Date of Birth:
D01
Time:
D02
Plurality
 Single delivery
D04
 Multiple birth
D03
No.:

D07Male
D05
 Live born D17
 Stillborn/miscarriage
Transferred to neonatal unit:
D – About the child


during labour
D20
 Time of death unknown
Transferred to (name
of unit):
 Yes
NoD27
D12
Head circumference:
D11
Live birth, died within 24
hours

before arrival
D22
 Dead after arrival
D21 Dead
D30
Date: D29
Life lasted:
Hours: D23

problems
D32
 Pre-mature
D33
 Birth defects
D31Respiratory
Neonatal diagnoses:
D37
D40
D44
 Hypoglyco. (<2 mmol/l)
 Transit. tachypnea
 Cerebral irritation
(To be completed by
D38
D41
D45
physician / pediatrician)  Cong.anaemia (Hb<13.5 g/dl)  Resp. distress syndrome  Cerebral depression

D36

D39 Hip
None
joint dysplasia treated
with pillow
 Fract. claviculae
D53
 Other fracture
D54
 Facial paresis
D55
 Plexus injury
D52
Signs of birth defects:
 No  Yes
D65
Record no:
D68 / D69

syndrome
D43
 Intracranial hemorrhage
D42 Aspiration
Treatment codes:
 Systematic antibiotics
D57
 Respiratory treatment
D58
 CPAP treatment
D56
Buttocks-vertex
length:

D47
 Neonatal fits
D46 Abstinence
Icterus, treated:

treatment
D60
 Transfusion
D59 Light
Maternity ward / Pediatric ward:

infections
D35
 Other, specify
D34 Perinatal

treated
D49
 Navel/dermal infection treated
D50
 Perinatal infections, bacterial
D51
 Perinatal infections, other
D48 Conjunctivitis
Icterus, cause:

incompatible
D62
 RH immunization
D63
 Physiological
D64
 Other cause
D61 ABO
Autorisert MBRN-part-D 12/02/2016
Discharged date:
Mother:
D70
Date: D25
Time:D26
D67
Physician:
Died later:
Mins.: D24
Specification of injuries, neonatal diagnose
s and birth defects – to be completed by physician:
D
5 min: D15
D13
For stillborn, note also:
Indication for transfer:
Apgar score:
Total length:
1 min: D14
For stillborn:  Uncertain sex
D19 Died
Specify cause of death in “D”
D10
D09
For stillborn: D18
 Died before labour
D16

D08 Female
If uncertain, specify in ”D”
Of total: D06
The child was:
Child’s weight:
Sex
For multiple
birth:
Child:
D71
Autorisert MBRN-part-D 12/02/2016