Standard

Operating

Procedure

(SOPs)

New Born Health

Neonatal-Perinatal Network of South East Asia Region

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F

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Standard Operating Procedure (SOP)

Field name Explanation / Definition

Centre Name Name of centre & country

Baby’s Hospital Record number This is the hospital registration number given to a baby

when baby is born or admitted

Mother Hospital Record number This is the hospital registration number given to mother

when mother is admitted

NNPD number This is a system generated 9 digit UNIQUE number pre-

fixed by county name abbreviation and health center

name/code like; BAN-24754-123456789 or IND-PGIME-

123456789

Tick any one option: Inborn livebirth or Outborn livebirth

Inborn livebirth A liveborn baby born within premises of your center with

>500 grams birth weight or >22 weeks of gestation or a

crown heel length of >25 cm.

A live birth is complete expulsion or extraction from its

mother of a product of conception, irrespective of duration

of pregnancy, which after separation, breathes or shows any

other evidence of life, such as beating of the heart, pulsation

of the umbilical cord, or definite movements of voluntary

muscles. This is irrespective of whether the umbilical cord

has been cut or the placenta is attached.

Outborn livebirth Live born baby not born within the premises of your center

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1. Basic Information

S.No. Specific Term Explanation/ Definition

i. Mother’s name * Name of the mother

ii. Date of Delivery * dd/mm/yyyy format

iii. Time of Delivery (24 hr format) (hh-mm)

iv. Baby’s Gender * Male / female / ambiguous (choose any one option)

v. Baby's Weight* Baby's Weight is the weight of baby taken soon after the birth or within

24 hours of birth. The birthweight of 2.35 kg is to be written as 2350.

vi. Mode of delivery * Vaginal / Cesarean section / Instrumental (choose any one option)

vii. Multiple birth Single / Twin / Triplet / Higher order (choose any one option)

viii. Gestation* (in weeks) Gestational should be calculated from the following in this order of

priority

1. First day of last menstrual period (LMP)

2. First trimester ultrasound

3. By Expanded New Ballard score (ENBS)

If ENBS has been expressed as range, then enter the average e.g. if

ENBS is coming as 30-32, enter as “31”.

Only completed weeks are to be entered e.g. if born at 35+3 weeks,

enter “35”.

ix. Delivery attended by Doctor / Nurse / ANM / Midwife (choose any one option)

x. Head Circumference Baby's Head Circumference in Centimetres

For Out Born babies only

i. Date of admission * dd/mm/yyyy format (choose any one option)

ii. Place of delivery Home / Hospital / Others (choose any one option)

iii. Delivery attended by Doctor / Nurse / ANM / Midwife / Traditional birth attendant / Others

(choose any one option)

iv. Gestation (in weeks) * If it is <37 weeks store as Pre Term

and if it is > 37 weeks say it Term

v. Weight at admission (g) * Baby’s weight at the time of admission in grams

2. Maternal Details:

i. Para Number of times the mother has delivered after 22 completed weeks / 5

months.

Note: For primigravida this should be recorded as ‘01’; there will be no

‘00’ entry for any baby.

ii. Severe Anemia If mother Hemoglobin is <7 g/dL.

iii. Antenatal care If mother has taken at least 4 antenatal checkups, then choose “yes”

iv. Gestational diabetes Hyperglycemia of varying severity diagnosed during pregnancy

(without previously known diabetes) and usually (but not always)

resolving within 6 weeks of delivery.

Standard oral glucose tolerance test (OGTT) is done at 24-28 weeks

after an overnight fast (fasting plasma glucose and a plasma glucose 2

hours after 75g glucose drink is done). A 2 hour level >=7.8 mmol/L

(or 140 mg/dL) is diagnostic of gestational diabetes.

v. Antepartum hemorrhage Antepartum hemorrhage (APH) is defined as bleeding from or in to the

genital tract, occurring from 20 weeks of pregnancy and prior to the

birth of the baby.

vi. Eclampsia Eclampsia is defined as the presence of new-onset grand mal seizures

in a woman with preeclampsia # # Preeclampsia is a syndrome defined by hypertension and proteinuria that also may

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be associated with edema, visual disturbances, and headache and epigastric pain.

vii. Cord prolapse Cord prolapse has been defined as the descent of the umbilical cord

through the cervix alongside (occult) or past the presenting part (overt)

in the presence of ruptured membranes.

viii. Obstructed labor Labor is considered obstructed when the presenting part of

the fetus cannot progress into the birth canal, despite strong uterine

contractions.

3. Labor/Delivery: i. Oxytocin/Other drug use

for induction of labor

Choose one of the given option

ii. Antenatal steroids

None/ Incomplete course /

Complete course

If baby is preterm (gestation <37 weeks), administration of either

Betamethasone/ Dexamethasone given for lung maturation.

Complete course: When betamethasone/ dexamethasone is given as IM

injection every 12 hourly for two days.

This is not applicable for babies with gestations 37 weeks or more.

4. At Birth Care: i. . Bag and mask ventilation Need for bag and mask ventilation

Explanation: For intramural babies, check the patient file; ask the

treating doctor if not mentioned in the file; for extramural babies first

ask for any birth or referral record for this information; if not available,

ask the person who attended the delivery; you may need to talk to that

doctor/person on phone; if information is still not available, then ask

the mother or care-taker.

ii. Birth Defects Check for visible BD, if found choose yes and fill BD form

5. Newborn Morbidities: i. Birth trauma Baby has any evidence of birth trauma like fracture, cephalhematoma,

visible bruises etc, if Yes; specify

ii. Hypoglycemia Y/N (choose Y or N)

iii. Meconium aspiration Presence of two of the following

Meconium staining of liqor or staining of nails or umbilical cord or

skin

Respiratory distress soon after birth, within one hour of birth

Radiological evidence of aspiration pneumonitis (atelectasis and/or

hyperinflation)

iv. Hypothermia Y/N (choose Y or N)

6. Respiratory Distress: i. Respiratory distress

syndrome (RDS)/

Hyaline membrane

disease (HMD)

Presence of all the following three criteria:

Preterm neonate

Respiratory distress (any two features: respiratory rate >60, chest

indrawing, expiratory grunt/groaning) having onset within 6 hours

of birth

Amniotic fluid L/S ratio of <1.5 or negative gastric aspirate shake

test or X-ray of chest showing poor expansion with air

bronchogram or reticulo-granular pattern or ground glass opacity.

OR

Autopsy evidence of HMD

ii. Pneumonia Neonate with respiratory distress AND positive blood culture or if any

two of the following:

Existing or predisposing factors: maternal fever, foul smelling

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liqor, prolonged rupture of membranes (>18 hours) or gastric

polymorphs more than 5 per high power field

Clinical picture of septicemia (poor feeding, lethargy, poor reflexes,

hypo / hyperthermia, abdominal distension etc.)

X-ray picture suggestive of pneumonia

Positive septic screen (see septicemia)

iii. Transient tachypnea of

newborn

Y/N (choose Y or N)

7. CNS Disorder:

i. Hypoxic ischemic

encephalopathy (HIE)

Stage III/Stage II/Stage I/

None

HIE 1: Irritable, hyperalert neonate, unable to suck but No seizures

HIE 2: Seizures with lethargy, hypotonia, unable to suck

HIE 3: Comatose, prolonged seizures, unable to sustain spontaneous

respiration, marked hypotonia, absent brain stem sign such as dilated

pupil, absent doll’s eye reflex.

ii. Seizures Paroxysmal alteration in neurologic function, i.e. motor, behavior

and/or autonomic function. The seizure can be of different types

namely subtle, clonic, tonic, or myoclonic. The seizures must be

differentiated from jitteriness.

Jitteriness is defined as symmetrical rapid movements of the hands and

feet. It is stimulus sensitive and may be initiated by sudden movement

or noise. There are no associated eye movements.

8. Systemic Infections:

Systemic sepsis Neonate having clinical picture suggestive of septicemia, the presence

of any one of the following criteria is enough for assigning probable

diagnosis of infection:

Existence of predisposing factors: maternal fever or foul smelling

liqor or prolonged rupture of membranes (>18 hrs) or gastric

polymorphs (>5 per high power field).

Positive septic screen (two of the five parameters (namely, TLC

(<5000/mm, band to total polymorph ratio of > 0.2, absolute

neutrophil count less than 1800 /cmm, C-reactive protein >1mg/dL

and micro ESR>10 mm 1st hour).

Radiological evidences of pneumonia.

CULTURE POSITIVE SEPSIS

Clinical picture suggestive of septicemia, pneumonia or meningitis

along with isolation of pathogens from blood or CSF.

Episode number refers to number of episodes of sepsis that the baby

developed during hospitalization.

Early onset: Onset <72 hours.

Late onset: Onset >72 hours.

9. Others:

i. Hyperbilirubinemia

(Need for phototherapy)

Total serum bilirubin level requiring phototherapy and/or exchange

transfusion

ii. Rh isoimmunization If mother blood group is negative and ICT is positive OR DCT positive

in neonate

iii. ROP requiring Laser If laser treatment is required for the Retinopathy of Prematurity

iv. Any other morbidity Any other morbidity that has not been covered in the form

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10. Therapy provided:

i. Intravenous fluids

Choose Yes or No.

ii. CPAP (Continuous

positive airway pressure)

iii. IMV

iv. Surfactant

v. Antibiotic(s) * If antibiotics are given, then choose “Yes” otherwise “No”.

If ‘Yes”, fill the following items; otherwise skip to ‘11’

Name If antibiotics are given then select name of antibiotic from the given

list:

Nam

e

Ab

bre

via

tion

Nam

e

Ab

bre

via

tion

Pencillin

Ampicillin

Cloxacillin

Gentamicin

Amikacin

Netilmicin

Cefazolin

Cephelexin

Ceftizoxime

Cefotaxime

Ceftrioxone

Cefoperazone

Ceftazidime

Piperacillin

Vancomycin

Ciprofloxacin

Meropenam

Imipenam

Linezolid

Cefpodoxime

Ofloxacin

Pen

Amp

Clox

Gent

Amik

Netil

Cefaz

Ceph

Ceft

Cefo

Ceftri

Cefo

Cefta

Pipera

Vanco

Cipro

Mero

Imi

Lin

Cefpo

Oflo

Piperacillin-Tazobactum

Cefotaxime-Sulbactum

Metronidazole

Fluconazole

Amphotericin B

Cefoperazone-Sulbactum

Amoxycillin-Clauvulanic acid

Cefipime

Cefixime

Erythromycin

Chloramphenicol

Amoxycillin

Cefotaxime

Ertapenam

Oxacillin/Cefoxitin

Teicoplanin

Aztreonam

Cefuroxime

Colistin

Voraconazole

ESBL+

Piptaz

Cefsul

Metro

Fluco

AmphoB

Cefopsul

AmoxClav

Cefi

Cefxi

Ery

Chlor

Amox

Cefo

Era

Oxa/Cefo

Teico

Azte

Cefu

Coli

Vora

Esblp

Duration (days) Here write the duration for which antibiotics are given in two digit e.g.

if it is given for 7 days then write as “07” for each antibiotic.

11. Outcome of newborn * Discharged / Died$ / Referred / Left against medical advice (LAMA)

$ Fill the following fields if baby died

Fill the following fields if there is neonatal / fetal death; otherwise skip to ‘48’.

12. Neonatal death *

i. Date of death

(dd/mm/yyyy)

For example If baby has died on 26th

August 2013, the write as

26/08/2013

ii. Time of death (24 hrs) Fill the time as per 24 hour format

e.g. If baby’s time of death is at 10 AM the write as 1000 and 10 PM

as 2200

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13. Causes of Neonatal / Death* i. Asphyxia If death of a neonate in the setting of and with features of perinatal

hypoxia and / or birth asphyxia followed by manifestations of or

hypoxic ischemic injury of brain (hypoxic ischemic encephalopathy) or

other organs, then “yes”

ii. Infection If death in a neonate attributable to infection like pneumonia or

septicemia or meningitis etc, then “yes”

iii. Prematurity If death is due to prematurity or its complications such as

intraventricular hemorrhage, hyaline membrane disease, patent ductus

arteriosus etc in a neonate with weight less than 1000 grams

Note: If preterm has died due to infections then the cause of death

should not be prematurity and should be labeled as infection.

iv. Birth Defect(s) Death due to lethal congenital malformation

v. Others If death cause is not as mentioned in the above list, then choose “yes”

and Mention the cause in detail

vi. Unknown Select “yes” if cause is not unknown

14. What was the single most important cause of neonatal death?

Asphyxia / Infection /

Prematurity/

Malformation(s) / Others /

Unknown

Select only one from the option that is immediate cause of the death

15. Maternal Death:

Did the mother die? Y/N; Choose any one of the option

Name of professional completing

the form

Write name of person who has fill the physical form.

* (Mandatory Field)