FAMILY NAME AND NAME: | Times after birth | |||||
---|---|---|---|---|---|---|
DATE OF BIRTH: | HOUR OF BIRTH: …./…. | |||||
PARAMETERS TO BE ASSESSED OR EVENTS TO BE RECORDED | 10 min* | 30 min | 60 min | 90 min | 120 min | |
Correct position of the newborn with mouth and nose visible and unobstructed (the assessment of this parameter does not require separation of the newborn from the mother’s chest or interruption of a possible first feed): YES/NO |  |  |  |  |  | |
Pink colour (skin and/or mucous membranes): YES/NO | Â | Â | Â | Â | Â | |
Normal breathing (no retractions or grunting or flaring of the nostrils): YES/NO | Â | Â | Â | Â | Â | |
Normal respiratory rate (30-60 breaths/min): YES/NO | Â | Â | Â | Â | Â | |
Normal Sp,O2: > 90% (if deemed necessary): YES/NO | Â | |||||
Skin temperature at 60 and 120 minutes after birth Normal reference values: 36.5-37.5 °C |  |  |  |  |  | |
Mother never left alone with the newborn: YES/NO | Â | Â | Â | Â | Â | |
First breastfeeding attempt (time) | Â | Â | Â | Â | Â | |
Comments | Â | Â | Â | Â | Â | |
Signature (midwife/nurse/doctor) | Â | Â | Â | Â | Â |