Guide To Completing The Facility Worksheets For Certificate Of Live Birth And Report Fetal Death

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National Center for Health Statistics
Guide to Completing
the Facility
Worksheets for the
Certicate of Live
Birth and Report
of Fetal Death
(2003 revision)
Updated May 2016
National Vital Statistics System
Training for completing medical and health information for the
birth certificate and report of fetal death is available online!
To access
“Applying Best Practices for Reporting Medical and
Health Information on Birth Certificates”
go to:
http://www.cdc.gov/nchs/training/BirthCertificateElearning.
Instructions
How to Use This Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Facility Information
Facility name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Facility ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
City, town, or location of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
County of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Place where birth occurred (Birthplace) . . . . . . . . . . . . . . . . . . . . . . .9
Prenatal Care and Pregnancy History
Date of first prenatal care visit. . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Total number of prenatal care visits for this pregnancy . . . . . . . . . . . . . . 10
Date last normal menses began . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Number of previous live births now living. . . . . . . . . . . . . . . . . . . . .12
Number of previous live births now dead . . . . . . . . . . . . . . . . . . . . . 13
Date of last live birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Number of other pregnancy outcomes.. . . . . . . . . . . . . . . . . . . . . . . 14
Date of last other pregnancy outcome.. . . . . . . . . . . . . . . . . . . . . . . 14
Risk factors in this pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Prepregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Gestational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Prepregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Gestational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Previous preterm births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Pregnancy resulted from infertility treatment . . . . . . . . . . . . . . . . . 18
Fertility-enhancing drugs, artificial insemination, or intrauterine
insemination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Assisted reproductive technology . . . . . . . . . . . . . . . . . . . . . . 19
Mother had a previous cesarean delivery. . . . . . . . . . . . . . . . . . . . 19
Infections present and/or treated during this pregnancy. . . . . . . . . . . . . . 20
Gonorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Hepatitis B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Obstetric procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
External cephalic version . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Labor and Delivery
Date of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Time of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Certifier’s name and title. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Date certified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Principal source of payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Infant’s medical record number . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Was the mother transferred to this facility for maternal medical or
fetal indications for delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Attendant’s name, title, and ID. . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Mother’s weight at delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Characteristics of labor and delivery. . . . . . . . . . . . . . . . . . . . . . . .27
Induction of labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Augmentation of labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Steroids (glucocorticoids) for fetal lung maturation received by
the mother before delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table of Contents
Labor and Delivery—Continued
Antibiotics received by the mother during delivery . . . . . . . . . . . . . . 29
Clinical chorioamnionitis diagnosed during labor or maternal
temperature ≥ 38°C (100.4°F) . . . . . . . . . . . . . . . . . . . . . . . . .29
Epidural or spinal anesthesia during labor . . . . . . . . . . . . . . . . . . . 30
Method of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Fetal presentation at birth . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Final route and method of delivery . . . . . . . . . . . . . . . . . . . . . . . 31
If cesarean, was a trial of labor attempted? . . . . . . . . . . . . . . . . . . .32
Maternal morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Maternal transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Third- or fourth-degree perineal laceration . . . . . . . . . . . . . . . . . . 32
Ruptured uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Unplanned hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Admission to an intensive care unit. . . . . . . . . . . . . . . . . . . . . . .33
Newborn Information
Birthweight or weight of fetus . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Obstetric estimate of gestation at delivery . . . . . . . . . . . . . . . . . . . . 34
Sex of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Apgar score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Plurality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
If not a single birth, order born in the delivery . . . . . . . . . . . . . . . . .37
If not a single birth, number of infants in the delivery born alive . . . . . . . 37
Abnormal conditions of the newborn . . . . . . . . . . . . . . . . . . . . . . . 38
Assisted ventilation required immediately following delivery . . . . . . . . .38
Assisted ventilation required for more than six hours . . . . . . . . . . . . . 39
NICU admission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Newborn given surfactant replacement therapy . . . . . . . . . . . . . . . . 40
Antibiotics received by the newborn for suspected neonatal sepsis . . . . . . 40
Seizure or serious neurologic dysfunction . . . . . . . . . . . . . . . . . . . 41
Congenital anomalies of the newborn . . . . . . . . . . . . . . . . . . . . . . . 41
Anencephaly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Meningomyelocele/Spina bifida . . . . . . . . . . . . . . . . . . . . . . . . 42
Cyanotic congenital heart disease . . . . . . . . . . . . . . . . . . . . . . . 42
Congenital diaphragmatic hernia . . . . . . . . . . . . . . . . . . . . . . . . 43
Omphalocele. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Gastroschisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Limb reduction defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Cleft lip with or without cleft palate . . . . . . . . . . . . . . . . . . . . . . 44
Cleft palate alone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Down syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Suspected chromosomal disorder . . . . . . . . . . . . . . . . . . . . . . . .45
Hypospadias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
Was the infant transferred within 24 hours of delivery?. . . . . . . . . . . . . .46
Is the infant living at the time of the report?. . . . . . . . . . . . . . . . . . . .46
Is the infant being breastfed at discharge? . . . . . . . . . . . . . . . . . . . . .47
Method of disposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Index of Items. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Table of Contents—Continued
How to Use This Guide
This guide was developed to assist in completing the facility worksheets for the revised Certificate of Live Birth and Report of Fetal Death (birth certificate [BC], facility
worksheet for the report of fetal death [FDFWS], report of fetal death [FDR]).
Denitions Instructions Sources Keywords and abbreviations
Defines the items in the order they
appear on the facility worksheet.
Provides specific instructions for
completing each item.
Identifies the sources in the medical
records where information for each
item can be found. The specific
records available will differ somewhat
from facility to facility. The source
listed first is considered the best
or preferred source. Please use
this source whenever possible. All
subsequent sources are listed in order
of preference. The precise location
within the records where an item can
be found is further identified by under
and or.
Example:
To determine whether gestational
diabetes is recorded as a “Risk factor
in this pregnancy” (item #14) in the
records:
The first or best source is the prenatal
care record.
Within the prenatal care record,
information on diabetes may be found
under:
• Medical history
• Previous obstetric (OB) history
• Problem list or initial risk
assessment
• Historical risk summary
• Complications of previous
pregnancies
• Factors this pregnancy
►Identifies alternative, usually
synonymous terms and common
abbreviations and acronyms
for items. The keywords and
abbreviations given in this guide
are not intended as inclusive.
Facilities and practitioners will
likely add to the lists.
Example:
Keywords and abbreviations for
prepregnancy diabetes are:
DM–Diabetes mellitus
Type 1 diabetes
IDDM–Insulin dependent diabetes
mellitus
Type 2 diabetes
Noninsulin dependent diabetes
mellitus
Class B DM
Class C DM
Class D DM
Class F DM
Class R DM
Class H DM
►Medications commonly used for
items.
Example: “Clomid” for “Assisted
reproduction treatment.”
Denitions Instructions Sources Keywords and abbreviations
►Look for is used to indicate terms
that may be associated with, but
are not synonymous with, an item.
Terms listed under look for may
indicate that an item should be
reported for the pregnancy, but
additional information will be
needed before it can be determined
whether the item should be
reported.
Example: “Trial of labor” for
“cesarean delivery”
MISSING INFORMATION Where information for an item cannot be located, please check “unknown” or write “unknown” (if using the paper copy of the
worksheet).
How to Use This Guide—Continued
This guide was developed to assist in completing the facility worksheets for the revised Certificate of Live Birth and Report of Fetal Death. (birth certificate [BC], facility
worksheet for the report of fetal death [FDFWS], report of fetal death [FDR])
Page 7 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
Mother
The woman who gave birth to, or
delivered the infant.
All birth certificate information
reported for the mother should be for
the woman who delivered the infant.
In cases of surrogacy or gestational
carrier, the information reported
should be for the surrogate or the
gestational carrier, that is, the woman
who delivered the infant.
FACILITY INFORMATION
1. Facility name (BC #5, FDFWS #1, FDR #8)
The name of the facility where the
delivery took place.
Enter the name of the facility where
the birth occurred.
If this birth did not occur in a hospital
or freestanding birthing center, enter
the street and number of the place
where the birth occurred.
If this birth occurred en route
to a hospital or freestanding
birthing center, that is, in a moving
conveyance, enter the city, town,
village, or location where the
child was first removed from the
conveyance.
If the birth occurred in international
waters or air space, enter “boat” or
“plane.”
Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Page 8 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
2. Facility ID (BC #17, FDFWS #2, FDR #9)
National Provider Identifier. Enter the facility’s National Provider
Identifier (NPI) number.
If no NPI, enter the state hospital
code.
NPI
3. City, town, or location of birth (BC #6, FDFWS #3, FDR #5)
The name of the city, town, township,
village, or other location where the
birth occurred.
Enter the name of the city, town,
township, village, or other location
where the birth occurred.
If the birth occurred in international
waters or air space, enter the location
where the infant was first removed
from the boat or plane.
4. County of birth (BC #7, FDFWS #4, FDR #6)
The name of the county where the
birth occurred.
Enter the name of the county where
the birth occurred.
If the birth occurred in international
waters or air space, enter the name
of the county where the infant was
removed from the boat or plane.
Page 9 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
5. Place where birth occurred (Birthplace) (BC #26, FDFWS #5, FDR #7)
The type of place where the birth
occurred.
Hospital
Check the box that best describes
the type of place where the birth
occurred.
1st Admission history and
physical (H&P) under–General
Admission under–
• Admitted from home, doctor’s
office, other or–
• Problem list or findings
2nd Delivery record under–
• Delivery information
• Labor and delivery summary
(L&D)
• Maternal obstetric (OB) or labor
summary under–delivery
3rd Basic admission data
4th Progress notes or Note
Freestanding birthing center
No direct physical connection with an
operative delivery center.
Home birth
The birth occurred at a private
residence.
FBC–Freestanding birthing center
If home birth is checked, check
whether the home birth was planned.
If unknown whether a planned home
birth, write “unknown.”
Clinic/doctor’s office
Other
Specify taxi, train, plane, etc.
Page 10 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
PRENATAL CARE AND PREGNANCY HISTORY
The prenatal care record is the preferred source for items 6 through 16. If the prenatal care record is not in the mother’s file, please contact the prenatal care provider and
obtain a copy of the record.
6. Date of first prenatal care visit (BC #29a, FDFWS #6a, FDR #23a)
The date a physician or other health
care professional first examined or
counseled the pregnant woman for the
pregnancy.
Enter the month, day, and year of the
first prenatal care visit.
If date information is incomplete,
enter all parts of the date that are
known. Report "unknown" for any
parts of the date that are missing.
If mother’s earliest prenatal care
records are not available (i.e., the
date of the first prenatal care visit is
unavailable), report “unknown.”
If “no prenatal care,” check the box
and enter “0” for item “total number
of prenatal care visits.”
1st Prenatal care record under–
• Intake information
• Initial physical examination
• Prenatal visit flow sheet
• Current pregnancy
2nd Initial physical examination
PNC–Prenatal care
7. Total number of prenatal care visits for this pregnancy (BC #30)
The total number of visits recorded in
the record.
A prenatal visit is one in which
the physician or other health care
professional examines or counsels the
pregnant woman for her pregnancy.
Do not include visits for laboratory
and other testing in which a physician
or health care professional did not
examine or counsel the pregnant
woman.
Access the most recent prenatal
records available. If up-to-date
records are not available, contact the
prenatal care provider for the most
current information.
Count the prenatal visits recorded
in the record. Exclude visits for
laboratory and other tests or classes
in which the mother was not seen
by a physician or other health care
professional for pregnancy-related
care. If it is not clear whether the
mother was seen by a physician or
other health care professional, include
the visit(s) in the total number.
1st Prenatal care record under–
Prenatal visit flow sheet
(count visits)
PNC–Prenatal care
continued on next page continued on next page
Page 11 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
7. Total number of prenatal care visits for this pregnancy (BC #30)—Continued
Do not include classes, such as
childbirth classes, where the physician
or health care professional did
not provide individual care to the
pregnant woman.
Count only visits recorded in the
most current record available. Do not
estimate additional prenatal visits
when the prenatal record is not up to
date.
Enter the total number of prenatal
visits.
If no visits are recorded, enter “0.” If
the number of prenatal visits is equal
to 0, the “no prenatal care” box should
also be checked for item “Date of first
prenatal care visit.”
See above See above
8. Date last normal menses began (BC #30, FDFWS #8, FDR #32)
The date the mother’s last normal
menstrual period began.
This item is used to compute the
gestational age of the infant.
Enter all known parts of the date the
mother’s last normal menstrual period
began. Report "unknown" for any
parts of the date that are missing.
Do not estimate the date.
1st Prenatal care record under–
• Menstrual history
• Labor and delivery nursing
admission triage form
2nd Admission history and physical
(H&P) under–Medical history
LMP–Last menstrual period
Page 12 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
9. Number of previous live births now living (BC #35a, FDFWS #9, FDR #29a)
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.
If the first born, do not include this
infant.
If the second born, include the first
born, etc.
If no previous live-born infants,
check “none.”
See “Attachment to the Facility
Worksheet for the Live Birth
Certificate 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 history and physical
(H&P)
L–Now living
Look for:
G–Gravida–Total number of
pregnancies
P–Para–Previous live births and fetal
deaths > 28 weeks of gestation
T–Term–Delivered at 37 to 40 weeks
gestation
Page 13 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
10. Number of previous live births now dead (BC #35b, FDFWS #10, FDR #29b)
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, check “none.”
See “Attachment to the Facility
Worksheet for the Live Birth
Certificate for Multiple Births.”
1st Prenatal care record under–
• Pregnancy history information–
comments, complications
• Previous OB history–
comments, complications
• Past pregnancy history–
comments, complications
2nd Admission history and physical
(H&P)
See above
Expired
11. Date of last live birth (BC #35c, FDFWS #11, FDR #29c)
The date of birth of the last live-born
infant.
If applicable, enter the month and
year.
Include live-born infants now living
and now dead.
If date information is incomplete,
enter all parts of the date that are
known. Report “unknown” for any
parts of the date that are missing. Do
not estimate or guess a date.
1st Prenatal care record under–
• Pregnancy history information–
date
• Previous OB history–date
• Past pregnancy history–date
2nd Admission history and physical
(H&P)
DOB–Date of birth
Page 14 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
12. Number of other pregnancy outcomes (BC #36a)
Total number of other pregnancy
outcomes that did not result in a live
birth.
Includes pregnancy losses of any
gestational 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,
check “none.”
For multiple deliveries:
Include any losses regardless of
gestational age that occurred before
the delivery of this infant. This could
include losses occurring in this
pregnancy or in a previous pregnancy.
1st Prenatal care record under–
• Gravida section–“A” (abortion
or miscarriage)
• PARA section–“A”
• Pregnancy history information–
comments, complications
• Previous OB history–
comments, complications
• Past pregnancy history–
comments, complications
2nd Labor and delivery nursing
admission triage form
3rd Admission history and physical
(H&P)
Miscarriages
Fetal demise
AB–Abortion induced
SAB–Spontaneous abortion
TAB–Therapeutic abortion
Abortion spontaneous
Septic abortion
Ectopic pregnancy
Tubal pregnancy
FDIU–Fetal death in utero
IUFD–Intrauterine fetal death
13. Date of last other pregnancy outcome (BC #36b)
The date the last pregnancy that did
not result in a live birth ended.
Includes pregnancy losses at any
gestational age.
Examples: spontaneous or induced
losses or ectopic pregnancy
If applicable, enter the month and
year.
If date information is incomplete,
enter all parts of the date that are
known. Report “unknown” for any
parts of the date that are missing. Do
not estimate or guess a date.
1st Prenatal care record under–
• Pregnancy history information
• Previous OB history
• Past pregnancy history
2nd Admission history and physical
(H&P)
14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)
Risk factors of the mother during this
pregnancy.
Check all boxes that apply. The
mother may have more than one risk
factor.
If the mother has none of the risk
factors, check “none of the above.”
See below See below
Page 15 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Diabetes
Glucose intolerance requiring
treatment.
If diabetes is present, check either
prepregnancy or gestational diabetes.
Do not check both.
1st Prenatal care record under–
• Medical history
• Previous OB history under–
summary of previous
pregnancies
Prepregnancy
Diagnosis before this pregnancy.
• 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 history and physical
(H&P) under–
• Current pregnancy history
• Medical history
• Previous OB history under–
pregnancy related
• Problem list or findings
4th Delivery record under–
• Maternal OB or 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
Class B DM
Class C DM
Class D DM
Class F DM
Class R DM
Class H DM
Gestational
Diagnosis during this pregnancy.
Gestational:
GDM–Gestational diabetes mellitus
IDGDM–Insulin dependent
gestational diabetes mellitus
Class A1 or A2 diabetes mellitus
Page 16 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Hypertension
Elevation of blood pressure above
normal for age, sex, and physiological
condition.
If hypertension is present, check
either prepregnancy or gestational
hypertension. Do not check both.
See Diabetes
Prepregnancy (chronic)
Diagnosis prior to the onset of
this pregnancy–does not include
gestational (pregnancy-induced
hypertension [PIH]).
Prepregnancy:
CHT–Chronic hypertension
Benign essential hypertension
Essential hypertension
Preexisting hypertension
Gestational
Diagnosis in this pregnancy
(Pregnancy-induced hypertension or
preeclampsia).
Gestational:
PIH–Pregnancy-induced hypertension
Preeclampsia
Eclampsia
Transient hypertension
HELLP Syndrome
Eclampsia
Hypertension with proteinuria with
generalized seizures or coma. May
include pathologic edema.
If eclampsia is present, one type of
hypertension (either gestational or
prepregnancy) may be checked.
See Diabetes See Hypertension
Page 17 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Previous preterm births
History of pregnancy(ies) terminating
in a live birth of less than 37
completed weeks of gestation.
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–
• Medical complications
• Comments
3rd Admission history and physical
(H&P) under–
• Medical history
• Previous OB history under–
pregnancy related
• Problem list/findings
PTL–Preterm labor
P–Premature
Page 18 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Pregnancy resulted from infertility
treatment
Any assisted reproductive treatment
used to initiate the pregnancy.
Includes:
- Drugs (e.g., Clomid or Pergonal)
- Artificial insemination
- Technical procedures (e.g., in vitro
fertilization)
Check if any infertility treatment was
used to initiate the pregnancy. This
information is included on both the
mother’s and the facility worksheets.
Check “yes” if treatment is reported
on either worksheet.
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 history and physical
(H&P) under–
• Current pregnancy history
• Problem list/findings
See below
Fertility-enhancing drugs, artificial
insemination, or intrauterine
insemination
Any fertility-enhancing drugs (e.g.,
Clomid or Pergonal), artificial
insemination, or intrauterine
insemination used to initiate the
pregnancy.
Check if specific therapy (drugs
or insemination) was used. This
information is included on both the
mother’s and the facility worksheets.
Check “yes” if treatment is reported
on either worksheet.
See Pregnancy resulted from
infertility treatment
Fertility-enhancing drugs, or artificial
or intrauterine insemination:
Medications
Clomid, Serophene
Pergonal
Metrodin
Profasi
Progesterol
Crinone (progesterone gel)
Follistim
FSH–Follicle stimulating hormone
Gonadotropins
Hcg–Human chorionic gonadotropin
IUI– Intrauterine insemination
Page 19 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
14. Risk factors in this pregnancy (BC #41, FDFWS #14, FDR #36)—Continued
Assisted reproductive technology
(e.g., in-vitro fertilization [IVF]
gamete intrafallopian transfer
[GIFT])
Any assisted reproductive technology
([ART]/technical procedures [e.g.,
IVF, GIFT, or ZIFT]) used to initiate
the pregnancy.
Check if assisted reproductive
therapy was used. This information
is included on both the mother’s and
the facility worksheets. Check “yes”
if treatment is reported on either
worksheet.
See Pregnancy resulted from
infertility treatment
Assisted reproductive technology:
ART
Artificial insemination
AIH–Artificial insemination by
husband
AID/DI–Artificial insemination by
donor
In vitro fertilization
IVF-ET–In vitro fertilization embryo
transfer
GIFT–Gamete intrafallopian transfer
ZIFT–Zygote intrafallopian transfer
Ovum donation
Donor embryo
Embryo adoption
Mother had a previous cesarean
delivery
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 the mother has had a previous
cesarean delivery, indicate the number
of previous cesarean deliveries she
has had.
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 history and physical
(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 C/S
Low transverse C/S
Look for:
TOL–Trial of labor
Page 20 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
15. Infections present and/or treated during this pregnancy (BC #42)
Infections present at the time of the
pregnancy diagnosis or a confirmed
diagnosis during the pregnancy
with or without documentation of
treatment.
Documentation of treatment during
this pregnancy is adequate if a
definitive diagnosis is not present in
the available record.
Check all boxes that apply. The
mother may have more than one
infection.
If the mother has none of the
infections, check “none of the above.”
See below “+” indicates that the test for the
infection was positive and the
woman has the infection.
“–” indicates that the test was
negative, and the woman does not
have the infection.
Look for: treatment or Rx for specific
infection.
Gonorrhea
A positive test or culture for Neisseria
gonorrhoeae.
1st Prenatal record under–
• Infection history
• Sexually transmitted diseases
• Problem list
• Complications this pregnancy
• Factors this pregnancy
• Medical history
2nd Labor and delivery nursing
admission triage form under–
Comments
3rd Admission history and physical
(H&P) under–
• Current pregnancy history
• Medical history
• Problem list/findings
4th Delivery record under–
• Maternal OB/labor summary
• Labor and delivery admission
history
GC
Gonorrheal
Gonococcal
Treatment or Rx for Gonorrhea
NAAT–Nucleic amplification tests
Page 21 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
15. Infections present and/or treated during this pregnancy (BC #42)—Continued
Syphilis (also called lues)
A positive test for Treponema
pallidum.
See Gonorrhea TP-PA–T. pallidum particle
agglutination
STS–Serologic test for syphilis
RPR–Rapid plasma regain
VDRL–Venereal disease research
laboratories
FTA-AS–Fluorescent antibody test
Lues
Treatment or Rx for syphilis or lues
Chlamydia
A positive test for Chlamydia
trachomatis.
See Gonorrhea Treatment or Rx for chlamydia
Hepatitis B (HBV, serum hepatitis)
A positive test for the hepatitis B
virus.
See Gonorrhea Hep B
HBV
Treatment or Rx for hepatitis B
Hepatitis C (non A or non B
hepatitis [HCV])
A positive test for the hepatitis C
virus.
See Gonorrhea Hep C
HCV
Treatment or Rx for hepatitis C
Page 22 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
16. Obstetric procedures (BC #43)
Medical treatment or invasive or
manipulative procedure performed
during this pregnancy to treat the
pregnancy or to manage labor or
delivery.
If the mother has had none of the
procedures, check “none of the
above.”
See below See below
External cephalic version
Attempted conversion of a fetus from
a nonvertex to a vertex presentation
by external manipulation.
If checked, also indicate whether the
procedure was a success or a failure.
If more than one attempt, report
results of most recent attempt.
1st Prenatal care record under–
• Problem list
• Historical risk summary
• Complications this pregnancy
• Factors this pregnancy
2nd Labor and delivery nursing
admission triage form under–
• Complications
• Comments
3rd Admission history and physical
(H&P) under–
• Current pregnancy history
• Medical history
• Problem list/findings
4th Delivery record under–
• Maternal OB/labor summary
• Labor and delivery admission
history
• Labor summary record
Successful
Fetus was converted to a vertex
presentation.
Successful version:
Breech version
External version
Failed
Fetus was not converted to a vertex
presentation.
Failed version:
Unsuccessful external version
Attempted version
Failed version
Look for: malpresentation
Page 23 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
LABOR AND DELIVERY
17. Date of birth (BC #4, FDFWS #16, FDR #4)
The infant’s date of birth. Enter the month, day, and four-digit
year of birth.
If the date of birth of the infant is
unknown because the infant is a
foundling, enter the date the infant
was found.
1st Labor and delivery under–
Delivery record
2nd Newborn admission H&P
DOB–Date of birth
18. Time of birth (BC #2, FDFWS #17, FDR #2)
The infant’s time of birth. Enter the time the infant was born
based on a 24-hour clock (military
time). If time of birth is unknown
(foundling), enter “unknown.”
1st Labor and delivery under–
Delivery record
2nd Newborn admission H&P
19. Certifier’s name and title (BC #11)
The individual who certified to the
fact that the birth occurred:
M.D. (doctor of medicine)
D.O. (doctor of osteopathy)
Hospital administrator or designee
CNM/CM (certified nurse midwife or
certified midwife)
Other midwife (midwife other than
CNM/CM)
Other (specify)
Enter the name and title of the
individual who certified to the fact
that the birth occurred.
The individual may be, but need not
be, the same as the attendant at birth.
20. Date certified (BC #12)
The date the birth was certified. Enter the date the birth was certified.
Page 24 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
21. Principal source of payment (BC #38)
The primary source of payment for
the delivery at the time of delivery:
Private insurance
(Blue Cross/Blue Shield, Aetna, etc.)
Medicaid
(or a comparable state program)
Self-pay
(no third party identified)
Check the box that best describes the
primary source of payment for this
delivery. If more than one source of
payment for the delivery is recorded,
choose the source that appears to pay
for most of the delivery.
Check the source of payment for
the delivery, not the payer for the
newborn care or prenatal care, if
different.
1st Hospital face sheet
2nd Admitting office face sheet
Other
(Indian Health Service; CHAMPUS
or TRICARE; other government
[federal, state, or local]; or charity)
The principal source of payment is
important public health information
and is needed to monitor access to
care during delivery.
If “other” is checked, specify the
payer.
If the principal source of payment is
not known, enter “unknown” in the
space.
If unsure what source of payment a
given insurance falls under, check
with the billing office.
22. Infant’s medical record number (BC #48)
The medical record number assigned
to the newborn.
Enter the medical record number. 1st Infant’s medical record
addressograph plate
2nd Admitting office face sheet
under–History number
Page 25 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
23. Was the mother transferred to this facility for maternal medical or fetal indications for delivery? (BC #28)
Transfers include hospital to hospital,
birth facility to hospital, etc. Does not
include home to hospital.
If the mother was transferred from
another facility to this facility
for medical reasons related to the
pregnancy, check “yes.”
If yes, enter the name of the facility
the mother was transferred from. If
the name of the facility is not known,
enter “unknown.”
Check “no” if the mother was
transferred from home.
1st Labor and delivery nursing
admission triage form under–
• Reason for admission
• Comments
2nd Admission history and physical
(H&P)
3rd Labor & delivery – Delivery
record
• Maternal OB/labor summary
• Labor and delivery admission
history
• Labor summary record
Page 26 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
24. Attendant’s name, title, and ID (BC #27, FDFWS #21, FDR #14)
The name, title, and National Provider
Identifier (NPI) number of the person
responsible for delivering the child.
M.D. (doctor of medicine)
D.O. (doctor of osteopathy)
CNM/CM (certified nurse midwife or
certified midwife)
Other midwife (midwife other than
CNM/CM)
Other (specify)
The attendant at birth is the individual
physically present at the delivery
who is responsible for the delivery.
For example, if an intern or nurse
midwife delivers an infant under the
supervision of an obstetrician who
is present in the delivery room, the
obstetrician should be reported as
the attendant. If the obstetrician is
not physically present, the intern or
nurse midwife must be reported as the
attendant.
Enter the name, title, and NPI
number of the person responsible for
delivering the child.
Check one box to specify the
attendant’s title. If “other” is checked,
enter the specific title of the attendant.
Examples include nurse, father, police
officer, and EMS technician.
This item should be completed by the
facility. If the birth did not occur in
a facility, the attendant or certifier
should complete it.
1st Delivery record under–
Signature of delivery attendant
(medical)
25. Mother’s weight at delivery (BC #33)
The mother’s weight at the time of
delivery.
Enter the mother’s weight at the time
of delivery. Use pounds in whole
numbers only. For example, enter
140½ pounds as 140 pounds.
If the mother’s delivery weight is
unknown, enter “unknown.”
1st Labor and delivery nursing
admission triage form under–
Physical assessment–Weight
2nd Admission history and physical
(H&P) under–Physical
examination–Weight
Wgt–Weight
Page 27 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
26. Characteristics of labor and delivery (BC #45)
Information about the course of labor
and delivery.
Check all characteristics that apply.
If none of the characteristics of labor
and delivery apply, check “none of the
above.”
See below See below
Induction of labor
Initiation of uterine contractions
by medical or surgical means for
the purpose of delivery before the
spontaneous onset of labor (i.e., before
labor has begun).
Examples of methods include, but
are not limited to: artificial rupture
of membranes, balloons, oxytocin,
prostaglandin, laminaria, or other
cervical ripening agents.
Check this item if medication was
given or procedures to induce labor
were performed before labor began.
If it is not clear whether medication
or procedures were performed before
or after labor had begun, review
records to determine when labor
began and when medications were
given or procedures performed. If this
information is unclear or unavailable,
check with the birth attendant.
Induction of labor should be checked
even if the attempt to initiate labor
is not successful or the induction
follows a spontaneous rupture of the
membrane without contractions.
NOTE: Does not include
augmentation of labor, which applies
only after labor or contractions have
begun.
1st Delivery record under–
Maternal OB/labor summary
• Labor and delivery admission
history
• Labor summary record
2nd Physician progress note
3rd Labor and delivery nursing
admission triage form
IOL–Induction of labor
Pit Ind–Pitocin induction
ROM/NIL–Amniotomy induction or
induction for rupture of membranes,
not in labor
AROM–Artificial rupture of
membranes done before labor
Balloons
Oxytocin
Prostaglandin
Laminaria
Cervidil
Page 28 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
26. Characteristics of labor and delivery (BC #45)—Continued
Augmentation of labor
Stimulation of uterine contractions
by drug or manipulative technique
with the intent to reduce the time of
delivery (i.e., after labor has begun).
Check this item if medication was
given or procedures to augment labor
were performed after labor began. If
it is not clear whether medication or
procedures were performed before
or after labor had begun, review
records to determine when labor
began and when medications were
given or procedures performed. If this
information is unclear or unavailable,
check with the birth attendant.
NOTE: Do not include if induction of
labor was performed.
Same as 1st and 2nd sources for
Induction of labor
Pit stim–Pitocin stimulation
Pit aug–Pit augmentation
AROM–Artificial rupture of
membranes done during labor
Cervidil
Steroids (glucocorticoids) for fetal
lung maturation received by the
mother before delivery
Steroids received by the mother prior
to delivery to accelerate fetal lung
maturation. Typically administered
in anticipation of preterm (less than
37 completed weeks of gestation)
delivery.
Steroids include: betamethasone,
dexamethasone, or hydrocortisone
specifically given to accelerate fetal
lung maturation.
Does not include steroid medication
given to the mother for anti-
inflammatory treatment before or
after delivery.
Three conditions must be met for this
item. Check this item when 1) steroid
medication was given to the mother
2) prior to delivery 3) for fetal lung
maturation.
Steroids may be administered to
the mother prior to admittance to
the hospital for delivery. Review
the mother’s prenatal care and other
hospital records for mention of steroid
administration for this purpose.
1st Delivery record under–
• Maternal OB/labor summary–
comments
• Labor summary record–
comments
2nd Maternal medication record
3rd Newborn admission H&P
4th Maternal physician order sheet
5th Prenatal care records
Medications (before delivery):
Betamethasone
Betamethasone phosphate
Beta-PO4
Betamethasone acetate
Beta-Ac
Dexamethasone
Page 29 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
26. Characteristics of labor and delivery (BC #45)—Continued
Antibiotics received by the mother
during delivery
Includes antibacterial medications
given systemically (intravenous or
intramuscular) to the mother in the
interval between the onset of labor
and the actual delivery.
Includes:
Ampicillin
Penicillin
Clindamycin
Erythromycin
Gentamicin
Cefotaxime
Ceftriaxone
Mother should have undergone labor,
regardless of method of delivery.
Check the timing of the
administration of the antibacterial
medications. Check this item
only if medications were received
systemically by the mother during
labor. If information on onset of
labor cannot be determined from
the records, check with the birth
attendant.
See steroids (glucocorticoids) Medications (during delivery):
Ampicillin
Penicillin
Clindamycin
Erythromycin
Gentamicin
Cefotaxime
Ceftriaxone
Vancomycin
Look for:
SBE (sub-acute bacterial endocarditis)
prophylaxis
GBS positive or GBS + (Group B
streptococcus)
Maternal fever
Mother febrile
Clinical chorioamnionitis
diagnosed during labor or maternal
temperature ≥ 38°C (100.4°F)
Clinical diagnosis of chorioamnionitis
during labor made by the delivery
attendant.
Usually includes more than one of the
following: fever, uterine tenderness
or irritability, leukocytosis, fetal
tachycardia, maternal tachycardia, or
malodorous vaginal discharge.
Any recorded maternal temperature at
or above 38°C (100.4°F).
Check that recorded maternal
temperature is at or above 38°C
(100.4°F).
1st Delivery record under–
• Maternal OB/labor summary–
comments/complications
• Labor summary record–
comments/complications
2nd Newborn admission H&P
3rd Physician progress note
4th Maternal vital signs record
under–Temperature recordings
Chorioamnionitis
Chorio
Temp > 38°C or 100.4°F
Look for:
Maternal fever
Mother febrile
Page 30 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
26. Characteristics of labor and delivery (BC #45)—Continued
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.
Mother should have undergone labor,
regardless of method of delivery.
1st Delivery record under–
• Maternal OB labor summary
under–analgesia or anesthesia
• Labor summary record under–
analgesia or anesthesia
Epidural analgesia
Epid. given
Spinal given
27. Method of delivery (BC #46, FDFWS #23, FDR #38)
The physical process by which the
complete delivery of the fetus was
affected.
Complete sections C and D. See below See below
C. Fetal presentation at birth Check one of the three boxes. 1st Delivery record under–Fetal
birth presentation
Cephalic–presenting part of the fetus
listed as vertex, occiput anterior (OA),
or occiput posterior (OP).
Check only the final presentation at
birth.
Cephalic:
Vertex–OA, OP, LOA, ROA, LOP,
ROP, LOT, ROT
Face–LMA, LMT, LMP , RMA,
RMP, RMT
Brow
Sinciput
Mentum–chin
Breech–presenting part of the fetus
listed as breech, complete breech,
frank breech, or footling breech.
Breech: (Buttocks, sacrum)
Frank breech–LSA, LST, LSP, RSP,
RST
Single footling breech
Double footling breech
Complete breech
continued on next page continued on next page
Page 31 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
27. Method of delivery (BC #46, FDFWS #23, FDR #38)—Continued
C. Fetal presentation at birth—
Continued
Other–any other presentation not
listed above.
See above See above Other:
Shoulder
Transverse lie
Funis
Compound
D. Final route and method of
delivery
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.
Check one of the boxes. 1st Delivery record under–Method
of delivery
2nd Newborn admission H&P
3rd Recovery room record under–
Maternal data–Delivered
Vaginal/spontaneous:
VAG Del–Vaginal delivery
SVD–Spontaneous vaginal delivery
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
Vaginal/vacuum
Delivery of the fetal head through the
vagina by the application of a vacuum
cup or ventouse to the fetal head.
Vaginal/vacuum:
Vac Ext
vacuum
Cesarean
Extraction of the fetus, placenta, and
membranes through an incision in the
maternal abdominal and uterine walls.
Cesarean:
C/S–Cesarean section
LSTCS–Low segment transverse
Look for:
TOL–Trial of labor
Page 32 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
27. Method of delivery (BC #46, FDFWS #23, FDR #38)—Continued
If cesarean, was a trial of labor
attempted?
Labor was allowed, augmented, or
induced with plans for a vaginal
delivery.
Check “yes” or “no.” TOL–Trial of labor
28. Maternal morbidity (BC #47, FDFWS #24, FDR #39)
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 of the
above.”
See below See below
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 or
Operative notes
3rd Intake & output form
Transfused
Blood transfusion
Look for:
PRBC–Packed red blood cells
Whole blood
Third- or fourth-degree perineal
laceration
3° laceration extends through the
perineal skin, vaginal mucosa,
perineal body, and partially or
completely through the 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
4th degree lac.
4° LAC degree
3rd degree lac.
3° LAC degree
3a
3b
3c
Page 33 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
28. Maternal morbidity (BC #47, FDFWS #24, FDR #39)—Continued
Ruptured uterus
Tearing of the uterine wall. Uterine
rupture is a full-thickness disruption
of the uterine wall that also involves
the overlying visceral peritoneum
(uterine serosa).
Does not include uterine dehiscence,
in which the fetus, placenta, and
umbilical cord remain contained with
the uterine cavity. Does not include
a silent or incomplete rupture or an
asymptomatic separation.
1st Delivery record under–
• Delivery summary note–
• Comments or Complications
2nd Operative note
3rd Physician progress note
Unplanned hysterectomy
Surgical removal of the uterus that
was not planned before the admission.
Includes an anticipated, but not
definitively planned, hysterectomy.
See Ruptured uterus Hysterectomy
Look for:
laparotomy
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
L&D ECU–Labor and delivery
emergency care unit
Page 34 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
NEWBORN INFORMATION
29. Birthweight or weight of fetus (BC #49, FDFWS #25, FDR #18c)
The weight of the infant at birth. Enter the weight (in grams) of the
infant at birth.
Do not convert pounds (lbs.) and
ounces (oz.) to grams.
If the weight in grams is unavailable,
enter the birth weight in lbs. and oz.
1st Delivery record under– Infant
data
BW–Birthweight
Gms–Grams
kg–Kilograms
Lbs–Pounds
oz–Ounces
30. Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)
The best obstetric estimate of the
infant’s gestational age (OE) in
completed weeks is based on the
clinician’s final estimate of gestation.
For the clinician:
The best estimated delivery date
(EDD) is determined by the date
of the last menstrual period (LMP)
if confirmed by early ultrasound.
If ultrasound is not performed
or is unknown, the best EDD is
determined by the LMP. If the LMP
is unknown or inconsistent with the
early ultrasound, the best EDD is
determined by early ultrasound. For
deliveries resulting from the use of
assisted reproductive technology, the
best EDD is based on the known date
of fertilization.*
Accurate pregnancy dating is
important to improve outcomes
and is a research and public health
imperative. The best estimated due
date should be documented clearly in
the medical records.*
continued on next page
For the nonclinician:
Enter the final best obstetric estimate
of the infant’s gestational age in
completed weeks.
The OE should be based on the
clinician’s estimate of gestational
age at delivery. Look for the most
recent gestational age estimate in the
records (this can often be found in
the labor and delivery records under
“gestational age”).
If the most recent gestational age is
dated on or after the infant’s date of
delivery, enter this estimate.
If the most recent gestational age
is dated before the date of delivery,
add the number of days between the
most recent gestational age and the
date of delivery to the gestational age
estimate. For example, if the most
recent gestational age in the records
is 32 weeks, 5 days and is dated 3/24,
and the date of delivery is 3/31, add
7 days to the gestational age for the
final total of 33 weeks, 5 days.
continued on next page
1st OB admission H&P under–
• Weeks
• Gestational age
Gestation weeks (wks)
weeks gestational age
GA–Gestational age
EGA–Estimated gestational age
Page 35 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
30. Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)—Continued
* Adopted from: ACOG reVITALize
“Obstetric Data Definitions”
(available from: https://www.acog.
org/-/media/Departments/Patient-
Safety-and-Quality-Improvement/
2014reVITALizeObstetricDataDe
finitionsV10.pdf) and “Method for
Estimating Due Date” (available from:
http://www.acog.org/Resources-And-
Publications/Committee-Opinions/
Committee-on-Obstetric-Practice/
Method-for-Estimating-Due-Date).
The gestational age for the OE is
reported in completed weeks. If the
OE includes a fraction of a week (e.g.,
33 weeks, 5 days) always round down
to the nearest whole week (e.g., 33
weeks).
If a final best obstetric estimate of
gestation cannot be found, search for
the best obstetrical estimated due date
(EDD) and calculate the OE as shown
below.
If both the EDD and the OE are not
known, enter “unknown.”
If the date of delivery occurs before
the EDD, then use the following
calculation:
1) Find the most recent best EDD
(this may only be found in the
prenatal care records) and the date
of delivery.
2) Calculate the difference between
the EDD and the date of delivery
in days (e.g., EDD of 1/7/2015 –
date of delivery of 12/30/2014 =
8 days).
3) Subtract difference between the
EDD and the date of delivery
from 280 days (e.g., 280 days –
8 days = 272 days).
4) Divide the total number of days
from step 3 by 7 days (e.g., 272
days ÷ 7 days = 38.9 weeks) to
determine the OE in weeks.
5) Enter the OE in completed weeks
(e.g., 38 weeks).
continued on next page
See above See above
Page 36 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
30. Obstetric estimate of gestation at delivery (BC #50, FDFWS #26, FDR #18d)—Continued
See above If the date of delivery occurs after
the EDD, then use the following
calculation:
1) Find the most recent best EDD
(this may only be found in the
prenatal care records) and the date
of delivery.
2) Calculate the difference between
the date of delivery and EDD
in days (e.g., date of delivery of
1/5/2015 – EDD of 12/28/2014 =
8 days).
3) Add the difference between the
date of delivery and the EDD to
280 days (e.g., 280 + 8 = 288 days).
4) Divide the total number of days
from step 3 by 7 days (e.g., 288
days ÷ 7 days = 41.1 weeks) to
determine the OE in weeks.
5) Enter the OE in completed weeks
(e.g., 41 weeks).
See above See above
31. Sex of child (BC #3, FDFWS #27, FDR #3)
The sex of the infant. Enter whether the infant is male,
female, or if the sex of the infant is
ambiguous, enter “unknown.”
1st Delivery record under– Infant
data
M–Male
F–Female
A–Ambiguous or Not yet determined
(same as unknown)
U–Unknown
Page 37 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
32. Apgar score (BC #51)
A systematic measure for evaluating
the physical condition of the infant at
specific intervals following birth.
Enter the infant’s Apgar score at 5
minutes.
If the score at 5 minutes is less than
6, enter the infant’s Apgar score at 10
minutes.
1st Delivery record under–Infant
data
33. Plurality (BC #52, FDFWS #28, FDR #33)
The number of fetuses delivered live
or dead at any time in the pregnancy
regardless of gestational age, or if the
fetuses were delivered at different
dates in the pregnancy.
“Reabsorbed” fetuses (those that are
not delivered: expulsed or extracted
from the mother) should not be
counted.
Enter the number of fetuses delivered
in this pregnancy.
If two or more live births in this
delivery, see “Attachment to the
Facility Worksheet for the Live
Birth Certificate for Multiple
Births.”
1st Delivery record
2nd Admission history and physical
(H&P)
Single
Twin, triplet, quadruplet, etc. Multiple
(a, b, c …) or (1, 2, 3 …)
34. If not a single birth, order born in the delivery (BC #53, FDFWS #29, FDR #34)
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, or Baby 1, 2, etc.
Twin A, B, or Twin 1, 2
Triplet A, B, C, or Triplet 1, 2, 3, etc.
Look for:
Birth order or Set order
35. If not a single birth, number of infants in the delivery born alive (FDFWS #30)
The number of infants in this
delivery born alive 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 at any point in the
pregnancy. Include this birth.
1st Delivery record
2nd Admission history and physical
(H&P)
Look for:
Condition
Page 38 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
36. Abnormal conditions of the newborn (BC #54)
Disorders or significant morbidity
experienced by the newborn.
Check all boxes that apply.
If none of the conditions apply, check
“none of the above.”
See below See below
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 free-flow (blow-by) oxygen
only, laryngoscopy for aspiration of
meconium, nasal cannula, and bulb
suction.
1st Labor delivery summary
under– Infant Data or Breathing
Bag and mask ventilation
Intubation
Intubation and PPV–Positive pressure
ventilation
PPV bag/mask or ET–Positive
pressure ventilation via bag, mask,
or endotracheal intubation
IPPV bag–Intermittent positive
pressure ventilation via bag
IPPV ET–Intermittent positive
pressure ventilation via endotracheal
intubation
O2 via ET–Oxygen via endotracheal
intubation
Oxygen
Page 39 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
36. Abnormal conditions of the newborn (BC #54)—Continued
Assisted ventilation required for
more than six hours
Infant given mechanical ventilation
(breathing assistance) by any method
for more than six hours.
Includes conventional, high
frequency, or continuous positive
pressure (CPAP).
Excludes free-flow oxygen only,
laryngoscopy for aspiration of
meconium, and nasal cannula.
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
Page 40 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
36. Abnormal conditions of the newborn (BC #54)—Continued
NICU admission
Admission into a facility or unit
staffed and equipped to provide
continuous mechanical ventilatory
support for a newborn.
Include NICU admission at any time
during the infant’s hospital stay
following delivery.
Do not include units that do not
provide continuous mechanical
ventilation. Do not include well-baby
nurseries or special care nurseries
(i.e., Level II nursery).
Do not include if the newborn was
taken to the NICU for observation but
is not admitted to the NICU.
1st Labor and delivery summary
record under–Disposition
under–
• Intensive care nursery (ICN)
• Special care nursery (SCN)
ICN–Intensive care nursery
SCN–Special care nursery
NICU–Neonatal intensive care unit
PICU–Pediatric intensive care unit
Level II nursery
Newborn given surfactant
replacement therapy
Endotracheal instillation of a
surface-active suspension for treating
surfactant deficiency due to preterm
birth or pulmonary injury resulting in
respiratory distress.
Includes both artificial and extracted
natural surfactant.
Check both 1st and 2nd sources before
completion.
1st Labor and delivery summary
under–Neonatal medication
2nd Newborn medication
administration record
If given to newborn after birth:
Medications (given to newborn):
Surfactant
Survanta
Exosurf
Curosurf
Infasurf
Antibiotics received by the newborn
for suspected neonatal sepsis
Any antibacterial drug (penicillin,
ampicillin, gentamicin, cefotaxime,
etc.) given systemically (intravenous
or intramuscular). Does not include
antibiotics given to infants who are
not suspected of having neonatal
sepsis.
1st Newborn medication
administration record
Medications (given to newborn for
sepsis):
Nafcillin, Chloramphenicol
Penicillin, Penicillin G
Ampicillin, Gentamicin,
Kanamycin, Cefotaxime, Cefoxitin,
Vancomycin, Acyclovir, Amikacin,
Ceftazidime, Ceftriaxone, Cefazolin
Page 41 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
36. Abnormal conditions of the newborn (BC #54)—Continued
Seizure or serious neurologic
dysfunction
Seizure is any involuntary repetitive,
convulsive movement or behavior.
Serious neurologic dysfunction is
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 examination
Seizures
Tonic/Clonic/Clonus
Twitching
Eye rolling
Rhythmic jerking
Hypotonia
Obtundation
Stupor
Coma
HIE-Hypoxic-ischemic
encephalopathy
37. Congenital anomalies of the newborn (BC #55)
Malformations of the newborn
diagnosed prenatally or after delivery.
Check all boxes 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).
1st Labor and delivery summary
record under–Infant data
2nd Newborn admission H&P
Anencephalus
Acrania
Absent brain
Craniorachischisis
Exencephaly
Hydraencephaly
Page 42 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
37. Congenital anomalies of the newborn (BC #55)—Continued
Meningomyelocele/Spina bifida
Spina bifida is herniation of the
meninges 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 include spina bifida occulta
(a midline bony spinal defect without
protrusion of the spinal cord or
meninges).
See Anencephaly Meningocele
Rachischisis
Cyanotic congenital heart disease
Congenital heart defects that cause
cyanosis.
1st Physician progress notes under–
• Circulation
• Cardiovascular
TGA–Transposition of the great
arteries
TOF–Tetralogy of Fallot
Pulmonary or pulmonic valvular
atresia
Tricuspid atresia
Truncus arteriosus
TAPVR–Total/partial anomalous
pulmonary venous return with or
without obstruction
COA–Coarctation of the aorta
HLHS–Hypoplastic left heart
syndrome
IAA–Interrupted aortic arch
Page 43 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
37. Congenital anomalies of the newborn (BC #55)—Continued
Congenital diaphragmatic hernia
Defect in the formation of the
diaphragm allowing herniation of
abdominal organs into the thoracic
cavity.
1st Infant H&P
2nd Labor and delivery summary
record under–Infant data
Omphalocele
A defect in the anterior abdominal
wall in which the umbilical ring
is widened, allowing herniation of
abdominal organs into the umbilical
cord.
The herniating organs are covered
by a nearly transparent membranous
sac (different from gastroschisis
[see below]), although this sac may
rupture. Also called exomphalos.
Do not include umbilical hernia
(completely covered by skin) in this
category.
1st Labor and delivery summary
record under–Infant data
2nd Admission history and physical
(H&P) under–G.I.
Exomphalos
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 the absence of a
protective membrane.
See Omphalocele
Page 44 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
37. Congenital anomalies of the newborn (BC #55)—Continued
Limb reduction defect excluding
congenital amputation and dwarfing
syndromes.
Complete or partial absence of a
portion of an extremity, secondary to
failure to develop.
1st Labor and delivery summary
record under–Infant data
2nd Newborn H&P
Look for:
Amniotic bands
ABS–Amniotic band syndrome
Cleft lip with or without cleft palate
Incomplete closure of the lip. May be
unilateral, bilateral, or median.
See Limb reduction defect Cleft lip (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 category
above.
See Limb reduction defect
Down syndrome
Trisomy 21–A chromosomal
abnormality caused by the presence
of all or part of a third copy of
chromosome 21.
Karyotype confirmed
Karyotype pending
Check if a diagnosis of Down
syndrome, Trisomy 21 is confirmed or
pending.
1st Infant progress notes
2nd Genetic consult
Trisomy 21
Positive (confirmed)
Possible Down (pending)
Rule out (R/O) Down (pending)
Trisomy 21 mosaicism
Page 45 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
37. Congenital anomalies of the newborn (BC #55)—Continued
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
Check if a diagnosis of a suspected
chromosomal disorder is confirmed or
pending. (May include Trisomy 21.)
See Down syndrome Trisomy and then a number such as:
13–Patau’s syndrome
17 or 18–Edward syndrome
Positive (confirmed)
Possible trisomy (pending)
Rule out (R/O) (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)
- Third degree (on the penile shaft)
1st Labor and delivery summary
under–Infant data
2nd Newborn H&P under–
Genitourinary (GU)
Page 46 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
38. Was the infant transferred within 24 hours of delivery? (BC #56)
Transfer status of the infant from this
facility to another within 24 hours
after delivery.
Check “yes” if the infant was
transferred from this facility to
another within 24 hours of delivery.
Enter the name of the facility to which
the infant was transferred.
If the name of the facility is not
known, enter “unknown.”
If the infant was transferred more
than once, enter the name of the
first facility to which the infant was
transferred.
1st Infant progress notes
2nd Transfer form
Look for:
Disposition
39. Is infant living at time of the report? (BC #57)
Information on the infant’s survival. Check “yes” if the infant is living.
Check “yes” if the infant has already
been discharged to home care.
Check “no” if it is known that the
infant has died. If the infant has died,
make sure that a death certificate is
filed.
If the infant was transferred and the
status is known, indicate the known
status.
1st Infant progress notes
Page 47 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Denitions Instructions Sources Keywords and abbreviations
40. Is the infant being breastfed at discharge? (BC #58)
Information on whether the infant was
receiving breastmilk or colostrum
during the period between birth and
discharge from the hospital.
Breastfeeding refers to the
establishment of breastmilk through
the action of breastfeeding or
pumping (expressing).
Include any attempt to establish
breastmilk production during the
period between birth and discharge
from the hospital.
Include if the infant received formula
in addition to being breastfed.
Does not include the intent to
breastfeed.
Check “yes” if the infant was
breastfed at any time before being
discharged from the hospital.
Check “no” if the infant was not
breastfed before being discharged
from the hospital.
1st Labor and delivery summary
record under–Infant data
2nd Maternal progress note
3rd Newborn flow record under–
Feeding
4th Lactation consult
Pumping
Lactation consultation
LATCH score (Latch on, Audible
swallow, Type of nipple, Comfort,
and Help—used to measure position
and attachment of the baby on the
breast)
Breast pump
Breast pump protocol
Breast milk
MM–Mother’s milk
FBM–Fresh breast milk
Attempt to breastfeed
41. Method of disposition* (FDFWS #32, FDR #13)
Burial
Cremation
Hospital disposition
Donation
Removal from state
Other (specify)
* Applicable to fetal deaths only.
Check only one method. 1st Labor and delivery summary
record under–Infant data
2nd Nursing note
3rd Attending death note
4th Social work note
The use of trade names is for identification only and does not imply endorsement by the Centers for Disease Control and Prevention,
U.S. Department of Health and Human Services.
Page 48 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Index of Items
A
Abnormal conditions of the newborn . . . . . . . . . . . . . . . . . . . . . . . 38
Admission to an intensive care unit (Maternal morbidity) . . . . . . . . . . . . 33
Anencephaly (Congenital anomalies of the newborn) . . . . . . . . . . . . . . .41
Antibiotics received by the mother during delivery
(Characteristics of labor and delivery) . . . . . . . . . . . . . . . . . . . . . . 29
Antibiotics received by the newborn for suspected neonatal sepsis
(Abnormal conditions of the newborn). . . . . . . . . . . . . . . . . . . . . .40
Assisted reproductive technology (Risk factors in this pregnancy) . . . . . . . .19
Assisted ventilation required for more than six hours
(Abnormal conditions of the newborn). . . . . . . . . . . . . . . . . . . . . .39
Assisted ventilation required immediately following delivery
(Abnormal conditions of the newborn). . . . . . . . . . . . . . . . . . . . . .38
Attendant’s name, title, and ID. . . . . . . . . . . . . . . . . . . . . . . . . . .26
Augmentation of labor (Characteristics of labor and delivery) . . . . . . . . . . 28
Apgar score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
B
Birthweight or weight of fetus . . . . . . . . . . . . . . . . . . . . . . . . . . .34
C
Certifier’s name and title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Characteristics of labor and delivery. . . . . . . . . . . . . . . . . . . . . . . .27
Chlamydia (Infections present and/or treated during this pregnancy) . . . . . . 21
City, town, or location of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Cleft lip with or without cleft palate (Congenital anomalies of the newborn). . .44
Cleft palate alone (Congenital anomalies of the newborn) . . . . . . . . . . . . 44
Clinical chorioamnionitis diagnosed during labor or maternal
temperature ≥ 38°C (100.4°F) (Characteristics of labor and delivery). . . . . . 29
Congenital anomalies of the newborn . . . . . . . . . . . . . . . . . . . . . . . 41
Congenital diaphragmatic hernia (Congenital anomalies of the newborn) . . . . 43
County of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Cyanotic congenital heart disease (Congenital anomalies of the newborn) . . . .42
D
Date certified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Date last normal menses began . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Date of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Date of first prenatal care visit . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Date of last live birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Date of last other pregnancy outcome . . . . . . . . . . . . . . . . . . . . . . . 14
Diabetes (Risk factors in this pregnancy) . . . . . . . . . . . . . . . . . . . . . 15
Prepregnancy (Risk factors in this pregnancy) . . . . . . . . . . . . . . . . .15
Gestational (Risk factors in this pregnancy) . . . . . . . . . . . . . . . . . . 15
Down syndrome (Congenital anomalies of the newborn) . . . . . . . . . . . . . 44
E
Eclampsia (Risk factors in this pregnancy) . . . . . . . . . . . . . . . . . . . . 16
Epidural or spinal anesthesia during labor (Characteristics of
labor and delivery) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
External cephalic version (Obstetric procedures) . . . . . . . . . . . . . . . . . 22
F
Facility ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Facility name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Fertility-enhancing drugs, artificial insemination, or
intrauterine insemination (Risk factors in this pregnancy) . . . . . . . . . . . 18
Fetal presentation at birth (Method of delivery) . . . . . . . . . . . . . . . . . . 30
Final route and method of delivery (Method of delivery) . . . . . . . . . . . . . 31
G
Gastroschisis (Congenital anomalies of the newborn) . . . . . . . . . . . . . . .43
Page 49 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
Gonorrhea (Infections present or treated during this pregnancy) . . . . . . . . . 20
H
Hepatitis B (Infections present and/or treated during this pregnancy) . . . . . . 21
Hepatitis C (Infections present and/or treated during this pregnancy) . . . . . . 21
Hypertension (Risk factors in this pregnancy). . . . . . . . . . . . . . . . . . .16
Prepregnancy (Risk factors in this pregnancy) . . . . . . . . . . . . . . . . . 16
Gestational (Risk factors in this pregnancy) . . . . . . . . . . . . . . . . . . 16
Hypospadias (Congenital anomalies of the newborn) . . . . . . . . . . . . . . . 45
I
If cesarean, was a trial of labor attempted? (Method of delivery) . . . . . . . . .32
If not a single birth, number of infants in the delivery born alive . . . . . . . . .37
If not a single birth, order born in the delivery . . . . . . . . . . . . . . . . . . 37
Induction of labor (Characteristics of labor and delivery) . . . . . . . . . . . . .27
Infant’s medical record number . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Infections present and/or treated during this pregnancy. . . . . . . . . . . . . .20
Is the infant being breastfed at discharge? . . . . . . . . . . . . . . . . . . . . .47
Is the infant living at the time of the report?. . . . . . . . . . . . . . . . . . . .46
L
Limb reduction defect (Congenital anomalies of the newborn) . . . . . . . . . . 44
M
Maternal morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Maternal transfusion (Maternal morbidity) . . . . . . . . . . . . . . . . . . . . 32
Meningomyelocele/Spina bifida (Congenital anomalies of the newborn) . . . . .42
Method of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Method of disposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Mother had a previous cesarean delivery (Risk factors in this pregnancy) . . . . 19
Mother’s weight at delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
N
Newborn given surfactant replacement therapy (Abnormal conditions
of the newborn) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
NICU admission (Abnormal conditions of the newborn) . . . . . . . . . . . . . 40
Number of other pregnancy outcomes . . . . . . . . . . . . . . . . . . . . . . . 14
Number of previous live births now dead . . . . . . . . . . . . . . . . . . . . . 13
Number of previous live births now living. . . . . . . . . . . . . . . . . . . . .12
O
Obstetric estimate of gestation at delivery . . . . . . . . . . . . . . . . . . . . 34
Obstetric procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Omphalocele (Congenital anomalies of the newborn) . . . . . . . . . . . . . . .43
P
Place where birth occurred (Birthplace) . . . . . . . . . . . . . . . . . . . . . . .9
Plurality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Pregnancy resulted from infertility treatment
(Risk factors in this pregnancy) . . . . . . . . . . . . . . . . . . . . . . . . . 18
Previous preterm births (Risk factors in this pregnancy) . . . . . . . . . . . . . 17
Principal source of payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
R
Risk factors in this pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Ruptured uterus (Maternal morbidity) . . . . . . . . . . . . . . . . . . . . . . .33
S
Seizure or serious neurologic dysfunction (Abnormal conditions of
the newborn) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Sex of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Steroids (glucocorticoids) for fetal lung maturation received by
the mother before delivery (Characteristics of labor and delivery) . . . . . . . 28
Suspected chromosomal disorder (Congenital anomalies of the newborn) . . . . 45
Syphilis (Infections present and/or treated during this pregnancy) . . . . . . . . 21
Page 50 Guide to Completing the Facility Worksheet for the Certificate of Live Birth and Report of Fetal Death
T
Third- or fourth-degree perineal laceration (Maternal morbidity) . . . . . . . . 32
Time of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Total number of prenatal care visits for this pregnancy . . . . . . . . . . . . . . 10
U
Unplanned hysterectomy (Maternal morbidity) . . . . . . . . . . . . . . . . . . 33
W
Was the infant transferred within 24 hours of delivery?. . . . . . . . . . . . . .46
Was the mother transferred to this facility for maternal medical or
fetal indications for delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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