Multiple Birth Delivery Record Form
Use this form to document a delivery involving multiple newborns, including maternal delivery details and a separate record for each baby.
Mother and Delivery Identification
Mother's Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record Number
Delivery Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Hospital or Clinic Name
*
Attending Obstetric Provider Name
*
First Name
Middle Name
Last Name
Delivery Location / Unit
*
Please Select
Labor and Delivery
Operating Room
Postpartum Unit
Emergency Department
Other
Pregnancy and Labor Details
Gestational Age at Delivery (weeks)
*
Gravida
*
Parity
*
Plurality Confirmed
*
Singleton
Twins
Triplets
Quadruplets
Quintuplets or more
Labor Onset Type
*
Please Select
Spontaneous
Induced
Augmented
Cesarean
Other
Membranes Status
*
Please Select
Intact
Ruptured
Artificial rupture
Unknown
Time of Membrane Rupture
Hour Minutes
AM
PM
AM/PM Option
Major Pregnancy or Labor Complications
Preterm labor
Preeclampsia
Gestational diabetes
Placenta previa
Placental abruption
Fetal distress
Postpartum hemorrhage
Infection
Malpresentation
Other
Newborn Record - Baby A
Sex
*
Male
Female
Intersex
Unknown
Birth Weight (g)
*
Length (cm)
Head Circumference (cm)
Apgar Score at 1 Minute
Apgar Score at 5 Minutes
Delivery Outcome / Status
*
Please Select
Live born
Stillborn
Transferred
Deceased shortly after birth
Unknown
Immediate Resuscitation / Intervention Details
Newborn Record - Baby B and Additional Infants
Baby B Sex
*
Male
Female
Intersex
Undetermined
Baby B Birth Weight (g)
*
Baby B Length (cm)
Baby B Head Circumference (cm)
Baby B Apgar Score at 1 Minute
Baby B Apgar Score at 5 Minutes
Baby B Outcome / Status
*
Please Select
Live birth
Stillbirth
Transferred
Deceased
Unknown
Baby B Resuscitation / Intervention Details
Additional Infant(s) Included
Baby C
Baby D
Baby E
Baby F
Other infant(s)
Additional Infant Records
Post-Delivery Notes and Disposition
Placenta and cord notes
Estimated blood loss (mL)
Maternal postpartum condition
Please Select
Stable
Requires observation
Transferred to higher level of care
Other
Newborn disposition - Baby A
Please Select
Rooming-in
NICU
Transferred
Discharged with mother
Other
Newborn disposition - Baby B
Please Select
Rooming-in
NICU
Transferred
Discharged with mother
Other
Clinician signature
Submit Record
Submit Record
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