Form - World Health Organization

Database on Newborn Health and Birth Defects
Center Name
Baby’s Hospital Record No.
Mother’s Hospital Record No.
Inborn live birth
1.
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
NNPD Number
Outborn live birth
Basic information
Mother’s Name *
Date of Delivery *
d
d
m
m
y
y
y
y
Time of Delivery (24 hr format)
h
h
m
m
Baby’s Gender *
Male
/
Female
/
Ambiguous
Birth weight (g)
Head Circumference
(in cm)
Mode of delivery *
Vaginal
/
Cesarean section
/
Instrumental
Multiple birth
Single / Twin / Triplet / Higher order
Gestation
(in weeks)
Delivery attended by
Doctor / Nurse / ANM / Midwife
For Out Born babies only
d
d
m
m
y
y
y
y
i. Date of admission *
Home / Hospital / Others
ii. Place of delivery
Doctor / Nurse / ANM / Midwife / Traditional birth attendant / Others
iii. Delivery attended by
Pre Term (< 37 weeks)/ Term (>37 weeks)
iv. Gestation (in weeks) *
v. Weight at admission (g) *
2.
i.
iii.
v.
vii.
3.
i.
ii.
Maternal Details:
Para
Antenatal Care
5.
i.
6.
i.
iii.
7.
ii.
Severe Anaemia
iv.
Gestational Diabetes
Y / N
Y / N
vi.
Eclampsia
Y / N
Y / N
viii.
Y / N
(at least 4 antenatal check-up)
Antepartum Hemorrhage
Cord Prolapse
4.
Labor/Delivery:
Oxytocin/other drug for induction
Y / N
*
Antenatal steroids *
$ Complete
Y / N
Obstructed Labour
Y / N
At Birth Care:
I.
Bag and mask ventilation
II.
Birth defects
Y / N
$
None / IC / CC
(For gestation <35 weeks)
* Incomplete course
I.
Newborn (NB) Form
Y/N
If yes; fill BD Form at the end of this form
course
Newborn Morbidities:
Birth trauma
Y/N
Hypoglycemia
Y / N
iii.
Meconium aspiration
Y / N
iv.
Hypothermia
Y / N
ii.
Pneumonia
Y / N
Seizures
Y / N
ii.
(If yes specify)
Respiratory Distress:
RDS (HMD)
Y / N
Transient tachypnea of newborn
Y / N
CNS Disorders:
HIE
stage 3 / stage 2 / stage 1 / None
II.
Supported by WHO-SEARO and CDC Atlanta
8.
Systemic Infections:
Systemic sepsis
I.
Y
/
N
If ‘Yes’, Please fill the following fields; otherwise skip to ‘9’.
Episode No.
9.
Name of organism*
Onset
Culture
Early / Late
+ ve / - ve
Early / Late
+ ve / - ve
Early / Late
+ ve / - ve
Select from the list
Mandatory if + ve
Other:
Hyperbilirubinemia
I.
Y / N
(Need for phototherapy)
II.
Rh isoimmunization
Y / N
III.
ROP requiring Laser
Y / N
IV.
Any other morbidity
Y / N
If ‘Yes’, specify
10. Therapy provided:
I.
Intravenous fluids
Y / N
II.
CPAP
Y / N
III.
IMV
Y / N
IV.
Surfactant
Y / N
V.
Antibiotic(s) *
Antibiotics
Y / N
If ‘Yes’, fill the followings items; otherwise skip to ‘11’.
Codes
Codes
Codes
Codes
Codes
Codes
Name
Duration (days)
11. Outcome of newborn *
$ Fill
Discharged / Died$ / Referred / Left against medical advice (LAMA)
the following fields up to 14 if died option is selected otherwise skip to ‘15’
12. Neonatal death *
i.
Date of death (dd/mm/yyyy)
ii.
Time of death (24 hrs)
d
d
h
m
m
h
y
y
y
m
y
m
13. Causes of Neonatal / Death*
i.
Asphyxia
Y / N
ii.
Infection
Y / N
iii.
Prematurity
Y / N
iv.
Birth Defect(s)
Y / N
14. What was the single most important cause of
neonatal death?
v. Others
vi. Unknown
Y / N
If ‘Yes’, Specify
Y / N
Asphyxia /Infection/ Prematurity/ Birth Defect(s)/ Others/ Unknown
15. Maternal Death:
Y / N
Name of professional filled the physical form
Date:
* Mandatory Fields
Supported by WHO-SEARO and CDC Atlanta