1. Medical page 2 (the hospital/medical worksheet must be used to complete the following items) Filing a Birth Certificate Vital Statistics Services1

2. Risk Factors in this Pregnancy Vital Statistics Services2 If pregnancy resulted from infertility treatment you must check all that apply: Fertility-enhancing drugs, artificial insemination, or intrauterine insemination; or Assisted reproductive technology (e.g. in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT)

3. Risk Factors in this Pregnancy The patient may have more than one risk factor; check all that apply. If the patient had none of the risk factors, choose NONE. Vital Statistics Services3

4. Information about RiskFactors The risk factors contribute to the national data set and provide more specific information regarding fetal death events. For example, diabetes information is associated with macrosomia, cesarean delivery, metabolic abnormalities, and congenital anomalies. Management during pregnancy can reduce poor maternal and infant outcomes. Hypertension is associated with increased risk for preterm delivery, intrauterine growth restriction, maternal and perinatal morbidity and mortality. Vaginal bleeding during the pregnancy prior to the onset of labor is associated with increased risk for multiple adverse pregnancy outcomes. Pregnancy resulting from infertility treatment increases the incidence of multiple births. Vital Statistics Services4

5. Infections Present and/or Treated During this Pregnancy If the prenatal record is not available and the information is not available from other medical records, enter ‘‘unknown’’ in the space. More than one infection may be checked. – Gonorrhea (a diagnosis of a or positive test for Neisseria gonorrhoeae) – Syphilis (also called lues – a diagnosis of or positive test for Treponema pallidum) – Chlamydia (a diagnosis of or positive test for the herpes simplex virus) – Hepatitis B (HBV, serum hepatitis – a diagnosis of or positive test for the hepatitis B virus) – Hepatitis C (non A, non B hepatitis, HCV – a diagnosis of or positive test for the hepatitis C virus) – None of the above Vital Statistics Services5

6. Infections Present and/or Treated During This Pregnancy All of the listed infections are known to cause concomitant fetal and/or subsequent neonatal infection and thus have significant public health implications. In addition, there is no current national reporting system for these infections that focuses on the prevalence of perinatal transmission Vital Statistics Services6

7. Obstetric Procedures Medical treatment or invasive/manipulative procedure performed during this pregnancy to treat the pregnancy or to manage labor Check all boxes that apply Vital Statistics Services7

8. OB Procedures – Cervical Cerclage Circumferential banding or suture of the cervix to prevent or treat passive dilation. Includes: – MacDonald’s suture – Shirodkar procedure – Abdominal cerclage via laparotomy Vital Statistics Services8

9. OB Procedures - Tocolysis Administration of any agent with the intent to inhibit preterm uterine contractions to extend the length of the pregnancy. Medications: – Magnesium sulfate (for preterm labor) – Terbutaline – Indocin (for preterm labor) Vital Statistics Services9

10. OB Procedures – External cephalic version Attempted conversion of a fetus from a non- vertex presentation by external manipulation Successful: – Fetus was converted to a vertex presentation Failed – Fetus was not converted to a vertex presentation Vital Statistics Services10

11. Why is Obstetric Procedures Needed? Information on obstetric procedures is used to measure the use of advanced medical technology during pregnancy and labor. It is also used to investigate the relationship of these procedures to type of delivery and pregnancy outcome. Vital Statistics Services11

12. Risk Factors, Infections, and OB Procedures Vital Statistics Services12 If “previous preterm birth” is selected then there MUST be a response to “Previous live birth living/now dead” If the mother had a previous cesarean delivery, you must indicate the number of previous cesarean deliveries she has had.

13. Onset of Labor Check all that apply: – Premature rupture of the membranes (prolonged, greater than or equal to 12 hours) – Precipitous labor ( less than 3 hours) – Prolonged labor (greater than or equal to 20 hours) Prolonged labor and precipitous should NOT both be checked. Vital Statistics Services13

14. Characteristics of Labor and Delivery Information about the course of labor and delivery. Vital Statistics Services14

15. Onset of Labor and Characteristics of Labor and Delivery Vital Statistics Services15 Both of these items should not be checked, mark only one.

16. Method of Delivery The physical process by which the complete delivery of the fetus was effected. Vital Statistics Services16

17. Method of Delivery This information is used to correlate method of delivery with birth outcomes, to monitor changing trends in obstetric practice, and to determine which groups of women are most likely to have cesarean delivery. The method of delivery is relevant to the health of the mother, especially if it is by cesarean section. Information from this item can be used to monitor delivery trends across the U.S. Vital Statistics Services17

18. Maternal Morbidity Serious complications experienced by the mother associated with labor and delivery. Vital Statistics Services18

19. Method of Delivery and Maternal Morbidity Vital Statistics Services19 TIP: If you responded to letter ‘B’ as “YES” then the final route of delivery ‘D’ CAN NOT be “vaginal-vacuum”.

20. NEWBORN INFORMATION (THE HOSPITAL/MEDICAL WORKSHEET MUST BE USED TO COMPLETE THE FOLLOWING ITEMS) Filing a Birth Certificate Vital Statistics Services20

21. Birth weight Enter the weight (in grams) of the infant at birth Do not convert pounds and ounces (lbs. and oz.) to grams If the weight in grams is not available, enter the birth weight in lbs. and oz. Vital Statistics Services21

22. Infant Birth Weight This is one of the most important characteristics associated with infant mortality. It can also be related to prenatal care, socioeconomic status, and other factors surrounding the birth. The birth weight is used with information to plan and evaluate the effectiveness of healthcare. Vital Statistics Services22

23. Obstetric Estimate of Gestation The best obstetric estimate of the infant’s gestation in completed weeks based on the birth attendant’s final estimate of gestation. The estimate of gestation should be determined by all perinatal factors and assessments such as ultrasound, but NOT the neonatal exam. – Ultrasound taken early in pregnancy is preferred. Vital Statistics Services23

24. OB Estimate of Gestation This item provides information on gestational age when the Date of LMP began contains invalid or missing information. For records with a plausible LMP, it provides a crosscheck with length of gestation based on ultrasound or other techniques. Vital Statistics Services24

25. APGAR Score A systematic measure for evaluating the physical condition of the infant at specific intervals following birth No response is needed for the 1 minute score Enter the infant’s Apgar score at 5 minutes – If the score is LESS than 6, you MUST provide the 10 minute Apgar score Vital Statistics Services25

26. Birth weight, OB Estimate of Gestation, and Apgar Score Vital Statistics Services26 1.When entering the birth weight, enter it in Grams. 2.A 1-minute Apgar score is not required. 3.When the 5-minute score is less than 6 you must provide a 10-minute score.

27. 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. – “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. Vital Statistics Services27

28. Plurality Vital Statistics Services28 1. Enter the number of fetuses delivered in this pregnancy. If it is a singleton birth, you will not see “Birth Order”. 2. If not a single birth, enter the order born in the delivery. For example if twins enter 2 for plurality and then enter whether or not this fetus was the first or second born enter 1 or 2. Both fields are required to be answered.

29. Plurality Is Important This information is used to study plural deliveries and patterns shown to be related to birth weight and may help identify infants with future medical needs. The data can also be used to track changes in plural births related to use of fertility drugs and other assisted reproductive technologies. Vital Statistics Services29

30. Abnormal Conditions of Newborn Disorders or significant morbidity experienced by the newborn. Check all boxes that apply. Vital Statistics Services30

31. Congenital Anomalies Malformations of the newborn diagnosed prenatally or after delivery. Check all boxes that apply. Vital Statistics Services31

32. Was the Infant Transferred within 24 hours of delivery? Transfer status of the infant within 24 hours after delivery. If YES: choose the appropriate facility infant transferred to. Vital Statistics Services32

33. Is the Infant Living at the Time of Report? Information on the infant’s survival. – If the infant was not transferred, this question must be answered. Vital Statistics Services33

34. Why Collect This? This information can be used as a check to ensure that a birth and death record have been filed. It can also be used to ensure that immunization registries do not contact the parent(s) regarding enrollment. Vital Statistics Services34

35. Metabolic and Hearing Screening Metabolic Screening: – Choose Completed, Missed, or Waived Hearing Screening: – Choose Passed, Missed, or Failed If the infant passes in one ear but not the other it should be recorded as Failed Vital Statistics Services35

36. Why is Metabolic Screening Important? Newborn screening is the practice of testing every newborn for certain harmful or potentially fatal disorders that aren’t otherwise apparent at birth. These disorders can hinder an infant’s normal physical and mental development in a variety of ways. Source of information: http://kidshealth.org/parent/system/medical/newborn_screening_tests.html# Vital Statistics Services36

37. Why is Hearing Screening Important Data about newborn hearing is shared with the Wyoming Early Hearing and Detection program. It’s purpose is to ensure that all Wyoming children with hearing loss are identified as early as possible and provided with timely and appropriate management in order to develop to their highest potential. – (http://www.wyomingehdi.org/about/hearing- health-history-system/) Vital Statistics Services37