Guide To Completing The Facility Worksheets For Certificate Of Live Birth And Report Fetal Death
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Page Count: 50
- Table of Contents
- Instructions
- Facility Information
- Prenatal Care and Pregnancy History
- 6. Date of first prenatal care visit (BC #29a, FDFWS #6a, FDR #23a)
- 7. Total number of prenatal care visits for this pregnancy (BC #30)
- 8. Date last normal menses began (BC #30, FDFWS #8, FDR #32)
- 9. Number of previous live births now living (BC #35a, FDFWS #9, FDR #29a)
- 10. Number of previous live births now dead (BC #35b, FDFWS #10, FDR #29b)
- 11. Date of last live birth (BC #35c, FDFWS #11, FDR #29c)
- 12. Number of other pregnancy outcomes (BC #36a)
- 13. Date of last other pregnancy outcome (BC #36b)
- 14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)
- 15. Infections present and/or treated during this pregnancy (BC #42)
- 16. Obstetric procedures (BC #43)
- Labor and Delivery
- 17. Date of birth (BC #4, FDFWS #16, FDR #4)
- 18. Time of birth (BC #2, FDFWS #17, FDR #2)
- 19. Certifier’s name and title (BC #11)
- 20. Date certified (BC #12)
- 21. Principal source of payment (BC #38)
- 22. Infant’s medical record number (BC #48)
- 23. Was the mother transferred to this facility for maternal medical or fetal indications for delivery? (BC #28)
- 24. Attendant’s name, title, and ID (BC #27, FDFWS #21, FDR #14)
- 25. Mother’s weight at delivery (BC #33)
- 26. Characteristics of labor and delivery (BC #45)
- Induction of labor
- Augmentation of labor
- Steroids (glucocorticoids) for fetal lung maturation received by the mother before delivery.
- Antibiotics received by the mother during delivery
- Clinical chorioamnionitis diagnosed during labor or maternal temperature ≥ 38°C (100.4°F)
- Epidural or spinal anesthesia during labor
- 27. Method of delivery (BC #46, FDFWS #23, FDR #38)
- 28. Maternal morbidity (BC #47, FDFWS #24, FDR #39)
- Newborn Information
- 29. Birthweight or weight of fetus (BC #49, FDFWS #25, FDR #18c)
- 30. Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)
- 31. Sex of child (BC #3, FDFWS #27, FDR #3)
- 32. Apgar score (BC #51)
- 33. Plurality (BC #52, FDFWS #28, FDR #33)
- 36. Abnormal conditions of the newborn (BC #54)
- 37. Congenital anomalies of the newborn (BC #55)
- 38. Was the infant transferred within 24 hours of delivery? (BC #56)
- 39. Is infant living at time of the report? (BC #57)
- 40. Is the infant being breastfed at discharge? (BC #58)
- 41. Method of disposition* (FDFWS #32, FDR #13)
- Index of Items