date ___________ Results
						  ______________
APGAR Score ___________ One Minute; ____________ Five
						  minutes
Describe complications (tone, color, cry, injuries,
						  malformations)
Birth weight __________ Birth length _________ Chest
						  circ. __________ Head circ. _________
______________________________________________________________________________
Neonatal Course in Hospital:
Feeding: Breast only _________ Formula only _________
						  Breast and Formula ____________
Content of formula __________________
Progress in nursery (include weight gains or losses,
						  feeding or sleeping difficulties, diarrhea, respiratory distress, rashes, or
						  other significant details)
Discharge: Date _________ Weight ________ Length
						  _______ General condition ___________
Impressions and Recommendations:
Signature ________________________
Date ________________________