PeriData Variable Selector
This corresponds with PeriData.Net Birth Worksheet: All Fields (rev. 9/29/2021).
Input the project name associated with this data request:
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Download Data
Birth Circumstances
Mother
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Legal
Potential Adoption
Foundling
Refusal
Safe Haven
Surrogate
Birthplace
Type of birth facility**
Hospital
Free standing birthing center
Home (intended)
Home (not intended)
Home (unknown if intended)
Clinic/doctor's office
En route to hospital
Another hospital
Other, specify type of facility
Infant/Fetal Mortality
Fetal Death
Fetal death
Prenatal
Intrapartum
None
Infant Death
Infant death
Neonatal
Post-neonatal
None
Plurality and Birth Order
Number of fetuses delivered (plurality)
Birth order
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Mother's medical record number* (This item will not be made available.)
Mother's hospital admission number (This item will not be made available.)
Mother's Current Legal Name
First (This item will not be made available.)
Middle (This item will not be made available.)
Last (This item will not be made available.)
Suffix (This item will not be made available.)
Mother's Name Prior to First Marriage
First (This item will not be made available.)
Middle (This item will not be made available.)
Last (This item will not be made available.)
Suffix (This item will not be made available.)
SSN (This item will not be made available.)
Date of birth*
Reported age**
Calculated Age
Mother's Birthplace
Country
State
Phone Number
Phone type (This item will not be made available.)
Mother's phone # (This item will not be made available.)
Marriage/Paternity
Was the mother married at birth or at any time between conception and birth?
Has the mother ever been married?
If no, has a paternity acknowledgement been signed?
Is the biological father the legal husband of the mother?
Labels selected for Birth Certificate (This item is will not be made available).
Mother/Father
Parent/Parent
Unknown
Mother's Race
Unknown
White
Black or African American
American Indian or Alaska Native
American Indian or Alaska Native, specify first tribe
American Indian or Alaska Native, specify second tribe
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Laotian
Hmong
Other Asian
Other Asian 1
Other Asian 2
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other Pacific Islander 1
Other Pacific Islander 2
Other Race
Other Race 1
Other Race 2
Mother
Mother Address
Infant
Husband
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Mother's Race
Primary race**
Mother's Hispanic Origin
Hispanic
Mexican
Puerto Rican
Cuban
Other
Other, specify
Mother's Education
Select best category for highest degree or level of school completed**
8th grade or less
9th - 12th grade; no diploma
High school degree or GED
Some college credit, but not a degree
Associate degree
Bachelor's degree
Master's degree
Doctorate or professional degree
Mother's Employment (1 year ago)
Occupation
Type of firm
Informant
Name (This item will not be made available.)
Relation to infant
Mother
Father
Grandmother
Interpreter
Friend
Other, specify
Interpreter used?
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Mailing
In care of (c/o)
Street (This item will not be made available.)
City/Locality (This item will not be made available.)
State
ZIP code
Unit Type (This item will not be made available.)
Unit Number/Range
Residence Location
Does the mother physically reside at the standardized mailing address?
Yes
No
Country
State/Province
Canadian province/territory
County**
City/village/township** (This item will not be made available.)
Residence Street
Street
ZIP code
ZIP code extension
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Infant's medical record number* (This item will not be made available.)
Infant's hospital admission number (This item will not be made available.)
Infant's Name
First (This item will not be made available.)
Middle (This item will not be made available.)
Last (This item will not be made available.)
Suffix (This item will not be made available.)
Infant's Sex
Infant’s Sex
Male
Female
Not yet determined
Sex from infant’s first name
Male
Female
Cannot determine from name
Date/Time of birth
Date of birth*
Week, extracted from Date of birth
Month, extracted from Date of birth
Year, extracted from Date of birth
Time of birth*
Social security number requested for infant
Parent signature captured for SSN request
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Husband's Current Legal Name
First (This item will not be made available.)
Middle (This item will not be made available.)
Last (This item will not be made available.)
Suffix (This item will not be made available.)
Husband's Name Prior to First Marriage
First (This item will not be made available.)
Middle (This item will not be made available.)
Last (This item will not be made available.)
Suffix (This item will not be made available.)
SSN (This item will not be made available.)
Date of birth*
Reported age
Calculated Age
Husband's Birthplace
Country
State
Husband's Race
Unknown
White
Black or African American
American Indian or Alaska Native
American Indian or Alaska Native, specify first tribe
American Indian or Alaska Native, specify second tribe
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Laotian
Hmong
Husband
Father
Pregnancy History
Current Pregnancy
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Husband's Race
Other Asian
Other Asian 1
Other Asian 2
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other Pacific Islander 1
Other Pacific Islander 2
Other
Other Race 1
Other Race 2
Primary race
Husband's Hispanic Origin
Hispanic
Mexican
Puerto Rican
Cuban
Other
Other, specify
Husband's Education
Select best category for highest degree or level of school completed
8th grade or less
9th - 12th grade; no diploma
High school degree or GED
Some college credit, but not a degree
Associate degree
Bachelor's degree
Master's degree
Doctorate or professional degree
Husband's Employment (1 year ago)
Occupation
Type of firm
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Father's Current Legal Name
First (This item will not be made available.)
Middle (This item will not be made available.)
Last (This item will not be made available.)
Suffix (This item will not be made available.)
SSN (This item will not be made available.)
Date of birth*
Reported age
Calculated Age
Father's Birthplace
Country
State
Father's Race
Unknown
White
Black or African American
American Indian or Alaska Native
American Indian or Alaska Native, specify first tribe
American Indian or Alaska Native, specify second tribe
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Laotian
Hmong
Other Asian
Other Asian 1
Other Asian 2
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other Pacific Islander 1
Other Pacific Islander 2
Other
Other Race 1
Other Race 2
Primary race
Father's Hispanic Origin
Hispanic
Mexican
Puerto Rican
Cuban
Other
Other, specify
Father's Education
Select best category for highest degree or level of school completed
8th grade or less
9th - 12th grade; no diploma
High school degree or GED
Some college credit, but not a degree
Associate degree
Bachelor's degree
Master's degree
Doctorate or professional degree
Father's Employment (1 year ago)
Occupation
Type of firm
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Did the mother have any previous pregnancies?
Yes
No
Number of pregnancies including current pregnancy
Pregnancies ending full term, number
Pregnancies ending preterm, number
Previous Live Births
Number of previous live births now living
Number of previous live births now deceased
Month of last live birth
Year of last live birth
Other Terminations: Spontaneous or Induced
Number of all previous other pregnancy outcomes
Number of previous other pregnancy outcomes at greater than or equal to 20 weeks
Month of last other termination
Year of last other termination
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Payment
Principal source of payment for this delivery*
Medicaid/BadgerCare Plus
Private insurance
Self pay
Indian Health Service
CHAMPUS/TRICARE
Other Government (Federal, State, Local)
Other
Other, specify
Current Pregnancy
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Payment
Medicaid version
Medicaid fee-for-service (T19)
Medicaid HMO
Principal source of payment for prenatal care*
Medicaid/Badgercare Plus
Private insurance
Self pay
Indian Health Service
CHAMPUS/TRICARE
Other Government (Federal, State, Local)
Other
Other, specify
Medicaid version
Medicaid fee-for-service (T19)
Medicaid HMO
Enrolled in prenatal care coordination
Did mother get WIC food for herself during this pregnancy?
Mother's Height
Feet
Inches
Inches (calculated from reported Feet and Inches)
Mother's Weight
Prepregnancy - pounds
Prepregnancy BMI
At delivery - pounds
Weight change
Estimated Date of Delivery
Date last normal menses began
Estimated date of delivery from last menstrual period
Estimated date of delivery from ultrasound
Prenatal Care
Received prenatal care
Yes
No
Month of pregnancy prenatal care began**
Date of first prenatal care visit*
Week of pregnancy prenatal care began
Date of last prenatal care visit
Week of last prenatal visit
Total number of prenatal visits**
Group prenatal care
Yes
No
Care transferred during pregnancy (weeks)
Transfer reason
Prenatal Labs/Postpartum vaccines
Mother's blood group
O
A
B
AB
Mother's RH status
Positive
Negative
Rh Immune Globulin/Rhogam - postpartum
Yes
No
Unknown
Rubella immune
Yes
Equivocal
No
Rubella given postpartum
Yes
No
Unknown
MS-AFP
Normal
High
Low
Not done
Unknown
HIV tested**
HIV positive (This item is currently not available.)
Hepatitis B tested
Hepatitis B
Hepatitis C
Genital herpes/herpes simplex virus (HSV)
Genital warts/human papilloma virus (HPV), treated
Genital herpes/herpes simplex virus (HSV), active at delivery
Genital warts/human papilloma virus (HPV)
Genital herpes/herpes simplex virus (HSV), treated
Chlamydia
Chlamydia, treated
Gonorrhea
Gonorrhea, treated
Syphilis
Syphilis, treated
Cytomegalovirus (CMV)
Other STD
Other STD, specify
Tobacco Use
Cigarette use three months prior to pregnancy or during pregnancy
Yes
No
Cigarettes or packs
Cigarettes
Packs
Cigarettes or packs
Mother lives with smoker
Yes
No
Alcohol Use
Alcohol use during pregnancy
Yes
No
Average number of drinks per week during pregnancy
Clinical Trials
Experimental clinical trial affecting pregnancy
Current Pregnancy
Antepartum Risk Factors/Previous Pregnancies
Antenatal Risk Factors/Current Pregnancy
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Clinical Trials
Enrolled in clinical trial affecting exclusive breast milk feeding
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Previous Cesarean
Number of previous Cesareans
Previous preterm birth
Previous precipitous labor
Previous LBW (Low birth weight is defined as an infant weighing LESS THAN 2500gm (from 1500gm to 2499gm/5lb 8oz) at birth)
Previous VLBW (Very low birth weight is defined as an infant weighing LESS THAN 1500gm ( from 100gm/2lb 3oz to 1499gm/3lb 5oz) at birth)
Previous ELBW (Extremely low birth weight is defined as an infant weighing LESS THAN 1000gm/2lb 3oz at birth)
Other previous poor pregnancy outcome
Previous SGA
Previous IUGR
Previous fetal death/stillbirth
Previous macrosomia
Previous postpartum depression
Previous Preeclampsia*
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Infertility
Infertility treatment
Assisted reproduction technology
Fertility enhancing drugs
Diabetes
Prepregnancy (diagnosis prior to this pregnancy)
Insulin used
Gestational (diagnosis in this pregnancy)
Insulin used
Hypertension
Chronic hypertension in pregnancy* (This item is currently not available.)
Gestational hypertension*
Preeclampsia without severe features*
Preeclampsia WITH severe features*
Chronic HTN with superimposed preeclampsia without severe features*
Chronic HTN with superimposed preeclampsia WITH severe features*
Hypertension
Hypertensive Emergency*
Yes
No
Hypertension
Hypertensive emergency treatment within 1 hour*
Yes
No
Eclampsia
Hypertension
Eclampsia
Vital Records Hypertension
Prepregnancy (chronic)
Gestational (PIH, preeclampsia)
Obstetric History
Preterm labor this pregnancy
Preterm labor this pregnancy, treated
Incompetent cervix
Prior uterine surgery
Uterine or cervical anomaly
Prolonged preterm ROM (>24 hours)
Prolonged preterm ROM (>24 hours), treated
Hydramnios
Hydramnios, treated
Oligohydramnios
Oligohydramnios, treated
Vaginal bleeding during this pregnancy prior to onset of labor
Placenta previa this pregnancy
Multiple gestation this pregnancy
Substance use/abuse
Cocaine
Methamphetamine
Heroin
Hallucinogens
Rohypnol
Marijuana
Specify other
Infections
Bacterial vaginosis
Bacterial vaginosis, treated
Yeast
Yeast, treated
Trichomoniasis
Trichomoniasis, treated
Other vaginal infections, specify
Other vaginal infections, treated
Listeria
Parvovirus (Parvovirus B19)
Toxoplasmosis
COVID-19
COVID-19 ever diagnosed? (This item is currently not available.)
COVID-19 Diagnosis date (This item is currently not available.)
COVID-19 diagnosis during pregnancy (This item is currently not available.)
Gestational week at diagnosis (Calculated in Peridata.Net) (This item is currently not available.)
COVID-19 vaccination received (This item is currently not available.)
Type of COVID-19 vaccination received (This item is currently not available.)
Most recent COVID-19 vaccination date (This item is currently not available.)
Other infectious diseases
Other infectious diseases, specify
Maternal Conditions
Group B strep positive
Group B strep collection date
Abnormal PAP smear during pregnancy
Antenatal Risk Factors/Current Pregnancy
Antenatal Procedures
Antepartum Medications
Intrapartum Data
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Urinary tract infections this pregnancy
Urinary tract infections this pregnancy, treated
Anemia this pregnancy (HCT < 30/Hgb <10)
Hemoglobinopathy this pregnancy
Coagulation disorder
Rh sensitization
Other iso-immunization
Biliary/liver disorder
Cardiac disease
Autoimmune disease
Antiphospholipid syndrome
Specify collagen vascular disease
Asthma
Acute or chronic lung disease
Renal disorder/disease
Renal disorder/disease, specify
Renal dialysis or end stage renal disease
Thyroid disease
Cancer this pregnancy
Cancer this pregnancy, specify
Cancer treatment this pregnancy
Fetal Conditions
Decreased fetal movement
Abnormal fetal heart rate/rhythm
Suspected IUGR this pregnancy
Fetal compromise this pregnancy
Suspected Fetal CNS Anomaly
Diagnosed fetal anomaly
Specify diagnosed fetal anomaly
Fetal damage
Postterm, > 41 6/7 weeks
Maternal Characteristics
Maternal traumatic injury during this pregnancy
Domestic violence during this pregnancy
Maternal surgical procedure during this pregnancy
Other antenatal risk factors during this pregnancy
Other antenatal risk factors during this pregnancy, specify
Psychiatric Disorders
Pre-pregnancy Depression
Depression, during pregnancy
Other psychiatric disorder(s) (This item is currently not available.)
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Procedures
Antenatal Testing findings: delivery indication
Non-stress test
Result
Reactive
Non-reactive
Biophysical profile
Score
Amniocentesis this pregnancy
Reason
Genetic diagnosis
Lung maturity
Reduction of polyhydramnios
Other
Chorionic Villus Sampling (CVS)
Unstable lie at term
Failed external cephalic version this pregnancy
Successful external cephalic version this pregnancy
Cervical cerclage this pregnancy
Tocolysis this pregnancy
Percutaneous umbilical blood sampling this pregnancy
Fetal surgery
Other procedures
Hospitalization
Hospitalized antenatally this pregnancy
Inpatient pregnancy-related hospital days prior to delivery
Number of antenatal inpatient admissions excluding birth admission
Mother transferred into this facility for maternal medical or fetal indications for delivery
Name of facility mother transferred from
Name of facility mother transferred from, specified
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Prenatal vitamins (OTC and/or prescribed)
Prenatal iron
Antibiotics
Group B strep, adequacy of treatment
Antibiotics less than 4 hours prior to birth
Antibiotics more than 4 hours prior to birth
Antibiotics given but unknown time frame
Antibiotics indicated but not given
Scheduled C-section - antibiotics not indicated
Anticonvulsants
Hormones
Analgesics
Antidepressants
Psychotropics
Tocolytics prior to birth admission
Anticoagulants
Steroids for fetal lung maturity
Steroids course
Partial course
Full course
Provider (LIP)-documented reason for not initiating
Other antepartum medications
Antihypertensives
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Date of admission
Time of admission
Date labor began
Time labor began
Length labor
In labor on admission
2 or more contractions every 10 minutes on admission
Cervical dilation of 3 cm or more on admission
Events of labor and/or delivery
Placenta previa (labor and delivery)
Vasa previa
Intrapartum Data
Intrapartum Medications
Intrapartum Procedures
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Prolonged latent phase
Prolonged active phase
Arrested in active phase
Precipitous labor (< 3 hours)
Prolonged labor (20 hours or more)
Dysfunctional labor
Cephalopelvic disproportion
Shoulder dystocia
Fetal intolerance of labor
Moderate/heavy meconium staining of the amniotic fluid
Premature rupture of the membranes less than 12 hours prior to the onset of labor
Premature rupture of the membranes greater than or equal to 12 hours prior to the onset of labor
PROM length of time
Premature/Prolonged 12-17 hours
Premature/Prolonged 18-23 hours
Premature/Prolonged 24 hours or more
Clinical chorioamnionitis
Febrile
Seizures
Nuchal cord
True knot in cord
Cord prolapse
Abruptio placenta
Abnormal/excessive bleeding
Ruptured uterus
Ruptured uterus timing
Prior to labor onset
After labor onset or during delivery
Unspecified
HELLP Syndrome
Uterine atony
Retained placenta
Placenta accreta/percreta
Inverted uterus
Anesthetic complications
Other intrapartum complications
Other intrapartum complications, specify
Blood Loss/Hemorrhage
Uterine Bleeding
Blood Loss
Obstetric hemorrhage (multi-select)
Antepartum (prelabor)
Intrapartum (labor to <2hrs post-delivery)
Postpartum (>2hrs post-delivery)
Maternal transfusion
4 or more units transfused
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Hypertension/Preeclampsia Management
Antiplatelet agent
Aspirin
Yes pregnancy only
Yes pregnancy and postpartum
Unknown
Antihypertensive agents
Hydralazine
Pregnancy only
Pregnancy & postpartum
Labetalol
Pregnancy only
Pregnancy & postpartum
Methyldopa
Pregnancy only
Pregnancy & postpartum
Nifedipine
Pregnancy only
Pregnancy & postpartum
Seizure prophylaxis or control
Magnesium sulfate
Pregnancy only
Pregnancy & postpartum
Seizure prophylaxis or control
Postpartum therapy length
<24 hours of therapy
>=24 hours of therapy
Seizure prophylaxis or control
Analgesia
Analgesia, specify
Antihypertensives
Tocolytics during birth admission
Magnesium sulfate
Tocolysis
Neuroprotection
Antibiotics
Other
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Anesthesia
General
Epidural
Epidural, type
Labor with vaginal delivery
Labor with C-section
C-section only
Spinal
Pudendal
Paracervical
Local
Other, specify
Vital Records Anesthesia
Anesthesia (epidural or spinal)
Labor
Induction
Cervical ripening
Method/agent for cervical ripening
Prostaglandin - misoprostol
Prostaglandin - dinoprostone
Prostaglandin - other
Balloon Catheter
Membrane Stripping
Laminaria
Other
Unknown
Method/agent for cervical ripening 6
Method/agent for cervical ripening 7
Method/agent for cervical ripening 8
Induction by oxytocin/pitocin
Induction by AROM
Bishop Score
Augmentation
Augmentation by AROM
Augmentation by Oxytocin/pitocin
Membranes
Spontaneous rupture
Intrapartum Procedures
Attendant
Delivery
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Spontaneous rupture onset
Prior to the initiation of induction
After the initiation of induction
Unknown
Fluid
Clear
Meconium stained
Bloody
No fluid
Monitoring
External auscultation
Electronic fetal internal
Electronic fetal external
Uterine contraction, internal
Uterine contraction, external
Fetal pulse oximetry
Fetal scalp sampling
Ultrasound (during labor and delivery only)
Other Perinatal Procedures
Amnioinfusion
Hysterotomy/Hysterectomy
Postpartum sterilization
Maternal admission to ICU
Maternal transfusion
4 or more units transfused?
Unplanned operating room procedure following delivery
Unplanned hysterectomy
Water birth
Intrapartum procedures - other
Intrapartum procedures - other, specify
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Primary Provider Information
Primary obstetric provider, other
Primary pediatric provider, other
Attendant
Attendant first name
Attendant last name
Attendant title
MD
DO
CNM
Licensed Midwife
Other Midwife
Other
Attendant title, other
Wisconsin License number
Resident attendant 1, other
Resident attendant 2, other
Resident attendant 3, other
Student attendant, other
Nurse attendant 1, other
Nurse attendant 2, other
Pediatric attendant, other
Additional attendant 1, other
Additional attendant 2, other
Anesthesiologist/Anesthetist, other
Anesthesia resident, other
Neonatologist, other
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Number of fetuses delivered (plurality)
Number of fetal deaths in this delivery
Number of infants delivered alive
Birth order
Multiple Birth ID (This item will not be made available. This can be determined by the last digit in I_HOSP_REC and I_REC_NO.)
Presentation
Fetal presentation
Cephalic
Breech
other
Non-vertex presentation
Fetal presentation, specify
Other malpresentation
Compound
Shoulder/transverse lie
Chin
Brow
Face
Malpresentation, other
Method
Planned Cesarean
Forceps attempted but unsuccessful
Vacuum attempted but unsuccessful
Final route and method of delivery
Vaginal Spontaneous
Vaginal Forceps
Vaginal Vacuum
Cesarean
Breech extraction
Method: Vaginal
VBAC
Forceps applied
Low
Mid
Method: Cesarean
Type
Primary C-section
Repeat C-section
Uterine incision
Transverse
Vertical
Classical
Cesarean with forceps
Vacuum-assisted Cesarean
Trial of labor attempted
In labor prior to cesarean
Operative delivery indications
Trial of labor refused/maternal choice
Cephalopelvic disproportion
Dystocia
Malpresentation
Fetal intolerance of labor
Failure to progress
Failure to descend
Malposition
Labor not medically indicated due to fetal indication
Delivery
Maternal Postpartum Complications
Nursery Care
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Operative delivery indications
Labor not medically indicated due to maternal indication
Other, specify
Placenta
Grade, if available from US report
Suspected chorioamnionitis
Velamentous insertion
Sent to pathology
Blood Loss
Blood Loss
Laceration
Perineal
First or second degree
Third degree
Fourth degree
No
Perineal (3rd or 4th degree)
Other
Labial
Periurethral
Sulcus
Vaginal
Cervical
None
Other, specify
Episiotomy
Episiotomy
Midline
Mediolateral
Paramedian (combined or hockey stick)
None
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Mortality
Maternal death
Date
Time
Postpartum Hypertension
New Onset Postpartum Hypertension
Postpartum onset preeclampsia without severe features*
Postpartum onset preeclampsia WITH severe features*
Chronic HTN with postpartum onset superimposed preeclampsia without severe features*
Chronic HTN with postpartum onset superimposed preeclampsia WITH severe features*
Postpartum onset gestational hypertension*
Chronic HTN with superimposed preeclampsia WITH severe features* (This item is currently not available.)
Antihypertensive agents
Hydralazine
Yes, postpartum only
Labetalol
Yes, postpartum only
Methyldopa
Yes, postpartum only
Nifedipine
Yes, postpartum only
Seizure prophylaxis or control
Magnesium sulfate
Yes, postpartum only
Postpartum therapy length
<24 hours of therapy
>=24 hours of therapy
Morbidity
Wound infection
Mastitis
Endomitritis
Antibiotics
Yes, <24 hrs post delivery
Yes, >24 hrs post delivery
No
Unknown
Thromboembolic disease
Thromboembolic, specify
Anemia with transfusion
Anemia with iron supplement
HCT < 22.0 or hemoglobin < 7.0
Drop in HCT>11 or Hemoglobin>3.5
UTI
Depression
Other postpartum complications
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NICU Admission
NICU admission
NICU admission date
NICU care options
Mother-baby care, then transferred to high risk nursery/NICU
High risk nursery/NICU directly from labor/delivery
High risk nursery/NICU then transferred to mother-baby care
Newborn nursery care options
Normal newborn nursery/Mother-baby care
Transitional observation
Palliative care
Infant External Transfer
Transferred to another facility within 24 hours of delivery
Transferred to another facility after 24 hours of delivery
Facility
Facility name
Facility city
Facility county
Facility state
Facility country
Date
Inborn/Outborn
Birth Outcome
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Gestational Age
By LMP (weeks)
By ultrasound (weeks)
OB clinician's final estimate (weeks)
OB clinician's final estimate (days)
Newborn assessment
OB clinician's final estimate (calculated from reported weeks and days)
Birth Weight
Pounds
Ounces
Grams
Grams (Calculated from reported Pounds and Ounces)
Size for Gestational Age
Size for gestational age
AGA
SGA
LGA
Crown Heel Length
Inches
Centimeters
Centimeters (Calculated from reported Inches and Centimeters)
Head Circumference
Inches
Centimeters
Centimeters (Calculated from reported Inches and Centimeters)
APGAR
1 Minute
5 Minute
10 Minute
Neonatal Procedures
Other Postpartum or Neonatal Information
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Assisted ventilation required
Assisted ventilation required immediately after delivery
Assisted ventilation required for more than 6 hours
Surfactant
Antibiotics for neonatal sepsis
Cardiorespiratory Conditions
Treatments and procedures for cardiorespiratory conditions (This item is currently not available.)
Assisted Ventilation required for less than 30 minutes
Ventilator (This item is currently not available.)
CPAP (This item is currently not available.)
Assisted ventilation intermittent positive (This item is currently not available.)
Assisted ventilation continuous negative (This item is currently not available.)
Assisted ventilation intermittent negative pressure (This item is currently not available.)
Hyperbaric, intermittent or continuous (This item is currently not available.)
Laryngoscopy
Oxygen
Nitric Oxide (This item is currently not available.)
ECMO (This item is currently not available.)
Thoracentesis or chest tube (This item is currently not available.)
Imaging Procedures
Yes (This item is currently not available.)
CT of brain, head, and/or neck (This item is currently not available.)
MRI brain and/or spinal cord (This item is currently not available.)
GI/GU Procedures
Yes (This item is currently not available.)
TPN/Intralipid
PEG tube or G tube (This item is currently not available.)
Procedures for Infectious Process
Yes (This item is currently not available.)
GBS observation
GBS treated
Hematologic/metabolic Procedures
Yes (This item is currently not available.)
Hematologic/Metabolic (This item is currently not available.)
Phototherapy
Glucose gel for hypoglycemia
IV for hypoglycemia
Transfusions
Neurological Conditions
Yes (This item is currently not available.)
EEG (This item is currently not available.)
Cooling Protocol (This item is currently not available.)
Anticonvulsants
Vascular Access Lines
Yes (This item is currently not available.)
Umbilical arterial catheter (UAC) (This item is currently not available.)
Umbilical venous catheter (UVC) (This item is currently not available.)
PVCL or PICC line (This item is currently not available.)
Peripheral arterial line (This item is currently not available.)
Surgical Procedures
Yes
Specify
Circumcision
Other Procedures
Other neonatal procedures
Other neonatal procedures, specify
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Feeding - all infants
Maternal plan on admission for feeding IN HOSPITAL
Breast milk
Breast milk and formula
Formula
Unknown
Maternal or newborn indications for NOT breast milk feeding
Yes and documented in the newborn record
None
Unable to determine from newborn documentation
Galactosemia
Breast milk at discharge
Was donor milk used during hospitalization (This item is currently not available.)
Other Postpartum or Neonatal Information
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Breast milk level at discharge
Exclusive
Non-exclusive due to provider decision to supplement
Non-exclusive due to maternal decision
Non-exclusive for unknown reasons
Unknown
*NICU feeding - 28 days Infant in NICU at 28 days of life*
Infant in NICU at 28 days of life*
Any breast milk feeding during 28th day of life*
Yes
No - formula
No - NPO
Unknown
*NICU feeding - discharge
Type of breast milk feeding*
Mother's breast milk
Combination Mother's and donor breast milk
Donor breast milk
Unknown
*NICU feeding - general
Enteral feeding at discharge* (This item is currently not available.)
Human milk only
Human milk with either formula or fortifier
Formula only
None/NPO
*NICU feeding - general
Initiation of breast milk in the NICU*
Yes
No
Not Applicable
Unknown
*NICU feeding - general
Breast milk level at 28 days of life
Exclusive
Non-exclusive due to provider decision to supplement
Non-exclusive due to maternal decision
Non-exclusive for unknown reasons
Not applicable
None
Unknown
*Skin-to-Skin with Infant
Skin-to-Skin initiation after birth*
Yes, immediately after birth
Yes, but not immediately after birth
No
Unknown
Reason for separation relative to interacting with infant*
Infant not medically stable
Mother not medically stable
Maternal refusal or no interest
Not offered by clinicians
Unknown
Skin to Skin Duration*
60 mins or more
45-59 mins
30-44 mins
Under 30 mins
Unknown
NB Procedures and assessments done skin-to-skin*
Mother/Baby Interaction
Rooming in at least 23 hours per day*
Reason for not rooming in*
Diminished responsiveness to infant cues
Remained together during day but not rooming in at night
Medical Reason - maternal
Medical Reason - infant
Maternal refusal
Unknown
Maternal/newborn separation*
Maternal pumping or manual expression*
Yes
No, but plans to breastfeed
No, plans to formula feed
Unknown
Timing of first pump or expression after separation*
<= 2 hours
3 - 4 hours
5 - 6 hours
7 or more hours
Unknown
Other Information
Hepatitis B vaccine administered - infant
Hepatitis B vaccine administered date - infant
Hepatitis B vaccine administered time - infant
Hepatitis B lot number-infant
Reason Hepatitis B vaccine not given
Parental Refusal
Provider Preference
Unknown
Hepatitis B lot number-infant
HBIG-infant
HBIG administered date - infant
HBIG administered time - infant
HIV tested - infant
COVID tested - infant (This item is currently not available.)
COVID positive - infant (This item is currently not available.)
Toxicology
Tox sceen-infant
Tox screen results-infant
Positive
Negative
IF positive,
Amphetamines
Barbituates
Cocaine
Marijuana
Opiates
Other substances
Abnormal Conditions of the Newborn
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Seizure or serious neurologic dysfunction
Other serious neurological dysfunction
Significant birth injury
Specify birth injury
Respiratory
Respiratory (This item is currently not available.)
Apnea
Aspiration, not meconium (This item is currently not available.)
Atelectasis (This item is currently not available.)
Interstitial emphysema (This item is currently not available.)
Meconium aspiration syndrome
Pneumomediastinum (This item is currently not available.)
Pneumonia (This item is currently not available.)
Pneumopericardium (This item is currently not available.)
Pneumothorax (This item is currently not available.)
Respiratory arrest or failure (This item is currently not available.)
Respiratory Distress Syndrome (RDS)/Hyaline membrane disease
Respiratory hemorrhage (includes airway, tracheal, bronchial and pulmonary) (This item is currently not available.)
Transient tachypnea (TTN)
Cardiac/Hemodynamic
Cardiac/Hemodynamic (This item is currently not available.)
Cardiac arrest (This item is currently not available.)
Cardiac failure (This item is currently not available.)
Myocardial ischemia (This item is currently not available.)
Shock (This item is currently not available.)
GI/GU/Internal organs
GI/GU/Internal organs
Acute kidney failure (This item is currently not available.)
Necrotizing enterocolitis (NEC)
Solid organ injury
Solid organ injury (This item is currently not available.)
Infectious process
Infectious process (This item is currently not available.)
Bacteremia (This item is currently not available.)
Sepsis -GBS (This item is currently not available.)
Sepsis - Other organisms (This item is currently not available.)
Septic shock (This item is currently not available.)
Hematologic/Metabolic
Hematologic/Metabolic (This item is currently not available.)
Anemia
DIC (This item is currently not available.)
Hemolytic disease
Specify hemolytic disease
Hypoglycemia
Isoimmunization (This item is currently not available.)
Jaundice (hyperbilirubinemia)
Highest bilirubin value in mg/dL
Neurologic/brain/nerves
Neurologic/brain/nerves (This item is currently not available.)
Intraventricular hemorrhage (IVH) - nontraumatic (This item is currently not available.)
Intraventricular hemorrhage (IVH) - traumatic (This item is currently not available.)
Intracranial hemorrhage (ICH) - nontraumatic (This item is currently not available.)
Soft tissue hemorrhage - head (This item is currently not available.)
Traumatic brain hemorrhage or injury (This item is currently not available.)
Asphyxia or hypoxemia (This item is currently not available.)
Neonatal Encephalopathy
Seizures
Central and peripheral nervous system injury (This item is currently not available.)
Musculoskeletal or skin
Musculoskeletal or skin (This item is currently not available.)
Skeletal fracture (This item is currently not available.)
Clavical(s) fracture (This item is currently not available.)
Extensive ecchymosis (bruising) (This item is currently not available.)
Umbilical hemorrhage (This item is currently not available.)
Other
Other
Specify other
External Trauma
External trauma
No
Antenatal
Postnatal
Unknown
External Trauma
Specify external birth trauma
Infection
Specify infection
Newborn withdrawal syndrome
Neonatal Abstinence Syndrome/Neonatal Withdrawal Syndrome*
Infant at risk for NAS/NOWS
Infant with NAS/NOWS
Basis of NAS Diagnosis*
Maternal History*
AODA screening
PDMP
Biological testing
Other mental health issues
Source of maternal substance*
Supervise prescribed replacement therapy
Supervised prescribed pain therapy
Prescribed for psychiatric or neurological condition
Prescription substance obtained without prescription
Non-prescription substance
Unknown
Infant clinical signs of NAS/NOWS*
Screening tool completed*
Screening tool used*
Finnegan
Lipsitz
Other, specify
Confirmatory test for opioids positive*
Abnormal Conditions of the Newborn
Congenital Anomalies of the Newborn
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Treatment
NAS/NOWS Treatment
Feeding type
Breastfeeding / breast milk
Formula
Specialty formula
Formula and breast milk
Behavioral and environmental management*
Date Started
Time Started
Level of care within the facility at initiation
Level I (mom/baby care)
Level II (special care nursery)
Level III (NICU)
Level IV (NICU)
Pharmacological treatment*
Date Started
Time Started
Date Ended
Time Ended
Duration of pharmacological treatment(in days)
Length of NAS pharmacological treatment
Medications used for NAS treatment* (Select all that apply)
Morphine sulfate
Methadone
Phenolbarbital
Clonindine
Other
Other, specify
Level of care within the facility
Level I (mom/baby care)
Level II (special care nursery)
Level III (NICU)
Level IV (NICU)
Protocol
Standardized protocol used
Yes
No
Reason Standardized Protocol not used
Infant ineligible
Provider preference
No protocol adopted
Other
Iatrogenic*
Diagnoses with potential for state dysregulation independent of perinatal substance exposure*
No
Seizure disorder documented on EEG
Stroke or intracranial hemorrhage
Major CNS malformation
Other
Diagnoses or procedures requiring protracted sedation and/or analgesia
Yes
No
Total days prescribed
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Any Central Nervous System Anomaly
Anencephalus
Meningomyelocele
Spina bifida
Hydrocephalus
Microcephalus
Other central nervous system anomalies
Other central nervous system anomalies, specify
Meningomyelocele/Spina bifida
Any Circulatory/ Respiratory System Anomaly
Cyanotic congenital heart disease
Acyanotic congenital heart disease
Other heart malformations
Other circulatory/respiratory anomalies
Other circulatory/respiratory anomalies, specify
Any Gastrointestinal Anomaly
Rectal atresia/stenosis
Tracheo-esophageal fistula/esophageal atresia
Omphalocele
Gastroschisis
Other gastrointestinal anomalies
Other gastrointestinal anomalies, specify
Any Urogenital Anomaly
Malformed genitalia
Renal agenesis
Hypospadius
Other urogenital anomalies
Other urogenital anomalies, specify
Any Musculoskeletal/Integumentary Anomaly
Cleft lip with or without cleft palate
Cleft lip alone
Cleft palate alone
Polydactyly/Syndactyly/Adactyly
Club foot
Limb reduction defect
Diaphragmatic hernia
c
Other musculoskeletal/ Integumentary anomaly, specify
Chromosomal
Any Chromosomal Anomaly
Down syndrome
Down karyotype pending
Down karyotype confirmed
Congenital Anomalies of the Newborn
Maternal Discharge
Infant Discharge
Perinatal Mortality
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Suspected chromosomal disorder
Suspected chromosomal disorder, karyotype pending
Suspected chromosomal disorder, karyotype confirmed
Suspected chromosomal disorder, specify
Autosomal recessive polycystic kidney disease
Lethal chromosomal anomalies
Other chromosomal anomalies
Other chromosomal anomalies, specify
Other congenital anomalies
Other congenital anomalies, specify
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Type of discharge*
Home
Death
Transferred to other facility
Date
Time
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Discharged with mother
Not discharged at time birth certificate filed
Discharge destination*
Home
Foster care
Acute care facility
Other
Discharge destination, Other, specify
Infant Discharge Pending (This item is currently not available.)
Date of discharge*
Time of discharge*
Feeding type at discharge*
Breastfeeding/breast milk
Formula
Specialty formula
Formula and breast milk
Home medications prescribed*
None
Morphine
Methadone
Phenolbarbital
Clonidine
Other
Other, specify
Other 2
Other 3
Other 4
Other 5
Developmental follow-up referral
Yes
No
NA - transferred to another facility for a higher level of care
Public health referral
Public health referral
Newborn blood screen number
Hearing Screening
Newborn hearing screening performed
Date
Left ear
Pass
Fail
Right ear
Pass
Fail
Reason not screened
Broken appointment
Could not test
Missed
Refused
Infant medically ineligible
Invalid
Deceased
Transferred
Scheduled
Incomplete
No information
Reason not screened, other
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Date of death
Time of death
Estimated time of fetal death
Dead at time of first assessment, no labor ongoing
Dead at time of first assessment, labor ongoing
Died during labor, after first assessment
Died during delivery
Unknown time of fetal death
Autopsy
Placental exam performed
Initiating cause/condition of fetal death
Initiating cause/condition of fetal death
Pending
Rupture of membranes prior to onset of labor
Abruptio placenta
Placental insufficiency
Prolapsed cord
Chorioamniotitis
Other complications of placenta, cord, or membranes
Other complications of placenta, cord, or membrane, specify
Maternal conditions or disease, specify
Other obstetrical or pregnancy complications, specify
Fetal anomaly, specify
Fetal injury, specify
Fetal infection, specify
Other fetal conditions or diseases, specify
Unknown time of fetal death (This item is currently not available.)
Rupture of membranes prior to onset of labor
Abruptio Placenta
Placental Insufficiency
Prolapsed Cord
Chorioamniotitis
Perinatal Mortality
Other Calculated Variables
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Other complications of placenta, cord, or membrane
Other complications of placenta, cord, or membrane, specify
Maternal diseases/conditions
Maternal diseases/conditions, specify
Other obstetrical or pregnancy complications
Other obstetrical or pregnancy complications, specify
Fetal anomaly
Fetal anomaly, specify
Fetal injury
Fetal injury, specify
Fetal infection
Fetal infection, specify
Other fetal conditions/disorders
Other fetal conditions/disorders, specify
Disposition of the Fetus
Method of disposition
Burial
Cremation
Hospital Disposition
Donation
Other
Removal from state
Other
Name of disposing facility
Address of facility disposing of remains (street address, city, state, ZIP code)
City, Village, or Township of Facility Disposing of Remains
State of Facility Disposing of Remains
Zip Code of Facility Disposing of Remains
Cause of Infant Death
Immediate cause of death
Asphyxia
Blood group incompatibility
Congenital anomaly
Immaturity
Infection
IUGR
Metabolic disorder
RDS
Trauma
Other
Other
Source
Fetal cause
Maternal cause
Contributing cause of death 1
Source
Fetal cause
Maternal cause
Contributing cause of death 2
Source
Fetal cause
Maternal cause
Group responsible for disposition
Funeral home
Family
Coroner/Medical examiner removal
Hospital
Funeral home of disposition
Funeral home of disposition city
Funeral home of disposition phone number
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Mother Length of Stay
Length of Stay
Mother postpartum days
Mother-midnights
Mother-days
Mother postpartum hours
Infant Length of Stay
Length of Stay
EGA adjusted estimate of LOS attributable to prematurity for infants < 37 weeks EGA at birth
Non-NAS Length of Stay
EGA adjusted estimate of LOS attributable to prematurity for infants < 37 weeks EGA at birth
Identifiers
Mother identifier
Infant Hospital Record
Infant Record Number
Unique father identifier (This item is not available.)
Unique husband identifier (This item is not available.)
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