Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births

1 1/5/2017

ATTACHMENT TO THE FACILITY WORKSHEET FOR

THE LIVE BIRTH CERTIFICATE FOR

MULTIPLE BIRTHS

FINAL 12/16

This attachment is to be completed when at least two infants

in a multiple pregnancy are born alive.* Complete a full

worksheet for the first-born infant and an attachment for

each additional live-born infant.

A “Facility Worksheet for the Report of Fetal Death” should

be completed for any fetal loss in this pregnancy reportable

under State reporting requirements. Item numbers refer to

item numbers on the full worksheet.

*For “Delayed Interval Births,” that is, births in a multiple pregnancy

delivered at least 24 hours apart, a full worksheet, not an attachment

should be completed.

Mother’s medical record #____________

Mother’s name______________________

Child’s name/medical record # ________

___________________________________

Attachment _______ of _______________

Mother’s Pregnancy History

Sources: Prenatal care records, mother’s medical records

9. Number of previous live births now living (For this multiple delivery, include all live-born infants delivered before this infant

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

Number ____  None

10. Number of previous live births now dead (For this multiple delivery, include all live-born infants delivered before this infant in

the pregnancy who are now dead. in addition to infants from prior pregnancies):

Number____  None

12. Number of other pregnancy outcomes (For this multiple delivery, include all fetal losses of any gestational age - spontaneous

losses, induced losses, and/or ectopic pregnancies – occurring before delivery of this infant in the pregnancy in addition to losses from prior

pregnancies):

Number ____  None

Labor and Delivery

Source: Labor and delivery records, mother’s medical records

17. Date of birth: ___ ___ ___ ___ ___ ___ ___ ___

M M D D Y Y Y Y

18. Time of birth: ___________

(Enter time based on a 24-hour clock.)

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34. Order delivered in the pregnancy: _________

(Specify born 2

, 3

, 4

, 5

, 6

, 7

, etc. Include all live births and fetal losses resulting from this pregnancy)

26. Characteristics of labor and delivery (Information about the course of labor and delivery.)

(Check all that apply to this infant):

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

spontaneous onset of labor (i.e., before labor has begun). Does not include augmentation of labor.)

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

delivery (i.e., after labor has begun). Do not include if induction of labor was performed.)

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

(Steroids received by the mother prior to delivery to accelerate fetal lung maturation. Typically administered in anticipation of preterm

delivery. Includes betamethasone, dexamethasone, or hydrocortisone specifically given to accelerate fetal lung maturation. Excludes steroid

medication given to the mother as an anti-inflammatory treatment before or after delivery.)

 Antibiotics received by the mother during labor - (Includes antibacterial medications given systemically (intravenous or

intramuscular) to the mother in the interval between the onset of labor and the actual delivery: Ampicillin, Penicillin, Clindamycin,

Erythromycin, Gentamicin, Cefotaxime, Ceftriaxone, etc.)

 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 and/or irritability, leukocytosis, fetal tachycardia, maternal tachycardia, or malodorous vaginal discharge. Any maternal

temperature at or above 38C (100.4F).)

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

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

 None of the above

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

(Complete C, and D):

C. Fetal presentation at birth (Check one):

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

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

 Other - (Any other presentation not listed above, i.e., shoulder, funis, transverse lie, compound)

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

 Vaginal/Spontaneous - (Delivery of the entire fetus through the vagina by the natural force of labor with or without manual

assistance from the delivery attendant.)

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

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

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

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

 Yes  No

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

(Check all that apply to this infant):

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

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 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.)

 Ruptured uterus - (Tearing of the uterine wall. A full-thickness disruption of the uterine wall that also involves the overlaying 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.)

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

not definitively planned, hysterectomy.)

 Admission to intensive care unit - (Any admission, planned or unplanned, of the mother to a facility/unit designated as providing

intensive care.)

 None of the above

Newborn

Sources: Labor and delivery records, newborn’s medical records, mother’s medical records

29. Birthweight: ________________(grams) (Do not convert lb/oz to grams)

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

30. Obstetric estimate of gestation at delivery (completed weeks):________

(The best obstetric estimate of the infant’s gestational age in completed weeks based on the clinician’s final estimate of gestation.)

31. Sex: ________ (Male, Female, or Not yet determined)

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

Score at 5 minutes _______

If 5 minute score is less than 6: Score at 10 minutes _______

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

(Check all that apply to this infant):

 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.)

 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 and/or continuous positive pressure (CPAP). Excludes free flow

oxygen only, laryngoscopy for aspiration of meconium and nasal cannula.)

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

newborn.)

 Newborn given surfactant replacement therapy - (Endotracheal instillation of a surface-active suspension for the treatment

of surfactant deficiency due to preterm birth or pulmonary injury resulting in respiratory distress. Includes both artificial and extracted

natural surfactant.)

 Antibiotics received by the newborn for suspected neonatal sepsis - (Any antibacterial drug (e.g., penicillin,

ampicillin, gentamicin, cefotoxime etc.) given systemically (intravenous or intramuscular). Does not include antibiotics given to infants

who are NOT suspected of having neonatal sepsis.)

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 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.

Exclude symptoms associated with CNS congenital anomalies.)

 None of the above

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

(Check all that apply to this infant):

 Anencephaly - (Partial or complete absence of the brain and skull. Also called anencephalus, acrania, or absent brain. Also includes

infants with craniorachischisis (anencephaly with a contiguous spine defect).)

 Meningomyelocele/Spina bifida - (Spina bifida is herniation of the meninges and/or spinal cord tissue through a bony defect of

spine closure. Meningomyelocele is herniation of meninges and spinal cord tissue. Meningocele (herniation of meninges without spinal

cord tissue) should also be included in this category. Both open and closed (covered with skin) lesions should be included. Do not include

Spina bifida occulta (a midline bony spinal defect without protrusion of the spinal cord or meninges).)

 Cyanotic congenital heart disease - (Congenital heart defects which cause cyanosis.)

 Congenital diaphragmatic hernia - (Defect in the formation of the diaphragm allowing herniation of abdominal organs into the

thoracic cavity.)

 Omphalocele - (A defect in the anterior abdominal wall 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.)

 Gastroschisis - (An abnormality of the anterior abdominal wall, lateral to the umbilicus, resulting in herniation of the abdominal

contents directly into the amniotic cavity. Differentiated from omphalocele by the location of the defect and absence of a protective

membrane.)

 Limb reduction defect (excluding congenital amputation and dwarfing syndromes) - (Complete or partial

absence of a portion of an extremity associated with failure to develop)

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

 Cleft Palate alone - (Incomplete fusion of the palatal shelves. May be limited to the soft palate or may extend into the hard palate.

Cleft palate in the presence of cleft lip should be included in the “Cleft Lip with or without Cleft Palate” category above.)

 Down Syndrome - (Trisomy 21 – A chromosomal abnormality caused by the presence of all or part of a third copy of chromosome

21.)

 Karyotype confirmed

 Karyotype pending

 Suspected chromosomal disorder - (Includes any constellation of congenital malformations resulting from or compatible with

known syndromes caused by detectable defects in chromosome structure.)

 Karyotype confirmed

 Karyotype pending

 Hypospadias - (Incomplete closure of the male urethra resulting in the urethral meatus opening on the ventral surface of the penis.

Includes first degree - on the glans ventral to the tip, second degree - in the coronal sulcus, and third degree - on the penile shaft.)

 None of the above

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38. Was infant transferred within 24 hours of delivery? (Check “yes” if the infant was transferred from this facility to

another within 24 hours delivery. If transferred more than once, enter name of first facility to which the infant was transferred.)

 Yes  No

If yes, name of facility infant transferred to: _________________________________________

39. Is infant living at time of report? (Infant is living at the time this birth certificate is being completed. Answer “Yes” if the infant

has already been discharged to home care. Answer “no” if it is known that the infant has died. If the infant was transferred and the status is

known, indicate known status.)

 Yes  No Infant transferred, status unknown

40. Is infant being breastfed at discharge? (Check “yes” if the infant was receiving breastmilk or colostrum during the period

between birth and discharge from the hospital. 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.)

 Yes  No