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                Prenatal Care and Pregnancy History
          + Date of the first prenatal care visit
          + Total number of prenatal care visits for this pregnancy
          + Date last normal menses began
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          + Number of previous live births now dead
          + Date of last live birth
          + Number of other pregnancy outcomes
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          + Was the mother transferred to this facility for maternal medical or fetal indications for delivery?
          + Attendant’s name, title, and ID
          + Mother’s weight at delivery
          + Characteristics of labor and delivery
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                Newborn Information
          + Birthweight or weight of fetus
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          + Sex of child
          + Apgar score
          + Plurality
          + If not a single birth, order born in the delivery
          + If not a single birth, number of infants in the delivery born alive
          + Abnormal conditions of the newborn
          + Congenital anomalies of the newborn
          + Was the infant transferred within 24 hours of delivery?
          + Is the infant living at the time of the report?
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        36. Abnormal conditions of the newborn
          Abnormal conditions of the newborn
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              Category: Newborn Information
              BC # 54
              Definitions, instructions, sources, keywords and abbreviations
                Definitions                 Disorders or significant morbidity experienced by the newborn.
                                            Check all boxes that apply.                                   
                Instructions                                                                              
                                            If none of the conditions apply, check “none of the above.”   
                Sources                     See below                                                     
                Keywords and Abbreviations  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.
                  Definitions                                                                                                                                                         
                                              Excludes free-flow (blow-by) oxygen only, laryngoscopy for aspiration of meconium, nasal cannula, and bulb suction.                     
                  Instructions                                                                                                                                                        
                  Sources                     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                                            
                  Keywords and Abbreviations                                                                                                                                          
                                              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                                                                                                                                  
                  Assisted ventilation required for more than six hours
                                                Infant given mechanical ventilation (breathing assistance) by any method for more than 6 hours.
                    Definitions                 Includes conventional, high frequency, or continuous positive pressure (CPAP).                 
                                                Excludes free-flow oxygen only, laryngoscopy for aspiration of meconium, and nasal cannula.    
                    Instructions                Count the number of hours of mechanical ventilation given.                                     
                    Sources                     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                                              
                    Keywords and Abbreviations                                                                                                 
                                                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                                                                           
                    NICU admission
                      Definitions                 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.                                                                          
                      Instructions                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 –                                                                                                 
                      Sources                                                                                                                                                                                       
                                                    * Intensive care nursery (ICN)                                                                                                                                  
                                                  ICN – Intensive care nursery                                                                                                                                      
                      Keywords and Abbreviations  NICU – Neonatal intensive care unit                                                                                                                               
                                                  PICU – Pediatric intensive care unit                                                                                                                              
                      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.
                        Definitions                                                                                                                                                                                        
                                                    Includes both artificial and extracted natural surfactant.                                                                                                             
                        Instructions                Check both 1st and 2nd sources before completion.                                                                                                                      
                                                    1st Labor and delivery summary under – Neonatal medication                                                                                                             
                        Sources                                                                                                                                                                                            
                                                    2nd Newborn medication administration record                                                                                                                           
                                                    If given to newborn after birth:                                                                                                                                       
                                                    Medications (given to newborn):                                                                                                                                        
                        Keywords and Abbreviations    * Surfactant                                                                                                                                                         
                                                      * Survanta                                                                                                                                                           
                                                      * Exosurf                                                                                                                                                            
                                                      * Curosurf                                                                                                                                                           
                                                      * Infasurf                                                                                                                                                           
                        Antibiotics received by the newborn for suspected neonatal sepsis
                          Definitions                 Any antibacterial drug (penicillin, ampicillin, gentamicin, cefotoxine, etc.) given systemically (intravenous or intramuscular). Does not include antibiotics given to infants who are not suspected of having neonatal sepsis.
                          Instructions                                                                                                                                                                                                                                               
                          Sources                     1st Newborn medication administration record                                                                                                                                                                                   
                                                      Medications (given to newborn for sepsis):                                                                                                                                                                                     
                          Keywords and Abbreviations    * Nafcillin, Chloramphenicol                                                                                                                                                                                                 
                                                        * Penicillin, Penicillin G                                                                                                                                                                                                   
                                                        * Ampicillin, Gentamicin, Kanamycin, Cefotaxime, Cefoxitin, Vancomycin, Acyclovir, Amikacin, Ceftazidime, Ceftriaxone, Cefazolin                                                                                             
                          Seizure or serious neurologic dysfunction
                                                        Seizure is any involuntary repetitive, convulsive movement or behavior.
                                                        Serious neurologic dysfunction is severe alteration of alertness.      
                            Definitions                                                                                        
                                                        Excludes:                                                              
                                                          * Lethargy or hypotonia in the absence of other neurologic findings  
                                                          * Symptoms associated with CNS congenital anomalies                  
                            Instructions                                                                                       
                                                        1st Newborn H&P                                                        
                            Sources                                                                                            
                                                        2nd Physician progress notes under – Neuro Exam                        
                                                        Seizures                                                               
                                                        Tonic/Clonic/Clonus                                                    
                                                        Twitching                                                              
                                                        Eye rolling                                                            
                                                        Rhythmic jerking                                                       
                            Keywords and Abbreviations                                                                         
                                                        Hypotonia                                                              
                                                        Obtundation                                                            
                                                        Stupor                                                                 
                                                        Coma                                                                   
                                                        HIE – Hypoxic-ischemic encephalopathy                                  
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                                    Newborn Information
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                                          29. Birthweight or weight of fetus
                                        The weight of the infant at birth.
                                        Categories: Newborn Information
                                          30. Obstetric estimate of gestation at delivery
                                        This item is used to compute the gestational age of the infant.
                                        Categories: Newborn Information
                                          31. Sex of child
                                        The sex of the infant.
                                        Categories: Newborn Information
                                          32. Apgar score
                                        A systematic measure for evaluating the physical condition of the infant at specific intervals following birth.
                                        Categories: Newborn Information
                                          33. Plurality
                                        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.
                                        Categories: Newborn Information
                                          34. If not a single birth, order born in the delivery
                                        The order born in the delivery, live born or fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.).
                                        Categories: Newborn Information
                                          35. If not a single birth, number of infants in the delivery born alive
                                        The number of infants in this delivery born alive at any point in the pregnancy.
                                        Categories: Newborn Information
                                          36. Abnormal conditions of the newborn
                                        Disorders or significant morbidity experienced by the newborn (e.g., assisted ventilation required immediately following delivery, assisted ventilation required for more than six hours, NICU admission, newborn given surfactant replacement therapy, antibiotics received by the newborn for suspected neonatal sepsis, seizure or serious neurologic dysfunction).
                                        Categories: Newborn Information
                                          37. Congenital anomalies of the newborn
                                        Malformations of the newborn diagnosed prenatally or after delivery. (e.g., anencephaly, meningomyelocelep>
                                        Malformations of the newborn diagnosed prenatally or after delivery. (e.g., anencephaly, meningomyelocele/spina bifida, cyanotic congenital heart disease, congenital diaphragmatic hernia, omphalocele, gastroschisis, limb reduction defect, cleft lip with or without cleft palate, cleft palate alone, Down syndrome, suspected chromosomal disorder, hypospadias).
                                        Categories: Newborn Information
                                          38. Was the infant transferred within 24 hours of delivery?
                                        Transfer status of the infant from this facility to another within 24 hours after delivery.
                                        Categories: Newborn Information
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                    Last Reviewed: August 6, 2019
                      Source: National Center for Health Statistics
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                    * Facility Information plus icon
                        + Facility name
                        + Facility ID
                        + City, town, or location of birth
                        + County of birth
                        + Place where birth occurred (Birthplace)
                    * Prenatal Care and Pregnancy History plus icon
                        + Date of the first prenatal care visit
                        + Total number of prenatal care visits for this pregnancy
                        + Date last normal menses began
                        + Number of previous live births now living
                        + Number of previous live births now dead
                        + Date of last live birth
                        + Number of other pregnancy outcomes
                        + Date of last other pregnancy outcome
                        + Risk factors in this pregnancy
                        + Infections present and/or treated during this pregnancy
                        + Obstetric procedures
                    * Labor and Delivery plus icon
                        + Date of birth
                        + Time of birth
                        + Certifier’s name and title
                        + Date certified
                        + Principle source of payment
                        + Infant’s medical record number
                        + Was the mother transferred to this facility for maternal medical or fetal indications for delivery?
                        + Attendant’s name, title, and ID
                        + Mother’s weight at delivery
                        + Characteristics of labor and delivery
                        + Method of delivery
                        + Maternal morbidity (maternal transfusion)
                    * Newborn Information plus icon
                        + Birthweight or weight of fetus
                        + Obstetric estimate of gestation at delivery
                        + Sex of child
                        + Apgar score
                        + Plurality
                        + If not a single birth, order born in the delivery
                        + If not a single birth, number of infants in the delivery born alive
                        + Abnormal conditions of the newborn
                        + Congenital anomalies of the newborn
                        + Was the infant transferred within 24 hours of delivery?
                        + Is the infant living at the time of the report?
                        + Is the infant being breastfed at discharge?
                        + Method of disposition
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