9. Number of previous live births now living Definitions Instructions Sources Key words/Abbreviations The total number of previous live born infants now living Do not include this infant. Include all previous live born infants who are still living. For multiple deliveries: Include all live born infants before this infant in the pregnancy. Do not include abortions, (spontaneous/ miscarriages or therapeutic or elective abortions), fetal deaths/stillbirths For multiple deliveries include all live born infants before this infant who are now living. If the first born, do not include this infant. If the second born, include the first born, etc. If no previous live born infants, enter 0. If no information about previous births is available enter ‘Unknown’. See “Facility Worksheet Attachment for Multiple Births.” 1st Prenatal Care Record under: Intake information Gravida section – L (living) – last number in series Para section – L – last number in series Pregnancy history information Previous OB history Past pregnancy history 2nd Labor and Delivery Nursing Admission Triage Form under—Patient Data 3rd Admission H&P L – now living Look for: G -- Gravida - Total number of pregnancies P – Para – Previous live births as well as fetal deaths >20 weeks of gestation T – Term – delivered at 37 to 40 weeks gestation Note: fetal deaths >28 weeks of gestation: this is clinically incorrect; it is different from #13h (other poor pregnancy outcome) which is correct; NCHS is also incorrect in this section as well.
10. Number of previous live births now dead Definitions Instructions Sources Key words/Abbreviations The total number of previous live born infants now dead Do not include this infant. Include all previous live born infants who are no longer living. For multiple deliveries: Include all live born infants before this infant in the pregnancy who are now dead. If the first born, do not include this infant. If the second born, include the first born, etc. If no previous live born infants now dead, enter 0 If no information about previous births is available enter ‘Unknown’ See “Facility Worksheet Attachment for Multiple Births.” 1st Prenatal Care Record under Pregnancy history information - comments, complications Previous OB history complications Past pregnancy history complications 2nd Admission H&P (See #8 above) Expired 11. Date of last live birth Definitions Instructions Sources Key words/Abbreviations comments,
The date of birth of the last live born infant. If applicable, enter the month and year of birth of the last live born infant. Include live born infants now living and now dead. Unknown portions of the date should be entered as “99”. If the entire date is unknown mark the Unknown box. 1st Prenatal Care Record under: Pregnancy history information – date Previous OB history – date Past pregnancy history – date 2nd Admission H&P DOB – Date of birth 12. Number of other pregnancy outcomes Definitions Instructions Sources Key words/Abbreviations Total number of other pregnancy outcomes that did not result in a live birth. Includes pregnancy losses of any gestation age. Examples: spontaneous or induced losses or ectopic pregnancy. Include all previous pregnancy losses that did not result in a live birth. If no previous pregnancy losses mark ‘0’. For multiple deliveries: Include all previous pregnancy losses before this infant in this pregnancy and in previous pregnancies. 1st Prenatal Care Record under Gravida section – “A” (abortion/miscarriage) Para section - “A” Pregnancy history information - complications Previous OB history complications Past pregnancy history complications 2nd Labor and Delivery Nursing Admission Triage Form 3rd Admission H&P Miscarriages Fetal demise AB - Abortion induced EAB-Elective abortion SAB - spontaneous abortion TAB - therapeutic abortion Septic abortion Ectopic pregnancy Tubal pregnancy FDIU – fetal death in-utero IUFD – intrauterine fetal death/demise 13. Date of last other pregnancy outcome Definitions Instructions Sources Key words/Abbreviations comments,
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations None b-c Diabetes - Glucose intolerance requiring treatment. Pre-pregnancy - (diagnosis before this pregnancy). Gestational - (diagnosis during this pregnancy). If diabetes is present, check either pre-pregnancy or gestation diabetes. Do not check both. 1st Prenatal Care Record under Medical history Previous OB history under—summary of previous pregnancies Problem list or— initial risk assessment Historical risk summary Complications of previous pregnancies Factors this pregnancy 2nd Labor and Delivery Nursing Admission Triage Form under - Medical complications Comments 3rd Admission H&P under— Current pregnancy history Medical history Previous OB history under—pregnancy related Problem list/findings 4th Delivery Record under— Maternal OB/labor summary Labor and delivery admission history Labor summary record Prepregnancy: DM - diabetes mellitus Type 1 diabetes IDDM - Insulin dependent diabetes mellitus Type 2 diabetes Non-insulin dependent diabetes mellitus Gestational: GDM -- gestational diabetes mellitus, either diet controlled or medication controlled. IDGDM -- insulin dependent gestational diabetes mellitus.
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations d – f Hypertension Elevation of blood pressure above normal for age, gender, and physiological condition; high blood pressure Pre-pregnancy (chronic) Diagnosis prior to the onset of this pregnancy. Gestational Diagnosis in this pregnancy and includes: Pregnancy induced hypertension PIH. Pre-eclampsia: hypertension and after the 20th week of pregnancy. Eclampsia Eclampsia is “Hypertension with proteinuria with generalized seizures or coma. May include pathologic edema”. Instructions: If eclampsia is present, one type of hypertension (either Gestational or should be checked). If hypertension is present, check either prepregnancy or gestational hypertension w/o eclampsia or eclampsia. Only check one. See above Prepregnancy: CHT – chronic hypertension Essential hypertension Gestational: PIH – pregnancy-induced hypertension Preeclampsia Eclampsia
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations h - Other previous poor pregnancy outcome or risk factors History of pregnancies continuing into the 20th week of gestation and resulting in any of the listed outcomes: Perinatal death (including fetal, stillbirth and neonatal deaths Small for gestational age birth Additional risk factors Cervical procedures (cervical cone biopsy or conization) LEEP (loop electrical excision procedure) D&C – dilation and curettage Bleeding after 14 weeks Uterine anomalies 1st Prenatal Care Record under Medical history Previous OB history under—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 – Comments. 3rd Admission H&P under Previous OB history under—pregnancy related Complications Previous Pregnancies Problem list/findings IUGR – intrauterine growth restriction (retardation) FDIU – fetal death in-utero IUFD-Intrauterine fetal death SGA – small for gestational age SFD – small for dates Stillborn- infant/fetus born of any gestational age without signs of life Look for: PROM – premature rupture of membranes PPROM – preterm premature rupture of membranes
i – Pregnancy resulted from any fertility enhancing drugs, artificial insemination or intrauterine insemination 1st Prenatal Care Record under: Medical history Current pregnancy history Problem list or—initial risk assessment Medications this pregnancy 2nd Labor and Delivery Nursing Admission Triage Form under: Comments Medications 3rd Admission H&P under: Current pregnancy history Problem list/findings Artificial insemination Intrauterine insemination medications including but not limited to: Clomid Clomiphene Serophene Pergonal\ Metrodin Profasi Progesterol (not progesterone) Crinone (progesterone gel) Follistim FSH (follicle stimulating hormone) Gonadotopins HcG (human chorionic gonadotropin Pergonal
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations i – Pregnancy resulted from any assisted reproductive technology See above ART: Assisted reproductive technology Artificial insemination AIH: artificial insemination by husband In-vitro fertilization embryo transfer GIFT: gamete intrafallopian transfer ZIFT: zygote intrafallopian transfer Ovum donation, Sperm donation Donor embryo Embryo adoption j - Mother had a previous cesarean delivery (CS) Previous delivery by extracting the fetus, placenta, and membranes through an incision in the mother’s abdominal and uterine walls If yes, how many? If yes, please select the number of each type of cesarean section performed If the mother has had a previous Cesarean delivery, indicate the number of previous cesarean deliveries she has had. Do not count current pregnancy delivery After entering the number of previous CS select the number of different types of CS from following list (total should add up total number of prior CS deliveries): Prior classical (Vertical Uterine Incision) cesarean section Prior low transverse cesarean section 1st Prenatal Care Record under Past pregnancy history Past OB history Problem list or—initial risk assessment 2nd Labor and Delivery Nursing Admission Triage Form under - Comments 3rd Admission H&P under Past OB history Past pregnancy history under—problem list/findings C/S -- cesarean section Repeat C/S VBAC – vaginal delivery after cesarean LSTCS (or LTCS) low segment transverse cesarean section Classical cesarean section Low vertical cesarean section Low transverse cesarean section Look for: TOL – trial of labor k – Anemia Hematocrit < 30 or Hemoglobin < 10 See above. Hct – hematocrit Hgb – Hemoglobin
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations l. Cardiac disease (added to Ohio BC) Does not include hypertension alone. Include any heart disease present before pregnancy or identified during pregnancy, including: congenital heart defects, coronary heart disease, congestive heart failure 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record Look for : Maternal history of: CHF (Congestive Heart Failure) Cardiomyopathy Repaired Tetrology of Fallot (TOF) ASD (Atrial Septal Defect) VSD (Ventricular Septal Defect) Previous MI (Myocardial Infarction) Heart attack Cardiac ischemia Angina Congenital heart disease
p. Intrauterine Growth Restriction (IUGR) Or Fetal Growth restriction Fetus with an estimated fetal weight less than the 10th percentile for gestational age as determined by prenatal ultrasound. Check box yes or no IUGR is diagnosed before delivery The term size less than dates may be used to describe the uterine size but is not enough to define fetal growth restriction. If the term small for gestational age (SGA) is used in maternal record and describes the fetus before birth then can be used to designate IUGR Not determined after birth when the baby’s weight is less than the 10th percentile – this is small for gestational age (SGA) 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record *Not found in newborn record Look for designation in maternal record of: Poor fetal growth Fetal growth restriction IUGR Estimated fetal weight < 10th percentile Fetal abdominal circumference < 10th percentile Abnormal fetal Doppler studies
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations q. Renal (Kidney) Disease Maternal medical condition that involves her kidneys Click yes or no If the record indicated that the patient has renal disease and high blood pressure the proper designation is listed under hypertension Fetal congenital kidney abnormalities should not be listed here 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings Past medical history 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record Look for designation in maternal record of: Renal disease Kidney disease Acute renal failure or insufficiency Chronic renal failure of insufficiency Proteinuria without hypertension Nephritic syndrome Renal transplant Maternal congenital kidney abnormalities affecting pregnancy
14. Risk factors in this pregnancy Definitions Instructions Sources Key words/Abbreviations r. Cholestasis Reversible maternal liver condition of late pregnancy associated with increased bile in the blood stream and intense itching of skin Associated with increased risk of stillbirth Baby often delivered in the late preterm period Check Box yes or no 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings Past medical history 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record Look for designation in maternal record of: Cholestasis of pregnancy Intrahepatic cholestasis Obstetric cholestasis Risk factors in this pregnancy
Definitions Instructions Sources Key words/Abbreviations s. Blood Group Maternal antibody formation that may lead to fetal red blood cell destruction and fetal anemia Check box yes or no Mark only if a mother has a positive antibody screen not due to Rh immunoglobulin (Rhogam or Rhophylac). Do not mark as positive in a mother recently given Rh immunoglobulin . 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings Past medical history 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record Look for designation in maternal record of: Isoimmunization Allo-immunization Rh isoimmunization Anti-D alloimmunization Atypical antibody ammoimmunization Anti-Kell antibodies Anti-Duffy antibodies Anti-Kidd antibodies Anti-E antibodies Anti-C antibodies Hemolytic disease of fetus caused by maternal antibodies Fetal anemia caused by maternal antibodies MOC Doppler Ultrasound immune hydrops 14. Risk factors in this pregnancy
Definitions Instructions Sources Key words/Abbreviations t. Prior Nonpregnant Uterine Surgery A previous surgery performed outside pregnancy that increases the risk of uterine rupture in current pregnancy Check box yes or no Does not include uncomplicated D & C or surgical abortion, hysteroscopy or laparoscopy Only includes this listed under keywords Prior Cesarean section listed in section termed mother had a previous cesarean delivery 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings Past medical history 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record Delivery Operative note Look for designation in maternal record of: Prior Myomectomy Prior perforation of uterus during surgery Prior uterine reconstruction Uterine window noted during prior uterine surgery Prior surgical repair of uterine rupture outside of pregnancy 15. Infections present and/or treated during this pregnancy
f. Hepatitis B (HBV, serum hepatitis) A positive test for the hepatitis B virus Also, please enter the HBsAg test date and result on the Immunization screen. If there is no result available an HBsAg test should be performed and the infant should receive Hep B vaccine within 12 hours of birth. See Chlamydia Hepatitis B Hep B HBV Treatment or Rx for any of the above HBsAg g. Hepatitis C (non A, non B hepatitis, HCV) A positive test for the hepatitis C virus HCV RNA RIBA Anti-HCV Signal to cutoff ratio Check box if lab results indicate the presence (past or present) of the Hepatitis C virus or if the medicate records documents diagnosis or treatment of acute or chronic Hepatitis C See Hepatitis B Hep C HCV Treatment or diagnosis for any of the above h. Herpes Simplex Virus A positive laboratory test for Herpes Simplex Virus (HSV). Check box if current infection or past history of infection See bacterial vaginosis HSV Treatment, diagnosis for HSV In Utero Infection (TORCHS) Please note that TORCH is a term used for the infection of the fetus and not the mother, and is already addressed in other options. This item will be removed in a future version of the worksheet. Please do not select this option.
k. Measles (added to Ohio BC) Positive IgM for Measles Check box if lab results indicate a positive test for Measles or medical records document diagnosis or treatment of Measles 1st Prenatal Record under Infection history Problem list Complications this pregnancy 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 Measles Diagnosis or treatment of measles
p. Trichinosis (also called trichinellosis or trichiniasis) A diagnoses or positive test includes: IgG ELISA Western Blot Eosinophilia and elevated Creatinine Larvae in muscle biopsy Check box if lab results indicate: Positive test for Trichinoses Medical records document diagnosis or treatment of Trichinosis 1st Prenatal Record under Infection history Problem list Complications this pregnancy 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 Treatment or diagnosis for Trichinosis q. Toxoplasmosis (Toxo) A diagnosis of or positive test for Toxoplasma gondii A diagnosis or positive test includes: • IgM & IgG capture EIA IFA in tissue Observation parasites in tissue PCR Check box if laboratory evidence indicates that infection occurred during pregnancy Do not check box if laboratory findings indicate a past exposure (IgG only). See Trichinosis Toxo Diagnosis, treatment for Toxo r. Varicella Positive IgM for Varicella Check box if lab results indicate a positive test for Varicella or medical records document diagnosis or treatment of Varicella. See Measles Varicella Chickenpox Diagnosis or treatment of varicella or chickenpox
15. Infections present and/or treated during this pregnancy Definitions Instructions Sources Key words/Abbreviations s. HIV (Human Immunodeficiency Virus) Maternal infection with HIV virus that causes Acquired Immunodeficiency Syndrome (AIDS) Check box yes or no 1st Prenatal Care Record under Problem list or—initial risk assessment Complications 2nd Labor and Delivery Nursing Admission Triage Form under Admission chief complaint Comments Medications 3rd Admission H&P under Admission chief complaint Current pregnancy history Problem list/findings Past medical history 4th Delivery Record under Maternal OB/labor summary Labor and delivery admission history Labor summary record 5th Newborn Record Maternal risk factors Look for designation in maternal record of: HIV AIDS Human Immunodeficiency Virus
16. Obstetric procedures Definitions Instructions Sources Key words/Abbreviations d - Cervical cerclage Circumferential banding or suture of the cervix to prevent or treat passive dilation caused by cervical insufficiency or weakness Includes: McDonald’s suture Shirodkar procedure abdominal cerclage via laparotomy Note: May also see “ACD / ACE” which is Advanced Cervical Dilation or Advanced Cervical Effacement and is NOT the same as cervical insufficiency (ACD/ ACE is the beginning of preterm labor, days or weeks before the contractions start) 1st Prenatal Record under Medical history Problem list or— initial risk assessment Historical risk summary Complications this pregnancy Factors this pregnancy 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 McDonald’s suture Shirodkar procedure Abdominal cerclage via laparotomy Look for: Incompetent cervix Incompetent os Cervical insufficiency Weakness of the cervix
16. Obstetric procedures Definitions Instructions Sources Key words/Abbreviations e – Tocolysis Administration of any agent with the intent to inhibit preterm uterine contractions to extend the length of the pregnancy by stopping preterm labor Medications may include, but are not limited to: Magnesium sulfate Terbutaline –subcutaneous only Indocin® / (indomethacin) Nifedipine Sulindac 1st Prenatal Care Record under: Medical history Problem list or— initial risk assessment Historical risk summary Complications of previous pregnancies Factors this pregnancy 2nd Labor and Delivery Nursing 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 Medications Magnesium sulfate Terbutaline –subcutaneous only Indocin® / (indomethacin) Nifedipine Sulindac Look for: Preterm labor during this pregnancy
17. Progesterone Definitions Instructions Sources Key words/Abbreviations Was PROGESTERONE (any formulation) given to prevent preterm birth Was progesterone or “progestin” treatment received after the 1st trimester? See drug names. Look for : 17-OHPC, 17-P, caproate, Makena®, vaginal progesterone suppositories or gel or capsules, Prometrium®, Prochieve®, Crinone® Cervical ultrasound Cervical length Was cervical ultrasound done?
18. Was the mother transferred to this facility for maternal medical or fetal indications for delivery? Definitions Instructions Sources Key words/Abbreviations Transfers include: hospital to hospital birth facility to hospital Does not include home to hospital. If the mother was transferred from another facility check “yes.” If “yes,” enter the name of the facility the mother transferred from. If the name of the facility is not known, enter “unknown.” Check “no” if the mother was transferred from home. 1st Labor & Delivery Nursing Admission Triage Form under: Reason for admission Comments 2nd Admission H&P 3rd Labor & Delivery – Delivery Record: Maternal OB/labor summary Labor and delivery admission history Labor summary record
d - Nonvertex presentation (**Note: this section has been dropped from NCHS; it is also captured under #23c “fetal presentation at birth”) Includes any nonvertex fetal presentation. For example: • Breech • Shoulder • Brow • Face presentations • Transverse lie in the active phase of labor and delivery other than vertex • Compound Note: Nonvertex is presentation of other than the upper and back part of the infant’s head. Vertex is presentation of the upper or back part of the infant’s head. 1st Delivery Record under - Presentation 2nd Physician Progress Note 3rd Newborn Admission H&P Breech (buttocks) (sacrum) • Frank breech • LSA - left sacrum anterior • LST - left sacrum transverse • RSP - right sacrum posterior • RST - right sacrum transverse • Complete breech • Single footling breech • Double footling breech Shoulder presentation Transverse lie Face presentation (mentum)
24. Characteristics of labor and delivery Definitions Instructions Sources Key words/Abbreviations e- Steroids (glucocorticoids) or Antenatal corticosteroids (ANCS) for fetal lung maturation received by the mother before delivery Includes: Betamethasone Dexamethasone Hydrocortisone specifically given to accelerate fetal lung maturation in anticipation of preterm delivery. Does not include: Steroid medication given to the mother as an treatment before or after delivery. Not Prednisone. Medications given before the delivery. 1st Delivery Record under: Maternal OB/labor summary - comments Labor summary record 2nd Maternal Medication Record 3rd Newborn Admission H&P 4th Maternal Physician Order Sheet: OB Prenatal records OB Physician or Nurse hospital admission note Transfer note from referring hospital Medications – (before delivery): Betamethasone (BMZ) Betameth Dexamethasone (dex) Hydrocortisone –rarely used “Steroids” ANCS (antenatal corticosteroids) ACS, Steroids Roids Preterm labor 24 to 33 weeks gestation
f - Antibiotics received by the mother during delivery Includes any antibacterial medications given systemically (intravenous or intramuscular) to the mother in the interval between the onset of labor and the actual delivery. May include, but is not limited to: Ampicillin Penicillin Clindamycin Erythromycin Gentamicin Cefotaxime Ceftriaxone Cefazolin Amoxicillin Vancomycin Medications received during delivery. Same as steroids Medications: may include, but is not limited to: – • Ampicillin • Penicillin • Clindamycin • Erythromycin • Gentamicin • Cefataxine • Ceftriaxone • Vancomycin Cefazolin Look for: SBE (sub-acute bacterial endocarditis) prophylaxis GBS positive or GBS + (Group B Streptococcus) Maternal fever Mother febrile
24. Characteristics of labor and delivery Definitions Instructions Sources Key words/Abbreviations i - Fetal intolerance of labor was such that one or more of the following actions was taken: In-utero resuscitative measures such that one of the following actions was taken: in-utero resuscitative measures, further fetal assessment, or operative delivery. Includes any of the following: • Maternal position change • Oxygen administration to the mother • Amnioinfusion • Support of maternal blood pressure including medications and I.V. fluids • 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. 1st Delivery Record under Maternal OB/labor summary Labor summary record 2nd Newborn Admission H&P 3rd Physician Progress Note 4th Physician Order Sheet or - Nursing Notes LLP – left lateral position O2 – oxygen IV fluids Amnioinfusion Nitroglycerin Acoustic stimulation Vibroacoustic stimulation Scalp pH sampling Fetal oxygen saturation monitoring Terbutaline Low forcep delivery Vacuum extraction C/S --Cesarean delivery
24. Characteristics of labor and delivery Definitions Instructions Sources Key words/Abbreviations j - Epidural or spinal anesthesia during labor Administration to the mother of a regional anesthetic to control the pain of labor. Delivery of the agent into a limited space with the distribution of the analgesic effect limited to the lower body. 1st Delivery Record under Maternal OB labor summary under - analgesia/anesthesia Labor summary record under Epidural analgesia Epidural given Spinal given k – Abruption placenta (added to Ohio BC) Premature separation of a normally implanted placenta from the uterus. 1st Delivery Record under: Maternal OB/labor summary Labor summary record 2nd Newborn Admission H&P 3rd Physician Progress Note 4th Physician Order Sheet or - Nursing Notes Abruption placenta Abruptio placenta Placenta abruptio Chronic abruption l – Placenta previa (added to Ohio BC) Low attachment of the placenta, covering or very close to the cervix. See above Operative report Placenta previa Marginal previa Low lying placenta Partial previa
25. Method of delivery Definitions Instructions Sources Key words/Abbreviations The physical process by which the complete delivery of the fetus was affected. Complete every section: A, B, C, and D. If foundling, mark “Unknown to all items” See below See below Was delivery with forceps attempted but unsuccessful? Obstetric forceps were applied to the fetal head in an unsuccessful attempt at vaginal delivery. (This section has been dropped by NCHS) Check “yes” or “no.” 1st Delivery Record under - Delivery Summary 2nd Physician Delivery Summary or—Progress Note 3rd Recovery Room Record under—Maternal Data ― Complications LFD - Low forceps delivery LFD (attempted) B. Was delivery with vacuum extraction attempted but unsuccessful? (This section was dropped by NCHS) Ventouse or vacuum cup was applied to the fetal head in an unsuccessful attempt at vaginal delivery. Check “yes” or “no.” Same as above Vac ext -- Vacuum extraction (attempted) VAD --Vacuum assisted delivery unsuccessful
b - Vaginal/forceps – delivery of the fetal head through the vagina by the application of obstetrical forceps to the fetal head. Vaginal/forceps LFD – (low forceps delivery) c- Vaginal/vacuum – delivery of the fetal head through the vagina by the application of a vacuum cup or ventouse to the fetal head. Vac Ext (Vaginal/vacuum) Vacuum extraction: d - Cesarean – No labor attempted Extraction of the fetus, placenta, and membranes through an incision in the maternal abdominal and uterine walls without active labor. Cesarean: C/S – (cesarean section) LTCS – (low transverse cesarean section) Low Transverse C/S – Colpohysterotomy Uterotomy Porro’s Operation “Classical C-section” or Classical incision or Vertical C-section all refer to a vertical incision into the uterus rather than the more common low transverse C/S; complications are more likely Look for: TOL – (trial of labor)
e - Cesarean Labor attempted Extraction of the fetus, placenta, and membranes through an incision in the maternal abdominal and uterine walls Labor was allowed, augmented, or induced with plans for a vaginal delivery. Check “yes” or “no.” C/S – (cesarean section) LTCS – (low transverse cesarean section) Low Transverse C/S – TOL - trial of labor Colpohysterotomy Uterotomy Porro’s Operation “Classical C-section” or Classical incision or Vertical C-section all refer to a vertical incision into the uterus rather than the more common low transverse C/S; complications are more likely 26. Maternal morbidity Definitions Instructions Sources Key words/Abbreviations Serious complications experienced by the mother associated with labor and delivery. Check all boxes that apply. If the mother has none of the complications, check “None”. See below See below b - Maternal transfusion Includes infusion of whole blood or packed red blood cells associated with labor and delivery. 1st Delivery Record under Labor summary Delivery summary 2nd Physician Delivery Notes/Operative Notes 3rd Intake & Output Form Transfused Blood transfusion Look for: PRBC – packed red blood cells Whole blood
c - 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. 1st Delivery Record under Episiotomy section Lacerations section 2nd Recovery Room Record under - Maternal Data – Delivered 3rd degree lac. 3° LAC degree 4th degree lac. 4° LAC degree d- Ruptured uterus Tearing of the uterine wall. 1st Delivery Record under — Delivery Summary Note – Comments/Complications 2nd Operative Note 3rd Physician Progress Note Broad ligament hematoma Look for: Dehiscence of uterine scar Window oma e - Unplanned hysterectomy Surgical removal of the uterus that was not planned before the admission. Includes an anticipated, but not definitively planned, hysterectomy. Same as ruptured uterus above Hysterectomy C-Hyst (Cesarean+Hysterectomy) Laparotomy
f - Admission to an intensive care unit Any admission, planned or unplanned, of the mother to a facility or unit designated as providing intensive care. 1st Physician Progress Note 2nd Transfer Note ICU (intensive care unit) MICU (medical intensive care unit) SICU (surgical intensive care unit) g - Unplanned operating room procedure following delivery Any transfer of the mother back to a surgical area for an operative procedure that was not planned before the admission for delivery. Excludes postpartum tubal ligations. 1st Physician Operative Note 2nd Physician Progress Note 3rd Physician Order Repair of laceration Repair of laparotomy Drainage of purulent/septic material Exploratory laparotomy 27. Infant’s Medical Record Number: Insert infant’s identifying medical chart number 28. Birthweight or Weight of Fetus Definitions Instructions Sources Key words/Abbreviations The weight of the infant at birth Enter the weight (in grams) of the infant at birth. Do not convert pounds and ounces (lbs. and oz.) to grams. If the weight in grams is not available, enter the birth weight in lbs. and oz. 1st Delivery Record under - Infant Data 2nd Admission Assessment under - Weight BW – Birthweight Gms – grams kg - kilograms lbs - pounds oz – ounces
The order born in the delivery, live born or fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.). If this is a single birth, leave this item blank. Include all live births and fetal deaths from this pregnancy. 1st Delivery Record under— Birth Order 2nd Infant data Baby A, B, C, D, etc Baby 1, 2 , 3, 4 etc. Twin A, B Twin 1, 2 Triplet A, B, C Triplet 1, 2, 3 Look for: Birth order/Set order 34. If not a single birth, number of infants in the delivery born alive (or fetal deaths) Definitions Instructions Sources Key words/Abbreviations The number of infants in this delivery born alive or fetal deaths at any point in the pregnancy. If this is a single birth, leave this item blank. If this is not a single birth, specify the number of infants in this delivery born alive or a fetal death at any point in the pregnancy. Include this birth. 1st Delivery record 2nd Admission H&P Look for: Condition 35. Metabolic Kit Number Definitions Instructions Sources Key words/Abbreviations The number in the card used to take blood sample from the child to submit for metabolic screening Enter the number as listed in the card. 1st Delivery record 2nd Admission H&P 36. Name of Prophylactic used in eyes of child Definitions Instructions Sources Key words/Abbreviations
c - Assisted ventilation required for more than six hours Infant given mechanical ventilation (breathing assistance) by any method for more than six hours. Count the number of hours of mechanical ventilation given. 1st Newborn Respiratory Care Flow Sheet If in use for more than 6 hours: CPAP –(continuous positive airway pressure) IPPV – (intermittent positive pressure ventilation) HFV – (high frequency ventilation IMV - intermittent mandatory volume ventilation) HFOV – (high frequency oscillatory ventilation) 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
f - Antibiotics received by the newborn for suspected neonatal sepsis Any antibacterial drug that is given intravenous /IV or intramuscular/IM but not orally. 1st Newborn Medication Administration Record Medications given to newborn for sepsis including but not limited to: Nafcillin, Chloramphenicol Penicillin Penicillin G Ampicillin Gentamicin, Kanamycin Cefotaxime Cefoxitin Vancomycin Acyclovir Amikacin, Ceftazidime Ceftriaxone Cefazolin g - Seizure or serious neurologic dysfunction Seizure – any involuntary repetitive, convulsive movement or behavior. Serious neurologic dysfunction – severe alteration of alertness Excludes • Lethargy or hypotonia in the absence of other neurologic findings • Symptoms associated with CNS congenital anomalies 1st Newborn H&P 2nd Physician Progress Notes under - Neuro Exam Seizures Tonic/Clonic Clonus Twitching Eye rolling Rhythmic jerking Hypotonia Obtundation Stupor Coma (HIE) - Hypoxic-ischemic encephalopathy
n – Rectal/large intestinal atresia/stenosis (added to Ohio BC) Anorectal atresia/stenosis is a malformation characterized by absence of continuity of the anorectal canal or of communication between rectum and anus, or narrowing of anal canal, with or without fistula to neighboring organs. Intestinal atresia is a complete blockage or obstruction anywhere in the intestine. Stenosis is a partial obstruction that results in a narrowing of the opening (lumen) of the intestine. 1st Labor and Delivery Summary Record under—Newborn Delivery Information 2nd Newborn Admission H&P 3rd Physician Progress Notes Congenital absence of anus, appendix, large intestine or rectum Atresia of anus, colon or rectum Congenital or infantile obstruction of large intestine, occlusion of anus, or stricture of anus Imperforate anus or rectum Stricture of rectum, congenital o – Hirshspring’s disease (added to Ohio BC) Hirshspring’s disease is enlarged or dilated colon (megacolon), with absence of ganglion cells in the narrowed wall distally; causes inability to defecate (have bowel movements). 1st Labor and Delivery Summary Record under—Newborn Delivery Information 2nd Newborn Admission H&P 3rd Physician Progress Notes Aganglionosis Congenital dilation of colon Congenital megacolon Macrocolon
v - Down syndrome- Karyotype pending Trisomy 21 Check if a diagnosis of Down syndrome, Trisomy 21 is pending 1st Infant Progress Notes 2nd Genetic Consult. Trisomy 21 Possible Down syndrome (pending) Rule out (R/O) Down syndrome (pending) w - Down syndrome Karyotype confirmed Trisomy 21 - Check if a diagnosis of Down syndrome, Trisomy 21 is confirmed See above Trisomy 21 Positive (confirmed) x - Suspected chromosomal disorder Karyotype confirmed Includes any constellation of congenital malformations resulting from or compatible with known syndromes caused by detectable defects in chromosome structure. Check if a diagnosis of a suspected chromosomal disorder is confirmed (May include Trisomy 21.) Same as Down syndrome Trisomy and then a number such as: 13 - Patau’s syndrome 17 or 18 - Edward syndrome Positive (confirmed) y - Suspected chromosomal disorder- Karyotype pending Includes any constellation of congenital malformations resulting from or compatible with known syndromes caused by detectable defects in chromosome structure. Check if a diagnosis of a suspected chromosomal disorder is pending. (May include Trisomy 21.) Same as Down syndrome Trisomy and then a number such as: 13 - Patau’s syndrome 17 or 18 - Edward syndrome Possible Trisomy (pending) Rule out (R/O) (pending)