Birth Asphyxia Diagnostic Evaluation Form
Use this form to document the key clinical details, findings, and follow-up plan for a birth asphyxia diagnostic evaluation.
Perinatal and Delivery Context
Delivery Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Gestational Age at Birth (weeks)
*
Place of Birth
*
Delivery Type
*
Vaginal
Assisted vaginal
Cesarean
Unknown
Intrapartum Complications
Prolonged labor
Cord complication
Meconium-stained fluid
Maternal fever
Fetal distress
Premature rupture of membranes
None
Other
Neonatal Condition at Birth
Apgar Score at 1 Minute
*
Apgar Score at 5 Minutes
*
Need for Resuscitation at Birth
*
None
Stimulation only
Oxygen
Bag-mask ventilation
Intubation/advanced support
Unknown
Initial Breathing Status
*
Spontaneous breathing
Gasping/irregular breathing
Apnea
Unknown
Birth Weight or Estimated Neonatal Weight (g)
Diagnostic Findings and Clinical Assessment
Signs Observed After Birth
*
Poor tone
Weak cry
Low activity
Seizures
Respiratory distress
Altered consciousness
Feeding difficulty
Other
Neurologic Exam Summary
Laboratory or Imaging Findings
Clinician Assessment of Severity
*
Mild
Moderate
Severe
Inconclusive
Outcome and Follow-Up Plan
Current Neonatal Status
*
Stable
NICU Admission
Ongoing Monitoring
Transferred
Discharged
Deceased
Unknown
Treatment or Interventions Provided
Supplemental Oxygen
Positive Pressure Ventilation
Intubation
Chest Compressions
Medication Support
Therapeutic Hypothermia
NICU Care
Observation Only
Other
Follow-Up Recommendation
Clinician Name or Role
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