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SECTION 1 - PATIENT PARTICULARS 1. Name of patient:
2. RN: RN at participating hospital. If the baby dies in Labour room and has no RN,
then use the mother’s RN.
3. Mother’s IC number: New IC Passport No. 4. Date of Birth: ddmmyy
5. Time of Birth: Time entered as 24 hrs clock or ampm delete as relevant 6. Ethnic group: MalayChineseIndianOrang AsliBumiputra SabahBumiputra
SarawakForeignerOther Malaysian: If Bumiputra Sabah or Bumiputra Sarawak please specify the indigenous group. In the case of mixed marriages, ethnic group
of the baby is defined by the ethnic group of the mother.
7. Maternal Age: Age in completed years. 8. GPA: G__P__A of current pregnancy before delivery of this child
9. Marital status: marrieddivorcedwidowedsingle
SECTION 2 – BIRTH HISTORY 10. Antenatal Steroid: If “yes” a State number of doses given and b Interval of 1
st
dose to delivery – to tick 12hrs or 12hrs
11. Intrapartum Antibiotics: Includes both oral and parenteral antibiotics given in the
intrapartum period. Antibiotics mean antibacterial treatment
12. Birth weight grams: Baby’s body weight in grams to the nearest 1 gram 13. Gestation weeks: If 1
st
trimester gestational assessment was done by ultrasound this is the most reliable gestational assessment. If no ultrasound was done and the
mother is sure of her dates, these should be taken as correct unless there is a strong reason to suspect otherwise. If the dates are unsure or there is a strong reason to
suspect inaccuracy in the dates then the results of the neonatal gestational assessment by the new Ballard score should be used.
14. Growth status: based on Lubchenco charts. SGA10
th
centile; AGA 10-90
th
centile; LGA 90the centile. Appendix 1
15. Gender: Indicate Male, Female or Indeterminate
16. Baby Status: Inborn- born in the same hospital as the participating site. If born
within the wards of the participating hospital to be considered as inborn unless in the ambulance – born before arrival
Outborn: Born in another place includes BBA and transferred after birth to the NNU of the participating site. Include those born in the hospital compound.
To specify the referring center if relevant.
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17. Place of birth: 1. University Hospital
2. General Hospital 3. Private Hospital
4. District Hospital with specialist 5. District Hospital without specialist
6. Private Maternity Home 7. Home
8. Others e.g. In transit, please specify
All big city government hospitals are considered as General hospitals and ticked as 2.
District hospitals with specialist pertain to availability of specialist post even if this post is not filled.
18. Multiplicity: To indicate as singleton, twin, triplet or others ie quadruplets, etc. 19. Mode of delivery: Tick as relevant. Rarely more than 1 may apply. If LSCS,
indicate if its elective or emergency.
20. CRIB score: Apply scoring sheet Appendix 2 for all babies 1500 gm and below,
add up the scores and state the total score. Indicate NA if unable to score SECTION 3 – NEONATAL EVENTS
21. Ventilatory support: If given to tick what type of support was given.
1. CPAP -- Any continuous positive airway pressure administered to the baby by any means
2. IMV – Intermittent Mandatory Ventilation given via a mechanical ventilator. Excluded manual hand bagging during resuscitation at birth.
3. IMV+PTV – Patient – triggered ventilation is inclusive of synchronized mandatory ventilation SIMV and other Assist-Control modes
4. HFPPV – High frequency positive pressure ventilation of rate 120min 5. HFOV – High frequency oscillatory ventilation as delivered by an oscillator.
6. Nitric Oxide – Gas used as a pulmonary vasodilator and administered via a
ventilator 7. Others may include High Frequency Jet Ventilation HFJV or Liquid
ventilation Oxygen hoodhead-box therapy and incubator oxygen therapy are not included as
ventilatory support.
22. Total Duration of Ventilatory support: Inclusive of CPAP even if on air CPAP.
