Annexure 1.3: Reporting Format For Newborn Facility: Section A To Be Filled From Labor Room & OT Records (As Applicable)

Annexure 1.
3: Reporting Format for Newborn Facility
(All new born care facilities should submit a Monthly /Quarterly report to the District.
NBCCs will only fill in section A, while Section A, B and C will be filled in from all NBSUs
and SNCUs. A compiled report from all newborn care facilities in the district should be
forwarded to the State.)
State: Delhi District: central
Reporting period JULY 2021
Name of the Health Facility: Aruna Asaf Ali Govt. Hospital Contact Person_ Dr. Ritu Chopra
No. of beds Six Date of operationalization of unit: SNCU /NBSU /NBCC (Tick one or more
options as applicable) (For example, the DH will have all three, while the FRU will have both
NBSU and NBCC)
SECTION A
Section A to be filled from labor room & OT records (as applicable)
S. No Total number JULY 2021
1 Total Deliveries 168

2 Caesarean sections 16
3 Live-births 167
4 Still-births 1
4a. Fresh
4b.Macerated
1
5 Term babies 163
6 LBW babies (< 2.5 kgs.)
> 2500gm 124
1500 – 2499 gm 41
1000 – 1499 gm 2
< 1000 gm 0
7 Preterm births(Gestation) 4
>37 weeks 163
< 37 weeks 4
8. No. of newborns who required 4

resuscitation at birth
9. Total no. of new born deaths 1
10 No. of referrals made (to higher 1

facilities)1
11 Human Resource
MO
SN
12 Human Resource Trained (NSSK for
NBCC, F-IMNCI for NBSU and
FBNC for SNCU.
NSSK
MO
SN
SECTION B
Section B to be filled from the Special Newborn Care Unit/ Newborn Stabilization Unit
records
S. Total number In-born [ I ] Out-born [ O ]

No
7 Admissions in the Unit JULY JULY
2021 2021
7a Male 15 6
7b Female 11 4
In case of District hospital, the higher facility (like the NBSU or SNCU) may be in the same premises.
8 Birth weight /weight at
admission *
(Inborn – Record the birth
weight/ Extra-mural – Record
birth weight if available; if it is
not available ,record and report
8a > 2500gm 13 8
8b 1500 – 2499 gm 11 2
8c 1000 – 1499 gm 2 0
8d < 1000 gm 00 0
9 Gestation
9a >37 weeks 18 8
9b 8 2
34 – 37 weeks
9c < 34 weeks 0 0
10 Morbidity Profile
10 Respiratory Distress 1 0
a syndrome
10 Meconium aspiration 1 0
b syndrome
10 Other causes of 4 0
c respiratory distress
10 HIE/ Moderate-Severe 4 0
d Birth Asphyxia
10 Sepsis/ Pneumonia/ 4 5
e Meningitis
10f Major Congenital 0 0
Malformation
10 Jaundice requiring 11 4
g phototherapy
10 Hypothermia 0 0
h
10i Hypoglycemia 0 0
10j Others 1 1
11 Management (no. of
babies who received )
11 11 4
a Phototherapy
11 5 5
b Antibiotics
11 15 5
c Oxygen
12 Step down care
12 No. of babies managed

a in the unit from Postnatal
12 ward/
No of Step
babiesDown
managed in
b the step down from
SNCU
13 Outcome
13 Discharge 25 8
a
Referral 0 1
13 LAMA 0 1
b
13 Died 1 0
c
14 Duration of stay
14 < 1 day 1
a
14 1-3 days 0
b
14 4-7 days 0
c
14 >7days 0
d
14
e Average duration of stay
15 No. of Non- functional Equipment ( Non-functional equipment = not working >

7days/ month)
15 Phototherapy FUNCTIONAL
a Unit
15 Radiant warmer FUNCTIONAL
b
15 Oxygen NA
c concentrator
15 Suction Machine FUNCTIONAL
d
15 Generator / FUNCTIONAL
e Invertor
Section C
Section C to be filled from the Special Newborn Care Unit/ Stabilization Unit death records
S. Total number of deaths In-born Out-born

No
[ I_D ] [ O_D]
16 Mortality profile (Cause of JULY JULY
death) 2021 2021
16 Respiratory Distress 1
16a syndrome 0
Meconium aspiration 0
16b syndrome 0
HIE/ Moderate-Severe 0
16c Birth
Sepsis/ Asphyxia 0
Pneumonia/ 0
16d Meningitis 0
Major Congenital 0
16fe Malformation
Prematurity 0 0
16 Others 0 0
16g Cause not established 0 0
17h Duration between the time of 0 0
admission & death
17 < 1 day 1 0
17a 1-3 days 0 0
17b 4-7 days 0 0
17c >7 days 0 0
18d Age at death 0 0
18 < 1 day 1 0
18a 0 0
18b 1-6 days 0 0
19c ≥ 7 days
Birth weight /weight at the time 0 0
19 of death > 2500gm 0 0
a
19 1500 – 2499 gm 0 00
19b 1000 – 1499 gm 1 0
19c < 1000 gm 0 0
20d Gestation 0 0
20 0 0
a Term
20 PRE-term 1 0
20b Preterm Post term 0 0
c
Signature of the in charge: _____________________

Date:_________________________________

Annexure 1.3: Reporting Format For Newborn Facility: Section A To Be Filled From Labor Room & OT Records (As Applicable)

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Annexure 1.

3: Reporting Format for Newborn Facility

State: Delhi District: central

Reporting period JULY 2021

Section A to be filled from labor room & OT records (as applicable)

S. No Total number JULY 2021

1 Total Deliveries 168

8. No. of newborns who required 4

10 No. of referrals made (to higher 1

S. Total number In-born [ I ] Out-born [ O ]

12 Step down care

12 No. of babies managed

15 No. of Non- functional Equipment ( Non-functional equipment = not working >

S. Total number of deaths In-born Out-born

Signature of the in charge: _____________________

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