Database on Newborn Health and Birth Defects
Center Name
Baby’s Hospital Record No.
Birth Defects (BD) Form
Mother’s Hospital Record No.
NNPD Number
1
2
3
4
5
6
7
8
9
Birth Defects
1.
Basic information:
Mother’s Name
Date of Delivery *
Time of Delivery (24 hr format)
Mother’s Age (Years Completed)
Father’s Age (Years Completed)
Parental consanguinity *
Baby’s Gender *
i.
ii.
iii.
iv.
v.
vi.
d
m
h
Y/N
Male
vii.
viii.
Birth weight (g)
ix.
Head Circumference
x.
Mode of delivery *
xi.
Multiple birth
xii.
Gestation
xiii.
Delivery attended by
xiv.
Outcome
xv.
Autopsy (in case of still birth) *
2. History of birth Defects:
m
y
y
h
/
Female
y
m
/
y
m
Ambiguous
cm
Vaginal
/
Cesarean section
/
Single / Twin / Triplet / Higher order
(in weeks)
Instrumental
Doctor / Nurse / ANM / Midwife
Alive / Died / Still Birth – Fresh/ Still Birth – Macerated
Y / N
i.
Previous termination of pregnancy for malformation
ii.
Previous Still birth
iii.
Previous spontaneous abortion(s)
3.
d
Y / N
Y/N
If Yes, Please describe
Yes; if any birth defect found
Y/N
Y/N
Type of birth defect(s):
S/N
Type of Birth Defect
Full description
Code
ICD-10
C or P #
i.
ii.
iii.
iv.
v.
4.
Additional information/investigation if any
5.
Photographs taken
Y / N
Name of the professional completed the physical form
Date:
# C = Confirmed, P = Possible
* Mandatory Fields
Supported by WHO-SEARO and CDC Atlanta
Attach Photo (if yes selected)
Physician / Nurse / Other