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(To be completed by Mother or Father of Child) Please ll out both sides of this form -- any boxes left blank will delay the certicate from being led.
First Middle Last
State of Colorado
Sufx
General
Male
Female
Date of Birth:_____/____/______ Time of birth: ____:____ Is infant living at time of report: Yes No
AM PM Military
Is infant receiving breast milk? Name of Mother: Did mother get WIC food? Attendant Name:
Person who caught the baby
No
Middle
Maiden Name
Yes
No
First
Unknown
Middle Initial Last
Place of Birth
MD
DO
CNM
Registered Midwife
Street Street
Other: (specify)
City & County City & County State State Zip Zip
Address where baby was born: Infant transferred within 24 hours of delivery: Mother transferred prior to delivery: Principle source of payment: No Prenatal Care Yes Yes No If Yes, name facility transferred to:
Private insurance
MM DD
Self-pay
MM
Other (specify:_______________________)
DD YYYY
Number of visits for Date of Last Prenatal care visit: ______/______/________ Prenatal care: Date of First Prenatal care visit: ______/______/________ Month Prenatal care began: (1st, 2nd, 3rd ...) Prenatal Care Provider: Number of live births now living?
(not including this one)
Prenatal 1
0, 1, 2, 3 ...
Now Deceased?
/ / Mothers height:
/ Unknown
CIGARETTE SMOKING & ALCOHOL USE BEFORE AND DURING PREGNANCY: (For each time period, enter number of cigarettes and number of alcoholic drinks. If none, enter 0. Average number of cigarettes smoked per day and alcoholic drinks per week.) RISK FACTORS IN THIS PREGNANCY (Check all that apply) DIABETES Prepregnancy (Diagnosis prior to this pregnancy) Gestational (Diagnosis in this pregnancy) HYPERTENSION Prepregnancy (Chronic) Gestational (PIH, preeclampsia) Eclampsia HELLP Syndrome Previous preterm birth Previous infant > 4000 grams, (8.8 Lbs.) Other previous poor pregnancy outcome (Includes perinatal death, small-for-gestational age/intrauterine growth restricted birth) Three months before pregnancy: First three months of pregnancy: Second three months of pregnancy: Last three months of pregnancy:
Prenatal 2
Pregnancy resulted from infertility treatment--Check all that apply Fertility-enchancing drugs, Articial insemination or intrauterine insemination Assisted reproductive technology (e.g., in viro fertilization (IVF), gamete intrafallopian transfer (GIFT) Mother had a previous cesarean delivery If yes, how many? __________ Asthma Genital Herpes at time of delivery Other (Specify) ____________________________________________________ None Unknown Month Day Year
Check blood screening that apply: No blood test done for this pregnancy
Gonorrhea CMV Hepatitis B Rubella Herpes Simplex Virus
/ / /
/ / /
Unknown
INFECTIONS PRESENT/TREATED DURING THIS PREGNANCY (Check all that apply) Group B Strep (GBS) None HIV/AIDS Other (Specify) ________________________________________________________________________
Signature of Registrar:
Name of County:
Please complete all sections of worksheet to avoid any delays in ling. Mothers weight at delivery: Unknown
OBSTETRIC PROCEDURES (Check all that apply)
ONSET OF LABOR (Check all that apply) Premature Rupture of the Membrances (prolonged, >/= 12 hrs.) Precipitous Labor (< 3 hrs.) Prolonged Labor (>/= 20 hrs.) Other (specify) ___________________________________________ None Unknown Cervical carciage Tocolysis External cephalic version: Other (specify) ___________________________________________________ METHOD OF DELIVERY Was delivery with forceps attempted? Yes No If yes, was it unsuccessful? Yes No Was delivery with vacuum extraction attempted but unsuccessful? Yes No Fetal presentation at birth Cephalic (head down) Breech (bottom rst) Other Final route and method delivery (Check one) Vaginal/Spontaneous Vaginal/Forceps Vaginal/Vacuum Cesarean If cesarean, was a trial of labor attempted? Yes No Successful Failed None Unknown
CHARACTERISTICS OF LABOR AND DELIVERY (Check all that apply) Induction of labor Augmentation of labor Non-vertex presentation Steriods (glucoconticoids) for fetal lung maturation received by the mother prior to delivery Antibiotics received by the mother during labor Clinical chorioamnionitis diagnosed during labor or maternal temperature 38C (110.4F) Moderate/heavy meconium staining of the amniotic uid Fetal intolerance of labor such that one or more of the following action was taken: in-utero resuscitative measures, further fetal assessment, or operative delivery Epidural or spinal anesthesia during labor Other (Specify) _________________________ None Unknown Specify lbs or grams
MATERNAL MORBIDITY (Check all that apply) (Complications associated with labor and delivery) Maternal transfusion Third or fourth degree perineal laceration Ruptured uterus Unplanned hysterectomy Admission to intensive care unit Unplanned operating room procedure following delivery VBAC Abruptio Plancenta Placenta Previa Cephalopelvic disproportion (CPD) Cord prolapse Other (Specify) _____________________ None Unknown
LD
at 5 minutes
at 10 minutes
I certify that the above information is accurate to the best of my knowledge. In the event an error is made on this birth certificate by the hospital or county registrar during the registration process, I authorize the hospital or county registrar to act on my behalf as my legal representative to correct the error.
_______________________________________________________ Informant Signature _________________________________ Date
I:\HSVR\DATAMGT\FORMS2007
Child Med