Birth Presentation Assessment Form
Use this form to assess and record a newborn’s presentation at birth. Keep all entries concise and relevant to the assessment.
Birth Presentation Details
Date of Birth / Newborn Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presentation Type at Birth
*
Cephalic
Breech
Transverse
Oblique
Uncertain
Observed Head / Lie Position
Normal
Flexed
Extended
Longitudinal Lie
Transverse Lie
Oblique Lie
Uncertain
Primary Assessment Notes
Assessment Scoring and Observations
Presentation Characteristics Rating
*
Rows
1 - Poor
2 - Fair
3 - Moderate
4 - Good
5 - Excellent
Alignment
1
2
3
4
5
Descent
6
7
8
9
10
Ease of Presentation
11
12
13
14
15
Notable Concerns
16
17
18
19
20
Overall Assessment Rating
*
1
2
3
4
5
Additional Observations and Recommendations
Assessment Conclusion
*
Please Select
Normal presentation
Requires closer monitoring
Concerning presentation
Further evaluation recommended
Other
Reviewer and Record Details
Assessor Full Name
*
First Name
Middle Name
Last Name
Role or Department
*
Please Select
Assessor
OB/GYN
Midwife
Nurse
Pediatrics
Records
Other
Contact Email
*
example@example.com
Submit Assessment
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