| Document Date: 2014-06-20 09:52:25
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Facility Facility Worksheet / / MedicalCondition Congenital heart defects / Omphalocele / complete breech / craniorachischisis / _____Hypospadias / congenital heart disease / Spina bifida / Suspected chromosomal disorder / Meningomyelocele / serious neurologic dysfunction / umbilical hernia / coma / preterm birth / gastroschisis / Spina bifida occulta / diaphragmatic hernia / _____Anencephaly / acrania / fever / transient facial nerve palsy / _____Meningomyelocele/Spina bifida / lethargy / Seizure / fetal tachycardia / tricuspid atresia / leukocytosis / pain / stupor / Cleft Palate / injury / Meningocele / surfactant deficiency / Also called exomphalos / anomalous pulmonary venous return / Fetal Death / peripheral nerve injury / hypotonia / Trisomy 21 / Cleft Lip / herniation of meninges / hypoxic-ischemic encephalopathy / neurologic findings / Also called anencephalus / Significant birth injury / chorioamnionitis / anencephaly / anemia / Disorders / ____Clinical chorioamnionitis / respiratory distress / Down Syndrome / suspected neonatal sepsis / hypotension / / MedicalTreatment incision / hysterectomy / Antibiotics / acoustic stimulation / amputation / surfactant replacement therapy / mechanical ventilation / / MusicGroup Was / Yes / None of the above / / Organization US Federal Reserve / / Person Specify / / Position fetal head / / Product Penicillin / dexamethasone / Gentamicin / Ampicillin / Erythromycin / hydrocortisone / Ceftriaxone / /
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Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births This attachment is to be completed when at least two infants in a multiple pregnancy are born alive. Complete a full worksheet for t