h - Significant birth injury - 1st Labor and Delivery Summary Look for: (as applies to infant) skeletal fracture(s), peripheral Record under—Newborn Trauma Delivery Information Facial asymmetry nerve injury, and/or soft tissue Subgaleal (progressive or solid organ hemorrhage that 2nd Newborn Admission H&P requires intervention. Present extravasation within the scalp) Hemorrhage immediately following or within 24 hours after delivery. 3rd Physician Progress Notes Giant cephalohematoma Extensive truncal, facial and/or Includes: Any bony fracture or extremity ecchymosis accompanied by evidence of weakness or loss of sensation, but excludes fractured anemia and/or hypovolemia clavicles and transient facial and/or hypotension nerve palsy. Soft tissue hemorrhage Subcapsular hematoma of the requiring evaluation and/or liver treatment. includes sub-galeal Fractures of the spleen (progressive extravasation Adrenal hematoma within the scalp), hemorrhage, giant cephalohematoma, extensive Solid organ hemorrhage includes truncal, facial and/or subcapsular hematoma of the liver, extremity ecchymosis fractures of the spleen, or adrenal accompanied by evidence of hematoma. anemia and/or hypovolemia and/or hypotension. Solid organ hemorrhage includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma.
h - Significant birth injury - skeletal fracture(s), peripheral nerve injury, and/or soft tissue or solid organ hemorrhage that requires intervention. Present immediately following or within 24 hours after delivery. Includes: Any bony fracture or weakness or loss of sensation, but excludes fractured clavicles and transient facial nerve palsy. Soft tissue hemorrhage requiring evaluation and/or treatment. includes sub-galeal (progressive extravasation within the scalp), hemorrhage, giant cephalohematoma, extensive truncal, facial and/or extremity ecchymosis accompanied by evidence of anemia and/or hypovolemia and/or hypotension. Solid organ hemorrhage includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma. 1st Labor and Delivery Summary Record under—Newborn Delivery Information 2nd Newborn Admission H&P 3rd Physician Progress Notes Look for: (as applies to infant) Trauma Facial asymmetry Subgaleal (progressive extravasation within the scalp) Hemorrhage Giant cephalohematoma Extensive truncal, facial and/or extremity ecchymosis accompanied by evidence of anemia and/or hypovolemia and/or hypotension Subcapsular hematoma of the liver Fractures of the spleen Adrenal hematoma Solid organ hemorrhage includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma.